Af > a Y,0' i iu,c-sletv ®2ltUe£!ben Urban Bistrict Council. 1 926. THE 51st ANNUAL HEALTH REPORT. GEORGE F. BUCHAN, M.D., D.P.H., Medical Officer of Health. London: WIGHTMAN & CO., LTD., Regency Street, Westminster, S.W. 1. 2 WILLESDEN URBAN DISTRICT COUNCIL, 1926-27. ‡*†ouncillor Dr. G. W. R. SKENE, J.P. (Chairman). †MR. Councillor W. A. HILL (Vice-Chairman). Mr. Councillor T. V. BANISTER. *‡†Mr. Councillor W. M. BOLTON (Chairman, Health Committee). Mr. Councillor J. H. BIGNELL. *†MR. Councillor H. C. BLAXLAND. †Mr. Councillor C. HICKS BOLTON, M.A. *†mr. Councillor P. BOND. *‡†Mr. Councillor A. CAMERON. Mr. Councillor J. P. CLARKSON. †mr. Councillor J. CLEE. Mr. Councillor J. COMBER, J.P. ‡†Miss Councillor N. M. COWAN. †MR. Councillor A. E. DORAN. Mr. Councillor E. DROWN. †MR. Councillor H. E. DULCKEN. Mr. Councillor W. F. FRANKLIN. Mr. Councillor H. L. GAUNTLETT. ‡†MR. Councillor H. J. GOLBY. ‡†mrs. Councillor K. E. GREGORY. Mr. Councillor G. H. HISCOCKS. †MR. Councillor F. HOLMES. Mr. Councillor E. W. B. HUTT (Resigned 5th October, 1926). Mr. Councillor W. JEFFRIES. Mr. Councillor E. R. E. JONES. †Mrs. Councillor L. A. LARKIN. Mr. Councillor E. J. W. LOKER. Mr. Councillor J. G. MARDELL. ‡ †MR. Councillor A. C. MELLUISH. ‡†mrs. Councillor R. MOORE. *†MR. Councillor J. MORSE. Mr. Councillor H. L. MOSSLEY. Mr. Councillor C. REED. Mr. Councillor W. H. RENWICK (Elected 22nd October, 1926). ‡ †Miss Councillor M. E. ROYLE (Chairman, Hospital Visiting Committee). Mr. Councillor H. J. SAVORY. Mr. Councillor R. T. SEARCH. Mr. Councillor G. A. SEXTON, J.P. Mr. Councillor A. SMITH, J.P. Mr. Councillor W. A. STILTON †MR. Councillor H. THORLEY. ‡†MR. Councillor F. W. W. VIDLER. Mr. Councillor T. WATTS. Mr. Councillor E. L. WESTELL. †MR. Councillor W. D. WILLISON. † Member of Health Committee. ‡ Member of Hospital Visiting Committee. * Member of Health Assessment Sub-Committee. WILLESDEN EDUCATION COMMITTEE, 1926-27. †MR. Councillor E. L. WESTELL (Chairman). †DR. M. EPSTEIN, M.A., Ph.D. (Vice-Chaiman). Mr. Councillor T. V. BANISTER. Mr. Councillor C. HICKS BOLTON, M.A. Mr. Councillor W. M. BOLTON. †MR. Councillor P. BOND. ‡ †MR. Councillor A. CAMKRON. †MR. Councillor J. CLEE. ‡ †Mr. Councillor J. COMBER, J.P. †MR. Councillor H. L. GAUNTLETT. Mr. Councillor W. A. HILL. Mr. Councillor G. H. HISCOCKS. Mr. Councillor E. W. BRIDGES HUTT (Resigned 5th October, 1926). ‡†MRS. Councillor R. MOORE (Chairman of the Children's Care Committee). Mr. Councillor J. MORSE. Mr. Councillor W. H. RENWICK (Elected 26th October, 1926). †Miss Councillor M. E. ROYLE. †MR. Councillor A. SMITH, J.P. Mr. Councillor F. W. W. VIDLER. ‡†MR. Councillor T. WATTS. ‡ †Miss M. ALEXANDER, M.A. Mr. E. B. C. ARROWSMITH. †Mr. C. C. CARTER. ‡†MR. A. R. CLARK. Mr. J. KELLY. Mr. F. SHEPPARD. †REV. A. E. SMITH. Mr. A. E. SMITH. † Member of the Children's Care Committee. ‡ Member of the Children's Care Assessment Sub-Committee. 3 Town Hall, Dyne Road, Kilburn, N.W. 6 15th March, 1927. To the Willesden Urban District Council— The Local Sanitary Authority, and the Local Education Authority. I beg to submit herewith the Annual Health Report for Willesden for the year 1926. This Report includes :— (i.) The 51st Annual Report on the health and sanitary condition of the district ; (ii.) The 19th Annual Report on the health of children attending the public elementary schools; (iii.) The 7th Annual Report on the health of children attending secondary schools; (iv.) The 9th Annual Report on dental work in connection with children attending the public elementary schools, expectant and nursing mothers and children under 5 years; (v.) The 7th Annual Report on home nursing; (vi.) The 12th Annual Report on the provision of meals to children attending the public elementary schools; (vii.) The 35th Annual Report on the Municipal Hospital. The Report is written in accordance with the requirements of the Ministry of Health and Board of Education. VITAL STATISTICS. The population of Willesden at Midsummer, 1926, was 173,854. 2,700 births occurred in Willesden during 1926, giving a birth rate of 15.53 per 1,000 of the population. This is the lowest birth rate ever recorded in Willesden. 1,653 deaths occurred in 1926, giving a death rate of 9.51 per 1,000 of the population. The infant mortality rate in 1926 was 53 per 1,000 births. This infant mortality rate is equal to the lowest previously recorded, namely, 53 in 1923. 143 deaths of infants under one year occurred. 116 or 81.1 per cent. of these 143 deaths were due to:- 1. Congenital Malformations 6, Premature Births 42, Atrophy, Debility and Marasmus 10, Atelectasis 4; 2. Diarrhoea and Enteritis 10; 3. Whooping Cough 4; 4. Measles 3; 5. Bronchitis 6; and 6. Pneumonia 31. Year by year these six causes of death account for some 80 per cent. of all deaths of infants under one year of age and active measures are required to prevent these conditions proving fatal. CANCER. As an outcome of the interest aroused by the special memorandum of Dr. W. D. Champneys on this subject, appended to my annual report for 1925, the following resolution was passed by the Council at its meeting on October 5th, 1926 " That in view of the fact that out of the total number of adult deaths in Willesden for the last recorded year, one in six died of Cancer, and as this cause of death is steadily on the increase, it be an instruction to the Health Committee to consider the advisability of setting up a Special Committee, either of its own members or otherwise, for the study of the problem of Cancer in Willesden, to collect evidence, to publish information concerning possible preventive measures, and to enquire whether any, and if so what, palliative action would come within the powers of the Local Authority." The Health Committee considered this resolution at its meeting on 26th October, 1926, and decided to appoint three of its members, one of whom was its Chairman, to consult with the Local Medical Advisory Committee and report in due course. This conference took place on 2nd December, 1926, at the Town Hall, and the result of its deliberations was reported to the Health Committee by the Chairman on 14th December, 1926, the Ministry of Health's Circular 716 on Cancer being considered at the same time. After hearing their Chairman's report and considering the circular, the Health Committee recommended " that the objects of the Council could be best obtained by referring the question to the Health Propaganda Committee and to instruct the Committee to deal with the question as a part of Health Propaganda generally." This recommendation was adopted by the Council at its meeting on 28th December, 1926. 4 INFECTIOUS DISEASES. During the year 1926, 1,983 cases of Infectious Disease were notified as compared with 1,883 in the previous year. The total of 1.983 includes 466 notifications of Diphtheria as compared with 304 in 1925, 359 cases of Scarlet Fever as compared with 263 in 1925, and 232 cases of Pneumonia as compared with 356 in 1925. Return Cases of Scarlet Fever.—The following statement gives the return cases that have occurred during 1926 :— I. Home Cases.—Approximately 20. (a) No. of infecting cases giving rise to return cases not longer than 28 days after release from isolation 0 „ return cases they gave rise to 0 „ infecting cases per cent. of total home cases 0 „ return cases per cent. of total home cases 0 (b) No. of infecting cases giving rise to return cases more than 28 days after release from isolation 0 „ return cases they gave rise to 0 „ infecting cases per cent. of total home cases 0 „ return cases per cent. of total home cases 0 II. Hospital Cases.—Approximately 339. (a) No of infecting cases giving rise to return cases not longer than 28 days after discharge 12 „ return cases they gave rise to 18 No. of infecting cases per cent. of total hospital cases 3.5 „ return cases per cent. of total hospital cases 5.4 (b) No. of infecting cases giving rise to return cases more than 28 days after discharge 4 „ return cases they gave rise to 4 „ infecting cases per cent. of total hospital cases 1.2 „ return cases per cent. of total hospital cases1.2 Small Pox.—Two cases of Small Pox were not fied in Willesden during 1926, one of which proved fatal. The original case, a man of 43 years, was infected in Paris. He became ill in a London Hotel, but the disease was unrecognised. He moved with his wife to a nursing home in Willesden where his wife became ill with severe haemorrhagic small pox. The Medical Officer of Health was called in, diagnosed small pox and had the patients removed to the Kingsbury Small Pox Hospital where the woman patient died the same evening. All contacts, with one exception who had been vaccinated 5 years previously, were vaccinated immediately and no further cases occurred in Willesden. No vaccinations were performed by the Medical Officer of Health under the Public Health (Small-Pox Prevention) Regulations, 1917. Typhoid Fever.—7 cases of this disease were notified during 1926 as against 6 in 1925 and 19 in 1924. Of these 7, 4 were treated in the Municipal Hospital, 1 in a London Hospital and 2 in their own homes. Of the 4 cases removed to the Municipal Hospital 1 was diagnosed as probably Malaria and 1 as ulcerative colitis. Both recovered. The remaining 2 were diagnosed as Typhoid Fever, one recovered and one died, this being the only death recorded from Typhoid Fever during 1926'. The case treated in a London Hospital recovered. The 2 cases treated at home recovered. Infectious Diseases of the Nervous System, Cerebro-Spinal Meningitis, Poliomyelitis, Encephalitis Lethargica and Acute Polio-Encephalitis.—19 cases of these diseases were notified in 1926, 4 proved fatal, giving a fatality rate of 21 per cent, of cases notified. Non-notifiable acute infectious diseases are reported from the Public Elementary Schools and are found by The Health Visitors during the cotfrse of home visitation. During 1926, 1,061 cases of measles, which is not notifiable in Willesden, were visited by the Health Visitors. Whooping Cough is a notifiable disease in Willesden. 419 cases were notified during the year, but a total of 1,229 cases coming to their knowledge were visited by the Health Nurses. 5 MOTHERS AND CHILDREN UNDER FIVE YEARS. Municipal Centres.—At the Municipal Clinics. including the Ringworm Clinic, expectant mothers attended the medical consultations on 1.940 occasions; nursing mothers. 11,768. and children under 5, 25.376. making a total of 39.084 attendances. These figures when compared with the corresponding figures for 1925 show an increase of 12.965 attendances. Out of the total number of children born in Willesden during the year. 903 or 33.5 per cent. subsequently attended the Welfare Centres. The number of births occurring amongst expectant mothers who attended the Ante-Natal Clinic was 419; 58 per cent. of these mothers with their babies subsequently attended the Welfare Centre. Hospital Maternity Cases.—The following table shows the bookings for hospital confinement under the Council's schemes since hospital provision was first made by the Council for such cases:— Table No. 1.—Hospital Confinement Bookings. Four weeks ended No. of Confinement Cases Booked. 10.4.18 1 18.5.18 1 15.6.18 1 13.7.18 2 10.8.18 22 7.9.18 23 5.10.18 13 2.11.18 14 30.11.18 10 28.12.18 12 Total (1918) 99 25.1.19 14 22.2.19 13 22.3.19 17 19.4.19 12 New Council 1919-22. 17.5.19 16 14.6.19 17 12.7.19 21 9.8.19 20 6.9.19 25 4.10.19 36 1.11.19 20 29.11.19 26 27.12.19 30 Total (1919) 267 24.1.20 43 21.2.20 41 20.3.20 32 17.4.20 23 Memo. 24.3.20. Hospital full. Cases from half of district only admitted. 15.5.20 24 12.6.20 32 Memo. 8.6.20. Cases admitted from whole of district. but for medical reasons or home circumstances only. 10.7.20 43 7.8.20 36 4.9.20 31 2.10.20 37 30.10.20 40 ' 27.11.20 28 25.12.20 34 Total (1920) 444 6 Table No. 1.—Hospital Confinement Bookings—continued. Four weeks ended No. of Confinement Cases Booked. 22.1.21 31 19.2.21 34 19.3.21 36 16.4.21 35 £2 fee imposed at Council meeting, 22.3.21. 14.5.21 40 5.5.21. Cases to be booked for Hospital limited to 28 per month or 336 for the year (including Expectant and Nursing Mothers). 11.6.21 18 9.7.21 28 6.8.21 12 3.9.21 19 1.10.21 18 29.10.21 29 26.11.21 23 31.12.21 (5 weeks) 12 Total (1921) 335 28.1.22 27 25.2.22 33 Memo. re cases living in more than 3 rooms to show sound reason why they should be booked. 25.3.22 22 New Council 1922-1925. 22.4.22 15 From 1.4.22 cases to be booked for hospital not to exceed 32 per month (including Expectant and Nursing Mothers). 20.5.22 24 17.6.22 19 Illegitimate cases not admitted, except on surgical grounds, after 23.5.22. 15.7.22 31 12.8.22 22 9.9.22 17 14.9.22. Letters handed to applicants that they would probably go to Park Royal Hospital. Conditions re payment in advance and with-holding Admission Cards until payment complete imposed. 7.10.22 18 4.11.22 10 9.10.22. Solicitor's revised Admission Form and signature of husband required. 2.12.22 21 30.12.22 7 Total (1922) 266 27.1.23 28 24.2.23 20 24.3.23 19 21.4.23 5 New Scheme, 1.4.23. 19.5.23 7 On and after Midnight 30.4.23, cases sent to Park Royal Hospital. 16.6.23 5 Council meeting 29.5.23. Illegitimate cases 12 months residents of Willesden may be booked. 14.7.23 14 11.8.23 10 8.9.23 8 6.10.23 6 3.11.23 1 1.12.23 6 29.12.23 11 Total (1923) 140 26.1.24 9 23.2.24 3 22.3.24 8 Carried forward 20 7 Table No. 1.—Hospital Confinement Bookings—continued. Four weeks ended No. of Confinement Cases Booked. Brought forward 20 19.4.24 6 Letter from Board of Guardians—Special Ward will not be reserved for Council cases after 1.4.24. 17.5.24 2 14.6.24 6 12.7.24 10 9.8.24 11 • 6.9.24 4 4.10.24 11 Revised new scheme in force, 25.9.24 (Council meeting 23.9.24.) 1.11.24 10 29.11.24 4 27.12.24 11 3.1.25 (one week) 4 Total (1924) 99 31.1.25 10 28.2.25 13 28.3.25 7 25.4.25 8 New Council, 1925-1928. 23.5.25 9 20.6.25 11 18.7.25 8 15.8.25 9 12.9.25 12 10.10.25 14 7.11.25 14 5.12.25 14 2.1.26 17 Total (1925) 146 30.1.26 17 27.2.26 24 27.3.26 19 24.4.26 16 22.5.26 17 19.6.26 12 17.7.26 11 14.8.26 22 11.9.26 20 9.10.26 22 6.11.26 15 4.12.26 15 1.1.27 10 Total (1926) 220 During 1926, 229 Maternity Cases were admitted to Park Royal Hospital under the Council's scheme. Of these 229 cases, 222 were confined, 1 had a miscarriage and 6 proved not to be in labour. Of the 222 women who were confined, 217 were delivered of live infants and in 5 cases the infants were born dead. Two women died as a result of confinement. 8 Hospital Treatment of Children under 5 Years of Age.'—The following table gives particulars of the children under treatment at the Willesden General Hospital and St. Monica's Home Hospital under the Council's scheme during 1926:— Table No. 2. Willesden General Hospital. St. Monica's Home Hospital. Total. No. of Children in Hospital at 31st December, 1925 1 2 3 No. of Children admitted during 1926 81 3 84 Total No. of Children under treatment during 1926 82 5 87 No. of Children discharged during 1926 82 5 87 No. of Children died in Hospital during 1926 0 0 0 Mortality % 0 0 0 No. of Children remaining in Hospital at 31st Dec., 1926 0 0 0 The following table gives particulars of the conditions for which children were admitted during 1926, the treatment carried out and the results of such treatment:— Table No. 3.—Children under 5 Years Admitted to Hospital during 1926. Condition. No. Admitted. Forms of Treatment. Result of Treatment. In Hospital at end of 1926. Operative. General. Other forms. Remedied. Improved. Unchanged Died. Marasmus 7 . 7 . *2 3 2 . . Enlarged Tonsils and Adenoids *77 74 . . 74 . . . . Total 84 74 7 . 76 3 2 . . * Three cases not operated on. ** One case transferred to Municipal Hospital suffering from Measles—died two days after admission. Puerperal Fever.—During 1926 16 cases of Puerperal Fever were notified. This gives a case rate of 5.93 per 1,000 registered births, as against 2.90 in 1923, 4.20 in 1924 and 5.80 in 1925. 4 of these notified cases proved fatal, 1 death occurring in 1927, and in 1 case the home address was not in Willesden, which gives a case mortality of 25.0 per cent., as against 12.50 per cent. in 1925 and 16.7 per cent. in 1924, and a maternal mortality from this cause of 1.5 per 1,000 births. The maternal mortality from all causes was 1.9 per 1,000 births including the 2 deaths of Puerperal Fever cases referred to above but which do not appear as due to Puerperal Fever in the 1926 Death Tables. In 6 of the 16 notified cases a private doctor was in attendance at birth, in 2 cases the doctor arrived after the birth of the child, in 3 cases the birth was attended by a midwife, and in 3 cases the birth occurred in a Hospital. 1 case was a miscarriage attended by a doctor and 1 a miscarriage attended first by a handywoman who called in a doctor. The other particulars of the cases are as follows:— Table No. 4. 1 case normal. 1 case normal as far as ascertained—diagnosed Toxaemia due to septic teeth and constipation. 1 case normal—born before arrival of doctor. 1 case born before doctor's arrival—handywoman present—quick normal labour. Fatal. 1 case normal confinement—temperature rose fifth day. Curetted, nothing found. 1 case normal as far as ascertained—phlebitis. 1 case normal delivery—torn perineum—1 stitch—20 hours in labour. 1 case normal labour—1 suture in perineum—curettage, portion of placenta removed. 1 case patient sustained severe bruising of vulva during delivery—uterus explored— nil found—fatal. 1 case vaginal discharge for several months before confinement—septic knee joint— ante partum and post partum haemorrhage. 1 case instruments and chloroform. 1 case forceps delivery—perineum ruptured. 1 case forceps delivery and anaesthetic—delayed labour. 1 case chloroform and instruments—severe haemorrhage after confinement—partially retained placenta. 9 1 case miscarriage—handy-woman—doctor called in—placenta removed 2 days after miscarriage—fatal. 1 case miscarriage—piece of placenta retained—manually removed under anaesthetic. Specialist called in and diagnosed fibroid and tubo-ovarian abscess—operation performed and a mass of pelvic cellulitis found—did well for a few days and then had rigors—developed pneumonia and died. 16 3 cases were treated in the Municipal Hospital and recovered. 12 cases were treated in Park Royal Hospital, 9 recovered and 3 proved fatal. 1 case was treated in a nursing home outside Willesden and proved fatal. 16 Puerperal Fever Cases, 1926. Home Circumstances. Table No. 5. Number of Cases. Number of Rooms. Number of occupants, including new-born baby. Under 10 years. Over 10 years. Total. 1 1 1 (no baby, miscarriage) 2 3 2 2 1 2 3 (4 children had been sent away to relatives). 1 2 1 2 3 1 2 3 6 1 3 1 2 3 1 3 1 3 4 1 3 2 5 3 1 4 5 1 3 1 6 7 1 5 5 4 9 1 6 0 (no baby, miscarriage) 4 4 3 Occurred in hospitals. Puerperal Pyrexia.— Since 1st October, 1926, when this condition became compulsorily notifiable under The Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1926, 24 cases have been notified to the end of the year. 2 of these 24 cases were subsequently notified as Puerperal Fever, 1 proving fatal. Ophthalmia Neonatorum.— The number of cases of this disease notified during the year was 30, giving a case rate of 11.2 per 1,000 registered births. In 1 case no information was obtainable. In the other 29 cases, a private doctor attended at the confinement in 20 cases, a midwife in 4 cases, 1 case was attended by a private doctor in a nursing home, and the remaining 4 cases were born in hospital. Treatment was obtained at a hospital in 5 cases, at a nursing home in 1 case, at the Municipal Clinics in 8 cases, and by a private doctor at home in 15 cases. Complete recovery with unimpaired vision occurred in 27 cases, in 1 case 1 eye was permanently injured, while 1 case was still under treatment at the end of the year. The following table gives particulars:- Table No. 6. Cases. Vision unimpaired. Vision impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 4 - 4 3 1 - - 1 - 1 Still under treatment, progressing satisfactorily. 1 - 1 Nursing Home 1 - - - 8 - 8 Council's Clinics 8 - - - 15 15 15 1 No information obtainable. 10 School for Mothers at Clinic 1.—The year as a whole may be considered satisfactory. There has been a total attendance of 2,802, making an average of 11.72. There has not been quite such a large number of Expectant Mothers, but a larger number of Nursing Mothers have attended and availed themselves of the opportunities afforded them of learning how to cut out and make baby outfits, also other necessary garments. Bathing demonstrations have again been given, and highly appreciated, especially by the younger mothers. An Exhibition of very useful garments (made by mothers attending the needlework class) was held on 3 successive days, December the 15th, 16th and 17th, respectively. One could not help noticing, and many visitors remarked on the neatness and finish of the work. A cinematograph film entitled "A Dangerous Handicap," produced and kindly lent by the National Health and Cleanliness Council, was shown each afternoon. This was followed by a series of talks on " Life in China," illustrated with lantern slides, kindly given and arranged by Dr. Maitland (Clinic Medical Officer). Everybody present enjoyed and much appreciated the arrangement. Unfortunately the space is so limited that it is impossible to do all that might be done. The class-room was crowded out each afternoon. At one time as many as 75 adults (some of them with babies) were in the room. It was impossible to accommodate more, and several had to go away. In the Nursery attendances for the year 1926 numbered 3,031. During the exhibition as many as 40 babies were taken care of in the nursery, the space and accommodation being extremely inadequate for such a large number at one session. All the children shew a very good standard of clothing and personal hygiene. School for Mothers at Clinic 2.—The total attendances at this Mothercraft centre with 109 sessions were 932 for mothers and 331 for children, giving an average attendance per session of 8.6 mothers and 3 children. During the year 367 Expectant Mothers and 869 Nursing Mothers made 1,397 and 7,165 attendances respectively for Medical Consultations at Clinic 2. The session is from 2-4 p.m. Instruction in cutting out and making garments is given, as well as a short Health Talk. The only available room for the class is the Dental Waiting Room, 14 ft. x 13 ft*, when the Dentist is in the schools, usually 3 sessions p.m. weekly. Lack of space prevents the giving of practical demonstrations, grading the classes and increasing the attendances. School for Mothers at Lower Place.—There has been a total attendance of 392 for mothers and 283 for children, giving an average attendance per session of 9.5 mothers and 6.9 children. The premises here negative progress. They are small and so cold in the winter that from a health point of view it is not altogether desirable that the mothers should attend with their children on cold days. At all the centres the keenness and interest exhibited by the mothers in the Health Talks impress the Staff concerned with the urgent need of providing suitable premises for teaching mothercraft so that this valuable means of health propaganda may be made attractive and carried out in its various branches. Subjects of Health Talks.—The following syllabus of Health Talks given at Lower Place School for mothers during the 3 terms January-April, April-July, and September-December, 1926, are submitted as a sample of what is being done at these schools. LOWER PLACE MOTHERCRAFT CENTRE. Health Talks. January-April, 1926. 1. Teaching a baby clean habitsjfrom birth. 2. The importance of regularity with feeds, etc. 3. Teaching a child the importance of blowing its nose (with method of teaching a child how to blow nose. (Diagram.) 4. Ailments which could be avoided if child is taught to breathe properly. 5. The importance of fresh air and sunlight. The advantages of sun on the growth of a child. 6. Method of giving sun baths. 7. Why an Expectant Mother should attend an Ante-N,atal clinic. 8. Rules which should be observed by an Expectant Mother. 11 9. What to do in a case of A.P.H. before the Doctor arrives. 10. Requirements for Home Confinement. 11. Breast feeding. 12. How (a) to increase breast milk. (b) to re-establish breast milk. April-July, 1926. 1. Popular Fallacies— (a) Weaning. (b) Fatness. (c) Coaxing to eat. (d) Rupture. 2. Dangers of Flies and Vermin. 3. Character Framing. 4. Sleep. 5. Popular Fallacies— (a) Need of Food for Newly Born Infant. (b) Infant only crying because of hunger. (c) Washing Baby's Mouth. (d) Powdering. (e) Soft Spot. 6. Rickets—Cause and Prevention. 7. Care of the Teeth. 8. Common Ailments. First Aid Treatment. 9. Popular Fallacies— (a) Castor Oil. (b) Purgatives in Constipation. (c) Dummy. 10. Summer Diarrhoea. 11. Management of Children, 1 to 5 years. 12. Breast Feeding. 13. Care of Young Baby. September-December, 1926. 1. Hygiene of Pregnancy. 2. Bad Habits. 3. Care of the New Born Infant. 4. The Evils of Slapping. 5. Popular Fallacies— (i.) Exercise in Pregnancy. (ii.) Boils. (iii.) Eczema. 6. Breast Feeding. 7. Complications of Breast Feeding and Supplementary Feeding. 8. Popular Fallacies— (i.) Lotions as Disinfectants. (ii.) Darkened Rooms in Sickness. 9. Common Ailments of Children, 0-2 years. 10. Common Ailments of Children, 2-5 years. 11. Diseases of the Skin in Infancy. 12. How to make the Best of Little Houses. 13. Children's Fears. 14. Open Windows. THE SCHOOL MEDICAL SERVICE. Schools.—There are 35 public elementary schools in the district. Of this number 23 are Council and 12 church or non-provided schools. Included in the number of the Council schools are 3 special schools, 1 for mentally defective and 2 for physically defective children. Two of the Council schocls are temporary buildings, 12 The hygienic condition of the schools in Willesden is very variable. Many of the more modern schools leave little to be desired as regards ventilation, lighting, warming, equipment and sanitation, but some of the other schools fall short of the standard desirable. Water to the schools is supplied in all instances direct from the mains of the Metropolitan Water Board. Adequate facilities are provided for the supply of drinking water for the scholars. Medical Inspection.—During 1926 the average number of scholars on the Public Elementary School Rolls in Willesden was 21,845. The following groups of children were examined during the year:— (1) All children admitted to school for the first time; (2) All children between 8 and 9 years of age; and (3) All children between 12 and 13 years of age, together with children over 13 years of age who have not been examined on reaching the age of 12. The total number of children medically inspected at routine and special inspections during J925 was 15,795. Findings of Medical Inspections.—(a) Uncleanliness.—Cleanliness inspections were carried out in the schools on 731 occasions during the year 1926, the average number of visits paid to each school by the Health Visitor being 23. The total number of examinations and re-examinations made during the year was 48,017. The effect of this work is well illustrated in the following table0:— Percentage of nitty and verminous children recorded upon routine inspection at the schools from year to year since 1914:- Table No. 7. 1914 20% 1915 23% 1916-19 Results not recorded owing to war. 1920 11.9% 1921 9.8% 1922 8.3% 1923 8.2% 1924 7.1% 1925 6.0% 1926 5.9% (b) Tonsils and Adenoids.—During 1926, at routine and special medical inspections, 1,858 cases of enlarged tonsils and adenoids were discovered, as compared with 2,033 found in 1925, and 1,348 in 1924. (c) Skin Disease.—During 1926, at routine and special medical inspections, 1,863 cases of skin disease were detected, as compared with 1,519 cases in 1925, an increase of 344. (d) Enlarged Cervical Glands (non-tuberculous).—During 1926 at routine and special medical inspections 670 cases of this defect were noted as compared with 369 in 1925. Infectious Diseases.—The action taken to detect and prevent the spread of infectious diseases was the same as set forth in my Annual Report for 1925. Following Up.—All defects found at medical and dental inspections are notified to the parents, and it is the duty of the Health Nurses to follow up these cases in their homes in order to ascertain if the necessary treatment has been obtained. If nothing has been done she again explains the necessity for treatment to the parent, and advises as to the best method of obtaining such treatment. Medical Treatment.—During the year 1926 school children were followed up by the Health Department on account of 19,179 medical defects and 7,163 dental defects. Of those defects found to require treatment, medical or dental treatment was obtained for 12,498 and domestic treatment was obtained for 5,522. 88.3 per cent. of the medical defects were treated, 57.8 per cent. receiving medical treatment and 30.5 per cent. domestic treatment; 28 per cent. of the dental defects followed up were treated. No record is available of defects requiring treatment which were not followed up. Of the total medical defects treated 87 per cent., and of the total dental defects treated 97 per cent., were dealt with by the Education Committee. The remainder, or 13 per cent. of the medical defects and 3 per cent. of the dental defects treated were dealt with by private practitioners, voluntary hospitals, or other charitable institutions, or the Poor Law. In connection with the defects treated, the children concerned made 53,695 attendances at the School Clinics in 1926, as compared with 46,818 in 1925 and 37,305 in 1924. 13 In April, 1923, and again in September/October, 1924, revised schemes for Maternity and Child Welfare and School Medical Treatment came into force. The following table shews the effect of the revisions made from time to time on the attendances at the Council's Clinics Table No. 8. Four weeks ending M. & C.W. Clinic Attendances. S.M.S. Clinic Attendances. Total Clinic Attendances. Remarks. 22.1.21 3,953 5,250 9,203 Includes holidays. 19.2.21 4,140 7,205 11,345 19.3.21 3,875 7,250 11,125 16.4.21 3,697 5,292 8,989 Includes holidays. 14.5.21 4,125 6,558 10,683 11.6.21 3,497 5,321 8,818 Includes holidays. 9.7.21 3,505 6,004 9,509 6.8.21 3,147 3,381 6,528 Includes holidays. 3.9.21 3,420 3,290 6,710 Includes holidays. 1.10.21 3,557 5,990 9,547 29.10.21 1,971 2,824 4,795 Registration fee imposed 1/10/21 for M. and C.W. and S.M.S. 26.11.21 2,022 3,083 5,105 31.12.21 (5 weeks) 2,320 3,302 5,622 Includes holidays. Totals, 1921 (53 weeks) 43,229 64,750 107,979 28.1.22 2,076 2,781 4,857 Includes holidays. 25.2.22 2,516 3,443 5,959 25.3.22 2,334 3,423 5,757 22.4.22 2,117 2,459 4,576 Includes holidays. 20.5.22 2,340 3,196 5,536 17.6.22 2,117 2,767 4,884 Includes holidays. 15.7.22 2,168 3,640 5,808 Registration fee drawn 10.7.22 in respect of S.M.S. only. M. and C.W. registration fee still operative. 12.8.22 1,998 2,360 4,358 Includes holidays. 9.9.22 2,115 2,693 4,808 Includes holidays. 7.10.22 2,350 5,378 7,728 4.11.22 2,238 5,191 7,429 Includes holidays. 2.12.22 2265 5,559 7,824 30.12.22 1,765 4,124 5,889 Includes holidays. Totals, 1922 (52 weeks) 28,399 47,014 75,413 27.1.23 2,123 4,627 6,750 Includes holidays. 24.2.23 2,032 5,339 7,371 24.3.23 2,323 4,841 7,164 Registration fee in respect of M. and C.W. withdrawn 28.2.23. 21.4.23 2,284 3,254 5,538 Includes holidays. First Revised M. and C.W. and S.M.S. Schemes came into operation, 1.4.23. 19.5.23 2,284 3,266 5,550 16.6.23 2,082 3,008 5,090 Includes holidays. 14.7.23 2,230 3,139 5,369 11.8.23 1,889 1,959 3,848 Includes holidays. New Declaration Form for M. and C.W. Cases in force, 30.7.23. 8.9.23 1,304 1,617 2,921 Includes holidays. 6.10.23 1,558 3,547 5,105 3.11.23 1,473 3,426 4,899 1.12.23 1,235 3,543 4,778 29.12.23 987 2,414 3,401 Includes holidays. Totals, 1923 (52 weeks) 23,804 43,980 67,784 14 Table No. 8 (continued). Four weeks ending. M. & C.W. Clinic Attendances. S.M.S. Clinic Attendances. Total Clinic Attendances. Remarks. 26.1.24 1,219 2,435 3,654 Includes holidays. 23.2.24 1,477 3,527 5,004 22.3.24 1,477 3,476 4,953 19.4.24 1,203 2,792 3,995 Includes holidays. 17.5.24 1,272 2,984 4,256 Includes holidays. 14.6.24 1,200 2,914 4,114 Includes holidays. 12.7.24 1,428 2,897 4,325 9.8.24 760 . 1,155 1,915 Includes holidays. Clinic 2 closed for repairs. 6.9.24 745 960 1,705 Includes holidays. Clinic 2 closed for repairs. 4.10.24 1,614 3,452 5,066 Second Revised M. and C.W. Scheme in operation 25.9.24 Second RevisedS.M.S. Scheme in operattion 3.10.24. 1.11.24 1,831 3,815 5,646 29.11.24 1,771 3,614 5,385 3.1.25 (5 weeks) 1,605 3,284 4,889 Includes holidays. Totals, 1924 (53 weeks) 17,602 37,305 54,907 31.1.25 1,744 3,356 5,100 Includes holidays. 28.2.25 1,861 4,167 6,028 28.3.25 2,174 4,759 6,933 25.4.25 1,971 3,188 5,159 Includes holidays. 23.5.25 2,184 4,248 6,432 20.6.25 1,957 3,700 5,657 Includes holidays. 18.7.25 2,062 3,843 5,905 15.8.25 1,882 1,613 3,495 Includes holidays. 12.9.25 2,141 2,738 4,879 Includes holidays. 10.10.25 2,558 4,722 7,280 7.11.25 2,457 4,533 6,990 5.12.25 2,258 3,671 5,929 2.1.26 1,806 2,280 4,086 Includes holidays. Totals, 1925 (52 weeks) 27,055 46,818 73,873 30.1.26 2,559 2,873 5,432 Includes holidays. 27.2.26 3,048 4,249 7,297 Nutritive foods sold to all Clinical attendants when prescribed without income limit 23.2.26. 27.3.26 2,972 4,969 7,941 24.4.26 2,645 3,742 6,387 Includes holidays. 22.5.26 3,120 4,573 7,693 19.6.26 2,947 4,324 7,271 Includes holidays. M. & C.W. Cases to be personally seen by Clinic Doctors limited as far as possible as from 26.5.26. 17.7.26 3,233 4,450 7,683 14.8.26 2,836 2,374 5,210 Includes holidays. 11.9.26 3,387 3,265 6,652 Includes holidays. 9.10.26 3,885 5,352 9,237 6.11.26 3,693 5,145 8,838 4.12.26 3,413 5,095 8,508 Ministry of Health approved Scheme for free issue of nutritive foods, 18.11.25. 1.1.27 2,837 3,284 6,121 Includes holidays. Totals, 1926 (52 weeks) 40,575 53,695 94,270 15 Crippling Defects and Orthopeedics.—No general scheme for the treatment of such defects has yet been adopted, work of this kind being at present limited to the provision of instruments in necessitous cases and the maintenance of crippled children in special institutions, such as the Heritage Craft School Chailey, Sussex, and the Royal National Orthopaedic Hospital, Great Portland Street. These institutions provide not only treatment for the medical conditions of the children, but also education, being certified for this purpose by the Board of Education. Open-Air Education.—For the financial year 1927-28 a sum of £184 has been provided in the estimates for the provision of an open-air school. In January, 1925, the Board of Education's Circular 1,349 was received, drawing attention to the lack of open-air accommodation for defective children in some areas. In October, 1925, the School Medical Officer was instructed to report on a site in Pound Lane as regards its suitability for the purpose of an open-air school, and in view of the report made the Children's Care Committee came to the conclusion that this site was not large enough for this particular purpose. At the present time another and larger site is under consideration. Abnormal Children.—Under this category are included the following classes of children— During the year 1926, 397 special children were examined or re-examined. Of the 118 original examinations included in the 397 examined, 51 were found to be physically defective, 12 mentally defective, 1 partially blind, 1 epileptic, 22 dull or backward, 23 debilitated and anaemic, 3 defective vision and 5 normal. Leinster Road Mentally Defective School.—The certified accommodation at this school is for 90 children, and during the year under review the average number on the roll was 97, the actual number on the roll at 31st December, 1926, being 85. The average attendance for the year was 83. There were no children awaiting admission to this school at the end of the year. The staff which was reduced by one full-time assistant in 1923 remains at one Head Teacher and three full-time assistants. Arrangements were made, for the provision of a part-time assistant to train a class of boys in bootmaking, and this assistant started work early in 1925. Nine children were reported to the Local Control Authority as incapable of receiving further benefit from instruction in the school, 1 was reported with a view to being placed under guardianship, 3 were allowed to leave school, and 1 was transferred to'a residential institution. The certifying officer visits the school weekly for the purpose of revision of classification and for medical examination of the children. The parents are notified of any defects requiring attention. 75 such examinations were made during 1926. The school dinner is provided at the Granville Road Mission. On an average 34 children take dinner, 20 bring their own lunch, and the remainder go home. Furness Road Physically Defective School.—The certified accommodation at this school is for 60 children, and during the year the average number on the roll was 47, the actual number on the roll on the 31st December, 1926, being 48. The average attendance for the year was 39 and there are no children awaiting admission. This school takes the physically defective children over 12 years of age, the younger children attending Leopold Road Physically Defective School. The staff consists of one Head Teacher and one full-time assistant. The Head Teacher also acts as Head Teacher for the Junior School, the latter being in the care of an Assistant-in-Charge. I have called attention to the unsatisfactory nature of the school premises in several of my annual reports, including that for 1925. During the year 4 children were allowed to leave school before reaching the age of 16 years. The school dinner is provided at the Furness Road Feeding Centre. 36 children have their dinners there, 8 bring their own lunch and the remainder go home. Leopold Road Physically Defective School.—The certified accommodation at this school is for 40 children. During the year the average number on the roll was 46, the actual number on the roll on the 31st December, 1926, being 44. The average attendance for the year was 40, and there were no children awaiting admission at the end of the year. The staff consists of two assistant teachers, the senior being in charge. The dinners are brought from Strode Road Feeding Centre and are served in the Laundry Centre of Leopold Road School. All the children take the school dinners. During the year 10 children were transferred to ordinary elementary schools. A trained nurse who also acts as ambulance attendant is attached to each of the Physically Defective Schools. She treats such minor ailments as require it and supervises the personal cleanliness and the care of the teeth and hair of the children. She arranges for the repair of surgical instruments and boots and undertakes the massage of the children who have been ordered this treatment by their Surgeon and who are unable to attend a Hospital for this purpose. She also gives the children the medicines and nutritive drugs ordered by the Doctor, such as Syr. Ferri Phos. Co. Virol and Cod Liver Oil 16 Both schools are visited by the Certifying Medical Officer once a fortnight and each child is seen every six months. The parents are notified of any defects found which require attention. The majority of the children at these schools who are actual cripples attend periodically either an Orthopaedic Hospital or the Orthopaedic Department of a General Hospital. In a few cases difficulty is found in getting the parents to keep their children under the care of an Orthopaedic Surgeon. The cost of travel and the distances to the nearest hospitals are the chief factors in preventing this being carried out. Difficulty also arises when a case is ordered special daily treatment which can only be carried out in an Orthopaedic Department. When the Orthopaedic Clinic to be established in Willesden is in working order, these difficulties will disappear, and it will be practicable for every cripple child to be kept under the care of a Specialist and also to have such treatment as is considered necessary for the particular defect. Convalescence.—Convalescent homes for children attending the Physically Defective Schools are arranged by the Invalid Children's Aid Association and by the Shaftesbury Society. The Stamford Hill Cripples' Home has a branch at Thorpe Bay near Southend-on-Sea and this institution admits Willesden children at a reduced rate. The Education Committee have now made arrangements with the Russell-Cotes School of Recovery, Parkstone, near Bournemouth, for the reservation of two more beds at this Institution for Willesden boys, making 4 in all. This home was provided by the donors as a country residence near the sea for poor town boys and girls who are anaemic and debilitated and who are physically defective within the meaning of the Education Act, 1921, and it is recognised by the Board of Education as a Special Residential School. The boys are selected both from the physically defective and the ordinary elementary schools and the duration of the stay is six weeks, except in special cases when an additional six weeks' stay can be arranged. All the cases which have been to the Institution have shewn a distinct improvement on their return home. Stammering Children.—The special class for stammering children, privately conducted by Mr. A. D. Bradfield at Percy Road Council School during 1924, was taken over by the Council with the approval of the Board of Education on 3rd February, 1925, and has been conducted with considerable success ever since. This class consists of 10 boys, who receive 2 1-hour lessons per week. Similar classes, but of 12 children and including girls as well as boys, were started at Pound Lane Council School in January, 1926, and at Kensal Rise Council School in May, 1926. These two classes are also conducted by Mr. A. D. Bradfield. ANTHROPOMETRIC ENQUIRY. The Council's Medical Staff agreed in 1925 to co-operate with the Board's Anthropometric Committee in its enquiries. The object of this Committee is " to enquire into certain factors governing the growth and development of healthy children from infancy up to the age of 18 years and living under varied conditions, with a view to obtaining a series of anthropometric figures (norms) from all parts of the country which would be of value to School Medical Officers and others in the estimation and comparison of nutrition, physique, etc." To complete the schedule in each case involves the ascertainment of the following: Name, address, age, nationality, place of origin of father and mother, occupations of parents, order of child in family, standing height, sitting height, weight, chest measurement, colour of eyes (compared with test glass eyes), colour of hair (compared with test hanks of hair), three head measurements and any abnormality or disease. As all these facts must be ascertained with great accuracy to render them of any value for the purposes of the enquiry a considerable expenditure of time and care is involved in the completion of the schedule for each child. During 1926 the Council's Medical Staff completed 198 schedules, and the investigation is being continued. SECONDARY SCHOOL CHILDREN. During the year the arrangement by which the medical staff of the Willesden Council carry out the inspection of pupils attending Secondary Schools in Willesden on behalf of the Middlesex County Council has continued. 710 examinations of secondary school pupils have been carried out during the year 1926 as compared with 452 in 1925. The rapid increase in the number represents a considerable increase in the work of the department. 282 defects were found amongst the scholars examined. No provision has been made for the treatment of these defects, but the parents and Head Teachers are notified of them and are advised to the action to be taken. DENTAL WORK. The Ninth Annual Report of the Dental work of the Council shows that during the year 13,814 public elementary school children were dentally inspected as compared with 13,550 in the previous year. 10,250 of these children were found to require treatment as compared with 10,151 in the previous year. 4,923 attendances were made by children at the Authority's Clinics for treatment in 1926 as compared with 4,384 attendances in 1925 and 2,148 such attendances in 1924. 17 28 per cent, of the defects followed up by the Health Nurses were ascertained to have received treatment during the year as compared with 22 per cent. in 1925 and 11 per cent. in 1924. This percentage of children treated is likely to continue to increase under the new scheme of dental inspection adopted by the Education Committee at its meeting on 3rd February, 1926, after consideration of my report on the working of the dental scheme of October, 1924, appearing as Appendix L to my report for 1925. HOME NURSING SERVICE. The Home Nurse employed by the Council nursed 310 cases during the year, and in connection with such cases paid 2,635 visits. 570 of these visits were paid in the Kensal Rise Ward, 455 in the South Kilburn Ward, 341 in the Mid Kilburn Ward, 306 in the Stonebridge Ward, 286 in the Harlesden Ward, 219 in the North Kilburn Ward and smaller numbers in the other wards of Willesden. Of the 310 cases nursed during the year, 303 were new cases. 108 of these 303 new cases were referred by the Health Department for nursing, 32 by private doctors and 163 by Hospitals, Associations and private persons. Circumcision cases referred from Hospitals received 227 visits. SANITARY WORK. The total number of houses in Willesden at the end of 1926 was 25,357. During the year the total number of inspections and reinspections made by the Sanitary Staff was 25,323, as compared with 18,595 in 1925. This increase is appreciable when taking into consideration that although two additional inspectors commenced duty in November, 1925, there was no Chief Sanitary Inspector for a period of six months. Greater use is being made of Section 3, Housing Act, 1925, as indicated in the tabular statement of housing statistics, but much time is lost in dealing with the disputatious owner. The delay is occasioned by advertising for tenders, reporting to Committee and then Council for acceptance. During this period the owner obtains information as to progress from the published Council agenda, and by the time the contractor is ready to carry out his contract the owner by doing some of the work modifies the schedule to such an extent as to necessitate further inspections, the preparation of a fresh schedule of works to be done, and consequently an amended estimate. Twelve houses closed as unfit for human habitation during 1925 are still in occupation. Of two houses closed this year one is vacant and the other still occupied, although there is a prospect of obtaining possession in the near future. Good work has been done under the Public Health (Meat) Regulations, 1924, 1,783 special inspections having been made. One prosecution under these Regulations had a salutary effect. The trade generally have carried out improvements to their premises. Nearly all shops are now provided with glass windows, but certain traders in Willesden not unnaturally take exception to the non-observance of the regulations by traders in contiguous districts. MOTOR AMBULANCE SERVICE. The Motor Ambulance Service now numbers 10 vehicles, seven of which came into use in December, 1923, one in April, 1924, one in March, 1925, and one in July, 1925. These vehicles qpvered a total of 87,030 miles during the year ended March, 1926. During the same period 2,597 calls for abulances were answered. Five of the seven vehicles which came into use in December, 1913, have covered more than 100,000 miles each and require to be replaced, especially as the demands on the service are increasing and the necessary repairs to these old vehicles keep them longer and longer off the road. PROVISION OF MEALS. 110,787 meals have been supplied during the year to school children. The arrangement by which school children are fed by the Education Committee on the authority of the Guardians continues. The parents of the children receiving meals are always parents in poor circumstances. During 1926 63 per cent. of the parents were unemployed, 9 per cent. were widows and 5 per cent. were deserted wives. MUNICIPAL HOSPITAL. 846 patients were admitted to the Municipal Hospital in 1926, as compared with 601, 626 and 674 in the three preceding years. During the year the Medical Superintendent has brought into operation at the Hospital the serum treatment of Scarlet Fever and the latest methods of prevention of Diphtheria amongst the staff. With regard to Scarlet Fever, he records that serum treatment reduced the percentage of cases that develop complications and that where the serum is given early enough it cuts short the disease. It is noteworthy that during the past year 306 cases of Scarlet Fever have been treated at, the Municipal Hospital without a single death. The Medical Superintendent has also employed the Dick test for Scarlet Fever amongst the patients in a non-Scarlet Fever ward in which a case of 18 Scarlet Fever had arisen. By this test and a subsequent prophylactic dose of Scarlet Fever antitoxin it is found that complete control over any further occurrence of cases can be maintained. With regard to the prevention of Diphtheria by Schick testing and active immunisation against the disease the Medical Superintendent records that since this method was brought into operation at the Hospital there have been no cases of diphtheritic sore throat amongst the staff. Previous to this year the incidence of Diphtheria amongst the nurses at the Hospital had been high. MIXED INFECTIONS. During the year 100 patients were admitted suffering from conditions other than Scarlet Fever or Diphtheria. 62 cases admitted as Scarlet Fever or Diphtheria proved to be suffering from Tonsillitis, while 10 cases of mixed infection occurred during the year. This large variety of cases, namely, 172 out of a total of 846 admitted, indicates the great necessity for isolation cubicles, which the Council propose now to erect. SPECIAL REPORTS AND ARTICLES. There are three reports appearing in the appendices written by members of the medical staff, to which I desire to call the attention of the Council. Artificial Light Treatment.—Dr. Haldin-Davis contributes the report on Artificial Light Treatment—Appendix G. He lays stress on the value of this form of treatment in anaemic and debilitated cases, including pre-tubercular cases, cases of enlarged glands, rickets, asthma and diseases of the skin. He also instances certain cases in which the mentality of the child was improved as a result of treatment. Altogether 196 cases attended at the Artificial Light Centre during the year 5,341 times. 17 was the average attendance per session, and each child treated was treated on the average 33 times. There is always a considerable waiting list for treatment at this centre. Rheumatism in Childhood.—Appendix H is written by Dr. C. T. Maitland, and deals with the important subject of Rheumatism in Childhood. This disease frequently causes damage to the heart, and it is estimated that about 50 per cent, of the mortality due to heart disease is primarily caused by Rheumatic infection. During the year 1926, 284 deaths, out of a total of 1,651, in Willesden, or more than 1 out of every 6 deaths was due to Heart Disease or Rheumatic Fever. Dr. Maitland indicates the important part that the School Medical Service can play in dealing with Rheumatism in Childhood, and indicates the necessity for the education of the public in regard to the manifestations of early Rheumatism and Heart Disease, the need for prolonged treatment in the early stage and the importance of the choice of an occupation for a child who has suffered from Heart Disease during school age. Dr. Maitland's article is well worthy of close perusal by the Council and the public. Diphtheria in the Stonebridge Area.—The report on Diphtheria in the Stonebridge area between 1st January, 1926, and 1st July, 1926, appears as Appendix I, and is written by Dr. Alice Gray. Dr. Gray has carefully analysed the various factors which may conceivably have been at work in giving rise to 133 cases of Diphtheria with 13 deaths in this area during the first six months of the year 1926. Dr. Gray concludes that the most important factor in the spread of disease is personal infection, and that this factor is a special menace in a family in which a case occurs and is not promptly brought to the notice of the doctor so that it may be removed to Hospital. Dr. Gray finally points out that many of the methods for the control of Diphtheria now in vogue are not of great value, and very properly emphasises the importance of utilising the newer methods for Diphtheria prevention, namely, Schick testing and immunisation. STAFF In January, 1926, the Council granted permission to the Medical Officer of Health to serve on the Departmental Committee on Vaccination at the request of the Minister of Health. The Committee consists of : Sir Humphry Rolleston (President of the Royal College of Physicians), Chairman; Dr. F. R. Blaxall, Dr. G. F. Buchan, Dr. A. E. Cope, Dr. Mervyn H. Gordon, Professor J. C. G. Ledingham, and Mr. J. R. Perdrau, with Dr. J. R. Hutchinson, a Medical Officer of the Ministry of Health, as Secretary. The Committee has been set up by the Minister with the following terms of reference:— " . . . to enquire into and from time to time report on:— (1) Matters relating to the preparation, testing, and standardisation of vaccine lymph; (2) The practical methods which are available in the light of modern knowledge to diminish or remove any risks which may result from vaccination; (3) The methods of vaccination which are most appropriate to give protection against risk of smallpox infection in epidemic and non-epidemic periods; 19 and to co-ordinate the work of investigation on these questions in this country and abroad, having regard to corresponding work undertaken by international health organisations." The work of the Committee is continuing. In June, 1926, your Medical Officer of Health was granted leave of absence at the request of the Ministry of Health for purposes of a study tour of public health in Denmark along with representatives of other nations. The tour occupied a period of seven weeks and the cost of the tour was defrayed by the League of Nations, with certain grants from the Rockefeller Foundation. Four weeks were spent in Copenhagen, which is a city with a population of about 600,000, while the remaining weeks were spent in the inspection of rural Denmark and various national institutions established for the unsound in mind or body. The public health work of Denmark represents a blending of the systems in force in England, namely, the Public Health service as it is known here and the National Health Insurance service. The National Health Insurance service, however, has a wider scope in Denmark than it has in England, while the Public Health service is correspondingly reduced. The institutions for the unsound in Denmark are mainly State institutions, and it is worthy of note that the General Hospitals of Denmark and Copenhagen compare very favourably indeed with the Voluntary Hospitals in this country. The tour was particularly instructive and useful, especially as the result of discussions which took place amongst the representatives of the 14 nations represented as to the methods in operation in their respective countries. There is no doubt that a study tour of public health in any country in company with representatives of other nationalities is of great service, and I have to thank the Council for enabling me to accept the invitation which was given me. Mr. Dibblin was appointed Chief Sanitary Inspector in succession to the late Mr. Woods, and took up his duties on 20th September, 1926. Your obedient servant, GEORGE F. BUCHAN, Medical Officer of Health. 20 THE FIFTY-FIRST ANNUAL REPORT FOR THE Year ended 31st December, 1926, ON THE HEALTH AND SANITARY CONDITION OF THE URBAN DISTRICT OF WILLESDEN. GENERAL STATISTICS. Area (acres) 4,384 Population 173,854 (estimated Midsummer, 1926) Number of inhabited houses 23,719 (Census 1921) Number of families or separate occupiers 41,235 (Census, 1921) Rateable value £1,057,108 Sum represented by a penny rate £4,405 (approx.) EXTRACTS FROM VITAL STATISTICS OF THE YEAR. Births— Total. Legitimate *2,617 Birth Rate (R.G.) 16.85 Illegitimate †83 Death Rate (R.G.) 10.01 Deaths 1,653 *(R.G.) 2667. † 117. ‡1,655. Number of women dying in, or in consequence of, childbirth from sepsis ... 2 from other causes 1 Deaths of Infants under one year of age per 1,000 births:— Legitimate 129. Illegitimate ... 14. Total ... 143. Deaths from Measles (all ages) 18 ,, ,, Whooping Cough (all ages) 8 „ „ Diarrhoea (under 2 years of age) 10 Table No. 9. NOTIFIABLE DISEASES DURING THE YEAR. Disease. Total Cases Notified. Cases admitted to Willesden Municipal Hospitals. Total Deaths. Diphtheria 466 441 34 Scarlet Fever 359 329 1 Enteric Fever (including Paratyphoid) 7 4 1 Puerperal Fever 16 3 2 Puerperal Pyrexia 24 2 - Pneumonia 232 1 103 Small Pox 2 2 1 Cholera - - - Plague - - - Erysipelas 68 6 8 Typhus Fever - - - Relapsing Fever - - - Continued Fever - - - Cerebro-spinal Meningitis 1 - - Poliomyelitis 9 1 1 Ophthalmia Neonatorum 30 3 - Malaria 2 - 1 Dysentery - - - Trench Fever - - - Encephalitis Lethargica 9 1 3 Acute Polio-Encephalitis - - - Anthrax - - - Tuberculosis:— (a) Pulmonary 271 - 136 (b) Non-Pulmonary 68 - 26 Whooping Cough 419 5 8 21 Table No. 10. TUBERCULOSIS. Age-Periods. New Cases. Deaths. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0 0 2 0 0 0 1 0 1 1 2 1 5 3 0 0 4 2 5 5 3 6 6 1 1 1 3 10 3 3 5 6 1 0 0 1 15 8 15 2 4 2 9 0 3 20 19 26 3 4 11 12 0 1 25 29 38 5 2 14 10 2 1 35 35 20 1 4 21 12 2 1 45 31 8 2 0 25 4 0 0 55 12 7 4 5 7 2 2 1 65 and upwards 1 3 1 0 0 3 1 0 Totals 145 126 34 34 82 54 12 14 PUBLIC HEALTH ACT, 1925, SECTION 62. Removal to hospital of infectious persons suffering from pulmonary tuberculosis. No action was taken under this section during 1926. Table No. 11. OPHTHALMIA NEONATORUM. No of cases Notified. Dr. in Attendance at Birth. Born in Hospital. Midwife in Attendance at Birth. Treatment. Results of Treatment. Still under treatment. Hospital. Clinic. Private Dr. Home Nurse Attending. No Defect. One Eye Permanently Injured. Both Eyes Permanently Injured. 30* 20 5† 4 6‡ 8 15 12 27 1 0 1 * In 1 case no information was obtainable. † 1 of these was born in a nursing home. ‡ 1 of these was treated by a private doctor in a nursing home. SUMMARY OF NURSING ARRANGEMENTS, HOSPITALS AND OTHER INSTITUTIONS AVAILABLE FOR THE DISTRICT. Professional Nursing in the Home. (a) General— (i.) The Willesden District Council employs one fully trained Hospital Nurse. She visits in the homes once or twice daily as necessary primarily to nurse grant earning cases under the Maternity and Child Welfare regulations. [Grant-earning cases are : Nursing of expectant mothers, maternity nursing, nursing of puerperal fever, puerperal pyrexia, measles in young children, whooping cough in young children, epidemic diarrhoea in young children and ophthalmia neonatorum.] The Nurse is provided on application to the Matron, Municipal Clinic (1), 9, Willesden Lane, Kilburn, N.W. 6; or to the Matron, Municipal Clinic (2), 381, High Road, Willesden, N.W. 10. The Council's Nurse acts under the direction of the Medical Practitioner in attendance upon the case. 22 (ii.) Willesden District Nursing Association (in affiliation with the Queen Victoria's Jubilee Institute for Nurses) was established in October, 1926, for the purpose of providing visiting nurses for the sick and infirm in all classes of the community. Hon. Secretary, Miss Hogg, 14, Chichele Mansions, N.W. 2. (iii.) District Nurses are also at work in connection with Nursing Associations, Churches, Missions, etc. (b) For infectious diseases, e.g., Measles, etc.— Carried out by the Council's Home Nurse as above. Midwives—Employment of, or subsidy to, practising Midwives, by Public Health Authority. The Council pays the fees of Midwives in home confinement cases where the economic circumstances of the patient are below the Council's scale. The fee agreed with the North West Middlesex Midwives' Association is £1 lis. 6d., but for a first confinement, £2 2s. The number of Midwives who at 15th February, 1927, had notified the Middlesex County Council of their intention to practise in Willesden was 18. There are also Centres situated in adjacent districts which are used by Willesden residents. CLINICS AND TREATMENT CENTRES. Name. Situation. Nature of Accommodation. By whom provided. Work Undertaken. Municipal Clinic (1) 9, Willesden Lane, Kilburn, N.W. 6 Two houses adapted and equipped for undertaking the care and supervision of the expectant and nursing mother and child up to school leaving age Willesden Urban District Council Maternity and Child Welfare and School Work—Medical and Dental— Schools for Mothers Municipal Clinic (2) 381, High Road, Willesden, N.W. 10 Ditto Ditto Health Department 54, Winchester Avenue, N.W. 6 Suitably equipped Medical Officer's room Ditto Examination of abnormal children. Lower Place School for Mothers Lower Place, Acton Lane, Harlesden, N.W. 10. Separate building in School Playground. Two rooms and usual offices Ditto School for Mothers. Tuberculosis Dispensary 3, Priory Park Road, Kilburn, N.W. 6 Middlesex County Council Tuberculosis Dispensary. Infant Welfare Centre and Club 84, Princess Road, Kilburn, N.W. 6 A house adapted and equipped for infant welfare work Voluntary Committee. Hon. Sec., Mrs. Howard Figgis Maternity and Child Welfare School for Mothers. " Princess " Day Nursery 47 and 49, Chichester Road, Kilburn, N.W. 6 Two houses adapted and equipped as a Day Nursery Voluntary Committee. Hon. Sec., Mrs. Howard Figgis Day Nursery. The Willesden V.A.D. Clinic 159, Willesden Lane, Kilburn, N.W. 6. One house adapted and equipped St. John's Voluntary Aid Detachment, Middlesex, 58 (Women's) Massage—Radiant Heat—Electricity —Medical Gymnastics—Artificial Light Treatment. Venereal Diseases Clinics The Middlesex in London, Royal Hospital from these County Council have made the Prince of Wales Hospital, , Richmond, in Surrey, omplaints. arrangements with Tottenham, in for the treatment General Hospitals Middlesex, and the of persons suffering 23 HOSPITALS FOR WILLESDEN. (a) Provided or Subsidised by the Local Authority or by the County Council. (1) Tuberculosis County Sanatorium, Harefield, Middlesex. Middlesex County Council. Clare Hall Sanatorium. „ „ „ (2) Maternity Park Royal Hospital, Acton Lane, N.W. 10. Provided by the Willesden Guardians. (3) Fever Willesden Municipal Hospital, Brentfield Road, Neasden, N.W. 10. vided by the Willesden Urban District Council. 122 beds (Ministry of Health Standard). (4) Smallpox Willesden Smallpox Hospital, Kingsbury. Provided by the Willesden Urban District Council. (b) Other Hospitals available for the District. {1) Children ... St. Monica's Home Hospital for Sick Children, 16, Brondesbury Park, N.W. The Willesden Council sends cases of Marasmus to this hospital under its Maternity and Child Welfare Scheme by arrangement with the Committee of the Hospital. Edgar Lee Home for Invalid Boys, 14, Stonebridge Park. The Home is for boys of 5-14 years of age suffering from heart disease and rheumatism. (2) General, etc. Park Royal Hospital, Acton Lane, N.W. Provided by the 'Willesden Guardians. General cases, Maternity Ward, Children's Ward. The Willesden Council sends Maternity cases to this hospital under its Maternity and Child Welfare Scheme by arrangement with the Guardians. Willesden General Hospital, Harlesden Road, N.W. General cases. The Willesden Council sends cases of Enlarged Tonsils, Adenoids, Deflected Nasal Septum and Marasmus to this hospital under its Maternity and Child Welfare and School Medical Service Schemes by arrangement with the Committee of the Hospital. St. Andrew's Hospital, Dollis Hill, N.W. For the reception of patients who, while not suitable subjects for free treatment in charitable institutions, are yet unable to meet the charges necessary to secure adequate medical or surgical treatment in private nursing homes. Adjacent London hospitals are also available for Willesden. INSTITUTIONAL PROVISION FOR UNMARRIED MOTHERS, ILLEGITIMATE INFANTS AND HOMELESS CHILDREN IN THE DISTRICT. {1) Queen Charlotte's Lying-in Hospital Convalescent Home, 20, Victoria Road, Kilburn, N.W. 6. (2) Harrow and Willesden Ruri-decanal Association for Preventive and Rescue Work, St. Mary's Home, 34, Craven Park, N.W. 10. (3) Park Royal Hospital (Willesden Guardians) and Guardians' Scattered Homes. See the Willesden Annual Health Report for 1919 for further details of Clinics, Hospitals, other institutions, including the Invalid Children's Aid Association, etc. AMBULANCE FACILITIES. Motor Ambulances are available as follows :— (a) For infectious cases— 1 infectious ambulance. (b) For non-infectious and accident cases— 2 accident ambulances. These Motor Ambulances have been established and are maintained by the Willesden Urban District Council. The garage is situated at the Municipal Hospital, Brentfield Road, Neasden, N.W. 10. An all-night service has been established, but this is only partial, as there is only one man on •duty, and any calls coming when he is out cannot be dealt with at once. 24 LABORATORY WORK. Pathological and Bacteriological Examinations. The agreement entered into by the Council with the Willesden General Hospital on the 1st February, 1925, is still in operation. The agreement provides for the following:— Examinations for Diphtheria Bacilli, Tubercle Bacilli, Meningococci, Gonococci, Pus organisms, and other germs. Blood examinations for Widal's reaction, or other reactions for Malaria or other conditions. Bacteriological examination of urine, or other fluids. Pathological examinations. Generally any other Bacteriological or Pathological examinations which may be required by a Medical Practitioner. Procedure. The procedure relative to the above mentioned examinations is as follows:— (1) All swabs and other specimens are sent direct to the Pathologist, Willesden General Hospital, Harlesden Road, N.W. 10. (2) The Pathologist, Willesden General Hospital, notifies positive swabs direct to Medical Practitioners by telegram or telephone. (3) The Willesden General Hospital forwards to Medical Practitioners one sterile swab to replace each swab sent for examination. (4) All applications for the necessary outfits are made to the Pathologist, Willesden General Hospital, Harlesden Road, N.W. 10. Outfits—Anti-toxin. Outfits for sending— Swabs of suspected Diphtheritic exudate or discharge, Blood from suspected Typhoid cases, Sputum from suspected cases of Pulmonary Tuberculosis, and Supplies of Diphtheria Anti-toxin may be obtained from any of the following depots night or day:— Kilburn Fire Station, Salusbury Road, N.W. 6. Willesden Green Sub-Fire Station, near Public Library, Harlesden Road, N.W. 10. Municipal Hospital, Brentfield Road, N.W. 10. General Hospital, Harlesden Road, N.W. 10. The above outfits and anti-toxin may be obtained during the day except Saturday afternoons and Sundays from the following :— Health Department, 54, Winchester Avenue, N.W. 6. Municipal Clinic (1) No. 9, Willesden Lane, N.W. 6. Municipal Clinic (2) No. 381, High Road, Willesden, N.W. 10. Messrs. Beeson Bros., High Street, Harlesden, N.W. 10. The following table shews the Chemical and Bacteriological examinations made during the year 1926:— Table No. 12. Nature of Specimens examined. Positive Result. Negative Result. Total. 1. Swabs for Diphtheria Bacilli 885 4,183 5,068 2. Swabs for Diphtheria (Virulence Tests) 18 2 20 3. Blood for Widal Reaction 1 21 22 4. Sputum for Tubercle Bacilli 90 360 450 5. Wassermann Test 4 4 6. Swab for Meningococci 1 7. Swabs for Gonococci 2 8. Swabs—Puerperal Fever Organisms 2 9. Swab for Bacillus Leprae 1 10. Swab from Tonsil 1 11. Swabs for Vincent's Angina 1 12. Sputum for Organisms 1 13. Cerebro-Spinal Fluid 8 14. Fluid from Pleural Cavity 3 15. Fluid 1 16. Blood Culture 7 25 Table No. 12—-continued. Nature of Specimens examined. Positive Result. Negative Result Total 17. Films for Gonococci 2 18. Discharge for Gonococci 8 19. Urine (General) 31 20. Vaginal Discharge 4 21. Faeces for Organisms 8 22. Pus 11 23. Tissue for Microscopical Examination 5 24. Neoplasm of Brain for Microscopical Examination 1 25. Carcinoma of Breast for Microscopical examination 2 26. Uterine Scrapings for Microscopical examination 1 27. Left Tube and Ovary for Microscopical examination 1 28. Malignant Epulis for Microscopical examination 1 29. Tissue of Brain for Microscopical examination 1 30. Liver 1 31. Omentum for Carcinoma 1 32. Abdominal Tumour 1 Grand Total 5,671 Table No. 13.—Sources of Specimens Examined. From Municipal Hospital 3,184 From private practitioners 1,499 From clinics and health nurses 642 From Park Royal Hospital 335 From other Hospitals or Institutions 11 Total 5,671 SANITARY ADMINISTRATION. List of Local Acts, Adoptive Acts, Bye-laws and local Regulations in force in the District, with date of adoption. Local Acts:— Willesden Local Board Act, 1876. Royal Assent 27.6.1876. Willesden Local Board Act, 1887. Royal Assent 8.8.1887. Willesden Sewerage Act, 1896. Royal Assent 14.8.1896. *Willesden Urban District Council Act, 1903. Royal Assent 11.8.1903. Adoptive Acts:— *Public Health Acts Amendment Act, 1890, Part III. Adopted 11.11.1890. *Public Health Acts Amendment Act, 1907, Parts II., III., IV., and X. Adopted 24.1.1911. Public Health Acts Amendment Act, 1907, Part VI. Adopted, 1925. * Public Health Act, 1925. Baths and Washhouses Acts, 1846-99. Adopted 14.2.1899. Burial Acts, 1852-1900. Public Libraries Acts, 1892-1901. Adopted 19.2.1891. Bye-laws:— *Common Lodging Houses (Public Health Act, 1875, s. 80). Adopted 14.10.1879. *Houses Let in Lodgings (Public Health Act, 1875, s. 90). Adopted 8.11.1892. *Slaughter Houses (Public Health Act, 1875, s. 169 and Towns Improvement Clauses Act, 1847, s. 128). Revised and adopted 27.9.1921. *Prevention of Nuisances (Public Health Act, 1875, s.44). Revised and adopted 13.7.1922. Bye-laws:— New Streets and Buildings (Public Health Act, 1875, s. 157 and Public Health Acts Amendment Act, 1890, s. 23). Adopted 16.10.1906. (Amended 1915 and 1920.) New Sewers (Willesden Local Board Act, 1887). Adopted 9.10.1888. Pleasure Grounds (Public Health Act, 1875, s. 164). Adopted 28.1.1896. *Drainage of Buildings (Public Health Acts Amendment Act, 1890, s. 23). Adopted 16.10.1906. *Rag and Bone Dealer (Public Health Act, 1875, s. 113). Adopted 29.9. 1908. 26 Local Regulations:— Small Holdings and Allotment Act, 1908. Adopted 25.11.1913. *Relating to underground sleeping rooms, Housing, Town Planning, etc., Act, 1909, s. 17 (7). Adopted 23.9.1913. * These are administered wholly or partly by the Health Committee. The unstarred are administered by other Committees of the Council. Sanitary Inspection] of the Area. Tabular summary of the work of the Sanitary Department during the year and action taken under the Public Health Acts, Housing Act, etc. Inspections: Number of premises inspected on complaint 2,077 Number of premises inspected in connection with infectious diseases 113 Number of premises under periodical inspection 1,862 Houses inspected from House to House (Housing Act, 1925) 1,263 For Certificates under the Rent Acts 21 Public House Urinals 331 Mews and Stables 639 Miscellaneous 95 Total number of inspections and re-inspections made 25,323 Action under Rent and Mortgage Interest (Restriction) Acts, 1920-25. Number of applications received for Certificates 21 Number of Certificates granted 8 Action Taken (under Housing and Health Acts): Notice to Inspect (Section 127, Housing Act, 1925) 3,383 Cautionary or Intimation Notices Issued 3,521 Number complied with 2,798 Statutory Orders issued 256 Number complied with 195 Summonses served 1 Number of convictions obtained 1 Summonses withdrawn 0 ,, dismissed 0 Houses Let in Lodgings (Tenement Houses): Number registered under Bye-laws 0 Number of contraventions 0 Common Lodging Houses: Number registered under Bye-laws 1 Number of Inspections made 22 Number of contraventions 10 Number remedied 9 Canal Boats used as Dwellings: Number of contraventions of Regulations 2 Number remedied 2 Movable Dwellings, Caravans, Tents, &c.: Number observed during the year 8 Number of nuisances therefrom abated 0 Number removed from district 0 Bakehouses: Number in district 62 Number of Inspections 245 Contraventions of Factory Acts 63 Contraventions remedied 58 Slaughter-houses: Number on register 8 Inspections of carcases, etc. 477 Contraventions of Bye-laws 4 Contraventions remedied 4 Cowsheds: Number on register 2 Number of inspections made 19 Contraventions of regulations Contraventions remedied 0 Number of milch cows in district 62 27 Dairies and Milkshops: Number on register 152 Number of inspections made 312 Frequency of inspection half-yearly Contraventions of regulations 11 Contraventions remedied 11 Unsound Food: Meat (including organs) surrendered 548 lbs. Fish surrendered 286 lbs. Fruit and vegetables surrendered 400 lbs. Bacon surrendered 40 lbs. Tinned Meat 49 lbs. Total 1,323 lbs. Method of disposal Destroyed. Offensive Trades: Number of premises in district (Rag and Bone Dealers) 8 Number of inspections made 60 Contravention of Bye-laws 2 Contravention remedied 2 Water Supply and Water Service: Percentage of houses supplied on constant system 100 Cisterns:— New provided 27 Cleansed, repaired, covered, etc. 397 Draw-taps placed on mains 32 Drainage and Sewerage of existing Buildings: Water Closets:— Number of water closets substituted for dry receptacles 0 Repaired, supplied with water or otherwise improved 606 Additional Closets constructed 61 Percentage of houses provided with water closets 100 Drains:— Examined, tested, exposed, etc. 422 Unstopped, repaired, trapped, etc. 350 Waste pipes, rain-water pipes, disconnected, repaired, etc. 661 New soil pipes or ventilating shafts fixed 86 Existing soil pipes or ventilating shafts repaired 229 Disconnecting traps or chambers inserted 133 Re-constructed 30 Cesspools:— Rendered impervious, emptied, cleansed, etc. 0 Abolished and drain connected to sewer 0 Percentage of houses draining into sewers 100 Disinfection: Rooms disinfected:— (a) Ordinary infectious diseases 760 (b) Phthisis 60 Articles disinfected or destroyed:— (a) Ordinary infectious diseases 1,571 (b) Phthisis 227 Dust: New bins provided 627 Periodical frequency of dust removal weekly Method of disposal By tipping and barging Sundry Nuisances abated: Overcrowding 21 Smoke 24 Accummulations of refuse 156 Foul ditches, ponds, etc., and stagnant water 12 Fowls, pigs, and other animals 34 Dampness 524 Yards and forecourts paved, repaved or repaired 578 Walls and ceilings cleansed 5,887 Leaky roofs made watertight 965 Additional ventilation provided under floors 244 Dilapidated plaster repaired 1,597 Flooring and other woodwork repaired 1,012 Damp-proof courses inserted 57 28 Sundry Nuisances abated—continued: Water supply reinstated 62 Washhouse floors repaved 391 Fireplaces and stoves repaired 554 Decayed brickwork repaired and repointed 308 Sinks provided or replaced 65 Additional light and ventilation to staircases 6 Larders or food cupboards provided 3 Gutters and rainwater pipes repaired 880 New sash cords and glass provided to windows 2,199 Smoke observations 244 Miscellaneous 770 Inspections of Premises where Food is prepared: Butchers', Provision, and General Shops 563 Fish shops 152 Eating houses 50 Greengrocers' shops 209 Ice-cream premises 92 Stalls 447 Canal Boats Acts, 1877-1884. The number of boats inspected during the year 1926 was 25 (40 inspections). On one boat the Master was without his certificate and in one instance there was overcrowding. Notices were sent to the owners respecting these infringements and complied with. No legal proceedings were taken during the year. No case of infectious disease has been notified or traced and no boats were detained for cleansing or disinfection. During the year, H.M. Canal Boats Inspector drew attention to the condition of children on board the boats used for conveying household refuse and suggested the Council should insert a clause in any contract prohibiting children on boats carrying this class of cargo. This was reported to the Council in November, 1926, when they adopted the following report of the Health Committee:— "We are of opinion that the Minister of Health should frame and issue regulations under the Canal Boats Acts, prohibiting the employment or permanent residence of children on barges or canal boats, and therefore recommend that the Minister be approached with a view to such regulations being made and issued. We further recommend that a clause be inserted in future Council contracts for the barging of refuse that children of school age shall not be employed or live on any barge used in connection with the carrying out of the contract." Smoke Abatement.—Nuisances caused by the emission of black smoke were more numerous than in former years due to the difficulty in obtaining suitable fuel for steam raising. There was a marked improvement towards the end of the year. Houses Let in Lodgings.—The Council has after much careful deliberation and considerable correspondence with the Ministry of Health approved draft bye-laws for Houses Let in Lodgings and now await their confirmation by the Ministry before they can be put into operation. The powers contained therein will be helpful in improving the general sanitary condition and amenities for the occupants of the class of property to which they are applicable. Offensive Trades.—There are 8 Rag and Bone dealers carrying on this business within the district, all complying with the Bye-laws. No other Offensive Trade is established. Underground Sleeping Rooms.—There are 723 houses with basements and approximately 400 rooms are used as sleeping apartments. The Regulations of the Council governing this class of property are for all practical purposes in abeyance pending the provision of alternative accommodation suitable for and within the means of what these occupiers can pay. HOUSING. The total number of houses in Willesden is 25.357. The following table shews building activities during the period stated:— Table No. 14. Year. For working classes. Not for working classes. Total. Houses erected by the Council. Houses erected by private enterprise. Houses erected by private enterprise. 1921-25 261 65 909 1,235 1926 129 122 462 713 Total for 6 years 390 187 1,371 1,948 29 Overcrowding.—Many cases of overcrowding were found during routine inspection, but no action was practicable, there being no alternative accommodation. Of the 32 cases of overcrowding set out in Table 16, page 33 of my Annual Report for 1925, only 3 out of 12 applications have been given accommodation in houses erected by the Council. HOUSING STATISTICS FOR THE YEAR 1926. Number of houses erected during the year:— (a) Total (including numbers given separately under (b)) 713 (b) With State assistance under the Housing Acts:- (i.) By the Local Authority 129 (ii.) By other bodies or persons 122 1.—Unfit Dwelling Houses. Inspection— (1) Total number of dwelling houses inspected for housing defects under Public Health Acts or Housing Act 3,340 (2) Number of dwelling-houses which were inspected and recorded under the Housing Consolidated Regulations, 1925 1,263 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 2 (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 130 2.—Remedy of Defects Without Service of Formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 2,361 3.—Action Under Statutory Powers. A. Proceedings under section 3 of the Housing Act, 1925. (1) Number of dwelling-houses in respect of which notices were served requiring repairs 129 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 77 (b) By Local Authority in default of owners 3 (3) Number of dwelling-houses in respect of which Closing Orders became tive in pursuance of declarations by owners of intention to close 0 B. Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 93 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:- (a) By owners 53 (b) By Local Authority in default of owners 7 C. Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925. (1) Number of representations made with a view to the making of Closing Orders 2 (2) Number of dwelling-houses in respect of which Closing Orders were made 2 (3) Number of dwelling-houses in respect of which Closing Orders were mined, the dwelling-houses having been rendered fit 0 (4) Number of dwelling-houses in respect of which Demolition Orders were made 0 (5) Number of dwelling-houses demolished in pursuance of Demolition Orders 0 INSPECTION AND SUPERVISION OF FOOD. Milk Supply.—There are 5 wholesale dealers, 152 retail milk purveyors, and 2 cowkeepers in this district. Their premises and utensils are frequently inspected. Sampling for the presence of Tubercle Bacilli was recommenced by the Willesden Council during the year with satisfactory results. The following table shows the number of licences granted for the sale of graded milk under the Milk (Special Designations) Order, 1923, during the year 1926:— Table No. 15. (a) "Certified" milk 15 (b) "Grade A (Tuberculin Tested)\" milk 7 (c) "Grade A" milk 2 (d) "Pasteurised" milk 14 30 One licence was granted by the Council to a local firm for the pasteurisation of milk. There were no refusals or revocations of retailer's licences during the year. The following Table gives the result of examination of samples of designated milk during the year 1926. Table No. 16. No. of Sample. Designation. No. of Bacteria per c.c. Remarks. 19 "Pasteurised" 5,830 A good sample. 20 "Pasteurised" 26,400 Conforms. 21 "Pasteurised" 94,350 Conforms. 22 "Pasteurised" 129,000 Unsatisfactory. 23 "Certified" 4,760 Very good sample. 24 "Pasteurised" 35,500 Conforms. 25 "Pasteurised" 31,550 Satisfactory. 26 "Pasteurised" 22,250 Conforms. 27 "Pasteurised" 1,320,000 Unsatisfactory. 28 "Pasteurised" 24,500 Conforms. 31 "Pasteurised" 1,260 Very good sample. 32 "Pasteurised" 33,600 Passes. 33 "Pasteurised" 1,660 Very good sample. "Public Health (Prevention of Tuberculosis) Regulations, 1925, relating to Tuberculous Employees in the Milk Trade."—No case of a tuberculous employee in the milk trade has come under my notice. Meat Inspection.—The Inspectors visit the slaughter-houses at the times set apart for slaughtering and examine the carcases and organs for evidence of disease. Shops and stalls are also kept under close observation. The number of private slaughter-houses in use in the area at the dates mentioned was:— Table No. 17. In 1920. In December, 1925. In December, 1926. Registered 4 4 4 Licensed 5 4 4 Total 9 8 8 Inspection and Supervision of Other Foods.—Inspections were made of all the bakehouses and other premises in the district where food is prepared. The 62 bakehouses in the district were inspected on 245 occasions, Notices being served in 63 instances for minor contraventions of the Factory and Workshops Acts. In three instances the standard of cleanliness left much to be desired and necessitated action on the part of the Health Department. Food and Drugs Acts.—These Acts are administered by the Middlesex County Council and I am indebted to Mr. R. Robinson, Chief Officer, Public Control Department, for the following tabular statement, shewing the number of samples taken in Willesden and the result of prosecutions instituted under the Acts during the year 1926:— 31 Table No. 18. List of Samples taken During the Year ended 31st December, 1926. Article. Taken. Adulterated. Milk 801 17 Milk, Separated 3 — Cream 5 1 Butter 38 - Apples 14 3 Arrowroot 10 - Dates 1 - Egg Powder 2 2 Fish Paste 3 - Flour, Self-Raising 1 - Gin 10 4 Lard 4 - Mustard 9 1 Olive Oil 2 - Pepper 4 - Sweets 3 - Whisky 4 - 914 28 Prosecutions, 4. Convictions, 4. ADMINISTRATION OF FACTORY AND WORKSHOP ACT, 1901. The following tables shew the number of premises visited in pursuance of the provisions of the Factory and Workshop Act and the action taken in connection therewith. Table No. 19. Factories, Workshops, Laundries, Workplaces and Homework. Inspection—Including Inspections made by Sanitary Inspectors. Premises. (1) Number of Primary Inspections. (2) Written Notices. (3) Prosecutions. (4) Factories (including Factory laundries) 190 53 - Workshops (including Workshop laundries) 455 95 - Workplaces (other than Outworkers' premises) 30 3 — Total 675 151 - 32 Table No. 20.—Defects Found. Particulars. (1) Number of Defects. Number of Prosecutions. (5) Found. (2) Remedied. (3) Referred to H.M. Inspector. (4) Nuisances under the Public Health Acts:— Want of Cleanliness 49 37 - - Want of Ventilation 9 7 - - Overcrowding — — - - Want of drainage of floors 3 3 - - Other Nuisances 32 30 - - Sanitary accommodation— Insufficient 3 — - - Unsuitable or defective 31 26 - - Not separate for Sexes 10 9 — - Unscreened for Sexes 11 7 - - Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouses (S. 101) - - - - Breach of special sanitary requirements for bakehouses SS. 97 to 100) 63 56 - - Other offences (Excluding offences relating to outwork) - - - - Total 211 175 - - Table No. 21.—Registered Workshops. Workshops on the Register (s. 131) at the end of the year. (1) Number. (2) Factories 149 Factories, Laundries 41 Workshops, Laundries 19 Domestic Laundries 5 Bakehouses 62 Dressmakers 56 Outworkers 261 Blouse Makers 10 Tailors 35 Bootmakers 88 Metal Workers 35 Wood Workers 26 Seamstresses 3 Motor and Cycle Makers 37 Upholsterers 9 Milliners 13 Miscellaneous 92 Total number of Workshops on Register 941 Table No. 22.—Other Matters. Class. (1) N umber. (2) Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act (s. 133) 1 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Act (s. 5)— Notified bv H.M. Inspector 25 Reports (of action taken) sent to H.M. Inspector 3 Other — Underground Bakehouses (s. 101) Certificates granted during the year — In use at the end of the year 17 33 THE NINETEENTH ANNUAL REPORT FOR THE Year ending 31st December, 1926, ON THE HEALTH OF CHILDREN ATTENDING THE PUBLIC ELEMENTARY SCHOOLS IN WILLESDEN. Giving the Tables required by the Board of Education. Table No. 23.—Corresponding to Table 1 of Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. Return of Medical Inspections for the year ended 31st December, 1926. A.—Routine Medical Inspections. Number of Code Group Inspections— Entrants 3,033 Intermediates 1,789 Leavers 2,160 Total 6,982 Number of other Routine Inspections 0 B.—Other Inspections. Number of Special Inspections 8,813 Number of Re-inspections 20,351 Total 29,164 Table No. 24.—Corresponding to Table 2 of Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. A.—Return of Defects Found by Medical Inspection in the Year ended 31st December, 1926. Defect or Disease. (1) Routine Inspections. Specials. No. of Defects. 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) Malnutrition 81 31 45 - Uncleanliness — — — — (see Table IV, Group V) Skin Ringworm: Head 1 — 49 — Body — — 25 — Scabies — — 23 — Impetigo 20 — 452 — Other Diseases (nontuberculous) 60 2 1,225 6 Eye Blepharitis 35 — 144 1 Conjunctivitis 12 — 166 1 Keratitis — — — — Corneal Opacities — 2 6 — Defective Vision (excluding Squint) 320 7 219 8 Squint 31 2 39 6 Other Conditions 18 — 67 — Spectacles broken — — 478 — Spectacles lost — — 44 - 34 A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1926—continued.. Defect or Disease. (1) Routine Inspections. Specials. No. of Defects. 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) Ear Defective Hearing 7 2 27 1 Otitis Media 36 — 177 — Other Ear Diseases 56 — 145 1 Nose and Throat Enlarged Tonsils only 723 343 295 2 Adenoids only 83 37 37 — Enlarged Tonsils and Adenoids 41 38 259 - Other Conditions 92 45 128 — Enlarged Cervical Glands (non-tuberculous) 276 80 314 — Defective Speech — 5 3 — Teeth Dental Diseases (see Table IV, Group IV) 2,107 2 - — Heart and Circulation Heart Disease: Organic 2 15 6 1 Functional 7 43 10 1 Anaemia 12 3 35 1 Lungs Bronchitis 18 3 41 — Other Non-Tuberculous Diseases - 11 28 - Tuberculosis Pulmonary Definite — — 1 — Suspected — 2 10 — Non-Pulmonary:— Definite:— Glands — — — — Spine — — - — Hip — — — — Other Bones and Joints — — — — Skin — — - — Other forms — — — — Suspected:— Glands — — 1 — Bones and Joints — — 1 -— Other forms — — — — Nervous System Epilepsy — 1 4 — Chorea 3 3 18 — Other Conditions 1 5 3 — Deformities Rickets 2 — 2 — Spinal Curvature 11 4 8 1 Other forms 13 37 30 — Other Defects and Diseases 221 75 3,324 122 Total 4,289 798 7,889 152 B.—Number of individual Children found at Routine Medical Inspection to require Treatment (excluding Uncleanliness and Dental Diseases). Group. (1) Number of Children. Percentage of Children found to require treatment. (4) Inspected. (2) Found to require treatment. (3) Code Groups— Entrants 3,033 1,104 36.4 Intermediates 1,789 606 33.9 Leavers 2,160 649 30.0 Total (Code Groups) 6,982 2,359 33.8 Other Routine Inspections 0 0 0 35 Table No. 25.—Corresponding to Table III. of Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. Return of all Exceptional Children in the area. Boys. Girls. Total. Blind (including partially blind) (i.) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind 4 0 4 Attending Public Elementary Schools 0 0 0 At other Institutions 0 0 0 At no School or Institution 0 0 0 (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind 7 7 14 Attending Public Elementary Schools 0 0 0 At other Institutions 0 0 0 At no School or Institution 0 2 2 Deaf (including deaf and dumb and partially deaf). (i.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf 7 4 11 Attending Public Elementary Schools 0 0 0 At other Institutions 0 0 0 At no School or Institution 0 1 1 (ii.) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the Deaf 5 1 6 Attending Public Elementary Schools 0 0 0 At other Institutions 0 0 0 At no School or Institution 0 0 0 Mentally Defective. Feeble-minded (cases not notifiable to the Local Control Authority). Attending Certified Schools for Mentally Defective Children 60* 40* 100 Attending Public Elementary Schools 1 0 1 At other Institutions 0 1 1 At no School or Institution 2 2 4 Notified to the Local Control Authority during the year. Feeble-minded 8 7 15 Imbeciles 0 1 1 Idiots 0 1 1 Epileptics. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics 5 3 8 In Institutions other than Certified Special Schools 0 0 0 Attending Public Elementary Schools 0 0 0 At no School, or Institution 2 1 3 Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 5 9 14 At no School or Institution 3 1 4 Physically Defective. Infectious Pulmonary and Glandular Tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board of Education 0 1 1 At other Institutions 0 0 0 At no School or Institution 0 0 0 Non-infectious but active Pulmonary and Glandular Tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board of Education 0 0 0 At Certified Residential Open Air Schools 0 0 0 At Certified Day Open Air Schools 0 0 0 At Public Elementary Schools 0 0 0 At other Institutions 0 0 0 At no School or Institution 0 0 0 Delicate Children (e.g., pre- or latent Tuberculosis, Malnutrition, Debility, Anaemia, etc.). At Certified Residential Open Air Schools 0 0 0 At Certified Day Open Air Schools 0 0 0 At Public Elementary Schools 110 64 174 At other Institutions 15 10 25 At no School or Institution 17 24 41 Active Non-Pulmonary Tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board of Education 0 0 0 At Public Elementary Schools 0 0 0 At other Institutions 0 1 1 At no School or Institution 0 2 2 Crippled Children (other than those with active Tuberculous disease), e.g., Children suffering from Paralysis, etc., and including those with severe Heart Disease. At Certified Hospital Schools 1 2 3 At Certified Residential Cripple Schools 2 0 2 At Certified Day Cripple Schools 38 48 86 At Public Elementary Schools 5 8 13 At other Institutions 0 0 0 At no School or Institution 8 7 15 * 9 boys are also Physically Defective. * 9 girls are also Physically Defective. 36 Table No. 26.—Corresponding to Table IV. of Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. Return of Defects Treated during the Year ended 31st December, 1926. Treatment Table. Group I.—Minor Ailments (excluding Uncleanliness, for which see Group V.). Disease or Defect. (1) Number of Defects Treated, or under Treatment during the Year. Treated. Under the Authority's Scheme. (2) Otherwise. (3) Total. (4) Skin:— Ringworm—Scalp 79 14 93 Body Scabies 23 7 30 Impetigo 469 53 522 Other Skin Diseases 1,260 104 1,364 Minor Eye Defects (external and other, but excluding cases falling in Group II.) 398 39 437 Minor Ear Defects 388 62 450 Miscellaneous (e.g., Minor Injuries, Bruises, Sores, Chilblains, etc.) 3,701 1,157 4,858 Total 6,318 1,436 7,754 Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.). Defect or Disease. (1) Number of Defects dealt with. Under the Authority's Scheme. (2) Submitted to refraction by private practitioner or at hospital apart from the Authority's Scheme. (3) Otherwise. (4) Total. (5) Errors of Refraction (including squint) (Operations for squint should be recorded separately in the body of the Report.) 442 5 0 447 Other Defect or Disease of the Eyes (excluding those recorded in Group I.) 0 0 0 0 Total 442 5 0 447* Total number of children for whom spectacles were prescribed:— (a) Under the Authority's scheme 398 (b) Otherwise 44 Total number of children who obtained or received spectacles:— (a) Under the Authority's scheme 327 (b) Otherwise 52 * In addition to this number 140 cases of visual defect received attention by Voluntary Hospital, Private Practitioner or Optician, but it was not known whether they were submitted to refraction. 37 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) 380 320 700 364 1,064 Group IV.—Dental Defects. Vide 8th Annual Report on Dental Work in connection with children attending the public elementary schools, expectant and nursing mothers and children under 5 years, herewith. Group V. Uncleanliness and Verminous Conditions. (i) Average number of visits per school made during the year by the School Nurses 22.8 (ii.) Total number of examinations of children in the schools by School Nurses 48,017 (iii) Number of individual children found unclean 2,341 (iv.) Number of children cleansed under arrangements made by the Local Education Authority 415 (v.) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 29 (b) Under the School Attendance Bye-Laws 0 (vi.) No. of school sessions at which inspections were conducted 731 (vii.) (i) Original Inspections:— Children examined (i.e., Cases not individual children) 39,633 Found unclean 3,148 Percentage found unclean 7.9 Excluded on account of uncleanliness 36 (ii.) Re-inspections:— Children examined (i.e., Cases not individual children) 8,384 Found unclean 5,044 Percentage found unclean 60.2 Excluded on account of uncleanliness 22 (iii.) Total:— Examinations 48,017 Exclusions on account of uncleanliness 58 Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. Notes on Table IV. (f). "A Statement as to the arrangements made by the Local Education Authority for cleansing verminous children and a record of the cases in which legal proceedings were taken, should be included in the body of the School Medical Officer's Report." The Authority has established a cleansing room at each of its two Municipal Clinics. Children suffering from nitty or verminous conditions are given the opportunity of being cleansed at these Clinics. The mothers are encouraged to attend with the children, so that they may see how the cleansing should be carried out. Baths are also given for scabies and other skin conditions as necessary. Record of cases in which legal proceedings were taken. 38 The following information has been supplied by the Chief Education Officer, to whom cases for prosecution are referred. Cases Under Section 87 of the Education Act, 1921. No. of Cases. Fined. Amount of Fine. Withdrawn. Dismissed. 8 10/- 6 Nil. 9 7/6 6 5/- Verminous Persons.—During 1926, adults made 65 attendances, children under 5 years 1,169 attendances, and school children 3,731 attendances at the Council's clinics for verminous conditions of scalp and body and treatment of skin conditions such as scabies. Thorough domestic cleansing of the home is advised by the Health Visitor, disinfection not being generally resorted to in verminous cases. 39—40 Table No. 27.—In this Table is embodied the information required in the N.B. to Notes on Table IV. of Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. Return showing the nature and number of all medical defects referred for following up, whether referred from Routine Medical Inspection, Medical Inspection of "Specials," or from other Sources, these latter having never been inspected by the Education Committee's Medical Officers; the number of visits and medical examinations made in connection therewith, and the extent to which remedial measures were carried out during 1926. CONDITIONS. No. of defects followed up No. of visits made on account of these defects. No. of Medical Examinations made on account of these defects. No. of times attended by Clinic Nurse only on account of these defects. No. of defects for which no report is available. No. of defects not needing treatment. No. of defects treated. Grand Total. Results of Treatment. Percentage of defects treated. No. of defects not treated. No. of defects under observation Servation at end of year and carried forward to succeeding year. Remedied. Improved. Unchanged. Under observation at end of year (result of treatment not known). School Clinic. Hospital (under Council Scheme) Voluntary Hospital or other charitable Institution. Infirmary or Poor Law. Private Practioner. Total. Domestic Treatment only. Excluding Domestic Treatment. • Including Domestic Treatment. Removed from observation. Remaining under observation. Total. Brought forward from previous year. New. Total. l 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Clothing— % % Unsatisfactory 3 19 22 52 2 - 1 - - - - - - - 20 ) 20 14 4 — 2 - 95.2 1 - 1 2 Footgear- Unsatisfactory 1 1 2 2 — — 1 — — — — — - — - 1 1 - - - - 50.0 - - - - Cleanliness of Head— Nits 206 2,885 3,091 3,151 282 77 41 - 159 - - - - 159 2,841 3,000 2,760 4 - 236 5.2 98.3 8 42 50 278 Pediculi 37 422 459 599 251 126 3 - 202 - - - - 202 : 248 450 424 - - 26 44.2 98.6 - 6 6 32 Other dirty conditions — 18 18 27 3 - 1 — 2 — — - — - 15 17 15 - — 2 11.7 100.0 - - - 2 Cleanliness of Body— Dirty 1 9 10 30 - - - - - - - - - - 9 9 9 - - - - 90.0 1 - 1 - Pediculi - 4 4 7 - - - - - - - - - - 4 4 2 - - 2 - 100.0 - - - 2 Fleabitten 4 23 27 52 — — — — — - — — — — 27 27 27 - - - - 100.0 - - - - Malnutrition 29 71 100 177 213 426 8 4 39 — 6 — 5 50 30 80 18 26 1 35 56.8 90.9 3 5 8 40 Nose and Throat— Enlarged Tonsils 492 1,043 1,535 3,505 1,398 13 75 110 97 140 164 4 12 417 6 423 322 4 - 97 30.8 31.3 396 531 927 628 Adenoids 23 85 108 216 113 - 1 7 13 9 11 - - 33 - 33 18 - - 15 33.0 33.0 23 44 67 59 Enlarged Tonsils and Adenoids 260 419 679 1,816 1,198 22 19 31 70 216 142 3 3 434 2 436 380 - - 56 68.9 69.3 81 112 193 168 Other conditions 42 263 305 568 386 69 6 14 109 2 5 - 64 180 69 249 190 5 54 63.1 87.3 15 21 36 75 Cervical or Neck Glands— Enlarged (non-T.B.) 103 600 703 691 576 177 17 11 277 — 27 1 48 353 83 436 295 14 — 127 52.2 64.5 19 220 239 347 External Eye Disease— Blepharitis 48 178 226 390 494 142 3 - 166 - 3 - 5 174 42 216 158 3 - 55 78.0 96.8 2 5 7 60 Conjunctivitis 11 209 220 321 611 243 1 - 159 - 6 - 12 177 39 216 184 1 - 31 80.8 98.6 2 1 3 32 Corneal Opacities 2 7 9 16 27 38 - - 5 - 3 1 - 9 - 9 3 - 1 5 100.0 100.0 - - - 5 Other conditions 11 99 110 147 208 15 1 2 67 - 7 — 2 76 29 105 89 — 1 15 71.0 98.1 2 — 2 15 Ear Disease— Chronic Suppuration of Middle Ear 66 218 284 572 1,112 968 10 - 199 - 20 - 14 233 25 258 176 6 2 74 85.0 94.1 3 13 16 87 Defective Hearing 10 40 50 60 74 1 1 4 26 - 2 - 1 29 3 32 10 8 - 14 64.4 71.1 2 11 13 25 Wax 12 125 137 101 252 48 2 1 113 - - - 2 115 6 121 101 - - 20 85.8 90.2 - 13 13 33 Other Disease 25 75 100 174 126 23 1 5 50 — 5 1 17 73 19 92 76 — — 16 77.6 97.8 — 2 2 18 Teeth—See Dental Returns Heart and Circulation— Organic Disease 5 13 18 68 18 — — - - - 7 1 5 13 - 13 - 4 4 5 72.2 72.2 3 2 5 7 Functional Disease 16 27 43 70 69 45 3 4 10 - 8 1 4 23 2 25 5 10 1 9 63.8 69.4 9 2 11 11 Anæmia 13 49 62 103 93 125 3 - 24 - 3 - 8 35 14 49 24 5 - 20 59.3 83.0 2 8 10 28 Other defects 3 5 8 12 3 — 1 — - — 2 — 4 6 - 6 1 2 — 3 85.7 85.7 1 - 1 3 Lungs— Bronchitis 51 1601 211 464 91 — 5 - 23 - 16 - 81 120 78 198 153 2 1 42 58.2 96.1 5 3 8 45 Tuberculosis — 2 2 9 5 10 1 - - - - - - - - - - - - - - - 1 - 1 - T.B. Suspected 11 13 24 61 50 34 5 1 3 - 9 - - 12 1 13 4 3 1 5 66.6 72.2 4 1 5 6 Other disease (non-T.B.) 12 67 79 186 97 138 — 1 26 — 8 1 23 58 17 75 58 5 — 12 74.3 96.1 3 — 3 12 Nervous System — Epilepsy 7 10 17 56 12 - 2 - - - 4 - 5 9 - 9 1 2 3 3 60.0 60.0 6 - 6 3 Chorea 21 40 61 208 32 4 - 3 - 31 - 17 51 - 51 21 11 1 18 89.4 89.4 2 4 6 22 Other Conditions 13 22 35 101 27 23 1 1 5 — 13 — 6 24 6 30 15 5 1 9 72.7 90.9 — 3 3 12 Skin- Ringworm Body Head 13 94 107 208 267 59 2 3 79 - 4 - 10 93 9 102 93 - - 9 91.1 100.0 - - — 9 Impetigo 63 609! 672 1,159 1,372 1,993 5 - 469 - 12 - 41 522 140 662 592 - - 70 78.2 99.2 - 5 5 75 Scabies - 31 31 61 139 138 - - 23 - 2 - 5 30 - 30 21. - - 9 96.7 | 96.7 - 1 1 10 Minor Injuries 84 933 1,017 1,018 2,314 2,432 10 7 808 - 24 2 40 874 125 999 956 2 - 41 87.4 99.9 - 1 1 42 Other disease (non T.B.) 108 1,595 1,703 2,488 2,510 2,830 16 19 1,260 — 19 2 82 1,363 285 1,648 1,384 6 3 255 81.7 98.8 5 15 20 270 Deformities— Rickets 3 3 6 18 10 — 1 - - - 2 - - 2 1 3 - 2 - 1 40.0 60.0 2 - 2 1 Spinal Curvature 3 19 22 46 12 — 4 1 1 — 6 - 1 8 - 8 — 4 — 4 47.0 47. 0 3 6 9 10 Other forms 20 57 77 163 83 26 2 4 12 — 25 — 2 39 12 51 4 25 1 21 54.9 71.8 8 12 20 33 Tuberculosis (Non-Pulmonary)— Definite — — — - - — — - - - - - - - - - - - - - - - - - — - Suspected—Glands 1 2 3 13 8 78 1 - 1 - 1 - - 2 - 2 - 1 - 1 100.0 100.0 - - — 1 „ Bones and joints 1 1 2 9 9 39 — - 1 - 1 - - 2 - 2 - 1 — 1 100.0 100.0 — - — 1 ,, Other forms - - - - - - - - - - - - - - - - - - - - - - - - - - Speech— Defective Articulation 1 9 10 19 5 — — 2 - — - — — — 1 1 — — — 1 — 12.5 3 4 7 5 Squint— Squint present 29 80 109 187 199 16 5 14 57 — 6 — — 63 — 63 18 26 4 15 70.0 | 70.0 12 15 27 30 Vision— Defect not ascertained 14 53 67 117 62 3 6 8 18 - 8 - 1 27 - 27 16 1 2 8 50.9 50.9 9 17 26 25 One eye normal 30 93 123 235 216 40 4 15 63 - 9 1 - 73 - 73 36 10 3 24 70.1 70.1 19 12 31 36 Both eyes 6/6 5 40 45 68 87 17 - 19 21 - - - - 21 - 21 15 - 2 4 80.7 80.7 5 - 5 4 „ 6/9 14 48 62 88 151 22 3 8 40 - 1 - - 41 - 41 27 1 3 10 80.3 80.3 5 5 10 15 One eye 6/9 other 6/12 or less 39 123 162 390 304 64 11 5! 92 - 10 - 3 105 - 105 68 13 7 17 71.2 71.2 21 20 41 37 Both eyes 6 /12 or less 104 233 337 742 677 145 16 10 194 - 32 - 8 234 - 234 115 64 4 51 75.2 75.2 28 49 77 100 Spectacles broken 47 500 547 356 992 26 8 31 493 - 7 - 10 510 - 510 470 - - 40 95.1 95.1 10 16 26 56 „ lost 13 48 61 60 106 5 3 3 47 — 1 — - 48 — 48 36 — — 12 87.2 87.2 6 1 7 13 Debility 124 849 973 1,593 2,369 938 13 4 664 - 48 1 92 805 118 923 520 14 2 387 84.2 96.5 12 21 33 408 Miscellaneous 343 3,941 4,284 7,377 6,084 1,320 49 372| 1,818 - 234 12 472 2,536 1,195 3,731 3,215 51 13 452 65.6 96.5 58 74 132 526 Grand Totals 2,597 18,582 19,179 30,427 25,799 12,954 376 693 8,008 367 954 31 1,105 10,465 5,522 15,987 13,140 345 61 2,441 57 8 88 3 800 1,323 2,123 3,764 Re-examinations in respect of Defective Vision other than Lost and Broken Spectacles and other conditions— No. of Visits 3,749 No. of times attended by Clinic Nurse only 137 No. of Medical Examinations 3,352 41 Certain Statistical Data. No. of Public Elementary Schools (excluding Special Schools) at December, 1926 32 No. of School Departments at December, 1926 73 Average Public Elementary School Roll, year ended 31st March, 1926 21,845 Total No. of Children medically inspected at Routine and Special Inspections 15,795 Total No. of Children dentally inspected 13,814 Total No. of Defects of every description "followed up" during 1926 26,342 Total No. of Defects of every description for which treatment was obtained during 1926:— Medical or Dental Treatment 12,498 Domestic Treatment 5,522 Total 18,020 Total No. of Attendances at the School Clinics during 1926 53,695 Special Schools. No. of Physically Defective Schools 2 (1 school formerly for mentally defective children was closed on 25/7/17 and re-opened on 13/12/20 for physically defective children). No. of Mentally Defective Schools 1 No. of children attending Special Schools during 1926:— Table No. 28. In Willesden. Outside Willesden. Total. Blind and Partially Blind — 20 20 Deaf — 19 19 Mentally Defective 113 8 121 Epileptic — 10 10 Physically Defective 148 16 164 Total 261 73 334 Table No. 29.—Corresponding to Appendix E of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Form of Annual Return of the After-Careers of Children under 21 Years of Age Formerly Attending Special Schools. Furness Road Physically Defective School. Leinster Road Mentally Defective School. Boys. Girls. Boys. Girls. 1. Number of children who have left the school and are under 21 years 21 31 40 32 2. Number who:— (a) Have since died 2 4 1 3 (b) Are known to be incapable by reason of mental or physical defect of undertaking employment 1 3 8 5 (c) Are in attendance at an Institution for further education (give details), and †2 † 1 † 1 † 2 (d) Are in any other Institution (specify Asylum, Workhouse, Colony for Epileptics, &c.) ††l - ** 7 *1 3. Number who are employed in:— (a) Industrial or manual occupations 9 7 13 5 (b) Agricultural or rural occupations — — — — (c) Domestic occupations, including those who are helping in the domestic work at home - 8 - 11 (d) Commercial, professional or clerical work 2 5 - - (e) Blind alley or other precarious occupations 1 1 3 - 4. Number who have left the neighbourhood or whose after-careers have not been traced 3 2 7 5 t In attendance at Technical, or Secondary Schools for further education. †† In a Convalescent Home. * In Caterham Asylum. **5 are in Institutions for Mentally Defectives, 1 is in Epileptic Colony and 1 is in Borstal. 5 Mentally Defectives and 2 Physically Defectives are unemployed. 42 Table No. 30. Return showing No. of Cases referred for following-up in 1926 and previous years with the view of Medical Treatment being obtained, Remedial Measures carried out, or other action taken. Year. Referred by A Total. Medical Inspection and Officers of Health Department. Head Teachers. Attendance Officers. Others. 1926 6,937 3,152 131 5,982 16,202 1925 6,224 4,003 121 4,939 15,287 1924 6,142 4,983 116 3,927 15,168 1923 4,900 4,230 131 4,715 13,976 1922 4,004 5,720 236 4,580 14,540 1921 4,203 4,779 248 5,711 14,941 1920 2,949 4,774 353 5,354 13,430 1919 1,796 4,167 451 3,538 9,952 1918 1,674 4,163 395 1,150 7,382 1917 1,227 3,372 441 427 5,467 1916 1,436 3,264 313 394 5,407 1915 1,308 3,429 109 298 5,144 1914 2,322 2,401 108 140 4,971 1913 1,092 1912 1,102 1911 1,030 1910 941 Table No. 31. Medical and Dental Treatment—Attendances at the Municipal Clinics, 1926 Condition. Mothers and Children under 5. School Children. Grand Total. Expectant Mothers. Nursing Mothers. Children under five. Total. 1. Cleansing 5 60 1,169 1,234 3,731 4,965 2. Throat, Nose and Ear Diseases 0 1 343 344 2,838 3,182 3. Minor Ailments 77 126 3,646 3,849 31,827 35,676 4. Eye Diseases 0 0 80 80 5,008 5,088 5. Ringworm, etc. 0 3 60 63 289 352 6. Artificial Sunlight 0 0 1,248 1,248 4,093 5,341 7. Medical Consultations 1,858 11,578 18,830 32,266 0 32,266 8. Total 1—7 1,940 11,768 25,376 39,084 47,786 86,870 9. Dental Consultations 288 663 540 1,491 5,909 7,400 10. Grand Total 2,228 12,431 25,916 40,575 53,695 94,270 43 Table No. 31—(continued). Clinic (I.). Clinic (II.). Grand Total. Mothers and Children under Five. School Children Total. Mothers and Children under Five. School Children. Total. 11. Medical Attendances 15,679 21,659 37,338 23,405 26,127 49,532 86,870 12. Dental Attendances 513 2,795 3,308 978 3,114 4,092 7,400 13. Total 16,192 24,454 40,646 24,383 29,241 53,624 94,270 Table No. 32. Shewing attendances at the Municipal Clinics each year since 1913. Year. Mothers and Children under 5 years. School children. Total. School for Mothers. Nursery. Grand Total. Medical. Dental. Total. Medical. Dental. Total. 1913 0 0 0 299 0 299 299 0 0 299 1914 0 0 0 2,517 0 2,517 2,517 0 0 2,517 1915 0 0 0 5,674 0 5,674 5,674 0 0 5,674 1916 389 0 389 9,593 0 9,593 9,982 0 0 9,982 1917 8,641 0 8,641 9,448 0 9,448 18,089 0 0 18,089 1918 32,169 1,165 33,334 15,811 2,403 18,214 51,548 44 220 51,812 1919 32,870 878 33,748 46,179 11,024 57,203 90,951 1,089 2,814 94,854 1920 51,468 1,823 53,291 64,588 10,670 75,258 128,549 2,354 3,452 134,355 1921 41,562 1,667 43,229 57,032 7,718 64,750 107,979 1,716 2,356 112,051 1922 27,505 894 28,399 39,989 7,025 47,014 75,413 1,616 2,190 79,219 1923 23,271 533 23,804 40,381 3,599 43,980 67,784 2,761 3,270 73,815 1924 17,082 520 17,602 34,845 2,460 37,305 54,907 2,896 2,808 60,611 1925 26,119 936 27,055 41,695 5,123 46,818 73,873 4,074 3,812 81,759 1926 39,084 1,491 40,575 47,786 5,909 53,695 94,270 4,126 3,645 102,041 The defects of School Children which were treated at the School Clinics during 1926 are shown in Table No. 27. 30 School Children and 8 children under 5 years of age were treated by X-rays for Ringworm of the Scalp. 1 child under 5 years of age was treated by X-rays for another skin condition. 6,917 Individual School Children attended the Municipal Clinics during 1926. Table No. 33. Return respecting the Provision of Spectacles during 1926. No. of pairs of Spectacles provided 454 Cost of Spectacles provided £73 3 10 Average cost per pair 3 3 No. of pairs provided at full charge made by Council 392 No. of pairs provided free or at reduced charge 62 Total amount received as above £78 15 0 Cost of repairs £35 7 7 Total amount received for repairs £25 0 0 Hospital Treatment of School Children under the Council's Scheme. Table No. 34. Hospital Treatment of School Children during 1926. No. of School Children in Willesden General Hospital at 31st December, 1925 7 „ ,, ,, admitted during 1926 383 „ ,, ,, under treatment during 1926 390 „ ,, ,, discharged during 1926 390 „ ,, ,, died in Hospital during 1926 0 „ ,, ,, remaining in Willesden General Hospital at 31st December, 1926 0 44 Table No. 35. Treatment of defects of Children admitted in 1926. Defect. No. Admitted. Forms of Treatment. Results of Treatment. Remaining in Hospital December 31st, 1926. Operative. General Remedied. Improved. Unchanged Died. Enlarged Tonsils and Adenoids 383* 380 - 380 - - - - Total 383 380 - 380 — — — — * 3 of these cases were not operated on. No School Children were admitted to St. Monica's Home Hospital. Table No. 36.—Employment of Children in Entertainments Rules, 1920. Particulars as to applications received in 1926 for certificates from the School Medical Officer. No. of Applications. No. Granted. Boys. Girls. Total. Boys. Girls. Total. Original applications 0 7 7 0 7 7 Applications for renewals 0 0 0 0 0 0 0 7 7 0 7 7 45 THE SEVENTH ANNUAL REPORT, for the Year ending 31st December, 1926. on the HEALTH OF PUPILS ATTENDING SECONDARY SCHOOLS IN WILLESDEN. Giving the Tables required by the Board of Education. Kilburn Grammar School—Boys. Willesden Polytechnic Trade School—Girls. Willesden County School—Boys and Girls. Willesden Polytechnic Building Trade School—Boys. The modified arrangements of the Middlesex Education Committee for Medical Inspection in Secondary Schools as set out in the letter of the Divisional Organising Officer, dated 16th January, 1926, require that medical inspection of pupils in these schools shall take place as follows:— (1) All pupils to be examined on commencing education in a Secondary School, such examination to be carried out before the close of the term in which a pupil is admitted. (2) All pupils to be examined at the age of 12 years. (3) All pupils to be examined at the age of 15 years. (4) In addition to the above routine groups, Headmasters and Mistresses to bring to the notice of the Medical Officers as "specials" any pupils suspected of being unfit. Arrangements have therefore been made to carry out medical inspection in Secondary Schools in accordance with the above schedule. In any term pupils are examined as follows:— (1) Pupils admitted during the current term. (2) Pupils who reached the age of 12 years during the preceding term. (3) Pupils who reached the age of 15 years during the preceding term. (4) Special cases. 40 Table No. 37.—Corresponding to Table I. of Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. Number of Pupils Inspected 1st January, 1926, to 31st December, 1926. A.—Routine Medical Inspections. Number of Code Group Inspections. Pupils examined. Aged. Kilburn Grammar School. Polytechnic Trade School. Willesden County School. Willesden Polytechnic Building Trade School. Total. Boys. Girls. Boys. Girls. Boys. Boys. Girls. Total. Entrants. Others. Total. Entrants. Others. Total. Entrants. Others. Total. Entrants. Others. Total. Entrants. Others. Total. Entrants. Others. Total. Entrants. Others. Total. Entrants. Others. Total. 10 years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11„ 54 0 54 0 0 0 33 0 33 28 0 28 0 0 0 87 0 87 28 0 28 115 0 115 12„ 67 23 90 0 0 0 28 11 39 28 11 39 0 0 0 95 34 129 28 11 39 123 45 168 13 „ 11 1 12 15 0 15 4 0 4 3 0 3 29 0 29 44 1 45 18 0 18 62 1 63 14 „ 1 0 1 26 0 26 1 0 1 1 0 1 28 0 28 30 0 30 27 0 27 57 0 57 15 „ 0 52 52 1 34 35 0 13 13 0 11 11 0 34 34 0 99 99 1 45 46 1 144 145 16 „ 0 0 0 0 0 0 0 0 0 1 0 1 0 1 1 0 0 0 1 1 2 1 1 2 Total 133 76 209 42 34 76 66 24 90 61 22 83 57 35 92 256 134 390 103 57 160 359 191 550 Note that in the above table a pupil examined as an entrant, and subsequently as having attained his or her birthday during the preceding term, appears twice, that is as 2 cases. B.—Other Inspections. Kilburn Grammar School. Polytechnic Trade School. Willesden County School. Willesden Polytechnic Building Trade School Total. Boys. Girls. Boys. Girls. Boys. Boys. Girls. Total. Number of Special Inspections 2 1 2 0 5 9 1 10 Number of Re-inspections 59 22 31 26 12 102 48 150 Total 61 23 33 26 17 111 49 160 47 Table No. 38—Corresponding to Table II. of Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. A.—Return of Defects Found by Medical Inspection in the Year Ended 31st December, 1926. Defect or Disease. (1) Routine Inspections. Special Inspections. Number of Defects. Number 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) Kilburn Grammar School (Boys). Willesden Polytechnic Trade School (Girls). Willesden County School. Willesden Polytechnic Building Trade School (Boys). Kilburn Grammar School (Boys). Willesden Polytechnic Trade School (Girls). Willesden County School. Willesden Polytechnic Building Trade School (Boys). Kilburn Grammar School (Boys). Willesden Polytechnic Trade School (Girls). Willesden County School. Willesden Polytechnic Building Trade School (Boys). Kilburn Grammar School (Boys). Willesden Polytechnic Trade School (Girls). Willesden County School. Willesden Polytechnic Building Trade School (Boys). Boys. Girls. Boys. Girls. Boys. Girls. Boys. Girls. Malnutrition 4 2 - - — 2 1 — 1 - - — — — — — — — — — Uncleanliness (See Table IV., Group v.) - - - - - - - - - - - - - - - - - - - - Skin Ringworm:— Scalp - - - - - - - - - - - - - - - - - - - - Body - - - - - - - - - - - - - - - - - - - - Scabies - - - - - - - - - - - - - - - - - - - - Impetigo - - - - - - - - - - - - - - - - - - - - Other Diseases (Non-Tuberculous). 1 - 1 - - - - - - - - - - - - - - - - - Eye Blepharitis - 1 1 - - - - - - - - - - - - - - - - - Conjunctivitis - - - - - - - - - - - - - - - - - - - - Keratitis - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Defective Vision (excluding Squint). 14 2 10 11 3 1 - 1 2 1 - - - - - - - - - - Squint - - - - - - - - - - - - - - - - - - - - Other Conditions - - - - - - - - - - - - - - - - - - - - Ear Defective Hearing - - - - 1 - - - - - - - - - - - - - - - Otitis Media - - - - - - - - - - - - - - - - - - - Other Ear Diseases - - - - - - - - - - - - 1 - - - - - - - Nose & Throat Enlarged Tonsils 19 5 1 — 5 3 - - - 1 - - - - - - - - - - Adenoids only — — 3 1 - - - - - - - - - - - - - - - - Enlarged Tonsils and Adenoids. 3 - - 2 - - - - - - - - - - - - - - - - Other Conditions 8 - - - 2 - - - - - - - - - - - - - - - Enlarged Cervical Glands (non-Tuberculous). 1 3 — 1 - - - - 1 - - - - - - - - - - - Defective Speech - - - - - - - - - - - - - - - - - - - - Teeth—Dental Diseases 39 13 8 16 19 — 3 - - - - - - - - - - - - - Heart and Circulartion. Heart Disease:— Organic - - - - - - - - - - - - - - - - - - - - Functional - - - - - - 1 1 1 - - - - - - - - - - 1 Anaemia - - - - - - - - - - - - - - - - - - - - Lungs - C Bronchitis 2 - - - - - - - - - - - - - - - - - - - Other — 1 - - - 1 - - - 1 - - - - - - - - - - culous Diseases. Tuberculosis Pulmonary:— Definite - - - - - - - - - - - - - - - - - - - - Suspected - - - - - - - - - - - - - - - - - - - - Non-Pulmonary: Glands - - - - - - - - - - - - - - - - - - - - Spine - - - - - - - - - - - - - - - - - - - - Hip - - - - - - - - - - - - - - - - - - - - Other bones and Joints. - - - - - - - - - - - - - - - - - - - - Skin - - - - - - - - - - - - - - - - - - - - Other forms - - - - - - - - - - - - - - - - - - - - Nervous System Epilepsy - - - - - - - - - - - - - - - - - - - - Chorea - - - - - - - - - - - - - - - - - - - - Other Conditions 1 2 - - - - 2 - - - - - - - - - - - - - Deformities. Rickets - - - - - - - - - - - - - - - - - - - - Spinal Curvature 4 1 — — — 1 2 4 2 - - - - - - - - - - - Other Forms - - 2 - - 1 3 - - - - - - - - - - - - - Flat Foot 2 — 1 4 — — — 6 4 — - — - - - - - - - — Other defects and diseases 2 2 — — — — 6 1 — 1 — - — — — — — - — — Total 100 32 26 36 30 9 18 13 11 5 - - 1 - - - - - - 1 48 B.—Number of Individual Pupils found at Routine Medical Inspection to Require Treatment (Excluding Uncleanliness and Dental Diseases). Group. Kilburn Grammar School. Willesden Polytechnic Trade School. Willesden County School. Willesden Polytechnic Building Trade School. Boys. Girls. Boys. Girls. Boys. Number of Pupils Number of Pupils Number of Pupils Number of Pupils Number of Pupils Inspected. Found to require treatment. Percentage of Pupils found to require treatment. Inspected. Found to require Treatment. Percentage of Pupils found to require treatment. Inspected. Found to require Treatment. Percentage of Pupils found to require treatment. Inspected. Found to require treatment. Percentage of Pupils found to require treatment. Inspected. Found to require Treatment. Percentage of Pupils found to require treatment. Code Groups:— Entrants (at any age) 133 27 20.3 42 7 16.7 66 12 18.2 61 14 23.0 57 4 7.0 Pupils aged 12 years 24 9 37.5 0 0 0.0 11 2 18.2 11 1 9.1 0 0 0.0 Pupils aged 15 years 52 11 21.2 34 4 11.8 13 3 23.1 11 2 18.2 35 7 20.0 Total (Code Groups) 209 47 22.5 76 11 14.5 90 17 18.9 83 17 20.5 92 11 12.0 **Other Routine Inspections - - - - - - - - - - - - - - ** During 1926 the following groups have been submitted to Routine Medical Inspection at the Secondary Schools in Willesden, and are all included under the Code Group Heading:— (a) All entrants (b) Pupils aged 12 years. (c) Pupils aged 15 years. Table No. 39.—Corresponding to Table IV. of Appendix H of the Annual Report of the Chief Medical Officer of the Board of Education for 1923. Return of Defects Treated during the Year ended 31st December, 1926. Treatment Table. Group I.—Minor Ailments (excluding Uncleanliness, for which see Group V.). Number of Defects Treated or Under Treatment During the Year. Defect or Disease. (1) Kilburn Grammar School. Willesden Polytechnic Trade School. Willesden County Schools. Willesden Polytechnic Building Trade School Boys. (2) Girls. (3) Boys. (4) Girls. (5) Boys. (6) Treated under the Authority's Scheme Otherwise. Total. Treated under the Authority's Scheme Otherwise. Total. Treated under the Authority's Scheme Otherwise. Total. Treated under the Authority's Scheme Otherwise. Total. Treated under the Authority's Scheme Otherwise. Total. Skin:— Ringworm—Scalp - - - - - - - - - - - - - - - Body - - - - - - - - - - - - - - - Scabies - - - - - - - - - - - - - - - Impetigo - - - - - - - - - - - - - - - Other skin diseases - - - - - - - - - - - - - - - Minor Eve Defects - - - - - - - - - - 1 1 - - - (External and other, but excluding cases falling in Group II.) Minor Ear Defects — - - - - - - 1 1 - - - - - Miscellaneous (e.g., Minor Injuries, Bruises, Sores, Chilblains. etc.). - 1 1 - 2 2 - - - - 1 1 - - - Total — 1 1 — 2 2 — 1 1 — 2 2 — — — 49 Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as minor Ailments—Group I.). No treatme nt has teen arranged for by the Local Education Authority, but at the Kilburn Grammar School (Boys).—In 5 instances the School Medical Inspector noted at a subsequent examination that the pupil now had spectacles. In 1 instance the School Medical Inspector noted on re-examination that the vision was normal. Willesden Polytechnic Trade School (Girls).—In 2 instances the School Medical Inspector noted on re-examination that spectacles had been obtained. In 1 instance the School Medical Inspector noted that the eyes had been tested by retinoscopy at Hospital and no spectacles ordered. Willesden County School.—In 1 instance (boys) and 4 instances (girls) the School Medical Inspector noted on re-inspection that spectacles had been obtained. In 2 instances (boys) the vision was normal and in 1 instance (boys) the vision could be passed on re-examination. Willesden Polytechnic Building Trade School (Boys).—In 1 instance the School Medical Inspector noted on re-inspection that the pupil had seen an oculist : vision much improved. In 1 instance the Medical Inspector noted that the pupil was wearing spectacles and the vision was not blurred now. Group III.—Treatment of Defects of Nose and Throat. Kilburn Grammar School (Boys).—In 3 instances the School Medical Inspector noted at a subsequent examination that the defect was remedied. In 2 instances he noted that the tonsils were still enlarged but under treatment. In 2 instances there was no active disease and in 2 instances the tonsils were normal on re-examination. Willesden Polytechnic Trade School (Girls).—No cases were recorded as having received treatment. Willesden County School.—In 2 instances (1 boy, 1 girl) the School Medical Inspector noted on re-inspection that the enlargement had subsided. In 2 instances (1 boy, 1 girl) the defect had been treated. Willesden Polytechnic Building Trade School (Boys).—No cases were recorded as having received treatment.- Group IV.—Dental Defects. Dental work is not done in connection with the Secondary Schools in Willesden. The School Medical Inspectors noted at the examinations during the year that of the cases previously referred for dental treatment 25 cases at the Kilburn Grammar School (boys), 6 cases at the Willesden Polytechnic Trade School (Girls), 11 cases (8 boys and 3 girls) at the Willesden County School (Boys and Girls), and 2 cases at the Willesden Polytechnic Building Trade School (boys) had received dental treatment. Group V.—Uncleanliness and Verminous Conditions. Inspection and treatment of uncleanliness has not been undertaken by the School Nurses in the Secondary Schools in 1926. Treatment of other Types of Defect. (a) The measures adopted for providing treatment or for securing improvement:— No measures have been adopted by the Authority for providing treatment. Notices were sent to parents informing them of the conditions requiring treatment, and the Head Teachers were notified of conditions requiring special exercises and the like. Pupils with defects referred for treatment or requiring to be kept under observation were referred for re-examination at a subsequent visit of the School Medical Inspector. (b) The effect of the measures taken. The School Medical Inspector noted as follows:— Table No. 40. (a)—KILBURN GRAMMAR SCHOOL. Defect. No. Result. Malnutrition 3 Improving. Lungs:— Bronchial Catarrh 2 No active disease. Nervous System:— Chorea 1 Remedied. Deformities:— Flat Foot 2 Improved. 1 Unchanged. 50 (b)—WILLESDEN POLYTECHNIC. Defect. No. Result. Malnutrition 1 Improved. Anaemia 1 Improved. Deformities:— Spinal Curvature 1 Remedied. Flat Foot 1 Remedied. (c)—WILLESDEN COUNTY SCHOOL. Defect. No. Result. Boys. Girls. . . Deformities:— Round Shoulders 4 Improved. Flat foot 3 4 Improved. 2 Unchanged. Overlapping small toe on each foot 1 Unchanged—No treatment advised at present. Limited extension of right elbow 1 Improved. (d)—WILLESDEN POLYTECHNIC BUILDING TRADE SCHOOL (BOYS). Defect. No. Result. Nocturnal Enuresis 1 Improved. 51 THE NINTH ANNUAL REPORT for the Year 1926, on DENTAL WORK in connection with SCHOOL CHILDREN, EXPECTANT and NURSING MOTHERS and CHILDREN under 5 years. By E. A. JENNINGS, L.D.S., R.C.S.Eng. SCHOOL DENTAL SERVICE. During the year 12,219 children were inspected at the schools and 1,595 as special cases at the Clinics, making a total of 13,814. Of this number 10,250 were found to require treatment, 2,051 children actually presented themselves for treatment at the Clinics with a record of 4,923 attendances and the work involved in these cases includes the following:— The removal of 4,934 teeth (of which 775 were of the permanent series) under general and local anaesthetics. The preservation by the insertion of fillings of 1,901 permanent and 654 temporary teeth, also 515 other operations chiefly in the nature of cleaning and the local application of drugs. In comparison with the previous year it will be noticed there is an increase of 353 in the number of teeth filled and 714 in the number of extractions. The special cases have increased by 281 and attendance by 539 respectively, while the routine inspections amount to almost an identical figure. The following tables give the more detailed information of the year's work and probably represents as much as it is possible to do under present arrangements. Table No. 41, corresponding to Table IV., Group IV., of Appendix H. of the Annual Report of the Chief Medical Officer of the Board of Education for 1923, gives details of the age groups of children inspected, together with time given and work done at the Clinics on those cases, which received treatment under the Council's scheme. Table No. 41. Group IV. Dental Defects. (1) Number of children who were :— (a) Inspected by the Dentists :— 5 years „ 678 6 ,, 1,779 7 „ 1,324 8 „ 807 Routine Age Groups 9 „ 975 10 „ 1,494 11 „ 1,462 12 „ 1,387 13 „ 1,414 14 „ 878 15 „ 21 Total 12,219 Specials (see note d) 1,595 ... Grand Total 13,814 (b) Found to require treatment 10,250 (c) Actually treated at the Authority's Clinics 2,051 (d) Re-treated during the year as the result of periodical 334 examination Note.—(d) is included in (c). 52 (2) Half days devoted to Inspection 297 Treatment 709 Total 1,006 (3) Attendances made by children for treatment 4,923 (4) Fillings Permanent Teeth 1,901 Temporary Teeth 654 Total 2,555 (5) Extractions Permanent Teeth 775 Temporary Teeth 4,159 Total 4,934 (6) Administrations of anaesthetics :— General—For extractions 1,394 Local 741 (7) Other Operations Permanent Teeth 369 Temporary Teeth 146 Total 515 Table No. 42. Return showing number of cases referred for following up in 1926 and previous years, with a view to Dental treatment being obtained. Year. Referred by Dental Inspections and Officers of the Health Department. Head Teachers. School Attendance Officers. Others. Total. 1926 4,799 73 0 1,544 6,416 1925 7,159 75 1 1,294 8,529 1924 9,642 34 0 570 10,246 1923 6,504 98 2 605 7,209 1922 4.383 129 0 930 5,442 1921 2,624 293 16 1,116 4,049 1920 1,386 466 6 1,379 3,237 1919 2,833 654 17 1,371 4,875 Table No. 43. Return showing the number of dental defects referred for following up, the number of visits made in connection therewith and the extent to which remedial measures were carried out during 1926 at Health Visitors' last visit. Total number of defects coming under observation during 1926:— Brought forward, 1926 719 New during year 6,444 Total 7,163 Number of visits made by Health Visitors 6,103 Number of defects treated:— Clinic 1,965 Otherwise 68 Total 2,033 No report available 108 Number of defects for which no treatment had been undertaken at Health Visitor's final visit 4,645 Carried forward to 1927 377 Percentage of defects followed up which were known to have received treatment 28 58 Maternity and Child Welfare. The records in connection with the Maternity and Child Welfare Centres are as follows:— 634 mothers and children under 5 years were inspected and 161 brought forward from 1925, making a total of 795 for the year. Of these 276 were treated at the Clinics and 7 elsewhere and 278 did not avail themselves of the opportunity for treatment and 234 were carried forward to 1927. Altogether, 1,491 attendances were made by these patients, 1,428 teeth removed and 311 treated by conservative methods and 161 other operations on the gums and teeth. General anaesthetics were administered on 394 occasions. 51 mothers received dentures, 49 of which were at cost to the Council. Table No. 44. The table shows details of the children 0-5 inspected :— Number inspected 266 Number with no defect 16 Number with decayed temporary teeth Savable 98 Unsavable 134 Number with decayed permanent teeth Savable 2 Unsavable 2 Number of decayed temporary teeth Savable 264 Unsavable 400 Number of decayed permanent teeth Savable 9 Unsavable 5 Number with Sepsis 104 Number with other defects 4 Number referred for treatment 250 Number treated by other agencies 3 251 applications were made for treatment at the Clinics, 129 of these were granted free and 71 on payment of 2/6, the remaining 51, who either did not return forms or refused payment, were removed from observation. Table No. 45. Showing the number of dental defects referred for following up, the number of visits made in connection therewith and the extent to which remedial measures were carried out in 1926. (It should be noted that only the dental defects referred for the attention of the Health Visitors appear in this table.) Total number of defects coming under observation during 1926. (New cases and re-examinations) Brought forward from 1925 161 New during year 634 Total 795 Number of visits made by Health Visitors 629 Number of defects treated Clinic 276 Otherwise 7 T otal 283 Number of defects for which no treatment was undertaken 278 Carried forward, 1927 234 THE SEVENTH ANNUAL REPORT For the Year ending 31st December, 1926, on HOME NURSING. There has been no alteration in the Council's Scheme for Home Nursing during 1926. A record of the work done is given in the three following tables:— * 54 Table No. 46.—Showing Cases dealt with during 1926 and Results, Disease. Cases being nursed at end of 1925. New Cases during 1926. Removed from Observation during 1926—Results of Treatment. Still being Home Nursed at end of 1926. Number of Visits Paid during 1926. Died. Removed to Hospital or other Institutions. Recovered. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Expectant Mothers. N ursing I Mothers. | Children under Five. School Children. 1 Others. Total. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Expectant 1 Mothers. Nursing 1 Mothers. Children under Five. School Children. Others. Total. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Abdominal Pain — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 4 — 4 Acute Poliomyelitis — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 2 — — 2 Appendicitis — — — — — — — — 1 — — 1 — — — — — — — — — — — — — — — — — — — — — — — — — — 7 — — 7 Bathing Case — — — — — — — — 1 — — 1 — — — — — — — — — — — — — — 1 — — 1 — — — — — — — — 2 — — 2 Bleeding and Dis- charging Nose — — — — — — — — — — — — — — — — — — — — — 1 — 1 — — — — — — — — — — — — — — — 26 — 26 Bronchitis — — 1 — — 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 8 Broncho-Pneumonia — — — — — — — — — — — 1 — — — — — — — — — — — — — — — — — — — — — — — — — — 10 — — 10 Burns & Scalds — — — — — — — 1 2 l — 4 — — — — — — — — — — — — — 1 2 1 — 4 — — — — — — — 32 22 12 — 66 Cancer — — — — — — — — — — 1 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — 2 2 Circumcision — — — — — — — — — — — — — — — — — — — — — — — — — — 19 2 — 21 — — — — — — — — 202 25 — 227 Constipation — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 2 — — 2 Diarrhoea — — — — — — — —- 2 — — 2 — — — — — — — — 1 — — 1 — — 1 — — — — — — — — — — — 13 — — 13 Douching Cases — — — — — — 2 1 — l — 4 — — — — — — — — — — — 2 1 — 1 — 4 — — — — — — 111 12 — 6 — 129 Eczema — — 1 — — 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 20 Impetigo — — — — — — — — 3 ' — — 4 — — — — — — — — — — — — — — 2 1 — 3 — — 1 — — 1 — — 55 9 — 64 Impetigo and — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 11 — — 11 Blepharitis Influenza — — — — — — — — — — — — — — — — — — — — — — — — — 1 — — — — — — — — — — — — — — — 29 Injury at Birth — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1 — — 1 — — 29 — — 10 Jaundice — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 10 — 24 Mastitis — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 24 — — — 4 Mastoid — — — — — — — — — — — 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — 4 — 4 Measles — — — — — — — — 2 l — 3 — — — — — — — — 2 1 — 3 — — — — — — — — — — — — — — 4 2 — 6 Measles and — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 3 Bronchitis Measles and — — 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 2 — — 2 Conjunctivitis Ophthalmia — — 1 — — 1 — — 13 2 1 16 — — — — — — — — — — — — — — 13 2 1 16 — — 1 — — 1 — — 278 30 1 309 Ophthalmia — — 1 — — 1 — — 15 — — — — — — — — — — — — — — 1 — — — — — — — — — — — — — — 417 — — 417 Neonatorum Otorrhcea — — 1 1 — 2 — 10 7 1 18 — — — — — — — — 1 1 — 2 — — 10 7 1 18 — — — — — — — — 236 84 1 321 Pneumonia — — — — — — — — — 1 — 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — 13 — 13 Pyrexia — — — — — — — 1 1 1 — 3 — — — — — — — — — — — — — 1 1 1 — 3 — — — — — — — 9 3 1 — 13 Scarlet fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1 — — 1 Septic Conditions — — — — — — — — 6 9 — 15 — — — — — — — — — — — — — — 6 9 — 15 — — — — — — — — 26 104 — 130 Throat Conditions — — — _ — 24 97 2 123 — — — — — — — — — — — — — 24 96 2 122 — — — 1 — 1 — — 68 293 6 367 Whooping Cough — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 4 7 — 11 Worms — — — — — — — 1 28 25 — 54 — — — — — — — — — — — — — 1 28 25 — 54 — — — — — — — 1 231 147 — 379 Total — — 6 1 — 7 2 1 6 137 153 5 303 — — 1 — — 1 —- 1 7 4 — 12 2 5 131 149 5 292 — — 4 1 — 5 1ll 1,656 777 10 2,635 0 55 Table No. 47. Shewing Sources from which cases were referred for Home Nursing during the Year 1926. Referred by Number. Health Department 108 Private Doctors 32 Others 163 Total 303 Table No. 48. Shewing cases Home Nursed in Wards during 1926. Ward. No. of Cases brought forward from 1925. No. of Cases referred in 1926 Total. No. of Visits paid. 1. South Kilburn 1 57 58 455 2. Mid-Kilburn 0 47 47 341 3. North Kilburn 2 25 27 219 4. Brondesbury Park 0 6 6 25 5. Kensal Rise 2 42 44 570 6. Harlesden 0 28 28 286 7. Stonebridge 1 36 37 306 8. Roundwood 0 22 22 149 9. Church End 1 11 12 84 10. Willesden Green 0 20 20 106 11. Cricklewood 0 9 9 94 Total 7 303 310 2,635 57 THE TWELFTH ANNUAL REPORT FOR THE Year ending 31st December, 1926, ON THE PROVISION OF MEALS TO SCHOOL CHILDREN IN WILLESDEN. Feeding Centres.—Meals have been supplied at the four Feeding Centres under the control of the Education Committee, namely Gibbons Road, Furness Road, Strode Road and Lower Place, and at one voluntary centre at Granville Road. Dinners are still taken from Strode Road Feeding Centre to Leopold Road Physically Defective School. The dinners are served in the Laundry Centre by an Assistant from Strode Road Feeding Centre. Breakfasts.—The practice of serving breakfasts to children whose parents are unusually poor has been continued throughout the year. Most of these cases have been in the South Kilburn area, but breakfasts were served at all the Feeding Centres during the General Strike. The meal consists of cocoa made with dried milk and sugar, and bread and margarine. Staffing.—The staff employed at each of the Feeding Centres is approximately one assistant to every 50 children fed. Selection of Children.—Recommendations are accepted as heretofore from School Teachers, Health Nurses and the Clinic Medical Staff, subject to review by immediate investigation of the economic circumstances of the family. The total number of new application forms presented to the Education Committee's Centres throughout the year was 737. Recommendations are also re-, ceived from the Willesden Board of Guardians, an agreement having been made whereby they pay the Willesden Education Authority 1 /- per head per week or part of a week for each child fed at the Education Committee's Centres on their recommendation. This scheme came into operation on 30th October, 1922, the Guardians supplying every four weeks the list of children to be fed. The economic circumstances scale was revised and raised one shilling per head on the 20th November, 1924. Kilburn Feeding Centre.—Dinners.—The children of the South Kilburn area are fed at the Voluntary Centre established at the Presbyterian Mission Hall, Granville Road. No change has been made with regard to the serving of meals, and the table appointments are still one spoon. The meals are more appetising, but without much variety. The price per meal was raised from 4d. to 5d. on the 12th November, 1923. The earlier arrivals hurry through their meal and scramble out as soon as they have finished to make room for the newcomers, thereby making a constant stream of children through the dining room and destroying all possibility of order. Kilburn Breakfasts.—The provision of breakfasts at Carlton Vale School House has been continued throughout the year, the arrangements being carried out by the Caretaker. The number of application forms received from South Kilburn for the year was—Dinners 237—Breakfasts 105. Meals.—A two weekly menu was commenced in the Education Committees' Centres on April 6th, 1925. This provides four meat meals and one meatless meal one week, and three meat meals and two meatless meals the second week, each being followed by a pudding or stewed fruit. The price of meals for non-necessitous cases is 5d. as heretofore. ' STATISTICAL INFORMATION, YEAR ENDING 31st DECEMBER, 1926. Table No. 49.—Number of Meals Supplied. Supplied to :— Breakfasts. Dinners. Total. Free. Free. Paying. Guardians. Education Committees' Centres 4,498 52,199 262 5,798 62,757 Kilburn Voluntary Centre 7,721 15,343 — 6,069 29,133 Special Schools — 4,453 10,009 147 14,609 Feeding Centre Assistants 1,932 2,356 — — 4,288 Total 14,151 74,351 10,271 12,014 110,787 58 Table No. 50. Occupational List, 1926. List of parents whose children were fed during 1926 with comparative column for 1925. Occupation. No. of Children Fed during 1926. No. of Families Involved. Percentage. 1925. 1926. 1925. 1926. Unemployed 647 164 288 62.1 62.7 Widows 77 41 42 15.6 9.2 Deserted Wives 36 12 22 4.5 4.8 Orphans 7 3 4 1.1 .9 Labourers 90 21 35 7.9 7.6 Railwaymen Hawkers 91 13 7 1 33 4 2.6 .4 7.2 .8 Others 59 15 31 5.6 6.8 Approximate average cost per meal for food only, 2½d. ; total (gross) cost, 5¼d. 59 THE THIRTY-FIFTH ANNUAL REPORT FOR THE Year ending 31st December, 1926, ON THE MUNICIPAL HOSPITAL By A. G. TROUP, M.D., D.P.H. During 1926, 846 patients were admitted as compared with 601 in 1925, 626 in 1924, and 674 in 1923. Scarlet Fever. During the past year 306 cases of this disease were admitted, and there were no deaths. There were 203 cases in 1925. A considerable proportion of these cases were of a mild nature, a smaller proportion were of a moderately severe type, and a few were of a severe septic type. Serum Treatment of Scarlet Fever. During the year a certain number of Scarlet Fever cases have been treated with scarlet fever anti-toxin. The cases come under two categories, first, a few cases which have arisen in the Hospital, and second, cases admitted to Hospital in which the acute symptoms have been well marked. I think that the results obtained demonstrate that the treatment is beneficial, although a certain number of complications have occurred. The effect of the serum in some of the cases treated early has been striking. The acute symptoms, including the rash, disappearing within 24 hours, and the desquamation has been very slight. In the tables, only complications which arose after the serum had been injected are given. Number of cases treated 75 Percentage of cases which developed complications 21.3% Percentage of cases which developed complications during the year 1925 (serum had not been given) 37.9% Percentage of cases in which acute symptoms subsided within two days 72% Percentage of cases, treated within the first four days of illness, which developed complications 16% Percentage of cases treated on or after the 5th day of illness which developed complications 50% Table 51. Showing the day on which the serum was administered, number of subsequent complications, and the day on which acute symptoms subsided. Complications. Acute Symptoms Subsided. Day Given. No. of Cases. No. of cases with one. No. of cases with two. No. of cases with three. One day. Two days. Three days. Four days. Five days. Six days. Seven or more days. 1st 4 1 — — 1 1 — 2 — — — 2nd 25 3 1 — 12 8 1 1 — — 3 3rd 21 3 1 — 7 8 2 1 1 — 2 4th 13 1 — — 5 4 2 — — — 2 5th 6 2 1 — 2 3 — 1 — — — 6th 3 1 — — 1 1 — — 1 — — 7th — — — — — — — — — — — 8th 1 1 — — — 1 — — — — — 9th 2 — — 1 — — — — — — 2 Totals 75 12 3 1 28 26 5 5 2 — 9 60 Table 52. Showing the particular complications which arose. Complications. Cases with one Complication. Cases with two Complications. Cases with three Complications. Totals. Adenitis 1 3 1 5 Rheumatism 3 — — 3 Otitis Media 5 1 1 7 Albuminuria 3 — — 3 Nephritis — 1 — 1 Abscess — 1 1 2 Totals 12 6 3 21 All these complications can be described as mild except the nephritis, and the patient in this instance had a moderately severe attack. All the cases of otitis media cleared up without difficulty except one, and in this case the child had enlarged tonsils and adenoids which urgently required excision. Diphtheria. 368 cases were admitted, or 109 more than in the previous year. These cases may be classified as follows :—Faucial 264, faucial and nasal 34, nasal 31, bacteriological 16, laryngeal 10, faucial and laryngeal 6, aural 3, faucial and aural 2, vaginal 1, ophthalmic 1. One case was tracheotomied and recovered. A case on which tracheotomy was performed previous to admission to Hospital died from a sudden severe hemorrhage from the tracheotomy wound. The prevailing type of this disease has been of a severe character, and 27 deaths have occurred, giving a mortality rate of 7.7 per cent. In calculating the mortality rate, the bacteriological cases have been excluded. Several cases were admitted to Hospital too late for anti-toxin to be of any avail. Convalescent Diphtheria Carrier Cases. A certain small number of Diphtheria cases harbour the diphtheria bacillus in the throat or nose for a long time after they have recovered from the acute attack, and great difficulty is experienced in dealing with these cases as they resist all the usual forms of treatment. If the individual has any abnormal condition of the throat or nose, particularly enlarged tonsils and adenoids, the germs are provided with a suitable place in which to harbour. In the great majority of convalescent carrier cases, the diphtheria bacillus is of a virulent type, and such cases have been detained in Hospital from six to twelve months before they were free from infection The Council have given permission for suitable cases of this class to have excision of the enlarged tonsils and adenoids carried out, and 5 cases have been treated in this way with the following results :— Number of days in Hospital before operation. Number of days in Hospital after operation. Case A 126 40 „ B 122 16 „ C 84 23 „ D 84 18 „ E 54 19 In four of the cases the throat or nose proved to be free of diphtheria germs immediately after the operation had been carried out, which is a very satisfactory result. The fifth case took rather longer to clear up. 61 Other Infectious Diseases. 100 patients were admitted under this heading as follows :— German Measles 5 Ulcerative Colitis 1 Measles 39 Excision of Tonsils 1 Ophthalmia Neonatorum 3 Drug Rash 1 Erysipelas 7 Sub-acute abscess of pharynx 1 Puerperal Fever 2 Impetigo 1 Whooping Cough 2 Gingivitis and Periostitis 1 Mumps 1 Anterior Poliomyelitis 1 Pneumonia 6 Puerperal Pyrexia 3 Gastro-Enteritis 1 Typhoid Fever 2 Urticaria 1 Bronchitis 2 Laryngitis 3 Erythema Nodosum 1 Encephalitis Lethargica 1 Malaria 1 Post Influenzal Debility 1 Erythema 2 Empyema 1 Negative Cases 8 Pneumonia and Laryngitis 1 Seven deaths occurred : Typhoid Fever 1 Erysipelas 1 Pneumonia and Laryngitis 1 Measles 4 One of the cases of Typhoid Fever was of some clinical interest from the fact that the patient failed to develop a positive Widal Reaction. The case was admitted to Hospital towards the end of the second week of the illness, and he had had several intestinal haemorrhages previous to admission. The symptoms all pointed to Typhoid Fever, and a blood count showed a leucopenia. A Widal Reaction done on the 21st day of the illness proved negative to the Bacillus Typhosus, and the Bacillus Paratyphosus A and B. The patient had never been inoculated against Typhoid Fever. Several further haemorrhages occurred and the patient died on the 24th day of his illness. A post-mortem examination revealed typhoid ulceration of the ileum. Duration of Stay in Hospital. The following figures show the average stay in days for certain diseases :— Scarlet Fever, 47.2; Diphtheria, 54.1; and Other Diseases, 29.0. Sick Staff. The number of nurses who were off duty from sickness for 24 hours or more was 44, as compared with 38 in 1925. The number of days they were off duty was 726, 145 days more than the previous year. Nine nurses contracted Diphtheria, 1 Scarlet Fever and 1 Chicken Pox—all recovered. Amongst the Domestic Staff, 29 maids were off duty for a total of 492 days. In 1925 there were 17 members off duty for 256 days. One maid contracted Diphtheria. Schick Test and Active Immunisation against Diphtheria. Up to this year the Schick Test and the active immunisation against Diphtheria had not been carried out at this Hospital. The incidence of Diphtheria amongst the nursing staff has been high, and this is accounted for by the fact that Diphtheria of a virulent type was epidemic during the spring, and, as a consequence, the acute diphtheria ward was overcrowded. Early in the year the large majority of the nursing staff was Schick-tested and those giving a positive reaction were immunised. Later in the year a considerable number of the staff attached to the Municipal Clinics were similarly treated. After an interval of six months, the first batch of nurses who had been immunised were again Schick-tested and those giving a positive reaction had another course of toxin-antitoxin injections. Another batch will be due shortly to be re-Schicktested. In one case only has there been a moderately severe general reaction after the toxinantitoxin injection, and this only lasted for one day. Since the commencement of testing and immunisation nine cases of sore throats have occurred in Schick negative or in immunised nurses and these have all proved to be non-diphtheritic. Number of persons Schick-Tested 61 Number of persons giving a positive reaction 32 Percentage of persons giving a positive reaction 52.4% Number of persons re-Schick-Tested 11 Number of persons re-Schick-Tested giving a positive reaction 7 Percentage of persons re-Schick-Tested giving a positive reaction 63.6% All new nurses are now immunised before going on duty in the diphtheria wards. Dick Test. This test has been employed on a few occasions in which a case of Scarlet Fever has arisen in the Hospital. The patients in the affected ward have all been Dick-Tested and those giving a positive reaction have had a prophylactic dose of Scarlet Fever antitoxin administered. By this means it has been found that a complete control over the disease can be maintained. 62 Hospital Buildings. The Water Softening Plant came into use during the year, and has proved a success, the softness of the water after treatment being particularly noticed in the laundry and boiler room. The boilers when they were overhauled this year only required the interior scrubbed down instead of the usual chipping. Steam radiators have been installed in B Ward, including the theatre. The rebuilding of the Small-Pox Hospital at Kingsbury has been commenced, and will be completed during 1927. The question of the provision of a Cubicle Ward is at present being considered by the Council. A. G. TROUP, Medical Superintendent. Table No. 53. Scarlet Fever. Diphtheria. Other Diseases. Total. No. of cases admitted during 1926 306 368 172 846 Remaining in Hospital, December 31st, 1925 38 33 4 75 Total No. under treatment in 1926 344 401 176 921 Cases discharged 1926 313 322 163 798 No. of deaths 1926 — 27 8 35 Mortality — 7.01 4.5 4.1 Remaining in Hospital, December 31st, 1926 31 52 5 88 Table No. 54. Scarlet Fever. Age. Males. Females. Admissions. Deaths. Admissions. Deaths. —1 — — — — 1—2 7 — 3 — 2—3 5 — 6 — 3—4 13 — 13 — 4—5 23 — 16 — 5—10 61 — 74 — 10—15 11 — 28 — 15—20 4 — 13 — 20—25 7 — 9 — 25—30 1 — 1 — 30—35 1 — 4 — 35— 1 — 5 — Total 134 — 172 Table No. 55. Diphtheria. Age. Males. Females. Admissions. Deaths. Admissions. Deaths. —1 4 1 — 1—2 5 2 4 — 2—3 11 3 15 3 3—4 16 1 14 1 4—5 16 4 15 1 5—10 78 2 86 5 10—15 20 2 41 2 15—20 7 — 11 — 20—25 1 — 4 — 25—30 2 — 2 — 30—35 1 — 8 — 35— 1 — 5 1 Total 162 14 206 13 63 Table No. 56. Diphtheria.* Day of Disease on Admission. Number of Cases. 1st 16 2nd 72 3rd 107 4th 64 5th 35 6th and over 27 Total 321 * Bacteriological and Nasal cases are not included in this list. Table No. 57. Chief Complications of Scarlet Fever. Number of Complications Adenitis 41 Rheumatism 8 Otitis Media 32 Albuminuria 10 Nephritis 2 Empyema 1 Suppurative Arthritis 1 Abscess 10 Bronchitis 7 Serum Rash 1 Endocarditis 1 Erysipelas 1 Laryngitis 1 Total 116 Table No. 58. Chief Complications of Diphtheria. Number of Complications. Toxaemia 23 Paralysis 43 Cardiac Failure 2 Albuminuria 6 Adenitis 5 Otitis Media 12 Serum Eruption 2 Disordered Action of the Heart 27 Abscess 3 Dilatation of the Heart 2 Mastoiditis 1 Rheumatism 3 Broncho-Pneumonia 5 Bronchitis 2 Septicaemia 1 Haemorrhage from Tracheal Wound 1 Total 138 65 APPENDICES. APPENDIX A.—VITAL STATISTICS. Appendix A.—Table I. VITAL STATISTICS OF WHOLE DISTRICT DURING 1926 AND PREVIOUS YEARS; VITAL STATISTICS OF THE WARDS DURING 1926. Year. Population estimated to Middle of each Year. Whole District. Births. Total Deaths Registered in the District. Transferable Deaths Nett Deaths belonging to the District. Uncor rected Number. Nett. Number. Rate. of nonresi dents registered in the District. of residents not registered in the District. Under 1 Year of Age. At all Ages. Number. Rate. Number. Rate per 1,000 Nett Eirths. Number. Rate. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) 1911 156,572 3,863 4,001 25.6 1,618 10.3 10 240 495 124 1,848 11.8 1912 159,868 3,912 4,075 25.5 1,307 8.7 27 233 328 80 1,603 10.02 1913 163,644 3,891 4,037 24.7 1,449 8.9 23 251 325 80 1,677 10.24 1914 166,634 3,971 4,115 24.7 1,501 9.0 32 283 337 82 1,752 10.51 1915 166,840 3,641 3,775 22.6 1,792 10.7 44 282 344 91 2,030 12.16 1916 167,810 3,557 3,668 21.9 1,436 8.55 34 308 283 77 1,710 10.19 1917 169,344 2,704 2,816 16.6 1,571 9.27 45 292 309 110 1,818 10.73 1918 169,358 2,520 2,651 15.65 1,975 11.66 35 338 258 97 2,278 13.45 1919 170,625 2,843 2,924 17.13 1,519 8.90 39 286 242 83 1,766 10.35 1920 170,892 4,203 4,232 24.76 1,427 8.35 50 295 274 65 1,672 9.78 1921 ‡165,674* 3,442 3,464 20.91 1,469 8.87 54 262 255 74 1,677 10.12 1922 168,900 3,106 3,160 18.71 1,570 9.30 59 273 188 59 1,784 10.56 1923 169,831 2,977 3,063 18.04 1,380 8.13 72 280 162 53 1,588 9.35 1924 171,161 2,685 2,843 16.61 1,574 9.20 78 286 208 73 1,782 10.41 1925 172,503 2,552 2,755 15.97 1,465 8.49 83 304 170 62 1,686 9.77 1926 wards. 1. S. Kilb'n 173,854 15,051 2,444 258 2,700 319 15.53 21.19 1,422 157 8.18 10.43 88 2 319 31 143 22 53 68-97 1,653 186 9.51 12.36 2. Mid K'b'n 14,697 225 257 17.49 126 8.57 2 35 17 66-15 159 10.82 3. N. Kilb'n 13,490 128 162 12.01 101 7.49 3 36 10 61.73 134 9.93 4. Brondsb'y Park 9,604 81 92 9.58 83 8.64 3 27 5 54.35 107 11.14 5. Kensal Rise 13,632 162 185 13.57 96 7.04 0 21 4 21.62 117 8.58 6. Harl'd'n 17,660 218 240 13.59 131 7.42 2 28 12 50.00 157 8.89 7. Stonebridge 18,891 361 374 19.80 163 8.63 18 27 20 53.48 172 9.10 8. Roundwood 16,551 259 273 16.49 161 9.73 27 35 14 51.28 169 10.21 9. Church End 15,555 238 244 15.69 109 7.01 4 16 13 53.28 121 7.78 10. Willesden Green 17,492 265 286 16.35 122 6.97 4 34 22 76.92 152 8.69 11. Cricklewood 21,231 249 268 12.62 173 8.15 23 29 4 14.93 179 8.43 Area of District in acres (land and inland water) 4,384 Total population at all ages ‡165,674 at Census, 1921. Total families or separate occupiers 41,435 * Census Population, 1921. Re-adjusted by the Reg. Gen. because of holiday movement to 167,200. 66 Appendix A.—Table II.—DEATHS OF WILLESDEN RESIDENTS DURING THE YEAR 1926. CAUSE OF DEATH. (1) All Ages. (2) 0 to 1 (3) 1 to 5 (4) 5 to 10 (5) 10 to 15 (6) 15 to 20 (7) 20 to 25 (8) 25 to 35 (9) 35 to 45 (10) 45 to 55 (11) 55 to 65 (12) 65 to 75 (13) 75 to 85 (14) 85 Up. (15) Total deaths, whether of " Residents" or "Non-Residents," in Institutions in the District. (16) All Causes Certified 1,651 142 73 37 22 30 39 69 113 188 270 331 253 84 592 Uncertified 2 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... 1.—General Diseases. Enteric Fever 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 Typhus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Malaria 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Small Pox 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 18... 14 1 ... ... ... ... ... ... ... ... ... ... 12 Scarlet Fever 1 ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 Whooping Cough 8 ... 3 1 ... ... ... ... ... ... ... ... ... ... 1 Diphtheria 34 ... 19 9 ... ... ... ... ... 1 1 ... ... ... 31 Influenza 33 ... 2 ... ... ... ... ... ... 3 6 ... ... ... 3 Miliary Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Asiatic Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera Nostras ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Dysentery ... . .. Plague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Yellow Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Leprosy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... 3 ... ... ... 7 Other Epidemic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pyaemia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Septicaemia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Vaccinia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Glanders ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Anthrax (Splenic Fever) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Rabies ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tetanus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Mycoses: Actinomycosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pellagra ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Beri-Beri ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pulmonary Tuberculosis (not acute) 126 1 ... 1 1 10 23 23 29 28 8 2 ... ... 13 67. . . Phthisis (not acute and not defined as Tuberculosis) 6 . . . . . . . . . . . . . . . . . . . . . 3 1 1 1 . . . . . . 1 Acute Phthisis 1 . . . . . . . . . . . . . . . . . . 1 . . . ... . . . . . . . . . ... Acute Miliary Tuberculosis 3 . . . . . . 1 . . . 1 . . . 1 . . . . . . . . . . . . 1 Tuberculous Meningitis 15 . . . . . . 3 . . . 1 . . . l 1 ... ... . . . . . . 7 Tabes Mesenterica ... . . . . . . . . . . . . ... . . . ... ... ... ... ... . . . . . . . .. Other Peritoneal and Intestinal Tubercle 3 . . . . . . 1 . . . 1 . . . l . . . . . . ... . . . . . . 1 Tuberculosis of Spinal Column 2 . . . . . . . . . . . . 1 . . . . . . . . . 1 . . . . . . ... 1 Tuberculosis of Joints 1 . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . Tuberculosis of other organs 3 . . . . . . . . . . . . . . . . . . 1 . . . 1 1 . . . ... 2 Disseminated Tuberculosis 2 . . . . . . . . . . . . . . . . . . l 1 . . . . . . . . . . . . Rickets, Softening of Bones 1 . . . . . . ... . . . . . . . . . ... . . . . . . . . . ... . . . . . . 1 Syphilis 2 . . . . . . ... . . . . . . . . . ... ... 1 1 ... . . . . . . . . . Other Venereal Diseases ... . . . . . . . . . . . . . . . . . . ... ... ... ... . . . . . . . . . Cancer of Buccal Cavity 8 . . . . . . ... . . . . . . . . . . . . ... 1 3 3 1 3 Cancer of the Stomach, Liver, &c. 60 . . . . . . . . . . . . . . . . . . 2 3 9 18 16 9 3 13 Cancer of Peritoneum, Intestines and Rectum 62 . . . . . . . . . . . . . . . . . . 4 1 8 23 13 13 . . . 17 Cancer of the Female Genital Organs 29 . . . . . . . . . . . . . . . . . . . . . 7 7 11 1 2 1 6 Cancer of the Breast 25 . . . . . . . . . . . . . . . . . . 1 6 9 7 1 1 8 Cancer of the Skin 2 . . . . . . ... . . . . . . . . . ... ... ... 1 1 . . . 1 Cancer of other or unspecified organs 53 . . . . . . 1 . . . . . . . . . 1 4 9 15 13 . . . 20 Other Tumours (situation undefined) . . . . . . . . . . . . . . . . . . . . . ... ... . . . . . . . . . . . . Rheumatic Fever 8 . . . . . . 1 . . . . . . . . . . . . 1 . . . . . . 2 . . . . . . Chronic Rheumatism ... . . . . . . . . . . . . . . . . . . ... ... . . . . . . ... . . . . . . Osteo-Arthritis 4 . . . . . . ... . . . . . . . . . ... ... . . . 1 3 . . . . . . Gout . . . . . . . . . ... . . . . . . . . . ... ... ... ... ... . . . ... Scurvy ... . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . ... Diabetes 18 . . . . . . . . . . . . . . . 2 2 2 3 3 . . . 5 Exophthalmic Goitre 3 . . . . . . . . . . . . . . . . . . 1 1 ... ... 1 . . . 2 Addison's Disease . . . . . . . . . . . . . . . . . . . . . ... . . . ... ... ... . . . . . . Leucocythsemia (Leuchae mia) 5 . . . . . . 1 . . . . . . . . . ... . . . 2 ... ... . . . 2 Lymphadenoma 2 . . . . . . . . . . . . . . . 1 . . . . . . . . . 1 . . . . . . Anaemia, Chlorosis 11 . . . . . . ... . . . 1 . . . . . . 3 1 4 . . . 4 Other General Diseases 3 . . . . . . ... . . . . . . . . . . . . . . . 1 . . . 2 Alcoholism (Acute or Chronic) 2 . . . . . . . . . . . . . . . . . . ... . . . ... 2 ... . . . 1 Chronic Lead Poisoning . . . . . . . . . . . . . . . . . . . . . ... . . . ... ... . . . ... Other Chronic Occupational Poisoning . . . . . . . . . . . . . . . . . . . . . ... ... . . . ... . . . ... Other Chronic Poisoning ... . . . . . . ... . . . . . . . . . . . . ... . . . ... ... . . . ... 2.—Diseases of the Nervous System and of the Organs of Special Sense. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Encephalitis . . . . . . . . . . . . . . . . . . . . . ... . . . ... ... ... ... ... ... Cerebro-spinal Fever . . . . .. . . . . . . . . . ... ... ... ... ... ... ... ... ... ... Posterior Basal Meningitis 1 1 . . . . . . ... ... ... ... ... ... ... ... 1 Meningitis, other forms 3 1 ... 1 ... ... ... . . . 1 ... . . . . . . ... ... 1 68 Table II.—DEATHS OF WILLESDEN RESIDENTS—continued. CAUSE OF DEATH. All Ages. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 to 75 75 to 85 85 Up. Total deaths, whether of "Residents" or " Non-Residents," in Institutions in the District. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) 2.—Diseases of the Nervous System and of the Organs of Special Sense—Continued. Locomotor Ataxy 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 Other Diseases of the Spinal Cord 18 ... ... ... ... 1 ... 1 4 2 2 6 2 ... 8 Apoplexy 3 ... ... ... ... ... ... ... ... 1 ... ... 1 1 ... Serous Apoplexy and Oedema of Brain 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 Cerebral Congestion 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebral Atheroma ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebral Haemorrhage 100 ... ... ... ... ... ... 1 1 11 21 39 21 5 52 Softening of Brain 1 ... ... ... ... ... ... ... ... ... ... ... ... 1 ... Hemiplegia 2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Paraplegia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Forms of Paralysis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... General Paralysis of the Insane 3 ... ... ... ... ... 1 ... 1 1 ... ... ... ... ... Other Forms of Mental Alienation 7 ... ... ... ... ... 1 ... 3 2 1 ... ... ... ... Epilepsy 4 ... ... ... ... ... ... ... 1 1 1 ... ... ... 2 Convulsions (non-puerperal; 5 years and over) 1 ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 Infantile Convulsions under 5, with teething ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Infantile Convulsions under 5 2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chorea 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 Hysteria, Neuralgia, Neuritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Idiocy, Imbecility ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cretinism ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebral Tumour 11 ... ... ... ... ... ... 2 ... 6 ... ... ... ... 4 Other Diseases of the Nervous System 3 ... ... ... ... ... ... ... ... 2 ... ... ... ... 1 Diseases of the Eye and Annexa ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Mastoid Disease 3 ... ... 2 1 ... ... ... ... ... ... ... ... ... 2 Other Diseases of the Ears 2 ... ... ... 1 ... ... ... ... 1 ... ... ... ... ... 3.—Diseases of the Circulatory System. Pericarditis 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 Acute Myocarditis 5 ... ... ... ... ... ... 1 ... 4 ... ... ... ... 2 Infective Endocarditis 3 ... ... ... ... ... ... 1 ... 1 1 ... ... ... 1 Other Acute Endocarditis 1 ... ... ... ... ... ... 1 ... ... ... ... ... 1 Valvular Disease 79 ... 1 ... 2 2 ... 3 2 6 19 22 19 3 5 69 Fatty Degeneration of Heart 13 ... ... ... ... ... ... l ... 1 3 4 4 ... 2 Other Organic Disease of the Heart 169 ... ... ... ... ... ... ... ... 8 30 64 53 14 67 Angina Pectoris 5 ... ... ... ... ... ... ... ... 1 1 3 ... ... ... Aneurysm 1 ... ... ... ... ... ... ... ... 1 ... ... ... Arterial Sclerosis 27 ... ... ... ... ... ... l 2 5 12 4 3 6 Other Diseases of Arteries 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... Cerebral Embolism and Thrombosis 9 ... ... ... ... ... ... ... 3 2 ... 1 3 . . . 2 Other Embolism and Thrombosis 4 1 ... ... ... ... ... ... ... 1 ... 1 ... 1 3 Diseases of the Veins (Varices, Hemorrhoids, Phlebitis, &c.) 4 ... ... 1 ... ... ... ... ... 1 2 ... ... ... 2 Status Lymphaticus 2 ... 1 ... ... ... l ... ... . . . ... ... ... ... 2 Other Diseases of the Lymphatic System 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... 1 Haemorrhage; other Diseases of the Circulatory System ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4.—Diseases of the Respiratory System. Diseases of the Nasal Fossae 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... Diseases of the Larynx ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Thyroid Body ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis 87 6 ... ... ... ... ... ... 1 4 12 17 33 13 38 Broncho-Pneumonia 62 28 13 ... ... ... ... ... 2 3 3 5 3 4 28 Lobar Pneumonia 19 3 ... ... ... ... ... ... 3 5 4 1 2 ... 3 Pneumonia (type not stated) 22 ... 3 ... ... ... ... ... 3 5 2 7 1 ... 18 Empyema 1 ... ... ... ... ... ... ... . . . 1 ... ... ... ... Other Pleurisy 5 1 ... ... ... ... ... ... ... 1 ... 2 ... ... ... Pulmonary Apoplexy and Infarction ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pulmonary Oedema and Congestion 6 1 ... ... ... ... ... ... 1 1 ... ... ... 3 1 Hypostatic Pneumonia 2 ... ... ... ... ... ... ... ... ... 1 ... 1 2 Collapse of Lung (3 months and over) ... ... ... ... ... ... ... ... ... ... ... . . . ... ... ... Gangrene of the Lung 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 Asthma 7 ... ... ... ... ... ... ... ... 1 ... 4 ... ... ... Pulmonary Emphysema ... ... ... ... ... ... .... ... ... ... ... ... ... ... ... Fibroid Disease of Lung 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... ... Other Disease of the Respiratory System 1 ... ... ... ... ... ... ... 1 ... ... ... ... 5.—Diseases of the Digestive System. Diseases of the Teeth and Gums 2 ... ... ... ... l ... ... 1 ... ... ... ... ... 2 Other Diseases of the Mouth and Annexa ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Pharynx, Tonsillitis 3 ... 1 ... ... ... l ... ... ... 1 ... ... ... 2 Diseases of Oesophagus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Perforating Ulcer of the Stomach 11 ... ... ... ... ... ... ... 5 2 2 1 1 ... 8 Inflammation of Stomach 3 ... ... ... ... ... ... 1 ... ... ... 1 ... 1 Other Diseases of the Stomach ... ... ... .... ... ... ... ... ... ... ... ... ... ... ... 70 Table 11.—DEATHS OF WILLESDEN RESIDENTS—continued. CAUSE OF DEATH. (1) All Ages. (2) 0 to 1 (3) 1 to 5 (4) 5 to 10 (5) 10 to 15 (6) 15 to 20 (7) 20 to 25 (8) 25 to 35 (9) 35 to 45 (10) 45 to 55 (11) 55 to 65 (12) 65 to 75 (13) 75 to 85 (14) 85 Up. (15) Total deaths, whether of " Residents' or " Non-Residents," in Institutions in the District. (16) 5.—Diseases of the Digestive System—Continued. Infective Enteritis 1 ... 1 ... ... ... ... ... ... ... ... ... ... ... ... Diarrhoea, not returned as infective 2 2 ... ... ... ... ... ... ... ... ... ... ... ... 1 Enteritis, not returned as infective ... 8 5 ... ... ... ... ... ... 1 1 ... ... 1 ... 3 Gastro-Enteritis, not returned as infective 4 3 ... ... ... ... ... ... ... ... ... ... ... 1 2 Dyspepsia, under 2 years ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Colic ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ulceration of Intestines ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 Duodenal Ulcer... 2 ... ... ... ... ... ... 1 ... ... ... 1 ... ... 3 Ankylostomiasis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Intestinal Parasites ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Appendicitis 11 ... 1 1 ... 2 1 1 1 2 2 ... ... ... 9 Hernia 6 1 ... ... ... ... ... ... ... ... 1 3 1 ... 5 Intestinal Obstruction 8 4 ... ... ... ... ... 2 ... ... ... 1 1 ... 4 Other Diseases of the Intestines 3 1 ... ... ... ... ... ... ... 2 ... ... ... ... 3 Acute Yellow Atrophy of Liver 2 1 ... 1 ... ... ... ... ... ... ... ... ... ... ... Hydatid of Liver ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cirrhosis of Liver (not returned as Alcoholic) 8 ... ... ... ... ... ... ... 1 3 3 1 ... ... 2 Cirrhosis of Liver (returned as Alcoholic) 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... Diseases formerly classed to " Other Diseases of Liver and Gall Bladder " 2 ... ... ... ... ... ... ... ... ... 2 ... ... ... ... Biliary Calculi 2 ... ... ... ... ... ... ... ... 1 1 ... ... 4 Other Diseases of the Liver 4 1 ... 1 1 ... ... ... ... 1 ... ... ... ... 1 Diseases of the Spleen 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... ... Peritonitis (cause unstated) 5 ... ... ... ... ... ... ... ... ... ... 1 ... ... 5 Other Diseases of the Digestive System 2 ... ... ... ... ... ... ... ... 2 ... ... ... ... 6.—Non-Venereal Diseases of the Genito-Urinary System and Annexa. Acute Nephritis 2 ... ... ... ... 1 ... ... 1 ... ... ... ... ... 1 Bright's Disease 23 ... ... ... ... ... ... 2 ... 2 6 10 3 ... 6 Nephritis (unqualified), 10 years and over, Uraemia 3 1 ... ... ... ... ... ... ... ... ... 2 ... .... ... Chyluria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of Kidney and Annexa 5 ... ... ... 1 ... ... ... 2 1 ... 1 ... 3 71 Calculi of the Urinary Passages 3 ... ... ... ... ... ... ... ... 2 1 ... ... ... ... Diseases of the Bladder 2 ... ... ... ... ... ... ... 1 ... 1 ... ... ... 1 Diseases of the Urethra, Urinary Abscess, &c. ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Prostate 14 ... ... ... ... ... ... ... ... ... 2 5 ... ... 10 Non-venereal Diseases of Male Genital Organs ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Uterine Haemorrhage (non-puerperal) ... ... ... ... ... ... ... ... ... ... ... ... ... ... Uterine Tumour (non-cancerous) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Uterus 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ovarian Cyst, Tumour (non-cancerous) 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... ... Other Diseases of the Female Genital Organs 2 ... ... ... ... ... 1 1 ... ... ... ... ... ... 2 Non-puerperal Diseases of the Breast (non-cancerous) 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 7.—The Puerperal State. Abortion ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Haemorrhage of Pregnancy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Uncontrollable Vomiting ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ectopic Gestation ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Accidents of Pregnancy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Haemorrhage ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Accidents of Childbirth ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever 2 ... ... ... ... ... ... ... ... ... ... ... ... ... 2 Puerperal Albuminuria and Convulsions 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 Puerperal Phlegmasia Alba Dolens and Phlebitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Embolism and Sudden Death ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Insanity ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Diseases of the Breast ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 8.—Diseases of the Skin and. of the Cellular Tissue. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Senile Gangrene 6 ... ... ... ... ... ... ... ... ... 1 1 3 1 4 Gangrene, other types ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Carbuncle, Boil 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... Phlegmon, Acute Abscess 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... 9 Ulcer, Bedsore 1 ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 Eczema ... ... ... ... ... . . . ... ... ... ... ... ... ... ... ... ... Pemphigus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Integumentary System 2 ... ... ... ... ... ... ... ... 2 ... ... ... ... ... 9.—Diseases of the Bones and of the Organs of Locomotion. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Bones 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... Diseases of the Joints 2 ... ... ... ... 1 ... ... ... ... ... 1 ... ... 1 Amputations ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Locomotor System ... ... ... ... ... ... ... ... ... ... ... ... ... ... 72 Table II.—DEATHS OF WILLESDEN RESIDENTS—continued,. CAUSE OF DEATH. 0) All Ages. (2) 0 to 1 (3) 1 to 5 (4) 5 to 10 (5) 10 to 15 (6) 15 to 20 (7) 20 to 25 (8) 25 to 35 (9) 35 to 45 (10) 45 to 55 (11) 55 to 65 (12) 65 to 75 (13) 75 to 85 (14) 85 Up. (15) Total deaths whether of " Residents " or " Non-Residents," in Institutions in the District. (16) 10.—Malformations. Congenital Hydrocephalus 1 ... l ... ... ... ... ... ... ... ... ... ... ... 1 Phimosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... Congenital Malformation of Heart 3 2 ... 1 ... ... ... ... ... ... ... ... ... Other Congenital Malformations 5 4 ... ... ... ... ... ... ... ... 1 ... ... ... 1 11.—Diseases of Early Infancy. Premature Birth 42 42 ... ... ... ... ... ... ... ... ... ... ... ... 10 Infantile Atrophy, Debility and Marasmus 10 10 ... ... ... ... ... ... ... ... ... ... ... ... 3 Icterus Neonatorum f* 1 1 /""\ 1 XT l 2 2 ... ... ... ... ... ... ... ... ... ... ... ... ... Sclerema and Oedema Neonatorum 1 l ... ... ... ... ... ... ... ... ... ... ... ... ... Want of Breast Milk ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of Umbilicus, &c ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Atelectasis 4 4 ... ... ... ... ... ... ... ... ... ... ... ... 2 Injuries at Birth ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cyanosis Neonatorum ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Lack of Care 1 l ... ... ... ... ... ... ... ... ... ... ... ... ... 12.—Old Age. Old Age 75 ... ... ... ... ... ... ... ... ... 2 18 32 23 44 13.—Affections produced by External Causes. Suicide by Poison 5 ... ... ... ... 1 1 1 ... ... 1 1 ... ... 3 Suicide by Asphyxia 7 ... ... ... ... ... 3 2 1 1 ... ... ... 1 i Suicide by Hanging or Strangulation 2 ... ... ... ... ... ... ... ... 1 l ... ... ... 1 Suicide by Drowning l ... ... ... ... ... ... ... ... ... 1 ... ... ... ... Suicide by Firearms l ... ... ... ... ... ... ... ... ... 1 ... ... ... ... Suicide by Cutting or Piercing Instruments 2 ... ... ... ... ... ... ... ... ... 1 ... ... ... 2 Suicide by Jumping from High Place ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Suicide by Crushing I ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Suicides l ... ... ... ... ... ... ... ... 1 ... ... ... ... ... Poisoning by Food ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Acute Poisonings ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Conflagration ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 73 Burns (conflagration excepted) 5 1 1 ... ... ... ... ... ... 1 ... 1 1 ... 5 Absorption of Deleterious Gases (conflagration ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... excepted) 3 2 ... ... ... ... ... ... ... ... ... 1 ... ... .... . . Accidental Drowning 5 ... ... ... 2 2 ... ... ... ... 1 ... ... ... ... Injury by Firearms ... ... ... ... ... ... ... ... ... ... ....... ... ... ... ... Injury by Cutting or Piercing Instruments ... ... ... ... ... ... ... ... ......... ... ... ... ... ... ... Injury by Fall 11 2 1 3 1 7 Injury in Mines or Quarries ... ... ... ... ... ......... ... ... ... ... ... ... ... ... ... Injury by Machines 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... Injury by Other Crushing, Vehicles, Railways, ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... slides, &c. 23 ... ... 5 1 1 2 1 4 3 2 3 ... 1 12 Injury by Animals ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Starvation ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Excessive Cold ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Effect of Heat ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Lightning ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Electricity (lightning excepted) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Homicide by Firearms ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Homicide by Cutting or Piercing Instruments ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Homicide by Other Means 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Fractures (cause not specified) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Violence ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 14.—Ill-defined Causes. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Dropsy ... ... — ... ... ... ... ... ... ... ... ... ... ... .... . . Syncope (aged 1 year and under 70) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Sudden Death (not otherwise defined) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...... Heart Failure (aged 1 year and under 70) 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 Atrophy, Debility, Marasmus (aged 1 year and under ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 70) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Teething ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pyrexia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Ill-defined Deaths ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cause not Specified ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 1,653 143 73 37 22 30 39 69 113 188 270 332 253 84 592 74 Appendix a.—table III.—infant mortality during 1926. Nett Deaths from Stated Causes at Various Ages under 1 Year of Age. Nett Deaths from all Causes under one year of age classified tn Wards. Cause of Death. Under 1 week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under One Year. South Kilburn. MidKilburn. North Kilburn Brondesbury Park. wards. Stonebridge. Roundwood. Church End. Willesden Green. Cricklewood. Kensal Rise. Harlesden. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (h) j (15) (16) (17) (18) (19) (20) (21) (22) All Causes f Certified 44 4 6 6 60 34 17 13 18 142 22 17 10 5 4 1 1 20 14 13 22 4 Uncertified — — — — — — 1 — — 1 — — — — — 1 — — — — — Small Pox — — — — — — — — — — — — — — — — — — — - Chicken Pox — — — — — — — — — — — — — — — — — — — — — Measles — — — — 1 2 3 2 — — — 1 — — — — — — Scarlet Fever — — — — — — — — — — — — — — — — — — — — Whooping Cough — — — — — 3 — 1 — 4 2 — — — — — 2 — — — — Diphtheria and Croup — — — — — — — — — — — — — — — — — — — — — Erysipelas — — — — — 1 — — — 1 — — 1 — — — — — — — — Tuberculous Meningitis — — — — — — 1 1 1 — — — — — — — — — Abdominal Tuberculosis (a) —. — — — — — — — — — — — — — — — — j^Other Tuberculous Diseases : — — — — — — — — 1 1 — — — — — — — — — — Meningitis (not Tuberculous) — — — — 1 — — 1 — — — — — — — — — — — Convulsions — — 2 2 — — — — — — — 1 — — — Laryngitis - - - - - - - - 1 — — 1 — Bronchitis — 1 — 1 3 2 6 - 1 - - - 1 1 - - - - Pneumonia (all forms) — — ; — — 9 6 8 8 31 8 2 2 1 1 1 1 - 1 2 — Diarrhoea — - - - - 1 - - 2 1 1 - - - 1 5 2 4 5 — Enteritis 1 — - 1 3 2 1 1 8 - 2 1 - - 1 1 1 — — — Gastritis - - - - - - - - - - - - - - - - — 2 — Syphilis ; ' i - - - - - - - - - — — — — — — Rickets - - - 1 1 - 1 1 - - - - - — — — Suffocation, overlying 1 — — — 1 1 - 2 - - 1 - - - - 1 — — - Injury at birth — — — - - - - - - - - - - - 1 - — — Atelectasis 3 — — — 3 1 - - - 4 - 2 1 - - - - - — — — Congenital Malformations (b) 3 - 1 — 4 1 - 1 - 6 - 1 - 1 - 1 2 1 — — . — Premature Birth 28 1 3 2 4 37 4 1 42 6 2 2 - 2 3 4 4 6 9 4 ^ Atrophy, Debility and Marasmus 2 - 2 1 5 3 1 1 - 10 2 1 1 1 - 2 2 1 - - - Other Causes 7 — — 1 8 4 3 — 3 18 - 3 1 2 — 3 2 2 2 3 - Total Deaths 44 4 6 6 60 34 18 13 18 143 22 17 10 5 4 12 20 14 13 22 4 Deaths—Legitimate 39 4 5 5 53 34 15 11 16 129 18 15 8 5 4 11 20 12 12 21 3 Illegitimate 5 - 1 1 7 — 3 2 2 14 4 2 2 - - 1 - 2 1 1 1 Births—Legitimate ... ... ... ... ... ... ... ... ... 2,617 310 250 156 89 178 237 358 266 237 974 962 Illegitimate ... ... ... ... ... ... ... ... ... 83 9 7 6 3 7 3 16 7 7 12 6 Total Births ... ... ... ... ... ... ... ... ... 2,700 319 257 162 92 185 240 374 273 244 286 268 Infant Mortality Rate— Legitimate ... ... ... ... ... ... ... ... ... 49.29 58.06 60.00 51.28 56.18 22.47 46.41 55.87 45.11 50.63 76.64 11.45 Illegitimate ... ... ... ... ... ... ... ... ... 168.67 444.44 285.71 333.33 — — 333.33 - 285.71 142.86 83.33 166.66 Infant Mortality Rate ... ... ... ... ... ... ... ... ... 52.96 68.97 66 15 61.73 54.35 21.62 50.00 | 53.48 51.28 j 53.28 76.92 14.93 Population ... ... ... ... ... ... ... ... ... 173854 15,051 14,697 13,490 9.604 13,632 17,660 18,891 16.551 115,555 ' 17,492 21,231 (a) Under Abdominal Tuberculosis are included Deaths from Tuberculous Peritonitis and Enteritis and from Tabes Mesenterica. (b) Want of Breast Milk is included under Atrophy and Debility. ' APPENDIX A—Table IV.-CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1926. Notifiable Disease. Number of Cases Notified. Total Cases Notified in each Ward. At Ages—Years. South Kilburn. Mid-Kilburn. North Kilburn. Brondesbury Park. Kensal Rise. Harlesden. Stonebridge. Roundwood. Church End. Willesden Green. Cricklewood. Total Cases removed to Willesden Municipal Hospital. At all ages. Under 1. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (ID (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) Small Pox 2 - - - - 2 - - - - 2 - - - - - - - - 2* Cholera (C) Plague (P) - - - - - - - - - - - - - - - - - - - - Diphtheria (including Membranous Group) 466 9 130 258 42 24 3 - 55 48 11 6 23 31 154 40 41 45 12 441 Erysipelas 68 3 3 5 7 14 25 11 10 5 5 2 3 7 7 11 6 4 8 6 Scarlet Fever 359 1 99 197 41 19 2 — 39 46 13 23 22 24 68 31 31 38 24 329 Typhus Fever - - - - - - - - - - - - - - - - - - - - Enteric Fever 7 — — 1 1 3 2 — — — — 1 — — 1 1 2 1 1 4 Relapsing Fever (R) Continued Fever (c) - - - - - - - - - - - - - - - - - - - - Puerperal Fever 16 — — ' — 5 11 — — 1 — — 1 — 1 6 3 — 3 1 3 Puerperal Pyrexia 24 — — — 8 16 — — 1 6 2 — — 3 9 1 — — 2 2 Cerebro-spinal Meningitis 1 1 - - - - - - - - - - - - - - - - - - Poliomyelitis 9 1 4 2 2 — — — 2 — 1 — — — 1 1 — 1 3 1 Ophthalmia Neonatorum 30 30 - - - - - - 1 2 2 — 2 4 9 2 5 2 1 3 Pulmonary Tuberculosis 271 2 3 14 68 122 58 4 51 29 18 9 20 20 34 29 18 22 21 — Other forms of Tuberculosis 68 — 8 23 13 12 11 1 11 10 1 3 6 3 5 13 5 7 4 — Whooping Cough 419 55 189 167 2 6 — — 75 33 10 19 26 38 88 35 23 43 29 5 Pneumonia 232 18 38 37 27 56 41 15 55 50 8 12 11 14 35 17 14 14 2 1 Malaria 2 - - - - - - - - - - - - - - - - - - - Dysentery - - - - - - - - - - - - - - - - - - - - Trench Fever - - - - - - - - - - - - - - - - - - - - Encephalitis Lethargica 9 — 1 — 2 5 1 — 3 1 2 1 - - - - - 1 1 1 Acute Polio Encephalitis - - - - - - - - - - - - - - - - - - - - Anthrax - - - - - - - - - - - - - - - - - - - - Totals 1,983 120 475 704 218 292 143 31 304 230 76 77 113 145 417 186 145 181 109 798 * Removed to Willesden Small Pox Hospital, Kingsbury. 75 77 APPENDIX B. Showing Acts of Parliament, Local Government Orders, Memoranda, and Circularletters issued by Government Departments with regard to the Public Health, Education and Maternity and Child Welfare Services during the Year 1926. Training and Appointment of Health Visitors.—Circular No. 680 (Ministry of Health 22nd March, 1926). Welfare of the Blind.—Circular No. 681 (Ministry of Health, 29th March, 1926). Sanitary Office^' Order, 1926.—Circular No. 701 (Ministry of Health, 29th May, 1926). The Sanitary Officers' Order, 1926.—27th May, 1926. Diseases of Animals—Markets, Sales and Lairs Temporary Order of 1926.—23rd January, 1926. The Foot and Mouth Disease (Packing Materials) (Amendment) Order of 1926.—19th January, 1926. Supervision of Smallpox Contacts.—Circular No. 698 (Ministry of Health, 10th May, 1926). Public Health (Imported Food) Regulations, 1925.—Circular No. 708 (Ministry of Health, 23rd June, 1926). Milk and Dairies Order, 1926.—Circular No. 711 (Ministry of Health, 12th July, 1926). Public Health (Imported Milk) Regulations, 1926. Public Health (Imported Food) Regulations, 1925.—Circular No. 713 (Ministry of Health, 14th July, 1926). Public Health (Tuberculosis) Regulations, 1912.—Circular No. 718 (Ministry of Health, 23rd July, 1926). Milk and Dairies Order, 1926.—Dated 6th July, 1926. The Public Health (Imported Milk) Regulations, 1926.—6th July, 1926. Diseases of Animals.—Order of the Ministry of Agriculture and Fisheries, dated 27th March, 1926, suspending operation of the Diseases of Animals Disinfection Order of 1925. Diseases of Animals.—Diseases of Animals Disinfection Order, 1926. Diseases of Animals.—Market, Sales and Lairs (Amendment) Order of 1926.—14th May, 1926. Notification and Treatment of Ophthalmia Neonatorum.—Circular No. 617 (Ministry of Health, 9th August, 1926). Notification and Treatment of Ophthalmia Neonatorum.—Circular No. 617a (Ministry of Health, 9th August, 1926). Puerperal Fever and Puerperal Pyrexia.—Circular No. 722 (Ministry of Health, 9th August, 1926). The Midwives and Maternity Homes Act, 1926.—Circular No. 724 (Ministry of Health, 16th August, 1926). The Public Health Ophthalmia Neonatorum Regulations, 1926.—dated 31st July, 1926. The Public Health Notification of Puerperal Fever and Puerperal Pyrexia Regulations, 1926.— dated 31st July, 1926. Cancer.—Circular No. 716 (Ministry of Health, 16thJSeptember, 1926). # Cancer of the Breast.—Memoranda (Ministry of Health, August, 1926). Provision of Facilities for Practical Training of Candidates for Sanitary Inspectors' Certificate.- — Circular No. 736 (Ministry of Health, 4th October, 1926). The Midwives and Maternity Homes Act, 1926. Code of Regulations for Public Elementary Schools.—Board of Education. Elementary Education (Substantive Grant) Amending Regulations No. 1, 1926.—Board of Education. 78 APPENDIX C. REPORT ON THE EDUCATION OF DEAF CHILDREN IN THE WILLESDEN URBAN DISTRICT. I beg to report in accordance with the following Minute of the Children's Care Committee :— " No. 2764, G.A. (23/12/19), Royal School for Deaf and Dumb, Margate. The parents withdrew the above-named child from the Institution on 28th November, 1925, notwithstanding our advice that this should not be done. We have adjourned consideration of this case until the child reaches the age of 7 years. In connection herewith we have requested the Medical Officer to report on the number of deaf and dumb children in the district, and the possibilities of providing for their education locally." The number of deaf children in the area and the number now being educated at Residential Deaf Schools are shown in the accompanying table :— Defect. Total No. of children. No. attending special residential schools. No. attending special day schools. No. attending ordinary elementary schools. No. not attending school. Deaf-mute 12 7 2 0 3 Deaf semi-mute 3 0 1 0 2 Semi-deaf 7 3 0 4 0 Total 22 10 3 4 *5 * Of these children not attending any school, 2 are under 5 years of age, 1 is under 7 years of age and has been withdrawn by the parents from a residential institution, 1 is suffering from severe heart disease which renders her attendance at school inadvisable, and the parents of the remaining child have been ordered by the Court to send her to a residential institution but have not yet complied with this order. Willesden Deaf Class.—It will be seen from the above Table that the number of children available and suitable for a deaf class in Willesden is only 13, viz., 10 children in Residential Schools for the Deaf and 3 children attending Special Day Schools, which is too small a number to make a Willesden Deaf Class or School a practical proposition. L.C.C. Deaf Schools {Day).—It might be possible for the Education Committee to arrange with the London County Council for the admission to their Special Day Deaf Schools of all the Willesden children at present being maintained in residential deaf institutions. There would, however, probably be considerable delay in their admission to these schools even if there should be accommodation available, as such delay is experienced at present in arranging the admission of the few children (3 at present) now sent from Willesden to these schools. Moreover, it seems very doubtful if any economy would be effected by such an arrangement as the following figures show :— Total cost per annum of maintaining each child at the Royal School for Deaf £ s. d. and Dumb Children, Margate 75 0 0 Grant payable on each child . 37 10 0 Net cost per child per annum . £37 10 0 Net cost per annum of sending child to L.C.C. School (Day)forDeaf andDumb £ s. d. Children, Ackmar Road, Fulham 29 10 0 Ditto. Hugh Myddleton Deaf School, Finsbury, E.C 35 0 0 In the case of these two Schools the Education Committee is charged the net cost as above by the L.C.C., to whom the grant for the children attending is paid direct. Moreover, no contribution is payable by the parents. When considering the possibility of transferring the 10 Willesden children now in Residential Deaf Institutions either to a special class in Willesden or to London County Council special day schools, it should be borne in mind that all of these children have not available in their own homes the healthy surroundings, good food, and well-regulated existence that obtains in residential schools. GEORGE F. BUCHAN, Medical Officer of Health. To be presented to the Children's Care Committee on the 13th January, 1926. APPENDIX D. WILLESDEN EDUCATION COMMITTEE. STAMMERING CHILDREN. I beg to report in accordance with the following Minute of the Children's Care Committee of 13th January, 1926 :— " Treatment of Stammering Children. The Managers of the Kensal Rise Group of Council Schools ask us to consider the advisability of extending at the earliest possible moment the existing facilities for the treatment of stammering children. A second class has just commenced at the Pound Lane Council School, and, before any further action is taken hereon, we are of opinion that it would be advisable for the Medical Officer to report on the progress of the scholars attending the stammering classes already formed. We therefore recommend— That the Managers of the Kensal Rise Group of Council Schools be informed that the Committee have adjourned consideration of their application pending the receipt of the above report." Pound Lane Class.—'This class having opened as lately as 12th January, 1926, no information of any value is at present available with regard to the progress of the scholars attending the class I propose, therefore, with your approval, to report on this matter at a later date. Percy Road Class.—The following particulars, therefore, refer only to the class held at the Percy Road Council School. The information given has been obtained from the reports of the Head Teachers, Mr. Bradfield, the instructor of the class, and the parents. GEORGE F. BUCHAN, Medical Officer of Health. To be presented to the Children's Care Committee on the 10th February, 1926. Name, Age and School. Condition on Admission to Class. Present Condition. Remarks. G, J. (10.9.14). Percy Road Boys. Consonantal and Vowel difficulties—A,E,H, I,0,Y. Faulty breath control. Contortion. Many bad habits of speech overcome. Nearly cured. Co-operating well. J, R. (14.8.11). Percy Road Boys. Involuntary jerky movements of legs. Unable to read aloud in class. Severe stammering. Bad habits completely overcome. No longer nervous and self conscious. Does not stammer. H, W. (19.4.14). Percy Road Boys. Much difficulty with many consonants. Faulty breathing. No consonantal difficulties now. Making rapid progress towards complete recovery. H, T. (18.4.13). Percy Road Boys. Consonantal difficulties—L,M,S,T. Faulty breath control. Jerky movements of legs. Greatly improved. Bad habits overcome. Stammers only occasionally when excited. Co-operating very well. V, W. (4.7.14). Percy Road Boys. Stammered badly, especially at beginning of sentences. Much difficulty with consonants. Faulty breathing. Can now read without hesitation. Difficulty still in answering questions when spoken to suddenly. Attendance in school poor. R, J. (7.10.12). Percy Road Boys. Very bad stammering. Consonantal difficulties— C,D,J,K,M,N,R,S,W. Breath control faulty, contortion, jerky movements of legs. Many bad habits of speech overcome. Stammering in his thoughts (hitherto very stubborn feature) now yielding to treatment. Taking an intelligent interest in his progress. W, H. (24.3.14). Salusbury Road Mixed Very bad stammering. Consonantal and vowel difficulties—A,B,C,G,H,M,N,S,W. Faulty breathing. Contortion, very defective articulation. Great improvement during first 3-4 months, but no improvement lately owing to failure to carry out instructions. Very lazy and indifferent. Defective vision. Father also has an impediment and this handicaps boy. S, A. (1.12.13). Formerly attending Gordon Memorial Boys. Now attending Christ Church. Very bad stammering. Consonantal and vowel difficulties—B,F,H,M,O.R,V. Faulty breathing, contortion, jerky movements of limbs, defective articulation. Did well at first, but owing to development of indifference, progress has not lately been well maintained. Would improve much more rapidly with better effort and attentiveness. J, J. (1.6.19). Chamberlayne Wood Road Boys. Much difficulty with many consonants, faulty breathing, defective articulation. Very backward in reading. Did well while in attendance from September 11th to November 10th, 1925. Treatment interrupted owing to having to go to hospital. W, F. (16.4.13). Formerly attending Holy Trinity Boys. • Consonantal and vowel difficulties—C,D,E,F,H, J,K,M,N,P,Q,S,T,W. Faulty breathing, twitching of forehead, jerky movements of legs. All bad habits completely overcome. Doing well. Very impulsive. 80 APPENDIX E. MOTOR SERVICE. I beg to report on the above for its twelfth complete year ending March 31st, 1926. There are ten motor vehicles used in connection with this service, seven of which came into use December, 1913, one in April, 1924, one in March, 1925, and one in July, 1925. Up to the end of March, 1926, these ten vehicles had covered a total of 723,497 miles. A ten year loan was obtained to purchase the first seven cars and the last payment in respect of this loan was made in September, 1923. The last three cars were purchased out of revenue. All the cars are in service and working daily. There is no reserve car. All repairs are done at the garage. The routes of the School Ambulances have now been increased to 12, 11 of which are for Physically and Mentally Defective children and one for Blind Children. Approximately 140 children are carried daily to and from school. 25,949 Calls have now been made for Ambulances and 13,494 houses have been disinfected since the Motor Service was inaugurated in 1913. During the year under review the chief work has been :— Conveyance of Ambulance patients, Physically Defective, Mentally Defective, Blind and Stammering Children, and Children to Laundry Classes. Disinfection including the removal and return of bedding and other articles ; carriage of clinic aundry ; and Certain work for other departments. A day and night service is in operation for Ambulance calls. The personnel of the service consists of :— 1 Mechanic Superintendent and Engineer. 1 Assistant Engineer. 12 Motor Drivers. 1 Disinfector. The working hours are 47 per week. The service, in addition to the foregoing, undertakes the following work :— Repairs to three vehicles in the Engineers' Department, and four fire engines, and Engineering work of Municipal Hospital in respect of which an Assistant Engineer is employed. Calls for the Ambulance are heavy, V.A.D. calls alone occupying a considerable time. Not infrequently it occurs that several cases are waiting for removal. In these circumstances, as far as possible, the most serious cases are removed first. A certain number of accident calls have not been answered owing to the car or driver being engaged, and lack of means of calling assistance. The following table shows the number of miles run under the various headings since the inception of the service :— Mites Run during the Year ending 31st March. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1924. 1925. 1926. Total. 20,592 17,579 20,530 22,933 23,365 24,454 25,445 30,440 30,792 31,106 31,322 45,944 324,502 — 6,343 9,857 9,664 7,857 8,731 9,222 7,266 5,706 6,232 7,630 8,871 7,540 94,919 Accidents, Sickness and Infectious Cases — 9,491 8,002 7,871 6,965 12,703 20,275 23,664 24,403 19,407 16,669 16,653 20,626 186,729 — 5,977 4,998 4,488 3,337 4,534 5,055 4,947 5,923 5,248 4,460 5,037 5,186 59,190 Conveyance of Wounded to Hospitals and Entertainments 1,978 5,020 1,636 1,173 49 — — — — — — 9,856 Conveyance of Grave Diggers — — — — — 263 — — — — — — — 263 Concert Parties to Hospitals for Wounded _ _ 138 378 72 126 77 192 — — — — — 983 Education Department — — — — — 123 287 341 313 689 807 435 6,407 9,402 Accountant's Department — 416 2,292 1,546 1,321 1,290 647 104 12 — 9 — 37 7,674 Engineer's Department, including Committees — 243 90 119 120 205 67 207 234 286 366 185 356 2,478 Clerk's Department — — — 75 89 105 8 56 99 50 27 18 132 659 Health Department — — — — — 313 239 156 60 171 34 — 128 1,101 Registration Department — — 1,217 — — 15 — — — — — — — 1,232 Refugee Work — 774 209 56 — 78 84 — — — — — — 1,201 Recruiting Demonstration — 28 681 — — — — — — — — — — 709 — 181 242 73 275 256 238 394 251 239 86 388 368 2,991 Dollis Hill House Hospital Committee — — 75 311 200 82 95 60 136 119 115 — — 1,193 — — — — 1,591 601 407 33 — — — — — 2,632 Miscellaneous — 53 75 — 496 24 30 60 51 404 271 671 192 2,327 General, including all foregoing 12,571 — — — — — — — — — — — — 12,571 Elections — — — — — 187 72 — 71 144 73 126 94 767 Library Committee — — — — — — — — — 17 — 37 20 47 Investigation Committee — — — — — — — — — 44 — — — 44 12,571 44,098 47,433 50,131 46,892 54,174 61,306 62,925 67,699 63,842 61,653 63,743 87,030 723,497 82 Miles Run by each Vehicle. Car Number. Delivery to 31/3/14. 1/4/14 to 31/3/15. 1/4/15 to 31/3/16. 1/4/16 to 31/3/17. 1/4/17 to 31/3/18. 1/4/18 to 31/3/19. 1/4/19 to 31/3/20. 1/4/20 to 31/3/21. 1/4/21 to 31/3/22. 1/4/22 to 31/3/23. 1 /4/23 to 31/3/24. 1/4/24 1/4/25 to 31/3/26. Miles run since delivery to * 31/3/26. Disinfecting Van M.X. 1884 2,755 6,440 5,196 4,605 3,926 5,229 5,318 3,943 6,054 5,336 4,475 4,877 4,748 62,902 Landaulette M.X. 2056 1,466 6,385 10,579 10,248 7,981 8,947 9,358 7,746 6,222 7,375 8,727 9,470 8,000 102,504 School Bus M.X. 2057 1,801 7,648 6,915 10,208 8,735 7,275 8,711 8,114 8,335 9,049 10,350 9,5S6 9,270 105,997 Infectious Ambulance M.X. 2058 1,418 5,591 3,912 2,803 3,596 4,728 11,383 11,327 9,964 8,808 5,138 4,140 o,080 78,888 School Bus M.X. 2059 2,254 7,176 9,036 10,680 9,060 7,604 8,609 5,954 10,603 12,318 8,939 11,267 9,896 113,396 Accident Ambulance M.X. 2060 725 3,900 4,686 4,961 6,240 8,899 11,235 15,715 15,754 10,086 13,483 10,104 9,938 115,726 School Bus M.X. 2061 2,152 6,958 7,109 6,626 7,354 11,492 6,692 10,126 10,767 10,870 10,541 10,216 8,502 109,405 Ambulance M.F. 4117 — — — — — — — — — — — 3,697 11,854 15,551 School Bus M.H. 3908 — - — — — — — — — — — 386 11,922 12,308 Education Car M.H. 8989 — — — — — — — — — — — — 6,820 6,820 Totals 12,571 44,098 47,433 50,131 46,892 54,174 61,306 62,925 67,699 63,842 61,653 63,743 87,030 723,497 The above table shews the number of miles run by each vehicle during the twelve complete financial years from April 1st, 1914, to March 31st, 1926, and since delivery to the latter date. Calls. The following table shews the number of calls for the Disinfecting Van, Infectious Ambulance, and Accident Ambulance respectively during the twelve complete years, 1st April, 1914, to 31st March, 1926, and since delivery to the latter date. — Delivery to 31/3/14. 1/4/14 to 31/3/15. 1/4/15 to 31/3/16. 1/4/16 to 31/3/17. 1/4/17 to 31/3/18. 1,4/18 to 31/3/19. 1/4/19 to 31/3/20. 1/4/20 to 31/3/21. 1/4/21 to 31/3/22. 1/4/22 to 31/3/23. 1 /4/23 to 31/3-24. 1/4/24 to 31/3/25 1/4/25 to 31/3/26. Total. No. of calls for Disinfecting Van 370 1,167 957 787 653 716 1,276 1,661 2,464 1,194 741 C65 843 13,494 *No. of calls for Infectious Ambulance 250 940 696 528 641 672 1,601 1,653 1,811 1,472 896 394 727 12,281 *No. of calls for Accident and Illness Ambulances 40 372 388 471 426 797 1,009 1,779 2,078 1,440 1,484 1,514 1,870 13,668 * Owing to the demand on the ambulances it is impossible to keep them to the work specified, and infectious cases are sometimes removed on the Accident Afhbulance and non-infectious on Infectious Ambulance. The Accident and Illness Ambulances also do relief school work. Year ending March 31st. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1924. 1925. 1926. Total No. of miles run by the 10 vehicles . 44,098 47,433 50,131 46,892 54,174 61,306 62,925 67,699 63,842 61,653 63,743 87,030 Total No. of gallons of petrol consumed 3,988.5 4,035 . 5 4,673 4,619 5,569 6,388 6,702 6,038 5,370 5,167 5,351 7,189 No. of miles per gallon of petrol consumed 11.0 11.75 10.73 10.15 9.73 9.59 9.05 11.21 11.888 11.932 11.89 12.106 Cost in pence per mile run 13.4 12.08 11.78 13.64 15.03 16.98 19.0 16.95 14.924 13.826 16.405 13.654 Storage Plant.—The petrol storage plant installed in January, 1915, is still working satisfactorily, and is now supplying the Engineer's Department of the Council also, saving that department Id. per gall., or £25 per annum. To save costs the petrol is sometimes conveyed with bedding and clothing, which appears undesirable. This plant, which finished paying for itself in 1919 by its saving in taking bulk supply, has cost nothing in upkeep except the replacement of one delivery hose. Workshop Plant.—This is in good order and effects a great saving, both in motor and hospit a repairs which are both increasing. Accidents.—I am pleased to report that no accidents occurred during the year. Replacements Required.—Seven of the vehicles attached to this service have now been in constant use for 12 years, and as the demands on the service are increasing, and the repairs to the vehicles become more frequent, replacements should be considered. Five of these vehicles have covered more than 100,000 miles each. Cloak Room.—This is now too small for the number of men concerned, and clothes are packed on top of one another or laid about. GEORGE F. BUCHAN. Medical Officer of Health. To be submitted to the Health Committee on the 12th October, 1926. 83 WILLESDEN URBAN DISTRICT COUNCIL. PUBLIC HEALTH DEPARTMENT MOTOR SERVICES. Year ended 31st March. 1926. Cost per mile Expenditure. £ s. d. £ s. d. Running Expenses :— Petrol 403 12 2½ Oils and Greases 33 13 9 Tyres 231 13 4 668 19 3½ 1.845 Wages and Emoluments :— Mechanic Superintendent 278 10 0 Drivers, etc 2,609 0 4½ National Insurance (Employers' Contributions) 19 11 4 2,907 1 8½ 8.017 Fixed and General Charges :— Rent (Garage and Mess Room) 187 0 0 Repairs, Plant, etc. 189 15 7 Painting, &c., Bodies of Vehicles 62 9 1 Coal, Gas, etc. 50 9 2 Uniforms and Overalls 120 4 2 Insurance of Vehicles 64 3 6 Motor Car Tax 79 7 6 Drivers' Licences 4 5 0 Accessories and Sundries 72 16 10 830 10 10 2.290 Depreciation and Interest Charges in respect of capital expenditure out of Revenue :— 4,406 11 10 12.152 Amount written off value of vehicles purchased from Revenue account in accordance with Medical Officer of Health's Valuation 481 8 8 Interest on capital employed 63 3 4 544 12 0 1.502 £4,951 3 10 13.654 Income. Use of Vehicles for— Conveyance of Patients 90 8 9 Election purposes 5 17 6 £96 6 3 Petrol consumed 7,189 galls. Miles run by all vehicles 87,030 „ run per gallon of petrol consumed 12.106 Finance Department, 31st July, 1926. APPENDIX F. For the consideration of the Health Committee. MEMORANDUM ON ANTE-NATAL CARE. The practice at the ante-natal clinics of the authority includes :— Attendances. (1) Attendance of the expectant mother monthly up to within six weeks of the expected confinement. (2) Attendance of the expectant mother fortnightly at the clinic during the last six weeks of pregnancy. Blood Pressure Test. During the course of attendance physical examination of the patient is conducted from time to time and the urine is tested at every attendance. The physical examination does not as a rule include a blood pressure test, although this is sometimes applied to confirm some provisional diagnosis. 84 The medical staff of the Authority are of opinion that this test should be carried out several times during the attendance of an expectant mother at the ante-natal clinics, not only for purposes of confirmation or otherwise of a condition provisionally diagnosed but for purposes of presaging the existence of some condition not otherwise apparent. It is claimed for this test that it may sometimes give warning of the onset of toxaemia during pregnancy, but the reservation must be made that the test is not absolute and will in some cases fail to give warning of danger. Nevertheless to the extent to which it may be helpful in suggesting possible danger ahead, it is a test which would be useful and should be carried out. 376 expectant mothers attended the ante-natal clinics 1,113 times during 1925 and 324 new cases and 117 cases brought forward from 1925 have made 1,574 attendances in 1926. An expectant mother then at present attends on the average 3 to 4 times during her pregnancy and probably occupies the time of a doctor 1 hour. The blood pressure test would take on the average something like five or six minutes or say add fifteen minutes to the average time now given by a doctor during the attendances of an expectant mother. This means that the following additional time has to be found per annum by the clinic medical staff on the basis of the current year's figures :— Approximate number of Expectant mothers attending during 1928 Approximate additional time required per annum for applying blood pressure test. Dr. Maitland, Clinic I. 65 16 hours. Dr. Nicoll, Clinic I. Ill 27 hours. Dr. Mackenzie, Clinic II. 176 44 hours. Dr. Gray, Clinic II. 169 42 hours. The total attendances of all cases actually seen by the medical staff during the 4 weeks ended 6/11/26 were as follows:— Dr. Maitland, Clinic I. 866 Dr. Nicoll, Clinic I. 1,193 Dr. Mackenzie, Clinic II 1,404 Dr. Gray, Clinic II 1,814 Each clinic medical officer spends 30 sessions every four weeks in the clinic. An afternoon session is 2f hours and a morning session 3 hours. Allowing that 30 cases may be seen per session it is obvious that 900 cases can be dealt with per doctor per 4 weeks and when the number is 1,000 a figure has been reached that may still be assumed to be not unreasonable. The above figures shew that it is possible for Dr. Maitland to carry out the test, that it may be just possible for Dr. Nicoll but that it is impossible for Drs. Mackenzie and Gray. Following-up. In the case of School Children who fail to attend the clinics at the times appointed by the Medical Officers subsequent visits are paid by the Health Visitors to ascertain if any reason of ill health prevented attendance. In the case of expectant mothers and babies this procedure is not operative. In the opinion of the medical staff it is desirable that the same procedure should be adopted in the case of expectant mothers to ascertain if illness often presumed by the patient to be either of a minor character or necessarily incidental to her condition has overtaken the expectant mother preventing her attendance. The institution of this procedure would, however, again tend to increase attendances with which the present staff are unable to cope. George F. Buchan, December, 1926. Medical Officer^of Health. APPENDIX G. REPORT ON ARTIFICIAL LIGHT TREATMENT FOR THE YEAR ENDED 31st DECEMBER, 1926. by H. HALDIN-DAVIS, M.D., M.R.C.P., F.R.C.S., Dermatologist to the Council. (1) The Medical Officer in charge of the treatment is H. Haldin-Davis, M.A., M.D., B.Ch., F.R.C.S., M.R.C.P., Dermatologist to the Willesden Urban District Council and Royal Free Hospital. His appointment was approved by the Board of Education and the Ministry of Health on the 31st August, 1925. 85 (2) The Nursing Staff employed in connection with the Artificial Light Therapy consists of:— Sybil Miriam Smith—Fully trained nurse, London Hospital, 4 years ; 3 months in the Light Department of the London Hospital giving treatments by means of the Finsen and Mercury Lamps ; conjoint certificate, Chartered Society of Massage and Medical Gymnastics ; Medical Electricity Certificate, Chartered Society of Massage and Medical Gymnastics ; C.M.B. Certificate ; Health Visitors' Certificate, Royal Sanitary Institute. Miss Smith has been doing the Artificial Sunlight work since the clinic opened on the 16th November, 1925. Elizabeth Nullis—Fully trained nurse, City of London Infirmary ; C.M.B. Certificate ; Health Visitors' Certificate, Royal Sanitary Institute ; 6 weeks' course in Ultra-Violet Therapy at British Humane Association, Humanity House, 11, Tufton Street, S.W. 1. (Acts in Nurse Smith's absence.) (3) The type of lamp used is a Flaming Carbon Arc of Siebe & Gorman working at 30 amps. (4) The current used is direct. The voltage from the main is 240, but this is reduced by means of a resistance to 95 at the terminals of the lamp. The lamp hangs in the middle of a small room, round it is arranged a quadrangular barrier which keeps the patients at a proper distance. About 10 patients can be treated simultaneously. Owing to the confined space the atmosphere is liable to become oppressive, but in order to counteract this tendency an ozoniser has been installed which works satisfactorily. 86 (5) ARTIFICIAL LIGHT TREATMENT, YEAR ENDED 31st DECEMBER, 1926. Conditions. Total Cases Seen. Treated. Discharged without Treatment, i.e., unable to attend. Left district or unsuitable. Waiting List. Condition Improved. Treatment suspended. Still under observation. RESULT OF TREATMENT. Discharged. Improved or Cured. Unable to attend. Left district. Unsuitable or no Improvement. Still under Treatment. Under 5 years. 5-14 years. Under 5 years. 5-14 years. Under 5 years. 5-14 years. Under 5 years. 5-14 years. Under 5 years. 5-14 years. Under 5 years. 5-14 years. Under 5 years. 5-14 years. Under 5 years. 5-14 years. Under 5 years. 5-14 years. T uberculosis—Pulmonary - 1 - 1 - - - - - - - - - - - 1 - - Tuberculosis—Spine - 1 - 1 - - - - - - - - - - - - - - Tuberculosis—Abscess, Chin — 1 - - - - - - - - - - - - - - - - Tuberculosis—Glands, Neck 3 3 2 3 — — 1 — — 1 — — 1 — — — 1 2 Tuberculosis—Glands, Iliac Fossae - - - 1 - - - - - - - 1 - - - - - - Been in Sanatorium — 9 — 8 — — — 1 — 2 — 3 — 1 — — . — 2 Pre Tuberculosis 4 19 4 15 — 1 — 3 1 6 3 4 — 2 — — — 3 7 35 6 29 - 2 1 4 1 9 3 8 1 3 — 2 1 7 General Debility and Malnutrition 27 46 19 39 4 4 7 2 13 7 12 4 1 — — 6 13 Anaemia 1 7 1 3 — — — 4 1 1 - - - - - - - 2 Marasmus 2 — 2 - - - - - 1 - 1 - - - - - - - Rickets 19 — 11 - 3 — 5 — 5 — 2 — — — — — 4 — 49 53 33 42 7 — 9 11 9 14 10 12 4 1 — — 10 15 Chronic Blepharitis - 2 - 1 - 1 — — — — — — — — — — — 1 Chronic Conjunctivitis - 1 - 1 - - - - - - - - - - - - - 1 Corneal Ulcer - - - - - - - - - - - 1 - - - - - - — 4 — 3 — 1 — — — — — 1 - - - - - 2 Prurigo - 2 - 2 - - - - - - - - - - - - - - Psoriasis - 1 - 1 - - - - - - - - - - - 1 — — Dermatitis and Eczema 2 2 2 1 - 1 - - - - 1 - - - - - 1 1 Chronic Eczema-Asthma 1 - 1 - - - - - - - - - - - - - 1 — Alopecia Areata - 8 - 6 — — — 2 — — — 6 - - - - - - Post X-ray Alopecia 1 1 1 1 - - - - - - 1 1 - - - - - - Chilblains — 1 — 1 - - - - - - - - - - - - - 1 4 15 4 12 — 1 — 2 — 2 2 7 — — — 1 2 2 Asthma 3 6 2 5 - - 1 1 - 1 - 2 - — — 1 2 1 Chronic Bronchitis 1 3 1 1 1 1 — — 1 — - - - - - Rheumatic Heart, Bronchitis - 1 - 1 - - - - - 1 - - - - - - - - Empyema - 1 - 1 - - - - - - - - - - - - - 1 4 11 2 8 - 1 2 2 — 2 3 — — — 1 2 2 Osteogenitic Defect - 1 - - - - - 1 - - - - - - - - - - Enuresis 2 3 2 2 - - - 1 - - 1 - - - - - 1 2 Mongol 2 - 2 - - - - - - - 2 - - - - - - - Petit-mal 1 1 1 1 - - - - - 1 1 - - - - - - - Post Osteomyelitis - 1 - 1 - - - - - - - - - - - - - 1 Post Infantile Paralysis - 1 - 1 - - - - - - - - - - - - - 1 Chronic Swelling Face, Dental - 1 - 1 - - - - - - - 1 - - - - - - Bad Dentition — 1 — 1 — — — — — — — 1 — — — — — — 5 9 5 7 - - — 2 - 1 4 2 — — — — 1 4 Grand Total 69 127 50 101 7 5 12 21 10 28 19 33 5 4 4 16 1 32 196 151 12 33 38 52 9 4 48 TOTAL NUMBER OF ATTENDANCES, YEAR ENDED DECEMBER 31st, 1926. Under 5 years 5-14 years Total. Attended and Treated 1,184 3,871 5,055 Attended for examination, e.g., new cases, cases treated and now under observation, cases unsuitable for treatment 64 222 286 1,248 4,093 5,341 Average attendance per session 17 Average number of treatments per child 33 CASES REFERRED BY Under 5 years 5-14 years Total. Clinic Doctors 48 115 163 Private Doctors 20 8 28 Hospital 1 2 3 Dentist — 2 2 69 127 196 87 (6) The general plan of campaign is to give each patient three treatments a week, beginning with 5 minutes exposure only, back and front, on the first occasion, and subsequently lengthening the exposure by five minutes each attendance until the maximum of half-an-hour back and front is attained, so that after a fortnight each patient has an hour's exposure at each attendance. In the case of very young babies these exposures have been diminished, especially at the beginning of treatment. In order that as many patients as possible may enjoy the treatment three sets of patients are kept under treatment simultaneously, so that there are six sessions a week. (7) It has been found that in most cases it is necessary to extend the period of treatment beyond the three months which was originally intended to be the limit. Three months seems hardly long enough a time in which to develop the full benefits of the treatment, and frequently the attendances of the patients are interrupted by trifling ailments, such as colds or feverish attacks, qr by the incidence of parents' holidays involving a temporary removal to the seaside. Such opportunities for a change of air are never discouraged as they are likely to prove of benefit at least equal to the artificial sunlight. In consequence of these considerations many of the patients attend over a period of four months although the average number of attendances per patient works out at 33 which is only equal to eleven weeks, supposing that three treatments are taken regularly each week. But as was pointed out above the regular succession of treatments is often interrupted. (8) The temperature and pulse of the patients have been taken occasionally only, no effect due to the treatment has been noted. Only two febrile patients have been treated, and in one case the temperature settled down during the period of treatment and the patient did very well. The precise diagnosis of this case was never established ; tuberculosis was suspected but no evidence of it other than the rise of temperature was discovered. The blood pressure was taken before and after treatment in 31 cases, in 18 there was no change, in 9 there was a slight fall and in 4 there was a slight rise. I do not think any definite conclusion can be drawn from these figures. (9) Treatment was begun on 16th November, 1925. (10) The total number of patients treated during the year ended 31st December, 1926, was 151. (11) A weekly record of weights is kept, and a monthly record of heights. The record of heights is only kept for children who are old enough to stand up unaided. (12) There are still no facilities for making either photographic or radiographic records of patients. As was pointed out in the report for last year the type of case treated in this clinic is as a rule not severe, and changes in structure and appearance definite enough to be recorded by such methods are extremely rare. The centre must be regarded as preventive rather than curative in type. One or two cases have been specially sent to hospital to be radiographed, notably one case where a chronic recurring empyema was sent for treatment, and it was desired to ascertain whether there was any indication for further surgical treatment. No such indication was found and the child was treated, but I regret to say that although at first the boy seemed to benefit and put on weight, a recurrence of the empyema took place while treatment was being carried on. (13) In general the children improved in brightness and alertness. I have no first hand reports from teachers, but in several instances the mothers volunteered the information that since their children had attended for artificial sunlight treatment they had done better at school, and one case, a mentally defective child of mongol type, was reported by her mother to have greatly improved in brightness, in tractability and in walking while under treatment. This child was under treatment for eight months, but has now left the district. (14) On the whole I am unable to give any general rule as to whether either the texture of the skin, the colour of the hair or the presence or absence of erythema or desquamation bear any relation to the benefit derived from the treatment. In any case the pigmentation produced by the long flame carbon arc lamp appears to be very moderate in degree. In a few cases there was produced a mottled erythema rather suggestive of german measles; this never lasted more than two days and was not followed by desquamation. (15) All the cases were submitted to general irradiation, no attempt was made to reduce lesions by local irradiation. A few cases were found to suffer from headache unless the heads were protected by brown paper shades. Two cases of summer dermatitis, a brother and sister were treated and both of these seemed to be benefitted as regards their general condition ; they put on several pounds weight and said they felt very well, but as might have been expected the skin lesions were unaffected. At any rate they did not get any worse. (16) The largest class of case treated was that which can only be described by the vague term " general debility." Any one accustomed to deal with children will know the sort of child meant by this term. On the whole they did very well, but not all equally well. A few put on as much as five pounds in four months treatment but this was exceptional. For the most part one had to rely on maternal reports for the estimation of their progress and these were very encouraging and there is no doubt of the popularity of the artificial sunlight centre, both among the parents and the local medical officers. There is always a waiting list of patients ready to begin treatment as soon as there is a vacancy. I think this must be regarded as good evidence that good work is being done. Other types of cases which deserve special mention are :— [a) Pretubercnlar cases and also cases which have been in sanatoria.—Under the term " pretubercular " are included cases of delicate children with a bad family taint of tuberculosis, but in 88 whom no definite evidence of tuberculosis has been found, and some who have been even inmates of a sanatorium but who have been discharged without the diagnosis of tubercle being established. Most of these patients seem to derive benefit from artificial sunlight. (b) Cases of enlarged glands.—In every instance except one these patients had enlarged glands in the neck. They had all previously had their tonsils and adenoids removed. In almost every case shrinkage of the glands was noted and in some they ceased to be palpable. Two cases who were suspended from treatment owing to the disappearance of the glands relapsed and had to have renewed recourse to artificial sunlight. (c) Cases of definite tuberculosis which had been in sanatoria.-—The results in these cases were not so good. It must be remembered that they were living at home, often under adverse circumstances and most of them hardly held their own and in several instances had to return to a sanatorium. (d) Rickets.—All the cases of rickets did well, as was to be expected. The lesions for the most part were not very severe, slight curved tibiae and genu valgum. But it is necessary for both parents and medical men to remember that ultra-violet light will not correct deformity, although it may prevent it from getting worse, and that mechanical measures for this purpose still remain necessary in many cases. (e) Asthma.—Artificial sunlight is of undoubted value in this disease. Out of six cases five were greatly benefited and three may be regarded as cured. (/) Various types of skin disease. Psoriasis.—One case only was treated, it did not derive any benefit, in fact it seemed to be made worse and the treatment was stopped. Eczema or dermatitis.—Four cases were treated, one a case of flexural eczema in a boy aged 10 with an ichthyotic skin which had persisted since infancy, did very well. Another in which the eczema was associated with asthma (a not infrequent combination) also did well although the progress of the case was interrupted at one time by the formation of large submental abscess. In treating cases of eczema the actual lesions were always kept covered, general irradiation alone being employed. Alopecia areata.—Six cases were treated, all did well. (17) The average cost of current per hour was 8-64d. (18) The average cost of each patient's treatment was £1 17s. 3d. H. HALDIN-DAVIS, January, 1927. Dermatologist to the Willesden Urban District Council. APPENDIX H. RHEUMATISM IN CHILDHOOD. (Being Notes bearing chiefly on its control, in relation to the School Medical Service) by C. T. Maitland, M.D., M.R.C.P., B.Sc., D.P.H., D.T.M. & H., Assistant Medical Officer. Definition.—The term " rheumatism " has been loosely used to describe various morbid conditions certain of which have no connection with the present subject, such as muscular rheumatism and chronic joint changes. The confusion in terminology is well brought out in the Ministry of Health's Report, "The Incidence of Rheumatic Diseases" (1924). The simple term rheumatism is best reserved for a disease commonly beginning in childhood and clinically as clear-cut as tuberculosis, whose danger lies in the damage it inflicts on the heart. The other manifestations, sore throat, acute joint inflammations, chorea (St. Vitus' dance), and less important conditions are of importance chiefly as indicators of the probability of accompanying cardiac involvement. The Causation of Rheumatism. I. Rheumatism an Infection..—The integration of the various rheumatic manifestations as primarily due to one underlying cause has been largely delayed by the failure to isolate unequivocally one organism as in all cases responsible. Nevertheless, the prevalent modern view is that a micrococcus is the specific cause—a streptococcus, similar in certain respects to that normally found in the human mouth. It is unnecessary to state the reasons which lead to that conclusion. However, the correlation of the clinical appearances and the provisional acceptance of rheumatism thus envisaged as a unity has been of great value, indeed was necessary, for the planning of successful preventive measures. In Dr. A. P. Thomson's words, " everything considered, the most reasonable hypothesis is that rheumatism is due to a streptococcal infection which probably enters first by way of the tonsil, soon'is engrafted in the lymphoid tissue of the alimentary tract, and also establishes itself in the various rheumatic lesions throughout the body. That general reinfection may occur from subsequent activity of any of the focal lesions (as happens for instance in tuberculosis) is not an unreasonable suggestion." 89 II. Contributory Factors.—But if the natural history of the disease demands the hypothesis of one specific organism as invariably causative, it is equally true that certain environmental conditions are so consistently present that their evaluation in predisposing to infection is of the first importance. Dr. Reginald Miller writes of " the multiplicity of the factors at work and the comparative lack of precise information available about them. Certain impressions have been accepted which are probably quite correct, but they are backed by little in the way of quotable statistics or definite evidence." Recent work has done much to fortify these earlier impressions, based upon the uncorrelated fruits of the prolonged clinical experience of shrewd observers. The following general conclusions, taken from Miller's " Report on the environmental and other predisposing causes of rheumatic infection" (1926), are thus stated:— " The disease in England is essentially one of children of the artisan class, living in damp rooms in an industrial town, attending an elementary school, and suffering from tonsillar sepsis." (a) Rheumatism a disease of childhood.—School medical officers are agreed that the incidence of heart disease is much greater among the group of children approaching leaving age than it is among those who have newly entered school at the age of five. Sir George Newman, reporting in 1925, is satisfied that a very substantial amount of the heart disease which proves mortal at premature ages is due to rheumatism contracted or first manifested during school life. Dr. Carey Coombs, who has given much attention to the subject, estimates that about twothirds of the cases of rheumatic heart disease in Bristol begin between the ages of five and fifteen. Dr. A. P. Thomson considers the evidence is very strong that it is during the years of elementary school life that the foundations of most of the cases of permanent cardiac damage are laid. He observes that it is not without significance that the total rejections on account of heart disease of young adult lives by insurance companies in the State of New York—2 per cent, of the proposals— is not much greater than among the leaving group of school children in the same area. (b) Rheumatism is a class disease.—This disease is unique in that not being infectious it is practically limited to the poorer classes, affecting rather the children of the skilled artisan than of the destitute. Thus, quoting from Miller's report, Hutchison from a very long experience of children's diseases affirmed in 1925, " rheumatism was certainly not specially a disease of the slum child, but he entirely agreed . . . that it was a disease of hospital and not of consulting practice and he could count on the fingers of one hand the cases of acute rheumatic carditis that he had seen in consultation in thirty-five years." Thomson, from large experience in Birmingham, wrote in 1926 : " It is almost unknown in the great public schools, or in the better-class private preparatory schools, and yet curiously enough, it is more frequent among the children of the decent poor than it is among the squalid." Coates and Thomas from investigations in Bath, wrote in 1925 : " In practically every instance the parents of the affected children were in steady work in receipt of a steady income, and generally belonged to the skilled artisan section of society." The causes of this peculiar class incidence are uncertain. If they were known, " a key position in the fight against the disease would have been gained " (Miller). It is possible that it is connected with the factor next to be mentioned, damp housing. Are the slum-dwellers protected by their overcrowding, living together in one room used also as a kitchen ? (Miller). Dr. K. D. Williamson has suggested that the probable reason is that the delicate rheumatic children of the very poor die early. (c) Rheumatism is associated with damp housing.—The traditional connection between rheumatism and dampness is confirmed by recent investigations. Miller concludes that it is the state of the home that matters, rather than the proximity of the house to water, the subsoil, or the altitude of the site, except in so far as these contribute to the dampness of the fabric. At London, Bristol, and Bath it was found that nearly two-thirds of the rheumatic cases studied for this purpose came from damp rooms. In a total of two hundred cases, care was taken to ascertain the condition of the rooms actually occupied by the patient when first diagnosed as suffering from rheumatism, and most of these were actually inspected. For certain reasons this proportion may be taken as a minimum. These are : that the self-respecting poor often dislike admitting that their rooms are damp ; that others accept a definite degree of dampness as normal; and that certain cases of choreic or post-scarlatinal rheumatism doubtfully or definitely not associated with dampness are included. Damp in Houses : Results of investigations in 196 cases. No.of Cases Rooms damp. Rooms dry. West London (Miller) 114 76 38 Bristol (Morrison and others) 52 30 22 Bath (Coates & Thomas) 30 16 14 Total 196 122 74 The influence of site, subsoil, proximity to water, altitude probably operates only indirectly by rendering the interior of the home damp. 90 Birmingham.—Thomson has noted on a map of the city (spot map) the situation of 400 cases collected in over 4 years. A glance at it shews very clearly that the vast majority of these lived along the banks of the streams, one of them notoriously liable to overflow and flood. But a further study of the map shews that the rheumatic zones do not exactly coincide with the poverty areas of the city, and that there are several poor districts that are relatively free. l.ondon.—Dr. Jean Shrubsall of the London County School Medical Service, found in 1912 that children suffering from rheumatic heart disease were definitely aggregated along the lines of the alluvial valleys marking the ancient courses of rivers. Confirmation of this result by Dr. F. C. Shrubsall in 1925 is well shewn on examining a spot map with contour line 50 feet above sea level. (d) Rheumatism is associated with diseased tonsils.—The relationship between rheumatism and sore throat has long been accepted. The rheumatic infection is now commonly regarded as invading the bodj' through the tonsils. Acute tonsillitis frequently ushers in a typical attack of rheumatism, especially when the heart or joints rather than the brain (chorea) become affected, and acute sore throats are liable to recur between subsequent attacks. Dr. M. O. Raven, of Broadstairs, has stressed the fact that infectious sore throats spreading in rheumatic wards are able to light up fresh rheumatic symptoms in some rheumatic cases, although he has never seen a sore throat set up rheumatism in a non-rheumatic child. Chronic tonsillitis (septic tonsils) is found more commonly in rheumatic than in normal children. All observers testify to this fact, although naturally the statistics of different individuals vary, since abnormality of the tonsil is determined on inspection by several factors, allowing of difference of opinion, as—signs of inflammation of the tonsillar surface and of the superficial structures of the throat surrounding it; general increase in size ; the appearance of the mouths of the crypts dipping into its substance ; and especially enlargement of the lymphatic glands of the neck with which it is connected. As regards the permanence of tonsillar disease, " in a few cases of acute tonsillitis the tonsils will recover completely, but such are a minority in rheumatic cases. Once a real chronic infection of the tonsils has been established there is no evidence to show that spontaneous recovery is possible during childhood." (Miller.) This, despite the application of paints and gargles to the surface of the tonsils. Of less clearly-grasped significance, and possibly a composite factor— (e) Rheumatism is a disease of towns.-—That rheumatism is especially rife in towns is accepted by those most interested in the problem. On the statistical evidence at present available Miller concludes that further investigation will fully confirm the view that rheumatic disease is a disease of towns in general, and of industrial towns in particular. This association he holds to be greater than is accounted for by the increased general sickness rate common to towns. In support of this view he mentions (1) the peculiar class incidence of the disease, which shuns the slums with their highest invalidity rate ; and (2) the Birmingham findings of Thomson, whose spot maps showed lack of coincidence between certain rheumatic areas and areas of general poverty. Other possible associations require brief mention. School Environment.—Rheumatism develops commonly in elementary school children, very rarely in private day or boarding school children, but whether any of the conditions pertaining to elementary school attendance definitely predispose to rheumatism is uncertain. Miller is disposed to regard school attendance as a minor predisposing factor, but the evidence is slight. Thus (1) whilst noting the insufficient arrangements made at certain schools for changing wet boots and clothing, he justly admits that the disease is less common in the country where exposure is greater, and amongst the poorest children who are least protected by clothing. (2) He supposes that catarrhal epidemics are commoner in State schools, leaving their harmful effects upon the tonsils. But even if it be allowed that such epidemic " colds " are commoner in State schools than in private schools, and that tonsillar infection is thereby increased, the means of detection and often of treatment are carried to such children by the school medical service through routine examinations and clinic facilities. And in private school children such " minor maladies " frequently go undetected and uncorrected. (3) He noted that parents frequently blame school stress for the onset of chorea. Whilst usually an unjust charge, he accepts the fact that cases occur in rheumatic children pressed in their studies for competitive examinations. He surmises that playtime must often be a greater source of fear to neurotic children than their working hours. Heredity.— It is doubtful whether heredity is a predisposing factor. It is true that rheumatism occurs more commonly in some families than in others. Thus Dr. R. H. Vercoe, a predecessor of mine at Willesden, but now of Chelmsford, after making enquiries about 700 children (including 100 rheumatic cases), concluded that a history of rheumatism in near relations was two and a half times commoner with rheumatic children than with no rheumatic children. But the common factor may be environment and not blood ! Patients suffering from malaria will frequently give a history of malaria amongst near relations—when the family live in a malarious district! 91 A. P. Thomson, of Birmingham, has been unable to confirm the view that rheumatism is hereditary. In his series of cases the incidence of true rheumatism in close relations was 25 per cent., and he believes that the " inclusion of complaints of pain loosely and not truly " described as rheumatism have in the past falsified statistical studies. It will be well in the present state of knowledge to go no further than agreement with Miller—that perhaps a hereditary influence aids and abets the environmental influence. Direct Contagion.—All the evidence points against the importance of this factor (Miller). When more than one case occurs in a dwelling the common factor of environment is present without postulating infection. Conditions of great poverty, destitution, underfeeding, overcrowding, excessive dirtiness do not seem to have an influence specifically towards rheumatic infection. The Gravity of Rheumatism. It may be said at once that rheumatism is one of the great disabling and killing diseases of this country, comparable in its malignity to tuberculosis and cancer. The significance of this fact has been but slowly grasped by medical and public opinion alike, and Miller is justified in complaining that " until quite recently the rheumatic infection has received less attention from the public health point of view than any other disease so prevalent and so harmful." For one reason, rheumatism is not notifiable. For another, its name is primarily and popularly associated with a spectacular affection of joints, always (with very rare exceptions) completely recovered from, and not occurring in all cases of rheumatism. But rheumatism disables and kills by its effects on the heart, and so insidiously may its poison operate that many a patient is found to have advanced and incurable " heart disease " (rheumatic) without having experienced any symptoms of rheumatism sufficient to drive him to seek medical advice. The mortality returns of the Registrar-General show that in 1925 in England and Wales 64,000 persons died of heart disease, 52,000 died of cancer, 40,000 died of tuberculosis. Statistical Relationship of Heart Disease and Rheumatism. What proportion of this great annual total of 64,000 deaths from heart disease—one-seventh of the total death-rate of the country—can be fairly attributed to rheumatism ? The history of the case when available is frequently characteristic, and so too are the signs revealed by an examination of the patient during life. Moreover, the effects of the rheumatic poison upon the muscular substance and lining membranes of the heart are in most cases so characteristic, both on naked eye and microscopic examination, that a trained pathologist can usually confirm the diagnosis made during life by an xamination of this organ. Dr. A. P. Thomson, on analysing 240 cases of heart disease at the Birmingham General Hospital, which he presumes to be a fairly representative sample of the general population, found that roughly 60 per cent, were very probably attributable to rheumatic infection. Dr. G. A. Allan, in Glasgow, analysing 320 cases, found 46 per cent, to be certainly due to the rheumatic infection and a further 13 per cent., although there was no definite history, there was a very great probability that a proportion of them were also due to the same cause. Allan thus finds it " reasonable to conclude that abou' 50 per cent, of the total mortality of heart disease, as recorded by the Registrar-General, is due to rheumatic infection " or approximately 30,000 cases per annum. And at present the death rate from heart disease from year to year is stationary. Now it is not only the vast aggregate of deaths from rheumatism that claims attention. These deaths are nearly all premature deaths preceded often by a lengthy period of great distress. " They present a mortality which cuts off life when it is sweetest and most valuable, the disease which infects in childhood, which spoils the productive power of early manhood, and which often causes a decade or more of invalidity before it kills."-—(Sir George Newman.) The post-mortem examination of patients under forty years of age who have died of heart disease almost always shows the lesions to be rheumatic in type. Frequently those awaiting their end must be in hospitals for very long periods. Home nursing is difficult, for " the majority of cases occur in working class people, and it should be emphasized that cardiac breakdowns are apt to occur at times in their lives when it is particularly desirable that they should be able to discharge their manifold duties efficiently ; in women who have become mothers, for instance, and again in men who have become responsible for the support of homes. It would be difficult to exaggerate the anxiety, distress and the deterioration of a family unit that may result from the crippling of a parent by the advance of rheumatic heart diseases." What are the causes of the other half—the non-rheumatic half—of this great mass of fatal heart disease ? The larger proportion of this other great army of 30,000 die from degenerations of the heart substance inexorably accompanying old age, or afflicting those whose organs are prematurely worn out by over work or unwise over-indulgence in food and drink or other unhealthy modes of life. Many of the remainder have contracted syphilis, and the uncured infection, choosing a proportion of cases to fasten upon the heart and blood-vessels rather than the brain or other tissues, slays .them in middle life. Others (usually in childhood) die from the inefficiency of a malformation of the heart (congenital heart disease) present at birth, and of which the cause is unknown. 92 A few succumb from hearts afflicted at the time of an attack of pneumonia, diphtheria, or other acute infection, or from some chronic infection of teeth or bowel. Thus, whilst there is undoubtedly opportunity through the practice of personal hygiene of postponing many of these deaths to a riper old age, it may be said that many of them have accomplished a long span of years and for the rest some fall prematurely through their own folly. Statistics derived from the School Medical Service.—It might be supposed that data available from all parts of the country derived from the periodical examination of school children, and the ascertainment of the disability which keeps children away from school for long periods (thus not finding their way to medical inspection) would admit of a general estimate of the extent of rheumatic infection amongst children of school age. But as Thomson has justly observed : "The statistics of the school medical service are vitiated by the fact the conditions of inspection do not, in general, permit of very exhaustive examination of the individual child, and inasmuch as the signs of rheumatism and early heart diseases are frequently unobtrusive, it. is probable that many of the cases are missed, or are simply placed in such categories as ' malnutrition,' ' anaemia ' or ' functional afflictions.' " Bearing this source of error in mind, it is yet helpful to note such facts as the following :— In his report for 1925, the School Medical Officer of the London County Council wrote : " From reports made by the school doctors it may be computed that there are in the London area certainly not less than 10,000 children who have suffered or are suffering from rheumatic symptoms. The great majority of these, of course, are not in need of any special treatment other than that they are already receiving, but they require careful watching. They are mostly attending school, and under the observation of the school medical service, and are known to the school care committees, who give the parents such advice and help as is, from time to time, desirable. There are about 1,000 of these children attending special (physically defective) schools whose hearts have been seriously and permanently injured ; and there are from 600 to 700 children absent from school for long periods on account of rheumatism. These last represent 25 per cent, of the chronic invalidity amongst children, and include all, or almost all, the children for whom special arrangements are still necessary." Researches undertaken by School Medical Officers in different areas during the last few years present figures not wholly comparable since some estimate the total volume of rheumatic cases in the school population examined, others the total volume of organic heart disease (made up chiefly of the most significant end-results of rheumatism) similarly found, whilst others discriminate between the numbers found at the three statutory age groupings—entrants, intermediates, and leavers. The prevalence of rheumatism would, from these scattered findings, appear to vary widely, and in some areas an alarmingly high proportion of the children examined were found to be infected. Thus, from Wigan, in 1919, is reported 21 per cent, of rheumatic children out of 1,211 examined ; from Cheshire, in 1920-1921, is reported 10 per cent, of the children attending the elementary schools ; whilst at Rhondda, in 1923, out of 5,000 examined 15-8 per cent, were rheumatic. Of equal or greater significance is the emergence of another fact—that far more cases are found amongst the older children than amongst the younger ; in other words, that the disease develops whilst the children are at school. Thus at Crewe, in 1924, amongst entrants 2-5 per cent., intermediate children 5-6 per cent., and leavers 15 per cent, were rheumatic. At Bath Dr. Thomas found the incidence of organic heart disease among 8,653 children examined at ordinary routine medical inspection to be : entrants 1 00 per cent., intermediates 0-98 per cent., leavers 2-36 per cent. The Manifestations of Rheumatism. It cannot be too emphatically stated that the typical rheumatic infection in children is a slow insidious process, whose existence is frequently not recognised—because the symptoms and signs are overlooked or misinterpreted—until permanent damage has been done to the heart. This subacute or chronic rheumatism manifests itself in many different ways, which may appear in one composite picture or more usually one or two features only are present at one time. It may be visualised as— (1) An infection smouldering in chronically diseased tonsils, and occasionally lighting up in them a more or less acute tonsillitis. (2) A state of mild intoxication due to the growth of the organism in the tonsils or other organs, revealed by undefined ill-health, pallor (due to blood destruction), loss of weight or failure to gain weight, undue excitability or depression, slight irregular fever. (3) An infection smouldering in heart muscle and heart valves, often with no symptoms in the early stages and unsuspected unless sought for. It may pass off without detectable permanent damage to the heart, or it may lead to valvular disease, hypertrophy and dilatation, or it may be so severe as to cause early cardiac failure. (4) An affection of the brain, chorea (St. Vitus's dance) of no permanent importance in itself (except in very rare cases), but it prevents schooling, and indicates the danger of accompanying heart affection, and therefore compels treatment. (5) Minor effects, signifying infection of fibrous tissue only, but of diagnostic import:— " Growing pains," not well localised, and usually related to the arms and legs ; painless fibrous nodules found fixed to the bones about the joints, over which the skin moves freely ; and skin eruptions. In a recent study of rheumatic infection in 141 children, Dr. Mary Bertram, of Glasgow, has estimated that the onset of the disease occurred in 60 per cent, of her cases at ages from 6-10 years ; that girls were more frequently affected than boys ; that 76 per cent, of her patients suffered from carditis, 73 per cent, from arthritis, 47 per cent, from chorea, 28 per cent, from tonsillitis, and 7 per cent, from subcutaneous nodules. Dr. Poynton on the other hand finds from a record of 1,108 probable first attacks of acute rheumatism under twelve years of age that 60 per cent, suffered from carditis, 56 per cent, from arthritis and 55 per cent, from chorea, with only some 8 or 9 per cent, having subcutaneous nodules. 93 Dr. Thomson describes the rheumatic child as " thin, anremic and nervous ; commonly sleep is broken, and often there are night ' terrors.' The appetite is usually poor. From time to time the child complains of vague pains (growing pains) in the joints or in the muscles, which are frequently brought on by exercise or by a change in the weather. This state of vague and ill-defined persisting ill-health is marked at intervals by the occurrence of feverish sore throats (frequently called ' colds' by the parents) or by the outbreak of obvious chorea. At any stage of the disease signs of cardiac involvement may be found." Acute Rheumatism (Rheumatic Fever) does occur in children but rarely in the form which the infection commonly takes in adults. Its characteristics, including high fever and swollen acutely painful joints, bring the cases under medical supervision. There is a marked tendency for inflammation of the heart and valves to develop during the course of the attack, and the after-care of the patient is of great importance. This is to secure that disease process in the heart is no longer active, and to adjust the patient's activities to the heart's capabilities. Unlike most acute fevers, in which one attack confers immunity, there is a definite liability to recurrence, when progressive deterioration of the heart is prone to occur. Chorea.—The fully developed signs of this manifestation of rheumatism are familiar to most people as "St. Vitus' Dance "—irregular involuntary movements of the face, limbs and trunk. But before the development of these symptoms there is in most cases a period, perhaps of some weeks, when definite though subtle changes in the child's disposition and behaviour should call the attention of the parent or teacher to the fact that it is unwell. Thomson describes the first change noticed as " general nervousness " with a loss of power of concentration. " The artisan mother notices that her girl becomes fidgety, dissatisfied and unable to settle to anything for more than a few minutes : usually, however, the child makes no complaint and no importance is attached to the observation until fresh attention is drawn to it by complaints from the school teachers that the child, although apparently quite well, is inexplicably failing in her work ; first in application—' she sits dreaming away taking no notice of anything or anyone around her '—as one teacher would put it, and then in execution. Handwriting suffers early and it is an interesting and instructive thing to look over the exercise books of a schoolgirl who has developed chorea. Often I have found that the neatness and clearness of the writing have given place to slovenly untidiness before any suspicion of the onset of chorea has been entertained. Too often choreic children in the early stages are punished in school before thej' are treated by their doctors. The appearance of the face alters soon ; the brisk, alert expression of the normal child gives place to one of dull and apathetic stupidity." He believes that if suitable treatment could be instituted early in this stage a large number of attacks of chorea could be avoided or at all events reduced in severity and duration. And the development of the case is thus pictured by Dr. Allan Warner : " The face and hands should be watched to see if there are any slight irregular movements, especially about the angles of the mouth and eyes. As the disease progresses, the muscles of the eyes may be involved, leading to squint and double vision. Reading is often difficult. Another important symptom is loss of muscular power. This is generally noticeable a short time after the beginning of the choreic movements, and later an arm may hang loosely by the side or leg be dragged in walking. A further symptom is lack of co-ordination of voluntary movements rendering the child awkward and clumsy. This condition is often the first to attract the parents' attention and they complain that the child has become careless and is constantly dropping and breaking glass and crockery. Such acts as dressing, writing or playing the piano are performed in an erratic manner. A good test for this condition is to see if the child can pick up a pin or some small object from the floor, when the hand will be seen to overshoot the mark in the attempt. During an attack of chorea the child is unusually pale and of rather a mournful appearance, loses appetite and is depressed in spirits. There is often loss of memory and sleeplessness. At the same time the physician may find evidence of heart disease." The Pathology of Rheumatism. A few words only are required here to describe the mechanism of the intimate action of the rheumatic infection upon the tissues, and the response evoked therein. During the active phases of the disease characteristic inflammatory nodules of microscopic size, shewing an organisation of cells of constant types, may be found arranged around small vessels in widely scattered parts of the body. These nodules presumably are found around the infective organism or substances carried from active rheumatic foci, such as diseased tonsils. In process of time these nodules are replaced by minute scars. Such scars do little harm in tissues like the skeletal muscles and the joints. But " if the poison attacks the noble tissues, the muscles or nerves of the heart—this cannot be replaced if destroyed, and if they are partially damaged can only recover completely if that damage be slight. When the fibrous tissues of the heart's framework, the valves, and the pericardium, are attacked and destroyed, they are replaced by scar tissue, and if they are the seat of prolonged irritation short of destruction they thicken and contract." The heart endeavours to compensate for mechanical disadvantages imposed by such injuries with its reserve power, and if they are healed lesions, i.e., if the rheumatic infection is dead, it may continue to be capable of meeting reasonable demands made upon it for an indefinite number of years. " In fact, should symptoms of heart failure be found in the young some degree of active infection is almost constant. It is an axiom that the chief cause for a cardiac breakdown in a child is active—I do not say fresh—infection. " I do not think we can ever get a real grasp of the problem of prevention unless we keep these two classes of injury before our mind, for it is injury to the muscle of the heart which particularly calls for prolonged supervision in convalescence, and the scarred valves disturb the work of the heart as a mechanical pump."—(Dr. F. J. Poynton.) Measures of Control. I. Prevention. This is the ultimate goal, but at present owing to the relative ignorance of medical science the measures possible are in part experimental and of uncertain value. They may be deduced from a consideration of the contributary factors :— (1) Improve the condition of damp houses.—Avoid especially dampness in the sleeping quarters of children of school age. This is an important aspect of the question of housing which cannot be enlarged upon here. (2) Maintain dry schools.—Dry premises, dry clothing and footwear of the scholars. The importance of sound boots and facilities for drying damp clothes and boots in school 94 may be mentioned—" to sit for several hours in damp boots and clothes constitutes a real danger to children many of whom are anaemic and under nourished and consequently less able than a normal child to resist infection." (3) Deal with Septic tonsils.—Apart from other considerations septic tonsils acquire an added significance in view of the frequency of rheumatism, its dangers, its association with such tonsils and the increasingly accepted view that their removal may prevent or at least favourably modify subsequent damage to the heart. II. Management of the Rheumatic Child. This is at present of greater practical importance. In many cases the rheumatic child is recognised before permanent damage is done and the proportion of cases thus taken in time should increase as the medical profession succeed in enlightening the public. " Frequently the patient has already been damaged and the most we can do is to stave off attacks. This limitation it is essential to recognise, for at present we are unable to control rheumatic heart disease with any certainty." When the nature of the disease is grasped, and especially its liability to relapse, the size and complications of this problem are seen to be of a large order. The child must be discovered, treated, and subsequently maintained for a long period of years under regular medical supervision. Notification of rheumatism is not required by law and the application of this measure which has been of great value in the control of other diseases does not find favour with most authorities at present. The uncertainty and variety of its early manifestations rendering its existence in cases a matter of opinion, the assumption that it is not infectious, and the limited institutional treatment available are amongst the reasons urged against notification. The three functions of discovery, treatment and after care, require some discussion. It must be admitted that practice lags far behind knowledge both in respect of lack of machinery and in the use of such machinery as is now available. Discovery and after care are of necessity bound up with the school medical service whatever be the other agencies—and this includes the private practitioner— that collaborate. The Discovery of Rheumatism and the School Medical Service. The responsibility for an increasingly effective control of this disease must depend more and more upon this service, which ministers to the population so largely at risk—children of school age attending state schools. In the matter of discovery of the disease in its earliest stages school medical officers have unrivalled opportunities. The children are theoretically accessible to their observation throughout their school years. But apart from the teacher or parent frequently failing to give the school or other physician an opportunity to make a timely diagnosis, say, of chorea, in its early stage, it is undoubted that even the three routine medical inspections during the child's school life are not adequately utilised for the detection of rheumatism. Dr. A. P. Thomson very justly writes of the service that " the conditions of inspection do not in general permit very exhaustive examination of the individual child, and inasmuch as the signs of rheumatism and early heart diseases are frequently unobtrusive it is probable that many of the cases are missed or are simply placed in such categories as ' malnutrition,' ' anaemia ' or ' functional ' affections." It is possible that some blame attaches to the unsatisfactory conditions under which the routine examination of the children is conducted. Noise from the class rooms and from traffic without may interfere with the examination of the heart. In school no couch may be available for the child to be examined in the recumbent position, but a table is equally serviceable and can surely always be obtained. It may be urged, too, that the number of cases to be seen within the time limits of the session precludes a sufficient detailed examination. But it cannot be too strongly emphasized that the school medical officer need not feel it incumbent upon him to diagnose rheumatism at the routine examination of school ; he need only suspect it—pale child, " nervous," failing to gain weight, not doing well in school, " growing pains," often septic tonsils, perhaps equivocal heart signs, perhaps dwelling in a basement or damp house. He should then refer such a child to the school clinic (if any) where it can be conveniently examined in more detail before advising its parent to seek treatment, or directly to a private physician or hospital. In any case the name of such a child should be noted and it should be inexorably followed up by the Service until it is known to be under treatment or to be declared fit by a competent authority. In fact it is probable that when the Service fails it is rather through the ignorance of its staff, or perhaps to put it in more kindly fashion, lack of awareness to the importance and frequency of rheumatism, and their failure to utilise the machinery available than because of the conditions of the inspection. The school doctor probably fails like other medical men for the reasons given by Dr. F. G. Poynton under the caption " imperfection in medical education." There seems to me some difficulty in the pathways of students who desire to gain a real clinical insight into the rheumatism of childhood. Except in the largest general hospital there is no great opportunity for a student during his time in the wards to see many cases of acute rheumatic carditis, and yet there is no doubt that at this age rheumatic heart disease requires unusually careful observation. In the adult the later and closing chapters of heart disease are seen with their alarming and striking symptoms ; in the child, the dawn of heart disease requires close attention and some special teaching Recently this weak point has been strengthened by the greater attention paid to children's disorders ; in the final examination it will doubtless lead to general progress." And if such criticism is just in respect of physicians failing in their handlings of frank cases of acute rheumatic carditis, it is reasonable to suppose that at least an equal lack of thoroughness is found 95 in connection with those earlier stages of the disease when the very diagnosis hangs in doubt. It is thus claimed that the school, physician should be at least an expert in detecting possible cases of rheumatism as he meets them at routine inspections and at the clinic. What can he do with such suspects ? His duty is to refer them for confirmation of the diagnosis. It must be insisted that these cases are not primarily cases of heart disease but rheumatism, and that among institutions, a clinic for children's diseases rather than a cardiac clinic is indicated. The out-patient's department of the children's hospitals or of the children's departments of general hospitals offer expert facilities in diagnosis and a certain oversight of treatment for those who cannot afford good private advice. At present in the absence of any working arrangement between the school medical officer and the specialist, the education authority only learns by chance, or at least informally, of the suspect's condition and the measures advised. The same ignorance naturally surrounds those cases for which private practitioners become responsible. For no apology is required when insisting upon the importance of sound advice, based upon a detailed careful physical examination and subsequent oversight at regular intervals. Until the medical profession and the public look upon rheumatism with the same dread as they do upon cancer, casual treatment will persist. Now the management of a case suspected or definitely labelled rheumatism is a long business. It is not only the treatment of this one " attack " that interests the school Medical Officer—the label must be attacked throughout school life. Consequently the unsatisfactory elements in the present arrangements are constantly before him. To remedy this in co-ordination is a point of administrative importance. The writer as a school physician has had excellent results when Willesden children in whom he has suspected rheumatism have seen at hospital consultants with whom he is on terms of friendship. They have written confirming the diagnosis and stating that treatment is being undertaken or making other suggestions. But this purely personal method cannot be generally employed. And yet it is necessary that the consultant on children's diseases should play his part in the scheme, and a willing part. Certainly a note from the hospital Almoner to the School Medical Officer at the first visit of any suspect or diagnosed case of rheumatism would be of real value. The suspicion has been entertained that influences are at work to seize upon rheumatism and remove it from general hospitals and consultants even as Tuberculosis was taken and surround it with a similar administrative barrier. This, some suppose, would be to the great hurt of all concerned, patients, teaching schools and therefore general practitioners, and consultants. After-care. After care is required for two separate considerations:— (1) To adjust the school life of the individual from time to time to any permanent damage to the heart suffered in a previous attack. (2) To maintain a constant watch against relapses. The ideals of management may well be (1) to allow the child's education to deviate as little as possible from the normal, having a strict regard for the capability of the heart. There is an inevitable atmosphere of invalidism in a special school, which should only be used for cases in which the heart is permanently crippled, or in the case of hospital schools, whilst the heart is being consolidated. (2) To maintain " a follow-up " system so efficiently that all cases are known to be constantly under observation by the school medical service. The Educational institutions available are:— (a) Ordinary elementary schools.—Most children after an attack of rheumatism, if properly treated and with suitable convalescence, are fit to return to ordinary school. The heart may be undamaged, or at least is competent to engage in the ordinary activities of school life. Drill, games and such occupations as laundry work may have to be prohibited. Dr. Allan Warner gives the following practical advice:— " Broadly speaking, in early heart disease some outdoor exercise such as walking or cycling (not against a strong wind or up a steep gradient) is distinctly beneficial, but the more strenuous games such as football, cross-country running, or swimming are inadvisable. The Swedish exercises given in our schools are not very strenuous, and the majority of children at school who have some cardiac lesion may take the drilling lessons with advantage." Even cases with a murmur due to organic heart disease. " Where there is not much enlargement of the heart and where the murmer is not much increased by exercise, may be allowed to drill provided that they are kept under observation." " When any heart weakness exists, the teachers should be informed of the case so as to obtain their co-operation in the treatment of the child in school. Less exercise should be given or entirely stopped if the child complains of feeling the strain of drill or shows any marked distress. In some cases it is well to start with quarter-time drill, then increasing after examination to half time and gradually to full time. Many cases of atonic hearts or of functional weakness are ameliorated or even made normal by such a process. In all cases of organic disease the parents should be told of the condition, care being taken not to cause unnecessary alarm. There is a prevalent idea that persons suffering from heart disease are liable to sudden death. If this view is held by the parents it is well to point out to them that sudden death from this cause, apart from congenital disease, is almost unknown in children ; that the special care that these children require is the maintenance of nutrition 96 and muscular tone by suitable diet and regulated outdoor exercises ; that the treatment does not so much consist of restraining the child from ordinary activities of life as in avoiding those conditions which tend to precipitate a further attack of rheumatism or other infectious disease." The rheumatic child may be away from school for 3 months or more, with an attack of chorea. On returning to school, it is well for both parents and teachers to remember that the child is still nervous and very sensitive to reproof or punishment. Overwork at school seldom if ever causes chorea, but fear of punishment or actual punishment not infrequently aggravates the nervous condition. Relapses are quite common, and if the child has been punished at school shortly before the relapse, parents not unnaturally attribute the fresh attack to the punishment. Children who are convalescing from an attack of chorea are often backward in their lessons, due to loss of memory and absence from school. They lack precision in manual work through want of co-ordination, and they are sometimes very troublesome through loss of self-control. Due allowance must be made for these deficiencies and possibly it is best to keep these children in a small class at an open-air school until the nervous system is in a more normal condition. (b) Special Schools.—A certain number of rheumatic cases find education in certified special schools, open-air schools, cripple schools and hospital schools. Of the total accommodation in these schools—in England and Wales—day schools 9,854 places, and residential schools 5,339 places—only a small minority are rheumatic or cardiac cases. (1) Hospital Schools.—Are " for education, and treatment of non-pulmonary tuberculosis and other crippling defects." It would appear that rheumatic cases would benefit especially from life in an institution where routine is devised for their special needs, such as at Baskerville; such institutions are ideally to fit their patients for a more or less normal life at an ordinary school. Such schools have been described above. (2) Cripple Schools.—Are "for children suffering from crippling defects or weak hearts." No treatment other than exercises is provided, so that only a certain class of rheumatic case is suitable —one in which the rheumatic infection is quiescent but where the heart has been permanently damaged so that modified ordinary life is unsuitable. (3) Sir George Newman draws attention to the fact that rheumatic children, including those suffering from chorea, do not as a rule do well at open-air schools. When at school regular examination of the children by the school or other doctor, say every three months, and the intelligent co-operation of parent and teachers is most desirable. Periodical examination and The Rheumatic Register.—Sir George Newman, reporting in " The Health of the School Child," 1924, advised as follows :— " The School Medical Officer should establish a register of all the children suffering from the principal manifestations of rheumatism (cardiac disease, chorea, and arthritis). Such children should be individually studied and kept under supervision." In Willesden no ad hoc register of these children is kept, but each case after being found at routine medical inspection or clinic consultation is followed up automatically, as in any other class of case, if it fails to return to see the Assistant School Medical Officer according to instructions. The institution of such a register might be of benefit, however, (1) In obviating any leakage of far greater import in rheumatism than in the generality of cases. (2) In calling attention to the prevalence of the disease, instructive to the school and other physicians as well as to parents, teachers and administrators. (3) In permitting routine intimation to the Head Teacher concerned who would then be prepared for advice in regard to the special management, if any, required by the child. (4) In expediting action by the sanitary authority in dealing with dampness in the dwelling, if present—-Or as a cogent reason why that family should change its dwelling, if by any means possible. It is advised that the register should include the names of suspected cases and confirmed cases separately grouped. The Medical Inspection card should carry a numbered item " Rheumatism," and an entry made there by the doctor even on slight suspicion, to allow of the case being carried to the Register. The writer believes that a Register and space for a Rheumatic entry on the Medical inspection card would achieve far more in the control of rheumatism at present than any general notification required under a Public Health Act. An efficient school medical service should be able to secure that all cases apart from gross parental neglect are under some sort of regular supervision. Can the school medical service attempt to be medically responsible for all rheumatic cases which have no private physician ? This is doubtful as at present organised. The writer holds that it would be most desirable that all school medical officers should be expert in the diagnosis and supervision of rheumatic cases. But such is not yet, and the consultant has a part to play. This question of the most feasible and efficient form of after-care supervision is an important one. Matters of financial stringency, actual and potential vested interests, and public apathy, jostle one another in impeding development. At Paddington Green Children's Hospital an effort has been made to meet this need, and the terms of the descriptive leaflet are given below. Emphasis is laid upon the fact that the services rendered are to supplement those of the customary physician of the patient, and there seems no reason why a similar collaboration with the school medical service should not be successful in other areas. 97 PADDINGTON GREEN CHILDREN'S HOSPITAL. (Incorporated.) RHEUMATISM SUPERVISORY CENTRE. (For the supervision of Children suffering from Rheumatism, St. Vitus' dance and Rheumatic Heart Disease.) The Centre is intended to meet the need shewn by rheumatic cases for careful supervision during periods of apparent quiescence to prevent the development of heart disease. The plan adopted is to supervise the care of the children when apparently well by periodical examinations, and to instruct the parents in writing to consult their usual practitioner or hospital, should fresh symptoms of rheumatism supervene. Treatment at the Centre itself is only given in urgent cases. In this way it is hoped that the Centre will form a useful link between practitioners, the School Medical Service and the hospitals for the benefit of the patients. Further, instruction is given to parents in the care of rheumatic children ; and investigations into the causation of rheumatism in Paddington are being made. The Centre is under the direction of Dr. Reginald Miller, Honorary Physician to the Hospital, and has behind it all the scientific resources of the Hospital. It is under the control of the Board of Management of the Hospital. Note. (1) The Centre is only open to rheumatic childrpn living in the Borough of Paddington (except in the case of children already patients of the hospital). (2) The Centre is open every Saturday. Admission 1 to 2 p.m. (3) No charge is made for admission. Any treatment given by the Hospital is subject to the usual charges for In or Out-patients. A leaflet (parents paper), to be given to the parent of each child brought to this supervisory centre, contains the following advice :— PADDINGTON GREEN CHILDREN'S HOSPITAL. (Incorporated.) RHEUMATISM SUPERVISORY CENTRE. (FOR RHEUMATISM, ST. VITUS'S DANCE & RHEUMATIC HEART DISEASE). The Centre is open every Saturday. Admission (free) 1 to 2 o'clock. The object of the Centre is to keep a watch over your child, so as to prevent it from getting a fresh attack of rheumatism or developing heart disease, without your knowing that anything is wrong. The chief danger of rheumatism in children is heart disease, and this may develop so quietly that it can only be detected by a doctor's examination. The Centre offers you the opportunity of having your child's heart examined periodically with a view to preventing its becoming affected. The Centre is not a treatment clinic, and will not interfere in any way with the treatment from the Hospital or private doctor who usually looks after your child. It is intended to help you to take the best care of your child while it is apparently well, and to warn you as early as possible of any symptoms requiring medical attention. A card will be sent to you to remind you when your next visit is due ; but if you are in any doubt or difficulty about your child, you can bring it to the Centre on any Saturday. If the child becomes ill, do not wait for the Centre to be open, but obtain advice at once from : You should read the suggestions overleaf. "Rheumatism, and Parents and Teachers. In view of the characteristics of this disease, enlightenment of these two classes of persons would greatly assist the medical profession, and in turn engender in it a greater sense of responsibility for the control of rheumatism. The following leaflet (based upon one issued by Dr. F. J. Poynton) has been issued by the Bristol Education Committee to all its head teachers. 98 Heart Disease in Childhood. (1) Heart disease is one of the greatest causes of death and invalidity at the present day. Last year 59,800 people died of this ailment in England and Wales—that is to say, one death in every eight was due to heart disease. (2) Many cases of heart disease commence in childhood and are frequently unnoticed at their onset. If cases are treated properly in the earlier stages a cure can usually he effected, but once the heart is seriously damaged complete recovery is impossible. (3) The most frequent cause of heart disease in childhood is rheumatism. Rheumatism is due to an organism which is liable to attack the heart and cause heart disease. In addition, this organism is the cause of chorea (or St. Vitus' dance), which is simply rheumatism of the brain. It may also be the cause of chronic sore throats. This rheumatism is frequently quite mild in character in children, so mild that parents may call it " growing-pains." (4) Rheumatic heart disease is oTten painless and requires a doctor's examination for its detection. Shortness of breath, loss of flesh, and pallor, are early signs that this organ is affected. (5) Pains in muscles and joints should receive immediate attention as being possibly the onset of rheumatism, which may be followed by heart disease or chorea. Rheumatism frequently recurs, especially in spring and autumn. (6) Great nervousness, dreaming at school work, alteration in disposition, and slight twitchings, are often evident before chorea begins, and are most important warnings. (7) When injured by rheumatism or chorea, the heart recovers slowly from the poisoning, and one of the greatest dangers to the child's future is for it to resume ordinary life before the heart is cured. (8) Three things are specially necessary to combat the present loss of life and efficiency caused by heart disease. (1) Education of the public in regard to heart disease in childhood. (2) Prolonged treatment in the early stage of cases where the heart has become affected. This must be under close medical supervision, and in the case of poorer children can only be obtained in hospitals which are able to keep cases for a lengthened period. Such treatment should extend over some months. The first exercise taken must be carefully watched and graded. (3) Choice of occupation for a child who has suffered from heart disease in school is most important. Very many lives are wasted through such children taking the wrong career. The Paddington Green Children's Hospital Rheumatic Supervisory Centre has the following injunctions for parents drafted by Dr. Reginald Miller. On the Care of Rheumatic Children. 1. Rheumatism is caused by infection by a germ, and is a common disease of children, in whom it often attacks the heart. This is the great danger of the disease. Rheumatism is the commonest cause of heart disease in children. 2. Rheumatic attacks of all sorts often start with a sore throat. A sore throat in a rheumatic child is always a dangerous symptom. 3. Common symptoms of rheumatism in children are :— Sore throat. Paleness. Pains in muscles. Shortness of breath. Painful joints. Fidgetiness or nervousness. 4. Chorea, or St. Vitus' dance, is rheumatism attacking the brain. Its chief danger is the tendency for the heart to be injured at the same time. Unusual nervousness, disturbed sleep, fidgety movements, or a tendency to drop things, may be warnings of St. Vitus' dance 5. Rheumatic heart disease is often painless and may only be discovered by a doctor's examination. 6. If the heart has been injured by rheumatism, its recovery is very slow, and permanent harm may be done by letting the child resume an ordinary life before recovery is satisfactory. 7. An occupation in life for a child with heart disease requires very careful choice. 8. Rest is very necessary for rheumatic children. They should always be put to bed early, and they should be made to lie down during the day if they seem at all tired or if there is any aching of the limbs. 9. Damp is bad for rheumatism ; basements are dangerous. Rheumatic children should sleep in the sunniest and driest room available. If they get wet, their clothes should be taken off and dried at once. Water-tight boots are especially important. 10. Rheumatism tends to recur, especially in the winter months. In writing of the prevention of chorea, Dr. F. J. Poynton recommends the giving of simple lectures on chorea and rheumatism to school teachers. The mortality from rheumatism far exceeds 99 that from all the infectious fevers together, but in the past teachers have been instructed chiefly in the early detection of fevers. Their failure to observe, or at least to interpret, the early signs of chorea in their pupils has received unfavourable medical comment. Cases of habit spasm, of little importance, they are prone to refer to the school physician, but the change in disposition and the first movements of the early choreic case are passed over, until a frank attack necessitates several months away from school. This criticism does an injustice to the better type of teacher, who may well look to the medical profession for the instructions—such as is contained in the leaflet cited—on which to build an understanding of rheumatism as a disease process, and of the early signs and symptoms of its manifestations. Treatment—(during active phases of the disease). Home.—Thomson's words deserve quotation—" For the vast majority of rheumatic children satisfactory treatment at home is simply impossible. A busy mother of the artisan class can hardly be expected to keep at rest a child who makes no complaints of ill-health and who to ordinary observation appears quite well. Even if, in exceptional cases, she can be made to understand the need for rest, it is almost impossible for her to make the necessary arrangements. If the child is strictly confined to bed it rapidly becomes peevish and neurotic, and it must be remembered, too, that the environment of the home is frequently one that actually predisposes to rheumatism. If the child is allowed up (as they nearly always are) it is probably worse off playing about the house and neighbourhood that it is at school, provided that the teacher is informed that the child is rheumatic and requires special supervision." And Sir George Newman's—"Acute rheumatism and chorea are diseases for which the provision of institutional treatment is particularly important. Few diseases are less suited for home treatment in the kind of home in which the patients usually live—the bustling, noisy, crowded and often insanitary homes of the poor in our great cities. Moreover, it has been shown, and may be accepted as proved, that in the present state of our knowledge the liability to recurrent attacks of acute rheumatism and to permanent heart damage is considerably diminished by a prolonged convalescence, a convalescence of a kind unobtainable in the ordinary working-class home." It is this unsatisfactory influence of the home environment except under unusual circumstances that militates against the success of treatment by private practitioners or the out-patients' departments by hospitals. Nevertheless at present it is almost inevitable that most children with mild attacks of rheumatism, whether with chorea or with slight heart changes, or both, should remain at home, for lack of appropriate institutional accommodation. By keeping the patient at rest in a living room during the day, mental depression is less likely than if an attempt is made to keep it in bed. Hospital.—" The treatment of acute rheumatism must be directed towards securing and maintaining rest. This should be followed by the prevention, or failing that, the limitation of cardiac involvement, the amelioration of cardiac disability and the treatment of sequelae. Cases of acute rheumatism should receive prolonged hospital treatment. General hospitals, children's hospitals and the Guardians' hospitals all take their share in the care of rheumatic children, and it is to their work we owe much of our knowledge of aetiology, treatment and after history of the disease. But hospital accommodation is limited and it is unfortunately impossible for the hospital owing to pressure on its beds to give children the prolonged rest and treatment essential after the acute stage has passed. Accordingly a child must be discharged during its convalescence, to return not infrequently to a poor home where indifferent feeding, faulty hygiene, and the harassing life in the midst of a large family are the very conditions which favour a recrudescence of the disease." (Sir George Newman) The deficient accommodation in general hospitals for rheumatic cases is familiar to all medical men. But this deficiency results from a present forced misuse of the beds in such hospitals. If after the acute phase cases could be transferred for convalescence elsewhere, the general hospitals could effect a far greater turn over of cases taken in for just that period when their particular contribution of expert nursing is required. The convalescent rheumatic case does not need general hospital nursing, but the alternative at present is so often only the ill-equipped home of the child, that out of pity it is kept in and " blocks " a bed, that might have been given to another acute case. Dr. F. J. Poynton writes:— In private practice we should not dream of choosing a hospital ward in this part of London for a slow convalescence. We need auxiliary hospitals, because skilful supervision is required, and rheumatism is notoriously treacherous. It is not only fresh air and sun that I look for in these hospitals. Rest is a necessary part of the treatment of rheumatic heart disease ; but blind unreasoning rest is bad—for there is no better tonic for the young heart than exercise, and convalescence from rheumatic carditis should be a history of graded exertion and not aimless rest. The auxiliary hospital can supervise these graded exercises with every hope of success. The ultimate goal is plain— it is to send the child back to its home with a heart strengthened to the level of carrying on ordinary life ; and if that is unattainable to ascertain the limitations and advise the parents." It was a consideration of the unsatisfactory results of home treatment, and the lack of hospital and convalescent homes where education could be continued, that led Dr. A. P. Thomson, Special School Medical Officer, Birmingham, to suggest in 1921, that the Baskerville Residential School at Harborne should reserve places for rheumatic children and gradually almost the whole of the accommodation which allows for 100 children has been devoted to such cases. Because of the importance of such pioneer efforts, his description of the administration of this school, written in 1926, is followed in extenso. 100 " So far as I am aware, this was the first school of this type to be organized, and inasmuch as our experience may be of some value to others who may have to deal with the same problem, I will summarize the general principles that have been found of value. For the internal organization of the school Miss Smith, the head mistress, has been almost alone responsible, and it is a pleasure to me to be able to pay a tribute to the great skill and devotion which have characterized all her work in what was, in the early stages, a very difficult problem; The present daily routine at Baskerville is as follows 7.20—Get up. 8. 0—Breakfast. 8.30—Play, rest, or simple household duties (e.g., making bed, etc.), 9.20—" Nerve rest." 9.30—Prayers and singing. 10. 0-12. 0—Morning school. 12. 5—" Nerve rest." 12.15—Dinner. 1. 0- 2.15—Resting, play or free walks in garden. 2.30- 4.30—Afternoon school. 4.35—" Nerve rest." 4.45—Tea. 5.15- 8. 0—Going to bed, or recreation, depending on age or stages of convalescence. In addition, the resting pulse and temperature of each child have been carefully recorded on continuous charts, which also contain clinical notes by myself, particulars of treatment and of exercise permitted, and records of the body weight. As a rule, the school is conducted on what may be called ' partial open-air lines ' ; that is, in fine summer weather the children are out of doors as much as possible, and their clothing at times is so slight that it is almost negligible, but in winter and in cold, damp sunless weather my opinion is that they need shelter and warmth. We have found that it is important to ensure general quietness in the school, and to this end the children wear soft slippers and are taught to avoid slamming doors and banging things about. Fortunately, traffic noises do not intrude. Two warm baths are given each week. The head mistress tells me that one of the surest signs of improvement in a choreic girl is the recovery of her ability to get out of a bath unaided. Oddly enough after bathing choreic movements tend to become more marked. The diet is plain and simple, and calls for no comment. In summer, meat is limited, but there is no need for any special regime. The new admissions and those with severe carditis have almost total physical rest (stretchers with suitable desks are provided in the classrooms) ; their dormitory is also on the ground floor. By ' nerve rest ' is meant a period of ten minutes, during which all the children sit or lie absolutely still and silent with their eyes closed, and are carefully taught to relax all their muscles. These three intervals have proved particularly valuable. Early on I was so impressed with the importance of complete rest that I deliberately admitted to the school a number of crippled children who were almost totally immobilized by orthopaedic apparatus in order that they might serve as an object lesson for the rheumatic cases. We have found that this is now unnecessary, as new arrivals are always associated with children accustomed to the routine of the school, and for administrative reasons it is, I believe, better to organize a school of this type for the admission of rheumatic cases alone. The head mistress has shown great ingenuity in devising a progressive programme for cases of residual chorea. Briefly, it is as follows. At first the children are kept on stretchers ; while movements are marked they are given simple handwork to do, such as winding wool, sorting handkerchiefs and other household linen on a suitable desk. For recreation they are encouraged to play cards, dominoes and draughts, to string beads and to arrange flowers ; they also have picture books. A little later on they are allowed to paint and make artificial flowers and mats ; they are also encouraged to knit, crochet and to do easy raffia and fancy work. Knitting is particularly good for the choreic cases. When the children are first allowed up they dust furniture and clear tables after meals. Usually one month elapses before they undertake formal school work, and on beginning the time is limited to one hour. Throughout the school the educational work is individual. Classes are small and each child is given a card on which is written a list of tasks to be done. No time limit and no order of accomplishment is enforced, and there is no direct competition. When one card is completed another is given out. Frequently rheumatic children (particularly those with chorea) appear dull and backward at school work, but with suitable training they nearly all pick up very quickly, and several instances of marked improvement of the intelligence quotient has been observed within a few months Often, too, they are very ' uneven ' in the early stages ; ' good and bad ' days in school alternate in a surprising way, and we have found that it is no use persisting with school work on a ' bad ' day. When convalescence is almost complete croquet and clock golf are allowed, but no games with a moving ball; drill for periods of five to ten minutes and finally simple dances to slow music. As a result of experience I have come to the conclusion that for permanent benefit to result the period of residence at Baskerville for individual children should be at least six months." '' The results of the prolonged treatment of rheumatic children at Baskerville School have been satisfactory and encouraging. In the first place, we have found that with suitable control it is possible to proceed with their education without prejudice to their physical recovery. Indeed, I am now convinced that education may be a very valuable therapeutic measure, particularly in cases of residual chorea. Be it due to suggestion, education or merely improved environment, I can state as a fact that in no case at Baskerville have choreic movements persisted for more than a fortnight after admission (and we have admitted cases with very severe movements—so severe that they were unable to stand alone). This, in itself, would justify the institution of the school, but I have been even more impressed with the degree of recovery that has occurred in many of the children with damaged hearts. Nearly all of them, on admission, had signs of cardiac damage. A large proportion of them leave with normal hearts, and later examination shows that they may escape heart disease altogether. 101 The brief results are as follows : Of 70 children who have passed through the school and who left more than a year ago I have managed to keep in touch with 58. For statistical purposes 1 have classified these 58 cases into groups. A—Good (with normal hearts or with signs of slight cardiac damage which persists unchanged) 36 cases (62 per cent.). B—Deterioration of the heart condition or relapse of rheumatism. 15 cases (26 per cent.). C—Deaths. 7 cases (12 per cent.). These results will, I am sure, improve in the future in consequence of wider experience in the handling of these cases and of the recognition of the value of early complete tonsillectomy." Three other special residential schools for Rheumatic children are thus described in their " Report on the Organised After-care of Rheumatic Children," by Drs. G. A. Allan and A. P. Thomson. The Invalid Children's Aid Association have been pioneers in the provision of recovery hospitals for rheumatic cases. Edgar Lee Home, Willesden, is scheduled as a residential open-air school, and is under the management of the Invalid Children's Aid Association (London). It has accommodation for 22 boys. There is a local medical officer, and consulting physicians visit from London. The average period of residence is 119 days, and the cost of each patient per week is £1 8s. 0½d. The boys live indoors, but are taught in the open-air. Since 1918, 327 cases have been treated with encouraging results. The boys have simple games and a modified school curriculum. Kurandai Home School of Recovery, Hartfield, Sussex, is scheduled as an open-air school, and is under the management of the Invalid Children's Aid Association (London). It has accommodation for 50 girls and small boys. The children are housed in open-air shelters during summer and winter. This place was opened as an experiment and as a temporary home. The results have justified the plan, and a more permanent home is at present being sought. During the first year 123 cases were admitted for periods varying from one to twelve months (average five months), and only 2 cases had rheumatic relapses. There is a medical officer (Dr. Prince) in the village, and a consulting staff of London physicians. The average total cost of each patient per week is £1 is. 3½d. St. Mary's Home, Broadslairs. The Horsfall Hospital wards in St. Mary's Home have been set aside for the treatment of rheumatism, carditis, and chorea, under the care of Dr. M. O. Raven. During three and a half years 92 cases were admitted. Since October, 1925, education has been given by a fully certificated mistress. The average residence is about ten months. Out of 75 patients discharged, 6 had died, being severe and advancing cases of cardiac rheumatism. Of the remainder, 46 were re-examined, 31 had had no relapses, while 15 had shown active rheumatism, chorea, or carditis. Dr. Raven considers that the longer the stay the better is the progress, and that tonsillectomy is an important factor in controlling the recurrence of acute rheumatism, and rheumatic pains ; it is less effective in chorea. " Reports from these institutions prove their value in minimizing the severity of the after-effects of the disease, and diminishing the chances of recurrence." (Sir George Newman.) The Beneficial effects of removal of the Tonsils in Rheumatism. In the past removal of the tonsils has been largely practised in Rheumatism, and since parents and others are entitled to a confident opinion when an operative procedure is recommended and since tonsillectomy is one of the most definite elements in the treatment of rheumatism now currently proposed the matter will be summarised. Sir George Newman, in 1926, is able to conclude that whilst some have doubted the efficiency of removing enlarged tonsils after the occurrence of the first rheumatic attack as a preventive means against subsequent and recurrent attacks, the removal of enlarged and septic tonsils, and the improvement of oral hygiene forms perhaps the most important prophylactic measure we can take against the rheumatism of childhood. The statistical proof of the prevalent view thus voiced is based upon such recent researches as those of Miller in London and Thomson in Birmingham. Doubt of the efficiency of the operation had depended upon the subsequent occurrence in certain cases of the first rheumatic manifestation after removal, and also the failure of the operation at times to prevent relapses In studying this question most investigators have based their conclusions upon the proportion of cases which shewed recurrence after operation. Miller has attributed their contradictory results to a lack of detail in the findings. It is unreasonable to suppose that tonsillectomy has the same possibilities for benefit in a case after repeated attacks of carditis as it may be a case taken in the stages of rheumatism. He attacked the problem by studying the manifestations of rheumatism in children where tonsils had been removed. Analysis of his cases produces evidence strongly in favour of the value of the operation. Miller studied the rheumatic symptoms of 45 children after tonsillectomy, over periods of one to five years. These were compared with the symptoms of the same children before operation and controlled by an analysis of the symptoms of 133 children with tonsils. Sore throats, joint pains, and heart involvement in all its forms were found to be greatly diminished following operation. Muscular pains remain frequent, but tend to disappear gradually after operation. Chorea, on the other hand, appears to be totally uncontrolled by previous operation ; the great majority of first and later in-patient attacks of rheumatism occuring in such children consist of chorea, usually uncomplicated. Thomson, from a study of 100 consecutive cases admitted to the Baskerville Home, Birmingham, has shewn quite clearly that the children who had had the operation were far less prone to slight attacks of fever, which for lack of other cause he considered to be a rheumatic manifestation. More important still, they were far less likely to develop permanent cardiac injury as judged by the physical signs. 102 APPENDIX I. DIPHTHERIA IN THE STONEBRIDGE AREA BETWEEN THE 1st JANUARY, 1926, AND THE 1st JULY, 1926. by ALICE J. GRAY, M.A., M.B., Ch.B., D.P.H. Assistant Medical Officer. Between 1st January and 1st July, 1926, Diphtheria was particularly prevalent in the Stonebridge Area. 133 cases (including 5 which occurred in Park Royal Hospital) were notified in all. This shows a marked increase over the number of cases occurring during the corresponding months in the preceding 6 years:— There being 34 cases notified from 1st January to 1st July in 1920. „ 40 „ „ „ 1921. „ 19„ „ „ 1922. „ 67 „ „ „ 1923. „ 20 „ „ „ 1924. „ 15 „ „„ 1925. History of the Outbreak. By the end of January, 10 notifications of cases had been made. None of these proved fatal. The cases increased rapidly during February, when 24 were notified. Three of these cases died. Exactly double this number, i.e., 48 were notified during March when the maximum number of cases for any one month occurred. In addition the greatest number notified in any one week, viz., 17 were received during the third week of this month when the outbreak had reached its height. The death roll for March rose to four. Thereafter during £pril there was a rapid decline, the number of cases falling to 15 (two of which succumbed). This was followed by a rise to 25 cases (of which three died) during May, to be followed by an abrupt fall to 7 (one proving fatal) in June. The last case, a mild attack, was notified on 1st July. Age Incidence. Of the total number notified :— 43 (including 4 notified from Park Royal Hospital) were children below school age, that is under 5 years of age. The youngest case notified was 4 months old. 71 were school children (i.e., children between 5 and 14 years of age). 19 (including one notified from Park Royal Hospital) were adults whose ages ranged between 15 and 40 years. INVESTIGATIONS CONDUCTED WITH A VIEW TO DISCOVERING THE FACTOR OR FACTORS CAUSING THE SPREAD OF THE EPIDEMIC. School Attendance. As the greatest number of cases were occurring among school children, an investigation was accordingly made to endeavour to trace the spread of the epidemic to school attendance and particularly to attendance in the classes which had the largest number of cases. The schools found to be affected were :— (1) Stonebridge which had 39 cases:— 29 cases in the Infants' Department. 8 „ „ Girls' „ 2 „ „ Boys' „ (2) Wesley Road School which had 18 cases :— 11 cases in the Infants' Department. 7 ,, ,, Junior Mixed ,, (3) Acton Lane School which had 9 cases :— 8 cases in the Infants' Department. 1 case ,, Mixed ,, (4) Gibbons Road School had 1 case in the Mixed Department. (5) Barclay Home Blind School, Brighton, had 1 case. (6) Leinster Road M.D. School had 1 case. (7) "Strathmore," Greenhill Park, had 2 cases. 103 Also particular classes in Stonebridge, Wesley Road and Acton Lane Schools seem to have been affected, viz.:— (1) Stonebridge School— (a) In the Infants' School:— Average Age. Average No. in Class. 8 cases occurred in Class D. 6½ —8 45—50 8 „ „ „ F 5 —6 ½. 45—50 5 „ „ „ C. 4-7½ 45—50 4 „ ,, ,, G. 5 —6½ 45—50 2 „ „ „ B 7½—8½ 45—50 1 case „ „ A. 5 45—50 1 E 6 —7 45—50 (b) In the Girls' School:— 4 cases occurred in Standard 2. 11 46 1 case ,, ,, 1. 9½ 44 1 „ „ „ 3 10 48 1 „ „ „ 4 11½ 47 1 „ „ „ 5 21½ 47 (2) Wesley Road School— In the Infants' Department:— 4 cases occurred in Class B. 6—8 50 2 „ „ „ G 5—6 50 2 „ „ „ A 8 42 2 „ „ „ E 6 44 1 case „ „ F. 5 50 (3) Acton Lane School— In the Infants' Department:— 4 cases occurred in Class iii. 5—6 50 2 „ „ „ C 5—6 50 Then an attempt was made to link up the various cases occurring in the same class by comparing the cases under the following headings:— (a) Last date on which the case attended school. (b) Date of onset of the symptoms. (c) Date of removal to Isolation Hospital. In the case of Stonebridge School with the possible exception of three cases, 2 of which were in the Infants' Department and 1 in the Girls' Department which from a comparison of the above headings may have been infected from the preceding case in the class, it was impossible to establish a link between the remaining 36 cases which could be furnished by school attendance. In the case of Wesley Road School with one possible exception, and also in the case of Acton Lane School, this attempt was also unsuccessful. Hence except in the isolated examples given above the spread could not be attributed to school attendance. Milk Supply. An effort to trace the infection to the Milk Supply was also made. (1) The Milk Supply of the families in which the cases had occurred was investigated, and it was found that different dairies supplied different families living in the same street. For example, four different dairies supplied the families in which the cases had occurred in Shakespeare Avenue, namely:— Retail. Wholesale. (a) W. Dairy Milk supplied from W., Ltd. (b) H. B. Milk supplied from Leighton Buzzard, Aylesbury, and L. W. Dairies. (c) P. L. Milk supplied from W. Dairy Supply (d) W. Dairy Milk supplied from L. W. Dairies. (2) The amount of milk consumed was comparatively small in amount, varying from 1—1½ pints daily, per family. There was only one exception to this, viz., the B. family, Brett Road, who consumed 4 quarts of milk every day. 104 (3) The way in which the milk was consumed was investigated. It was found that in 78 cases :— 46 cases used milk in tea or pudding only. 11 cases used condensed or dried milk only. 10 cases had drinks of warm or boiled milk daily. 10 cases had drinks of unboiled milk daily. 1 case was breast fed. (This does not include the 5 cases occurring in Park Royal Hospital.) Hence from the above it would seem impossible to trace the source of the infection to the Milk Supply. Locality and Street. An attempt to trace the infection to a particular street was also made. The addresses of all the cases were scrutinised to find out if there was an outstanding number of cases in any one street. The figures given below show that they were fairly equally distributed throughout the neighbourhood:— 28 cases being in Brett Road. 19 ,, ,, Milton Avenue. 13 „ „ Shakespeare Avenue. 13 ,, ,, Melville Road. 13 „ ,, Carlyle Avenue. 8 „ „ Barry Road. While there were fewer cases in other streets. Family. An investigation of the cases from the point of view of the spread of infection through the family was next made. Multiple cases in one family were found to be common. The greatest number of cases occurring in any one family was 4. 57 Multiple cases occurred in families as follows :— 4 cases in 3 families. 3 „ „ 5 „ 2 „ „ 15 „ A comparison was then made of the date of onset of the symptoms and the date of removal to hospital of the cases occurring in the same family. This showed that family infection played a part in the spread of the epiemic, e.g.:- (1) 4 cases occurred in the family S., Milton Avenue. Name. Age. Date of onset. Date of Removal to Hospital. W. S 5 yrs. 8.3.26 9.3.26. Mrs. S. (Mother) 24 yrs. 16.3.26 16.3.26. Mr. S. (Father) 40 yrs. 18.3.26 19.3.26. J. s. 3 yrs. 25.3.26 26.3.26. (2) 4 cases also occurred in the family B., Brett Road. Name Age. Date of onset Date of Removal to Hospital. H. B 4 yrs. 3.3.26 5.3.26 R. B. 10 yrs. 8.3.26 10.3.26. R. B. 3 yrs. 8.3.26 10.3.26. D. G. (Step-sister living in same house) 17 yrs. 11.3.26 11.3.26. (3) Example of 3 cases occurring in one family, viz., B. (1), Brett Road. Name. Age. Date of onset Date of Removal to Hospital. E. B 2 yrs 10.2.26 15.2.26. T. B 5 yrs. 10.2.26 15.2.26. D. B . 13 yrs. 15.2.26 16.2.26. Similarly in the case of 2 cases occurring in the same family in the majority of instances the second case could be traced to the preceding case occurring in the family in question. 105 Another interesting point illustrating the part played by the family in disseminating the infection of Diphtheria in spite of the prompt measures taken to control the spread is that 46 per cent, of the total number of adults affected could definitely trace their infection to a preceding case or cases occurring among the children in their families. Examples:— Name. Age. Address. Date of onset. D. G 17 yrs. Brett Road 11.3.26. H. B 5 yrs. „ 3.3.26. R. B 10 yrs. „ 8.3.26. R. B 3 yrs. „ 8.3.26. W. E 16 yrs. Milton Avenue 16.5.26. P. E 4 yrs. „ 26.4.26. D. E 7 yrs. „ 27.4.26. N. E 10 yrs. „ 18.5.26. Mrs. H 39 yrs. Fairlight Ave. 11.3.26. O. H 6 yrs. „ 7.3.26. Mrs. S 29 yrs. Minet Avenue. 22.3.26. J. s. 5 yrs. „ 11.3.26. Mrs. S 24 yrs. Milton Avenue 16.3.26. Mr. S 40 yrs. „ 18.3.26. W. S 5 yrs. „ 8.3.26. J. S 3 yrs. „ 25.3.26. Hence the majority of adults were infected from children suffering from the disease during the period which elapsed before the case came to the notice of the Sanitary Authority and was removed to Hospital. This therefore shows that family infection has as usual played an important part in spreading this epidemic. THE TYPES OF DIPHTHERIA MET IN THIS EPIDEMIC. Of the 133 cases notified it was found that while undoubtedly 106 (excluding 1 case notified as Diphtheria and removed to M.A.B. Hospital of which we have no report) suffered from true Diphtheria Bacillus affections, the remaining 26 cases (with a few exceptions) suffered from what subsequently proved to be non-diphtheritic inflammatory affections of the respiratory tract. The cases were classified according to the extent of the local lesion, the amount of constitutional disturbance and the presence of complications into 5 types, viz., Very Mild, Mild, Moderate, Moderately severe and Severe. Thus 3 were found to belong to Very Mild type. 35 „ „ „ Mild 28 ,, „ ,, Moderate ,, 14 ,, ,, „ Moderately Severe type. 23 ,, ,, ,, Severe type. Thus while the majority of the cases were mild in type, 23 had severe attacks with marked toxaemia or lung complications on admission or who subsequently developed serious paralysis. The Mortality Rate. The Mortality Rate in this epidemic was as follows :— In adults, Nil. In children, 0—5 years, 20 per cent., 6 cases being fatal out of 30. In children attending school, 11.1 per cent., 7 cases being fatal out of 63. In considering this Mortality Rate, it is interesting to correlate the type of the attack with the corresponding Mortality Rate for that particular type, viz.:— Type. No. Fatal. No. Survived. Very Mild 0 3 Mild 0 35 Moderate 0 28 Moderately Severe 0 14 Severe 13 (56.5 per cent.) 10 This table therefore, demonstrates that it was only these patients who contracted the disease in its severe form who succumbed. Carriers. Of the total number of cases there were found to be 3 carriers— 2.8 per cent. (In calculating this rate the case D. B., who contracted Diphtheria in a moderate form, was admitted to hospital on 20.12.25 and discharged on 6.2.26, and re-admitted as a carrier on 16.2.26, is included as a carrier.) 106 METHODS OF CONTROL ADOPTED IN THE PRESENT EPIDEMIC. The methods of control were those in common vogue, viz., (1) Isolation of the patient in an isolation hospital as soon as he was notified to be suffering from Diphtheria. (2) Disinfection of the rooms and bedding of the house in which the case occurred. (3) Quarantine of contacts of school age. (a) All home contacts who had not previously suffered were excluded from school for 10 days and any who developed suspicious signs were swabbed by the Health Visitor who visited the affected homes daily. (b) All contacts in school were inspected twice daily, in the morning by a Medical Officer and in the afternoon by a Health Visitor. Any who developed suspicious signs or symptoms were swabbed and if necessary excluded from school until the result of the swab was known. (4) General improvement in sanitation. SUMMARY. It is interesting to note in this outbreak that the number of cases occurring in the different schools varied considerably. For example, Stonebridge School had 39 cases among approximately 900 scholars, while Wesley Road School had 18 cases among approximately 800 scholars. These two schools stand opposite to one another in the same road. They are Elementary Schools. The sanitary arrangements in both are very much alike and were found to be satisfactory. Further the number of cases occurring in Wesley Road and Acton Lane Schools were comparatively small, while isolated cases occurred in the remaining schools. This, therefore, goes to prove that the infection was presumably not spread through School Attendance. In addition the type of home which had the largest number of multiple cases was similar in structural and sanitary arrangements to those homes which had only one case or which escaped altogether. Further those multiple cases were found not in houses grouped together, but scattered throughout the various streets, nor was it found that the infection was localised to a particular street or streets. The important part played by family infection in spreading Diphtheria is well illustrated by this outbreak. Whole families were stricken with the disease within a few days of the entry of the infection, this proving that once it gains a footing in a family it spreads rapidly, attacking all susceptible adults and children alike. It is essentially a disease in which the infection is conveyed from person to person, and as most cases are not examined by a Doctor until they have been suffering from the disease for some hours at least, other people in their vicinity have been exposed to infection. Hence the futility of the above methods of control in protecting the immediate contacts from the risk of infection and limiting the number of cases. THE VALUE OF THE SCHICK TEST FOLLOWED BY ACTIVE IMMUNISATION OF THE SUSCEPTIBLE. The only way known at present in which members of a community can be protected against an attack of Diphtheria is by discovering by means of the Schick Test who are susceptible to the infection of Diphtheria and by actively immunising them against it. The value of this method has been well demonstrated in Birmingham, Edinburgh and New York, where Park in 1922 by this method reduced the number of cases occurring among school children by about 80 per cent. Similarly this method employed in isolation hospitals has made a notable reduction in the number of cases of Diphtheria occurring among the staff.