RicH 34 RicH 34 LONDON BOROUGH OF RICHMOND UPON THAMES ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH AND PRINCIPAL SCHOOL MEDICAL OFFICER For the Year 1965 A. M. NELSON M.B., Ch.B., D.P.H. Health Department, Elmfield House, High Street, Teddington, Middlesex. Telephone: Teddington Lock 4411. HEALTH DEPARTMENT, ELMFIELD HOUSE, HIGH STREET, TEDDINGTON, MIDDLESEX. July, 1966. To the Mayor, Aldermen and Councillors of the London Borough of Richmond upon Thames. LADIES AND GENTLEMEN, I have the honour to submit my Annual Report for 1965. The information as set out in the following pages is a distillate of the loyal, conscientious endeavour of the health department staff, who were called upon to contend with the implementation of the London Local Government reorganisation. The differences in emphasis, style, and methods of the former authorities has been accepted as an opportunity and a challenge to rethink many facets of the services provided. Change must be allowed to evolve, since local customs are born of local experience. Behind the recorded data and statistics, there exists individuals, who are people, and have asked for help. The health department, above all else, is in "business" to help people. The index of productivity is reflected in the amelioration of social suffering, although the financial yardstick must always be at hand. The Preventive Ideal should always be maintained. It is often easier to find the solution in the field of community medicine by terms of care, rather than the deeper and more difficult preventive procedures. If preventive measures are within the port' folio of the Health Services, then all our efforts should be concentrated on this basic philosophy. During the year a joint sub-committee of the Health and Welfare Committees prepared a plan for the development of the health and welfare services over the next 10 years 1966-76, and this was subsequently approved for submission to the Ministry of Health. The Health Committee gave very careful consideration to the question of fluorida' tion of the water supply at the end of the year, and had not taken a decision thereon. There are several lacunae in the local health services, especially in the field of mental health and the elderly. Expansion of these services will be necessary. A realistic approach to the solution of these needs will be dependent on your available financial resources. The goodwill, tolerance, and understanding, which I received from both Dr. John Maddison, Area Medical Officer, Middlesex County Council, and Dr. Eric Pereira, Divisional Medical Officer, Surrey County Council, during the preparatory months of 1964/1965 is acknowledged with thanks. I would like to place on record the well deserved honour bestowed on Dr. John Maddison by his election as President of the Society of Medical Officers of Health for the year 1965/66. 1 Grateful acknowledgment is made to the following for their help and collaboration in the common task of promoting the health of the residents of our borough:— The family doctors of Richmond upon Thames The hospital services and staff The Public Health Laboratory Service and all voluntary organisations. The Principal Chief Officers of the Borough. My thanks to Mrs. Stanley Weddle, who designed the cover. All the staff of the health department have given me loyal support and I would especially mention Dr. J. K. Craig, Mr. E. S. Herbert and Mr. H. J. Pugh. I conclude by thanking the Health Committee, particularly the Chairman, Coun' cillor F. D. GildayFox, for their constant encouragement. I am, Yours respectfully, A. M. NELSON, Medical Officer of Health. 2 CONTENTS page Members of Health Committee and Public Health Officers 4 Vital and General Statistics 5 Infectious Diseases 9 Health Services: Care of Mothers and Young Children 12 Midwifery and Home Nursing 21 Health Visiting 24 Vaccination and Immunisation 26 Prevention of Illness, Care and After Care 27 Home Help 43 Mental Health 44 Other Information 48 Sanitary Administration 53 School Health Service (follows above). 3 MEMBERS OF THE HEALTH COMMITTEE as at 31st December, 1965. His Worship the Mayor, Alderman M. W. Garrett, D.L., G.L.C., J.P. (ex-officio). The Deputy Mayor, Alderman H. A. Leon, M.B.E., J.P. (ex-officio). Councillor F. D. Gilday-Fox, B.A. (Chairman). Councillor S. D. Wade (Vice-Chairman). Councillor N. F. Barrow, LL.B. Councillor F. E. Chapman. Councillor D. J. Child. Councillor C. F. Garrud. Councillor M. Gold, M.R.C.S., L.R.C.P., D.Obst.R.C.O.G. Councillor S. Hayes. Councillor B. Hughes. Councillor G. H. Loman, J.P. Councillor R. H. Mitchison, F.V.I., M.R.S.H. Councillor B. L. Royle, J.P., A.M.I.E.R.E. Councillor R. H. Stevens. PUBLIC HEALTH OFFICERS Medical Officer of Health : A. M. NELSON, M.B., Ch.B., D.P.H. Deputy Medical Officer of Health : J. K. CRAIG, M.B.E., M.A., M.D., B.Ch., B.A.O., D.P.H., D.C.H,, D.I.H. Medical Officer for Special Duties : J. MADDISON, M.D., B.S., D.P.H. Senior Assistant Medical Officers : MARGUERITE E. M. JAMES, M.B.E., M.B., Ch.B., D.P.H. ELIZABETH WALES, M.B., B.S., D.C.H., D.P.H., D.R.C.O.G. Chief Dental Officer : G. H. TUCKER, L.D.S., R.C.S. Chief Public Health Inspector : E. S. HERBERT, M.A.P.H.I. Chief pursing Officer : MISS G. M. FRANCIS, S.R.N., S.C.M., H.V.Cert. Superintendent Health Visitor : MISS D. M. WOODS, S.R.N., S.C.M., H.V.Cert. Non-Medical Supervisor of Midwives and Home T^ursing Superintendent : MISS O. WILLIAMS, S.R.N., S.C.M., QUEEN'S NURSE. Chief Mental Welfare Officer : B. F. F. RADFORD, B.E.M., F.W.I., M.S.M.W.O. Chief Administrative Officer : H. J. PUGH. 4 VITAL AND GENERAL STATISTICS 1965 Area in acres 13,873 Population (census 1961) 181,030 Population—estimated to mid-year (as supplied by the Registrar-General) 181,130 Number of inhabited houses 57,590 Rateable value £10,335,219 Sum represented by a penny rate £42,650 Total M. F. Live Births—Legitimate 2,589 1,312 1,277 Illegitimate 244 137 107 Total 2,833 1,449 1,384 Live Birth rate per 1,000 of estimated Population 15.64 Adjusted Live Birth rate per 1,000 of estimated Population 15.80 Illegitimate Live Birth per cent. of total Live Births 8.61 Total M. F. Still Births—Legitimate 31 9 22 Illegitimate 7 2 5 Total 38 11 27 Still Birth rate per 1,000 live and still births 13.24 Total Live and Still Births 2,871 Infant Deaths (under 1 year of age):- Total M. F. Legitimate 37 24 13 Illegitimate 4 4 - Total 41 28 13 Infant mortality rate per 1,000 live births 14.47 Legitimate Infant mortality rate per 1,000 legitimate live births 14.29 Illegitimate Infant mortality rate per 1,000 illegitimate live births 16.39 Neo-Natal deaths Under 4 weeks of age Under 1 week of age Total M. F. Total M. F. Legitimate Illegitimate 31 4 20 4 11 29 4 18 4 11 Totals 35 24 11 33 22 11 Neo-Natal mortality rate (deaths under 4 weeks) per 1,000 total live births 12.35 Early Neo-Natal mortality rate (deaths under 1 week) per 1,000 total live births 11.65 Perinatal mortality rate (stillbirths and deaths under 1 week combined) per 1,000 total live and still births 24.43 Maternal mortality (including abortion) deaths Nil Maternal mortality rate per 1,000 live and still births Nil Total M. F. Deaths 2,175 1,069 1,106 Crude death rate per 1,000 of estimated population 12.01 Adjusted death rate 9.85 5 9 Distribution of Deaths by Age and Cause Registrar General's Official Returns, 1965 Cause of Death Age Group Under 1 1-4 5-14 15-24 25-44 45-64 65-74 75 and over Total Grand Total M F M F M F M F M F M F M F M F M F Tuberculosis, respiratory - - - - - - - - - - 1 - 1 1 2 - 4 1 5 Tuberculosis, other - - - - - - - - - - - 2 - - - - - 2 2 Syphilitic disease - - - - - - - - - - 1 - - - 2 2 3 2 5 Diphtheria - - - - - - - - - - - - - - - - - - - Whooping cough - - - - - - - - - - - - - - - - - - - Meningococcal infections - - - - - - - - - - - - - - - - - - - Acute poliomyelitis - - - - - - - - - - - - - - - - - - - Measles - - - 1 - - 1 - - - - - - - - - 1 1 2 Other infective and parasitic diseases - - - - - - 1 - - - 1 - 1 1 - 1 3 2 5 Malignant neoplasm, stomach - - - - - - - - - 1 6 5 11 2 8 15 25 23 48 Malignant neoplasm, lung, bronchus - - - - - - - - 3 - 41 15 38 5 15 6 97 26 123 Malignant neoplasm, breast - - - - - - - - - 1 - 22 - 8 - 10 - 41 41 Malignant neoplasm, uterus - - - - - - - - - 1 - 4 - 3 - 9 - 17 17 Other malignant & lymphatic neoplasms - - - - - - - - 5 3 40 31 28 34 32 46 105 114 219 Leukaemia, aleukaemia - - - 1 1 - - - 1 1 1 2 2 - 1 2 6 6 12 Diabetes - - - - - - - - - 1 - - 2 3 4 4 6 10 Vascular lesions of nervous system - - - - - - - - 2 - 16 17 24 26 53 146 95 189 284 Coronary disease, angina - - - - - - - - 4 2 105 7 75 55 83 117 267 181 448 Hypertension with heart disease - - - - - - - - - - 2 3 3 9 9 1/ 14 29 43 Other heart disease - - - - - - - - - - 15 15 27 15 39 118 81 148 229 Other circulatory disease - - - - - - - - 1 - 6 6 12 14 31 61 50 81 131 Influenza - - - - - - - - - - - - 1 4 2 4 3 7 Pneumonia 1 - - 1 - - 1 - - 2 9 5 i 1 10 38 50 60 68 128 Bronchitis 1 - - - - - - - - - 15 6 32 9 26 17 74 32 106 Other diseases of respiratory system - - 1 - - - - - - - 3 1 6 2 1 7 11 10 21 Ulcer of stomach and duodenum - - - - - - - - - - 2 4 5 2 4 6 11 12 23 Gastritis, enteritis and diarrhoea - - - - - - - - 1 1 3 2 2 1 2 2 8 6 14 Nephritis and nephrosis - - - - - - - - - - - - 1 - 1 2 2 2 4 Hyperplasia of prostate - - - - - - - - - - - - 2 - 8 - 10 - 10 Pregnancy, childbirth, abortion - - - - - - - - - - - - - - - - - - - Congenital malformations 10 5 - - - - - - 1 1 2 1 - 1 - 15 6 21 Other defined and ill-defined diseases 16 8 - 1 1 - 2 2 2 2 20 8 13 8 10 31 64 60 124 Motor vehicle accidents - - - - - 1 2 2 2 7 3 2 3 3 16 9 25 All other accidents - - 1 - 1 - 1 - 3 2 6 2 1 4 7 7 20 15 35 Suicide - - - - - - 2 - 6 2 8 9 1 2 1 1 18 14 32 Homicide and operations of war - - - - - - - - 1 - - - - - - - 1 - 1 28 13 2 4 3 1 10 4 32 19 311 169 299 214 384 682 1069 1106 2175 Main Causes of Death An analysis of the death returns reveals the following main causes of death : Disease Percentage of total deaths Death rate per 1,000 of the population Diseases of heart and circulatory system 39.13 4.70 Vascular lesions of nervous system 13.06 1.57 Bronchitis, Pneumonia, and other respiratory diseases 11.72 1.41 Cancer 21.15 2.54 Accidents, Violence 4.28 0.51 7 8 Infant Mortality, 1965. Net Deaths from stated causes at various ages under one year compiled from returns received. CAUSE OF DEATH TOTAL Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks 1-3 months 3-6 months 6-9 months 9-12 months Under one year Under four weeks M F M F M F M F M F M F M F M F Total from all causes 41 34 20 13 1 — — — — — 3 1 1 1 1 — — — Congential Malformation 12 8 4 3 1 — — — — — 1 1 1 1 — — — — Inter-Cranial injury at time of Birth 1 1 — 1 — — — — — — — — — — — — — Post-Natal Asphyxia and Atelectasis 15 15 11 4 — — — — — — — — — — — — — — Bronchitis and Bronchopneumonia 3 — — — — — — — — — 2 — — — 1 — — — Haemorrhagic Disease 3 3 3 — — — — — — — — — — — — — — — Prematurity 7 7 2 5 — — — — — — — — — — — — — — 6 Cases of Infectious Diseases Notified during the year 1965 DISEASE CASES NOTIFIED AT VARIOUS AGES (YEARS) Total Cases Notified Deaths Under 1 Year 1 2 3 4 5-9 10-14 15-19 20-24 25-34 35-44 45-64 65 and Over Age not known Diphthera - - - - - - - - - - - - - - - Dysentery 1 3 2 3 - 3 - 1 - - 2 1 1 - 17 - Erysipelas - - - - - - - - 1 - 1 5 2 - 9 - Food Poisoning - - - - - - - 3 - 1 - 2 - 6 - Malaria - - - - - - - - - - - - - - - Measles 64 190 240 304 289 840 40 10 5 3 5 2 - 1992 2 Meningococcal Infection - - - - - - - - - - - - - - - Ophthalmia Neonatorum - - - - - - - - - - - - - - - Pneumonia 3 1 1 - - - 1 - - 4 8 18 10 1 47 128 Poliomyelitis - - - - - - - - - - - - - - - - Puerperal Pyrexia - - - - - - - 1 - 1 1 - - - 3 - Scarlet Fever - - - 5 12 44 4 2 1 1 - - - - 69 - Smallpox - - - - - - - - - - - - - - - - Typhoid and Para-Typhoid - - - - - - - - - - - - - - - - Whooping Cough 1 1 - 2 4 - 1 - - - - 1 - 10 - Totals 68 195 244 312 303 891 45 18 7 10 17 28 14 1 2153 130 INFECTIOUS DISEASE The pattern of incidence of notifiable diseases followed the experience of previous years. For ease of comparison over the year the figures have been extracted from the various areas which now comprise the new borough and are given below: Disease. 1965 1964 Scarlet Fever 69 45 Acute Pneumonia 47 19 Whooping Cough 10 58 Measles 1992 234 Puerperal Pyrexia 3 4 Dysentery 17 4 Erysipelas 9 7 Food Poisoning 6 8 Scarlet Fever. Sixty-nine cases were notified; a fairly substantial rise compared with previous years. 1962 45 1963 43 1964 45 1965 69 Whooping Cough. There was a marked reduction in the number of cases notified : 1962 4 1963 69 1964 58 1965 10 Measles. This was a "measles" year. There were 1992 cases notified : 1959 1957 1963 1885 1960 57 1964 234 1961 2422 1965 1992 1962 112 As in the past the highest incidence of the disease occurred during the first quarter of the year reducing to the end of the year. The distribution of cases during each quarter of the year is shown below: M. F. Total 1st January— 31st March 650 600 1250 1st April—30th June 271 282 553 1st July — 30th September 60 59 119 1st October—31st December 29 41 70 Total 1010 982 1992 10 From the table below it will be seen that the first five years of childhood suffer the major incidence of the disease and the sexes are affected equally: M. F. Total Under 1 year 38 26 64 1 year 99 91 190 2 years 113 127 240 3 years 142 162 304 4 years 168 121 289 5 — 9 years 412 428 840 10 — 14 years 21 19 40 15 — 24 years 10 5 15 25 + 7 3 10 Total 1010 982 1992 There were two deaths from measles during 1965, one of whom was eligible for inclusion in the measles vaccine trial (see page 27). She was not so protected. Vaccination and Immunisation (see page 26). Food Poisoning. Six cases of food poisoning were notified during the year and the causative organism was identified by the Public Health Laboratory as S.typhi murium in three cases. One of these cases, despite the fact that he was symptom free after one week, continued to excrete S.typhi murium in his stool for eight weeks. Our epidemiological advice is based on the balance between clinical and bacteriological factors with each individual patient. In this instance the boy returned to his boarding school in the Midlands symptom free, although he was still bacteriological positive. Despite thorough investigation of all notified cases of food poisoning by the health department and the Public Health Laboratory Service, it was not possible to implicate any particular food as the vehicle. 1962 14 1963 6 1964 8 1965 6 Psittacosis. In the middle of the year a local resident was diagnosed as a case of psittacosis by a local hospital. The infection was attributed to a young budgerigar, which the patient's daughter had bought in a local pet shop and brought home. The bird was listless and appeared to have difficulty in breathing and died next day. Twelve days later the patient sickened. No other ill birds were found in the pet shop in question when investigated nor in any other of the pet shops within the borough. The City of London Veterinary Officer, engaged by this authority in connection with the Diseases of Animals Act, 1950, gave valuable advice and assistance in ensuring the thorough disinfection and cleaning of bird cages in all pet shops, particularly the one which had sold the infected bird. 11 Anthrax. The Minister of Health suggested that certain orders in force requiring the notification of infectious diseases should be revoked. In consequence the Council requested the Minister to revoke the Orders in force in the former Boroughs of Barnes, Richmond and Twickenham requiring the notification of Anthrax as an infectious disease. Weekly Newsletter. A communication is sent out by the health department each week to family doctors, hospitals and adjacent medical officers of health informing them, amongst other things, of the number of notifiable diseases reported during the preceding week in the Borough. This has proved an invaluable means of contact with family doctors and their response to these newsletters has been most encouraging. Venereal Diseases. I am indebted to Dr. J. L. Fluker and Dr. N. Rosedale for the following observations of the patients treated at the Special Clinics at West London and West Middlesex Hospitals respectively:— West London Hospital 1965 1964 Male Female Male Female Syphilis 141 57 122 48 Gonorrhoea 1,077 314 1,107 407 Other Diseases 3,204 1,491 2,906 1,211 West Middlesex Hospital Syphilis 16 2 18 14 Gonorrhoea 135 26 124 28 Other Conditions 580 292 520 283 It has been pointed out by Dr. Fluker that the general trend amongst those suffering from Syphilis is to seek treatment at an earlier stage than in the past. He also points out that Yaws is tending to be diagnosed more frequently than previously. CARE OF MOTHERS AND YOUNG CHILDREN Ante-Natal and Post-Natal Clinics Number of cases attended : Ante-Natal Attendances Post-Natal Attendances 807 2808 181 193 Sessions held (Medical Officer in attendance) 410. Ante-Natal relaxation and post-natal exercises are taught in all the clinics. 627 women made 3,545 attendances at these clinics during the year. Premature Births. The weights of all babies are entered on the birth notification cards. Visits to those babies under 5lbs. 8oz. are made at more frequent intervals and where necessary these babies are admitted to either the Kingston or West Middlesex Hospitals. These babies are placed on the "Observation Register" so that they can be clinically examined in order to detect developmental defects at an early date. If a baby should have a defect, then surveillance can be maintained to ensure that appropriate comprehensive therapy can be instituted. 12 13 Premature Births Number of premature births (as adjusted by any notifications transferred in or out of the area). Weight at birth Premature live births Premature stillbirths Born in hospital Born at home or in a nursing home Nursed, entirely at home or in a nursing home Transferred to hospital on or before 28th day Total births Died Total births Died Total births Died Born within 24 hours of birth in 1 and under 7 days in 7 and under 28 days within 24 hours of birth in 1 and under 7 days in 7 and under 28 days within 24 hours of birth in 1 and under 7 days in 7 and under 28 days in hospital at home or in a nursing home (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) 1 2 lb. 3 oz. or less 4 3 1 — — — — — — — — — 7 — 2 Over 2 lb. 3 oz. up to and including 3 lb. 4 oz 13 4 6 — — — — — 1 — 1 — 4 — 3 Over 3 lb. 4 oz. up to and including 4 lb. 6 oz 29 4 1 — — — — — 2 — 1 — 5 1 4 Over 4 lb. 6 oz. up to and including 4 lb. 15 oz. 22 — — — 3 — — — — — — — 2 5 Over 4 lb. 15 oz. up to and including 5 lb. 8 oz 44 1 — — 9 — — — 1 1 — — 1 6 Total 112 12 8 — 12 — — — 4 1 2 — 19 1 1 = l,000g, or less, 2 = 1,001 - l,500g, 3 = 1,501 - 2,000g, 4 = 2,001 - 2,250g, 5 = 2,251 - 2,500g. Incidence of Congenital Malformations Since 1st January, 1964 the Ministry of Health have required all congenital malformations in new-born babies to be notified by Local Health Authorities to the Registrar General, so as to enable the latter to complete statistical information from which to detect any national or regional changes in the pattern of congenital malformations. The number of babies born with defects during 1965 was 67. Puerperal Pyrexia Regulations Three cases of puerperal pyrexia were notified during the year. All occurred in domiciliary practice and subsequently recovered. Family Planning Health education in family planning in the Borough is largely undertaken by the medical officers, nursing staff, and social workers in their day-by-day educational activities and, additionally, facilities are available for talks on this subject to voluntary societies and family groups. Family doctors are also concerned with family planning advice and may provide it as part of the general medical care of their patients, many of whom will choose to go to their own doctors for such advice. The Council do not operate family planning clinics of their own but have made available to the Family Planning Association three clinics for the purpose of holding family planning sessions at Hampton Wick, Richmond and Whitton. No charge is made for the use of the premises. The Council accepts financial responsibility for advice and treatment, including supplies, given to women to whom pregnancy would be detrimental to health and who are referred by the Council's medical officers. No charge is made to the patients in this category. During 1965 six women were so referred. Care of Unsupported Mothers and Their Babies Local health authorities have a statutory duty under the National Health Service Act, 1946 to make arrangements for the care of expectant and nursing mothers and their infants. The majority of those mothers who may be termed unsupported are unmarried, but there are also a few who are married but who are homeless and thus have special needs. A full-time Social Welfare Worker is employed by the Council, who is responsible for seeing that each patient receives ante-natal care and hospital or residential accommodation if necessary and gives to the mother any necessary assistance in the care of the baby on discharge from a mother and baby home. If the mother is unable to provide the necessary care the Social Welfare Worker will assist by endeavouring to find suitable residential employment, foster home, or, when required, help with application to an adoption agency. The Council accepts financial responsibility for the provision of accommodation in mother and baby homes for unsupported persons first discovered to be pregnant when living in the Borough, and these women are required to contribute towards the cost according to their means. There are no mother and baby homes in the Borough. During the year the Council were responsible for the cost of 105 cases placed in homes outside the area. One gets the impression that there has been an increase in the volume of the work, but despite this trend, it has been possible to offer hostel accommodation to all who have 14 requested it. There has also been the growing practice for women, even in extreme need, to refuse residential care in homes and hostels. A fair number have cancelled their arrangements and asked for alternative plans. There has also been the tendency for girls to leave the hostels after a few days, showing a need for greater flexibility in the service offered to the unsupported mother. Many of the more sensitive and intelligent women accept hostel accommodation reluctantly, and although some settle well, others are critical. For those who leave it has been possible to make suitable alternative plans with a few families. The arrangements have worked well showing that the community might solve the problems of an increasing number of women unable to accept residential help in hostels. In these instances the women are responsible for their own maintenance to the family. It is always possible to give some kind of adequate help. This can start in very early pregnancy and be continued through until the post natal period is over. For the mother who wishes to keep her child and has no home to which she can go, the service comes to an abrupt halt. There are very few facilities indeed that can be said to be satisfactory. This comment is based on the fact that the urgent need for housing the unsupported mother has largely been ignored for a very long time. Illegitimate children are always socially at risk and will be more so until their mothers can be assisted with their accommodation problems. The deciding factor in many a child's adoption has been the inability of its mother to find a place to live. Adoption may not be in the best interests of either, and as yet little is known of the effects of adoption on children in their later years. I am indebted to Miss H. Oliver, Social Welfare Worker, for these observations on the care of the unsupported mother and her child. Total Number of Cases referred in 1965:— Jan. — March April — Dec. Total Unsupported mothers 27 125 152 Referred by Medical Social Workers 75 Health Visitors 21 Doctors 32 Statutory Social Workers 4 Voluntary Social Workers 10 N.C.U.M.C 7 Citizens' Advice Bureau 3 152 The Mothers Marital Status Single 137 Married 10 Separated 2 Divorced 3 Education Sec. Mod. 112 Grammar 29 Convent 6 Technical College 3 University 2 Domicile In area 116 Outside area 36 Religion C. of E. 121 Free Church 7 R.C 22 Moslem 2 Occupation Doctor 1 Nurses 25 Teachers 3 Geologist 1 Students 14 Hairdressers 16 Factory 27 Office Workers 42 Housemother 1 Domestic Hotel Workers 17 Petrol Pump Attendants 3 Civil Servants 2 15 The Mothers (continued) Ages 14 years 2 15 „ 2 16 „ 7 17 „ 16 18 „ 19 19 „ 27 20 „ 21 21-30 40 31-40 17 Over 40 1 Countries of origin other than G.B. Ireland 10 India 1 Pakistan 1 China 1 Finland 1 W. Germany 1 Cyprus 1 Putative Fathers Marital Status Single 76 Married 33 Divorced 5 Unknown 38 Occupation Doctor 1 Dentist 1 Teachers 3 Students 13 Office Workers 56 Swimming Instr. 1 Manual 39 Unknown 38 Ages 16 years 2 17 „ 4 18 „ 9 19 „ 21 20 „ 22 21-30 35 31-40 5 Unknown 54 Countries of origin other than G.B. Ireland 7 Pakistan 4 Persia 2 Lebanon 1 W. Indies 3 Greece 1 Cyprus 1 Turkey 1 China 1 Australia 3 S. Africa 1 Italy 2 W. Germany 1 America 3 Ways in which unsupported mothers have been helped. By admission to working girls hostels in early pregnancy 25 By admission to maternity homes and hostels 73 By admission to flatlet house for mothers and babies 3 By providing private accommodation 5 By reconciliation with parents and relatives 10 By private financial agreements and affiliation orders 26 By adoption through registered adoption agencies 42 By fostering arrangements 14 By residential nurseries 3 By baby being taken into care by Children's Dept. 3 At the end of 1965 the mothers who decided to keep their babies were living in the following way Had returned to parents or relatives 52 Had married putative father 11 Were co-habiting 16 Had accepted residential work 5 Were living in flatlet house for mother with babies 3 Were living in. lodgings 7 Mothers who parted with babies By adoption 42 Taken into care 3 Arrangements still incomplete 10 Still births 3 152 16 17 Child Welfare Centres Number of children who attended during the year Number of sessions held by Total number of sessions in columns (5)-(8) (9) Number of children referred elsewhere (10) Number of children under observation at end of year (11) Born in 1965 (1) Born in 1964 (2) Born in 19601963 (3) Total (4) Medical Officers (5) Health visitors (6) G.Ps. employed on a sessional basis (see note 2) (7) Hospital medical staff (8) 2595 2322 2350 7267 1355 38 — — 1393 306 3021 Total attendances during the year 50,866. Survey of Childhood Cancers During 1965 the health department continued to co-operate in this survey which is being carried out by Dr. Alice Stewart of the Department of Social Medicine, Oxford University. The work involves an investigation into the medical history of families of children who have died from cancer or leukaemia. The names of these children are supplied from Oxford, suitable matched 'controls' are selected from birth records, the co-operation of parents is sought by the health visitor and interviews to obtain the required information are undertaken by a medical officer. Phenylketonuria A simple urine test can detect this rare but very distressing disease in the first few weeks, when it is amenable to treatment. The test is now available for all children born in the borough and is performed by the health visitor. No tests were positive. Early Detection of Deafness In order that children who are deaf can benefit from auditory training, testing for hearing is done by the health visitor during the first year. Ophthalmia Neonatorum (See page 49). Child Welfare Centres At the end of the year, there were 12 child welfare centres. (For location of centres etc. see map inside the cover at the end of the report). One centre has 4 sessions a week, two have three sessions a week, 6 have two sessions a week, 3 have one session a week. In order to meet the demands for child welfare centres in areas where premises are not available, an arrangement has been made with Surrey County Council for the use of its mobile clinic. Five sessions in alternate weeks are held at sites in Hampton, Twickenham and Whitton. The work in the centres is changing, with an emphasis on the awareness of the early signs of certain defects. The screening is carried out by doctors with special experience and interest in developmental paediatrics. Children with certain familial, obstetric and neonatal histories are "observed" at regular intervals so that deviations from the normal can be discovered early and the parents helped to obtain the correct medical and educational treatment. For details of attendances etc. during the year see page 17. At the end of the year no Council's clinics were being used by family doctors for patients on their list. Orthopaedic Service Of the 134 children under five years of age treated at the Orthopaedic Clinic during the year, 5 3 were new cases seen by the surgeon, 81 were re-examinations at the surgeon's clinic. These children made 368 attendances. 18 Defective Vision Dr. Helen Casey, Consultant Ophthalmic Surgeon, in her report states : "I think it is noteworthy that the age of the patient is getting younger. Quite a number of babies attend for investigation of strabismus. It is an excellent idea, as it cannot be too much emphasized, that the treatment of strabismus should begin more or less from the age of one year. Binocular function must be established very early in life. Certainly from the point of view of a preventive health service the evidence grows of the success of the pre-school medical examination in relation to the care of children's eyes. These babies, if squints, are refracted under atropine, fundi examined, and glasses or orthoptic supervision or early surgery arranged at the hospital of the patient's choice. Dr. P. T. Clover, at the Royal Hospital, Richmond, and the Royal Eye Hospital Surbiton, is very helpful, as well as Mr. Kapur and Mr. Langley at the West Middlesex Hospital." Dental Treatment — Expectant and Nursing Mothers and Children. Mr. G. Tucker, L.D.S., R.C.S., Chief Dental Officer, reports as follows: It will be seen from, page 5 that there were 2,833 births to mothers living in the borough during 1965. From the Department of Education and Science's quinquennial surveys carried out in the past in Twickenham it can be assumed that at least 90% of these children will have some dental decay by the time they reach school age. The average number of decayed, extracted or filled teeth per child at this age is 5. Assuming that the birth rate will remain roughly the same and in spite of there being about 0.3 p.p.m fluoride in the water supplies in the Borough, the problem facing the community is in the order of 10,000 decayed teeth every year in children aged 4 years alone. The addition of 0.7 p.p.m. fluoride to the water supply would be expected to halve this incidence of dental disease. Only 3 51 children under 5 years old were brought to the dental clinics by parents seeking treatment during the year. Of these children 102 did not require treatment, which shows that a good proportion of mothers who do bring their children to the clinic do so early enough for them to become used to dental procedures before dental disease becomes visible in the mouth. Pre-School Children Examined at clinic 351 Requiring treatment 249 Commenced treatment 205 Attendances for treatment 509 Fillings 397 Silver Nitrate treatment 17 Extractions 87 General Anaesthetics 43 Radiographs 1 The family dentist obviously has a large part to play in this sphere, but methods will have to be found to increase the number of mothers seeking advice and treatment for their young children. These children are otherwise not treated until they are in pain, or after inspection at school, when it may be too late for conservative treatment to be successful. Expectant and Nursing Mothers Examined 81 Requiring treatment 69 Commenced treatment 71 Attendances for treatment 288 Fillings 177 Gum treatment 34 Crowns or Inlays 4 Extractions 47 General Anaesthetics 11 Partial dentures 18 Radiographs 2 19 These figures show the small number of patients referred from the ante-natal clinics. Those patients treated have generally recently moved into the district, or they are mothers-to-be who are living with relatives in the Borough. They attend because they can be seen immediately, and usually have treatment completed by the time their baby is born. Deprived Children In order that the health visitor can make her routine visits, when a deprived child under five has moved to a new address, my colleague the Children's Officer, notifies the health department. Nurseries and Child-Minders Regulation Act, 1948 At 31st December, 1965, 46 child-minders were receiving children under the age of five years and 21 private day nurseries (including one factory day nursery), were on the register. These nurseries are regularly visited by a senior medical officer and a health visitor. The Barnes and Mortlake Day Nursery, which is included in the above figures, is a private nursery with 25 places and receives a grant from the Council. Daily Minders There were no daily minders receiving fees from the authority at the end of the year. Municipal Day Nurseries There are in the Borough three day nurseries maintained by the Council for necessitous children from the age of six weeks to five years of age. Admission to the day nurseries is determined by priority categories. The standard daily charge is 4/- or 6/6d. per day. Accommodation:— Castelnau, Barnes 45 children Parkshot, Richmond 53 children Gifford Lodge, Twickenham 40 children Children with defects are also admitted to the day nurseries to aid their development emotionally, physically, mentally and socially. Welfare Foods The Council is responsible for the distribution of welfare foods (National Dried Milk, cod liver oil, fruit juices, etc.) supplied by the Ministry of Health. In addition various proprietary brands of dried milk and dietary supplements are sold at the welfare centres on the recommendation of the medical officers, health visitors or family doctor. I gratefully acknowledge the work of all voluntary helpers. Cervical Cytology During the latter part of the year arrangements were made at the request of the Consultant Pathologist, St. Stephen's Hospital, Chelsea, for cyto-screening for cervical carcinoma by the laboratory of a limited number of specimens taken from women in the Borough clinics in Richmond and Barnes, the catchment area served by the South West Metropolitan Regional Hospital Board. 20 This is a pilot scheme in which women are asked to co-operate in the comparison of smears taken in a standard way at the clinics by doctors and smears taken by themselves at home later and despatched to the laboratory. Each woman taking part in the scheme is issued with appropriate instruction and "do-it-yourself kits" in the form of cytopipettes and postal containers. First priority is being given to women in the over 35 age group. The Borough has been allocated 20 — 25 specimens a month for examination at the laboratory. The number of women attending the clinics was 35. DOMICILIARY MIDWIFERY AND HOME NURSING SERVICES Staff 1 Non-Medical Supervisor of Midwives and Home Nursing Superintendent. 1 Deputy Non-Medical Supervisor of Midwives and Home Nursing Superintendent. 12 Full-time Midwives. 3 Part-time Midwives. (1.25)* 3 Full-time District Nurses/Midwives. 31 Full-time District Nurses. 4 Part-time District Nurses. (2.0)* * equivalent whole-time. MIDWIFERY SERVICE Training Five midwives are approved as teachers. Three midwives attended refresher courses as required by the rules of the Central Midwives Board. Twenty pupil midwives from the Epsom District Hospital and the King Edward VII. Hospital, Windsor, completed their training on the district, and at the end of the year four were in training. Nine nurses from West Middlesex Hospital taking their obstetric training spent a half-day on the district observing the work of the domiciliary midwives. Transport All the domiciliary midwives drive cars. Three use Council vehicles; the remainder have their own cars. Ante-natal Clinics Weekly sessions attended by midwives— at local authority clinics 7 at family doctor clinics 11 Mothercraft Mothercraft and relaxation classes were held at all clinics. A total of 627 women attended. 21 Some of the midwives and health visitors have attended the course arranged by the National Childbirth Trust on the psychoprophylactic method for childbirth. This method of preparation for motherhood is becoming increasingly popular and expectant mothers in the Borough are most anxious to attend classes at local health authority clinics. At the end of the year a further Seminar was being arranged in the Borough for the instruction of midwives and health visitors in this method of childbirth. Domiciliary Deliveries Number of domiciliary confinements attended by midwives under N.H.S. arrangements. Number of cases delivered in hospitals and other institutions but discharged and attended by domiciliary midwives before 10th day (1) Doctor not booked (2) Doctor booked (3) Total (4) 17 711 728 360 This table relates to women delivered, and not, in the case of multiple births, to infants. All midwives in the domiciliary midwifery service have been advised that patients, who are to have a domiciliary confinement, should be referred to their family doctor either for booking or for the latter to refer the patient to a practitioner on the obstetric list. Notification of intention to practise Under the rules of the Central Midwives Board, 32 midwives notified their intention to practise within the Borough. Medical Aid Medical aid was required for 117 natients as follows:— During Pregnancy Mild Toxaemia 4 Antepartum haemorrhage 8 Hydramnios 2 Post-Maturity 1 Malpresentation 2 Ruptured vulva 1 Infant Prematurity 1 Asphyxia 2 Ophthalmia 14 Vomiting 1 Pyrexia 1 Early jaundice 1 General illness 4 In Labour Foetal Distress 7 Premature Labour 2 Malpresentation 3 Delay in Labour 12 Retained placenta 3 Ruptured perineum 17 Post-partum haemorrhage 9 Dr. wished to be present 2 Puerperium Secondary p.p.h. 3 Pyrexia 11 Thrombophlebitis 3 Suppression of lactation 1 Mastitis 1 Retained products 1 Early Discharges The domiciliary midwives nursed 360 mothers and babies discharged from hospital early in the puerperium. The majority of these mothers had planned discharges. 22 Maternity Outfits A maternity outfit is supplied free to each expectant mother arranging her confinement at home under the National Health Service, as well as — if requested — to those entering private nursing homes. A smaller pack is supplied to patients discharged from hospital 48 hours after delivery. Maternity Liaison Committee The Medical Officer of Health has been appointed a member of the Maternity Services Liaison Committee Catchment Area IV, whose purpose is to discuss midwifery problems of hospital, family doctors, and the local authority health department. HOME NURSING SERVICE Training 5 District Nurses received district training. 3 District Nurses attended Refresher Courses. 79 Hospital Student Nurses spent a day visiting patients in their homes observing the work of the District Nurses. Cases and Visits Total number of cases nursed 2,502 Number of above over 65 years of age 1,668 Number of above under 5 years of age 16 Total number of visits 93,495 Loan of Nursing Equipment The Middlesex Branch of the British Red Cross Society operate a loan of nursing equipment scheme on behalf of the Council. Under these arrangements a hire charge is collected from the patients by the British Red Cross Society and retained by the Society to enable it to purchase replacement equipment as required. If the patient is unable to meet the hire charge it is paid by the Council. The Council also purchases any additional equipment required to meet requests for loan of articles on the approved list. Other items of equipment are purchased in special cases. All transport required, e.g. for the collection and delivery of bulky articles, is provided by the Council. In general, the scheme is intended to facilitate simple short term nursing care in the patient's home. There are medical loan depots at King Street Parade, Twickenham, and Essex House, Barnes. Laundry Service Details of the laundry service and the provision of pads for incontinent patients are given on page 69. Marie Curie Memorial Foundation. Area Welfare Grant Scheme The Council agreed to participate in this scheme, which provides for the urgent needs of cancer patients, who are being nursed in their own homes. Such assistance is given only "in kind" and covers the provision of nursing assistance in addition to such necessities as linen and bedding, clothing, toilet necessities, special equipment, extra nourishment, extra fuel and many miscellaneous needs which cannot otherwise be met from either a statutory or another voluntary source. The scheme is operated on behalf 23 of the Foundation by Medical Officers of Health and Nursing Superintendents, who in practice act as agents of the Foundation. As an extension of the Area Welfare Grant Scheme and to combat the difficulty of finding nurses when required, the Foundation has introduced a Day and Night Nursing Service which is designed to facilitate the provision of nursing assistance and a "sitters-in" Service for cancer patients. The main provisions of the Service are that the Foundation recruits nurses or women with nursing experience and payments are made to them by the Council out of funds provided by the Foundation. The nurses are not in the employ of the Council, although they are supervised by their Medical Officers and Nursing Superintendent for the day-to-day working arrangements. All expenditure incurred under the scheme is met by the Marie Curie Memorial Foundation. HEALTH VISITING Staff 1 Chief Nursing Officer. 1 Superintendent Health Visitor. 21 Health Visitors. 2 (1.0)* Part'time Health Visitors. 9 (3.5)* Part-time Clinic Nurses. 1 Health Assistant. 1 Tuberculosis Health Visitor. 1 Student Health Visitor. * equivalent whole time. It has not been possible to initiate any major new aspects of health visiting during the year. It is hoped that two more health visitors will shortly be attending weekly infant welfare sessions in the surgeries of family doctors, making three in all, and a clinic nurse will attend once a fortnight at an ante-natal clinic in another surgery. Two clinic nurses go weekly to a clinic for older people in the surgery of another group of family doctors. In a borough where the number of people over 65 years is high, consideration will have to be given to development of health visiting in this age group (see page 32— Care of the Elderly). A senior member of the health visitor team, possibly of group adviser grade, is needed to organise a comprehensive service for the elderly with probably one or two health visitors concentrating on the special problems in this age group. Health visitors with a case load of families with young children find it difficult to give sufficient time to older people, although fresh orientation in this field is worthy of further study. There is one small project in operation assocated with the Teddington Clinic for Preventive Medicine for Older People (see page 32), where consecutive groups of eight to ten people attend a series of weekly talks lasting six weeks and given by a health visitor on such topics as nutrition, how to eat well on a small income and other economies, care of the feet, value of physical activity, how to adjust to irreversable disability, the importance of cultural interests and social contact, and the services available to help in times of difficulty. A physiotherapist also attends these sessions. 24 There is great opportunity for much more education of this kind for the older age groups which might be done in the clubs and for talks on similar lines appropriately adapted to middle-aged and pre-retirement groups. Another health visitor of the same grade could improve the quality of health education by co-ordinating and advising the district health visitors and encouraging more talks in schools and to outside organisations (see page 42). One health visitor has taken the Field Workers Instruction course and has already started training students in the new methods laid down by the Council for the Training of Health Visitors. Another health visitor will be taking the course early in the new year. There are still some students completing a course of integrated nursing training and we continue to receive 6 — 9 student nurses from West Middlesex Hospital, 3 from The Middlesex Hospital and 11 from Richmond Royal Hospital four times a year. Four health visitors have attended refresher courses. Chief Nursing Officer The primary object of this post must be to develop a closer working relationship and exchange of information between all sections of the nursing staff. Two meetings of all nursing staff have been held, at which items of general interest were discussed. It is proposed to have at least two each year, which not only gives all staff a chance to get to know each other but to which we hope to invite speakers on special subjects and to show new films and health education material. The Chief Nursing Officer must also keep abreast of current opinion and development by membership of committees and attendance at meetings and conferences and pass this information on to all the staff, stimulating them to develop, be progressive in outlook, receptive to new trends, and not afraid to try out new ideas. Her other role is in helping to form policy and to advise, support and encourage the staff, particularly the senior ones who have closer day-to-day contact with field workers. Health Visiting Cases visited by health visitors Number of cases 1 Children born in 1965 2,995 2 Children born in 1964 2,707 3 Children born in 1960-63 5,573 4 Total number of children in lines 1 — 3 11,275 5 Persons aged 65 or over 530 6 Number included in line 5 who were visited at the special request of a G.P. or hospital 88 7 Mentally disordered persons ... 135 8 Number included in line 7 who were visited at the special request of a G.P. or hospital 29 9 Persons, excluding Maternity cases, discharged from hospital (other than mental hospitals) 23 10 Number included in line 9 who were visited at the special request of a G.P. or hospital 12 11 Number of tuberculous households visited ... 8 12 Number of households visited on account of other infectious diseases 23 13 Number of tuberculous households visited by tuberculosis visitors 451 25 VACCINATION AND IMMUNISATION The tables below show the numbers of children under 16 who completed vaccinations or immunisation procedures during 1965. No comparable figures for previous years are available, due to the re-organisation of areas, but on the assumption that the 'take-up' has been similar in recent years, it may be estimated that probably about 90% of children are 'protected' against Diphtheria, Whooping Cough and Tetanus before their second birthday. The figure for vaccination against Poliomyelitis would be even higher — about 95%. The proportion of children protected against smallpox is comparatively low — about 50%. Table 1. Immunisation against Diphtheria/Whooping Cough/Tetanus/Poliomyelitis (separately or combined). Type of Vaccine YEAR OF BIRTH Others Under 16 Total 1965 1964 1963 1962 1958/61 PRIMARY COURSE DIPHTHERIA 1099 1293 136 41 58 34 2661 WHOOPING COUGH 1087 1272 100 29 21 5 2514 TETANUS 1098 1291 136 41 249 607 3422 POLIOMYELITIS 420 2344 257 114 186 102 3423 RE-INFORCING DOSES DIPHTHERIA — 362 720 130 1081 728 3021 WHOOPING COUGH — 174 324 70 224 20 812 TETANUS — 362 720 131 913 241 2367 POLIOMYELITIS — 15 31 33 1010 147 1236 Table 2. Vaccination against Smallpox. Age at date of Vaccination Under 1 1 2—4 5—15 Total No. vaccinated 258 1290 253 16 1807 No. revaccinated — — 7 28 35 B.C.G. Vaccination against Tuberculosis. See page 29. Protection against Enteric Fever During the year, agreement was reached with the South West London and Surrey Local Medical Committee, that schoolchildren visiting abroad in school parties may obtain T.A.B. inoculation either from their family doctor or from local authority clinics. I strongly support the advice that all who undertake overseas travel should be so protected. 26 Medical Research Council Investigations The measles vaccine trials started in 1964, in which the Middlesex County Health Department co-operated, continued during 1965. This involved the health visitors in the Twickenham area in contacting the parents of 783 children, at 3-monthly intervals in February, May and August, to record details of the child's health and the incidence of measles in the family. On completion of the trial, 134 children who had acted as unvaccinated controls were vaccinated in October. Up to the end of 1965, there had been no notified case of measles in a vaccinated child except for one case which developed a rash 24 hours after receiving his second injection and was notified as measles. During November and December, the department co-operated in an investigation into the reactions following triple vaccine in infants, the purpose of the trial being to compare three vaccines of different manufacture. These were given as part of the normal immunisation procedure; the health visitors were then asked to do a follow-up visit to the child's home next morning to complete a simple questionnaire on its reactions to the injection. 213 children were given the vaccine, and completed questionnaires were obtained for 207. PREVENTION OF ILLNESS, CARE AND AFTER-CARE Tuberculosis During 1965 there were 56 notifications of pulmonary tuberculosis and 5 notifications of non-pulmonary tuberculosis, in the Borough. For the corresponding area during the year 1964 there were 63 and 11 notifications respectively. New Cases. 1964 1965 Pulmonary 63 56 Non-Pulmonary 11 5 The total number of cases on the register at the end of the year is as follows: — Pulmonary 1460 Non-Pulmonary 201 The following table shows an analysis of cases notified in 1965. Age Periods. Respiratory Non-Respiratory M F M F 0—4 2 — — — 5—14 — 1 — — 15—24 2 6 — 1 25—44 5 7 1 — 45—64 12 8 — 2 65 and over 5 4 — 1 Age unknown 4 — — — Totals 30 26 1 4 27 There were 7 deaths from tuberculosis during 1965 viz: — RESPIRATORY MALES 4 1, age 55 years; 1, age 65 years; 2, over 75 years. FEMALES 1 1, age 65 years. OTHER FORMS MALES FEMALES 2 1, age 45 years; 1, age 55 years. Residents from the London Borough of Richmond upon Thames attend the Hounslow and Ashford Chest Clinics which serve the areas of Twickenham, Teddington, Hampton and Hampton Wick, and the Kingston Chest Clinic which serves the areas of Barnes and Richmond, with an ad hoc clinic to the Kingston Chest Unit at Richmond Royal Hospital. The following comments have been received from the Consultant Chest Physicians. Dr. C. O. Edwards, M.A., M.B., B.Ch., M.R.C.P., M.R.C.S., Kingston Chest Clinic writes: — "My impression of tuberculosis both in Kingston and Richmond is that the fication rate is remaining fairly static, and that cases of tuberculosis are still occurring and that we are a long way from total eradication. As, of course, the cases become rarer, our case findings and our search to find the existing cases must become more extensive and we must cast the contact net more widely. As you know it will always remain my view that the problem will never be defeated until some form of compulsion can be applied to those infectious cases who will not admit illness or accept treatment". Dr. R. Heller, M.D., Hounslow Chest Clinic, writes : — "Facilities for diagnosis and treatment of pulmonary tuberculosis as well as prevention and after care are provided by the Hounslow Chest Clinic and home visiting is carried out by Health Visitors attached to the Clinic. They are also responsible for the examination of contacts and for B.C.G. inoculation for the prevention of tuberculosis. A prominent part in the treatment is played by domiciliary chemotherapy (i.e., treatment with suitable drugs or injections given at home) on the recommendation of the Chest Physician, with the aid of the District Nurses provided by the Local Authority. Apart from the institutional treatment provided by the local Hospital Management Committee of the North West Metropolitan Regional Hospital Board in General Hospitals and in Chest Hospitals, there is also a London Borough of Richmond upon Thames Hostel for chronic ambulant male tuberculous patients. (See page 30). Facilities for convalescence, rehabilitation and training are provided by the Local Authority and the North West Metropolitan Regional Hospital Board. The Social side of the treatment and prevention of pulmonary tuberculosis is dealt with by the Welfare Department of the Hounslow Chest Clinic". 28 Dr. P. E. Baldry, M.B., B.S., M.R.C.P., Ashford Chest Clinic, writes: — "I don't think I have anything to contribute about the preventive aspects of tuberculosis as in this well housed area, with good X-ray facilities and prompt chemotherapy I think everything possible is being done to prevent the spread of this disease. I have always felt that the most important preventive aspect is early diagnosis and efficient chemotherapy and I must say that with the wide use of our miniature X-ray service by general practitioners we are picking up possible cases of tuberculosis promptly. I have no doubt, too, that the B.C.G. vaccination of school leavers should go on because it has proved its effectiveness; it is quite unusual these days to see a case of tuberculosis in "teen-agers" but because there is a small but increasing number of cases of active tuberculosis now resistant to chemotherapy about, it remains essential to give teen-agers all possible protection. I find that the number of active cases of tuberculosis, who have to be confined to their homes for any appreciable period is becoming extremely small and I think that for this reason the time is rapidly approaching when there is no place for a Health Visitor concentrated on tuberculosis alone but that this work could well be done by general health visitors". The continued decrease in the number of notified cases of this disease is heartening, but as pointed out by the Chest Physicians, increased effort is now necessary to search out and eradicate the remaining sources of infection. There seems to be a continued trend for the disease to be discovered in the more elderly population, and with the extension of clinics for the elderly, to other areas of the Borough, it may be possible to tackle this potential source more effectively. B.C.G. Vaccination against Tuberculosis B.C.G. vaccination of schoolchildren at about the age of 13 is carried out under Section 28 of the National Health Service Act. During 1965, 904 school-children were skin-tested; of these 735 were found negative and received B.C.G. vaccination. The details are as follows :— Skin tested 904 Found positive 131 Found negative 749 Vaccinated 735 After care Facilities Prior to the re-organisation of London Government and the formation of the new London Boroughs as from the 1st April, 1965, the responsibility for the provision of the tuberculosis care and after care services in the Twickenham, Teddington, and Hampton areas rested with the Middlesex County Council and were undertaken by medico-social workers of the Hounslow and Ashford Chest Clinics, who also dispensed extra nourishment grants on behalf of that County. The after care facilities for patients residing in the Richmond and Barnes area were undertaken by the Barnes and Richmond Chest and Tuberculosis Care Committee which received grants from the Surrey County Council towards the costs of the services provided, i.e., extra nourishment 29 (excluding milk) and other facilities for the relief and re-habilitation of patients under the guidance of the Chest Physician (Kingston and Richmond) and his staff. A special scheme was introduced by the Surrey County Council for the provision of milk. Whereas the Middlesex scheme of extra nourishment and the Surrey Scheme for the provision of free milk is confined to persons suffering from tuberculosis, the facilities provided by the Care Committee are available to all chest cripples. Since the 1st April, 1965, the schemes initiated by the former Middlesex and the Surrey County Councils have continued, but there were obvious reasons why such services should be uniform throughout the Borough in addition to being simple and flexible. At the end of the year, active consideration was being given to the Barnes and Richmond Chest and Tuberculosis Care Committee undertaking all after care facilities within the Borough, in conjunction with the Chest Clinics concerned, not only for the tuberculous, but for all chest cripples. Other chronic respiratory diseases are slowly replacing respiratory tuberculosis in its demands upon all the after care facilities of the Borough. The domiciliary supervision of the tuberculous in the Twickenham, Teddingtan and Hampton areas of the Borough is carried out by Tuberculosis Health Visitors from the Hounslow and Ashford Chest Clinics. In Barnes and Richmond this aspect of the work is undertaken by a special health visitor for the purpose (see page 24 — Health Visiting). Hostel for Homeless Tuberculous Males The 16 place hostel for homeless tuberculous males at 11, Rosslyn Road, Twickenham, was transferred to the London Borough of Richmond upon Thames from the former Middlesex County Council, consequent upon the re-organisation of London Government as from the 1st April, 1965. This hostel was originally set up by the former Middlesex County Council under Section 28 of the National Health Service Act, 1946 for homeless tuberculous males who were fit for discharge from hospital but because of their medical condition could not find other accommodation in the community. With the gradual reduction in the number of tuberculous patients requiring this type of accommodation the scope of the hostel has been extended to accommodate all types of chest cripples in need of "sheltered" accommodation. The places at the hostel are available to other local authorities, subject to the authority concerned being prepared to accept financial responsibility for maintenance charges. On the 1st April, 1965, there were eleven persons in residence. During the remainder of the year there was one admission, one discharge, and one death. At the end of the year, arrangements were in hand for further admissions. The hostel is staffed with a resident warden and assistant warden, who have been employed in that capacity at the hostel since it opened in October, 1951. There is also provision for adequate domestic staff, but considerable difficulty is experienced in obtaining suitable staff to work in a hostel of this nature. I am indebted to Dr. R. Heller, Chest Physician, and Dr. Mcintosh of the Hounslow Chest Clinic for their continued support and close co-operation in the running of the hostel. Every applicant is assessed by the chest clinic medical staff as to suitability for admission. The chest clinic is always available to the warden for advice and assistance, and the hostel is visited regularly by a tuberculosis health visitor and a 30 member of the chest clinic medical staff and general practitioner. The occupational therapist of the London Borough of Brent also visits the hostel. If their medical condition allows, residents are encouraged to find employment. Care of the Elderly The health department staff are experiencing some difficulty in placing old people in need of residential care, who therefore have to be cared for by the domiciliary services who at best can only give very short time cover. It is too early to evaluate hard statistics in this context yet. The result may be that the old person is left alone for many hours or days and certainly at night. Most of these are the elderly people, who come between Scylla and Charybdis: (A) They are not considered suitable for hospital admission because (1) they are not infirm enough, or more likely (2) there is not a bed available for them. (B) They are not considered suitable for a welfare home because they are not sufficiently mobile. Many of them are not willing to leave their own homes and their care therefore falls on the family doctor in collaboration with the domiciliary services. If nursing care is required, then the district nurse does invaluable work, often outside her normal scope of duty. Much more frequently the problem is the old person, living alone, often in untidy circumstances, who needs someone to look in daily, to make a meal, to do the shopping, the rudiments of cleaning and washing and even more important, to be someone to talk to. Meals on Wheels are excellent, but they can only come twice a week. The home help service is quite inadequate to deal with the demand. There are not nearly enough home helps to go round. Conditions in the home may be so filthy, the house in such a decrepit decorative state and the old person so cantankerous that, quite understandably, it may be difficult to get a home help to go in to do the work. If the older person is to be supported in the community then sufficiently adequate home help services should be provided before conditions get too bad. In view of the national shortage of domestic workers, then vocation training and monetary incentive is needed to make the job worthwhile. (See page 43 —Home Help Service). Loneliness, lack of social contact, with resultant deterioration in habits and health, affects elderly people regardless of social class or income. There may be many cases not known to the health department, so some system of notification of all people reaching retiring age would be helpful. Immediate action would not necessarily be indicated, but help should be forthcoming at the earliest realization of difficulties. Old people who are cared for by relatives, or more particularly a single relative, can be a tremendous burden. Theoretically, if they are mobile, then the welfare services can arrange short term care, but accommodation is limited. If they need nursing care, a small number have in the past in the Richmond and Barnes areas only, been taken into hospital for a short term stay to enable relatives to have a holiday. This scheme does not apply to the Twickenham area. There is clearly a need for this scheme to be extended as and when possible. Old people being discharged from hospital to adverse home circumstances could be greatly helped by provision for purely social therapy, i.e. food, shelter, and buildingup. While this short term rehabilitation is going on provision could be made to have 31 the home cleared, decorated and prepared to enable the old person to go back in the community. There is a need for geriatric health visitors to assess, advise, and mobilise neighbours and trades'people and put the old person in touch with social services. (See page 24 —Health Visiting). A trained social worker with a special interest in the elderly would be invaluable in case work with the elderly, depressed and lonely, and in giving supportive therapy to the families of senile difficult patients. It is envisaged that these two types of officers would work in partnership forming part of the community care team. The aim is to keep the old person in the community as long as possible; group dwellings with warden and old persons flatlets would go a long way to meet the need of a steadily rising elderly population in the Borough. My thanks to Dr. J. S. Finn, M.B., B.Ch., B.A.O., and Dr. J. D. B. Andrews, M.D., B.S., M.R.C.S., L.R.C.P., D.P.H., Consultant Geriatricians is acknowledged. The following contribution by Dr. John Maddison, M.D., B.S., D.P.H., appeared in PUBLIC HEALTH, November, 1965 — MAINTAINING THE HEALTH OF OLDER PEOPLE Much disability There exists amongst the elderly population a vast amount of ill-health and disability, much of which is preventable and remediable. This is the fundamental issue which needs to be emphasized again and again. You can observe the deteriorated elderly man or woman in your own family, on the streets, in welfare associations, at their Christmas parties, in your old peoples' homes, and in the hospitals. The multiple deficiency syndrome We have examined over 1500 people in our experimental clinic at Teddington, where we have available a wide range of diagnostic equipment, and we have observed that almost all elderly people have disabilities — some few, some many. Nearly onethird have nutritional deficiences and anaemia; sooner or later almost everyone suffers from deficiency of endocrines, especially of androgen or anabolic hormone, oestrogen, progestogen, or thyroxine; we all get artery disease; women get foot defects; we wear incorrect spectacles and we gradually go deaf. The disabilities of later life are multiple. From middle life onwards people begin to show signs of deterioation in their health; the disabilities increase in number and severity. They creep on insidiously without the person realizing there is anything wrong or the extent of it; they do not seek treatment. If these disabilities exist, as they do, and are preventable, as they are, then we should be vigorous in our endeavours to prevent them. Saving If we could prevent this enormous mass of disability in older people and keep every one of them healthy and happy in his own home, with full functional activity, able to work, in harmony with those around him — then the saving on the endurance and generosity of relatives and friends, on national assistance, on hospitals, on medical and welfare services would be enormous; and the increase in productive capacity for the nation would be very great. For if we prevented deterioration we would raise the 32 efficiency and working capacity of our older population. If a few million older people were in productive employment the benefit to everyone would be immense. The extra money they would earn would provide them with better food, and the extra activity would help to keep them fit. All this could be done if we could keep the old people healthy; it is not being done at present. The reason is that although our National Health Service makes provision for infants and children, nursing and expectant mothers, it makes no provision for a preventive health service for older people. Clinics. We need prevention clinics for older people which can discover the early clinical signs of deterioration; their aim should be to prevent or delay the onset of deterioration and to retard its progress. These clinics can be of various kinds: they can be held in local authority clinics; they can be part of a hospital out-patient department; they can be part of a hospital day treatment centre; they can be provided in the premises of practitioners. They can be staffed by hospital doctors, by medical officers of local authorities, or by practitioners, all of whom need special training. In whatever way this service is provided, the person attending needs the benefit of a high-class diagnostic and preventive service obtainable at one time and in one place. Older people will not be bothered with trailing round hospital departments on different days for examination of eyes, of ears, for electrocardiograph, photograph, X-rays, chiropody, haematology, or physiotherapy. If the full examination and all the ancillary investigations can be carried out scientifically and accurately in one place at the first attendance and without undue waiting or delay, then subsequent appointments are most likely to be kept; this has been our experience in our clinic. If the medical examination is to fulfil the proper and practical translation of the word "prevention", then the doctor must be as fully equipped with diagnostic apparatus as a consultant would be, and must be as clinically sound in the field of prevention as the consultant is in ward work. This service would be the first line of defence in the maintenance of the health of the elderly. The provision of quasi-socio-medical "chat and hope" centres for informal discussions with a doctor, where both hope for the best, is merely scratching at the surface of the problem. The limited equipment and facilities of the existing infant welfare clinics will not be sufficient. Middle life is the stage of active life for everybody; it is from this stage onwards that the defects begin. If we offered people the chance of preventive medical examinations there is no doubt great numbers would come to accept as quite normal their periodic appointments for their routine medical investigations. The preventive public health service may well become the most important medical service in the country. If an older person has his glasses put right, his diet improved and supplemented as necessary, his mineral, vitamin and hormone deficiences corrected, and his way of life suitably adjusted, there will soon be a marked improvement in health. There is improvement in appearance, muscle tone, physical activity and mental vigour. In his greater freedom of movement, and in the reassurance he gets from the clinical estimate of his powers, a greater mental stability develops. The psychological benefit is marked, and the whole pattern of life seems to change. One quite intelligent woman who came to the clinic saying 'I feel so miserable and wretched and ashamed of my appearance that I would like to die" improved so much that two years later, at the age of 83, she went abroad alone and enjoyed herself so much that she repeated the trip the following summer. Another woman undertook a successful journey to Canada years after she had abandoned all hope of ever being well enough to go. But although the early improvements can be quite spectacular, still more encouraging is the fact that in a good many cases the improvement remains steady and even increases. 33 Malnutrition Malnutrition in older people is common — not necessarily only in the poor; and hypochromic anaemia is widespread: we have very frequently found haemoglobin levels well below 70 per cent. The accompanying weariness, apathy, faintness, and disinclination amongst probably one-third of our older population is a disgrace to our prevention services. Admittedly much anaemia is due to diets deficient in protein and vegetables not easily obtained with insufficient money. But anaemia is so easily treated with iron preparations that to do this alone would be an immense contribution to our national welfare. Prevention Powder for Older People In attempting to provide treatment and nutritional supplements for older people with the multiple deficiency syndrome, we were faced quite early with the problem of prescribing numerous medicaments. An old person gets confused in trying to deal with say half a dozen kinds of tablets, and he soon ceases to be bothered. After trying numerous recipes we have evolved a prevention powder for older people which has an attractive appearance; mixes easily, has good keeping and emulsifying qualities; and a pleasant taste. It has a dried milk base and contains minerals and vitamins. We can add any of the hormones — thyroxine, androgen, anabolic steriods, oestrogen, or progestogen. A measure of powder weighing 13 G. is beaten up with about 4 fluid ounces (120 ml.) of warm water to make a pleasant milky drink. We recommend half a fluid ounce (15 ml.) of a refined deodorized linseed oil to be taken each day for the prevent' ion of artery disease, and this is easily emulsified in the drink and is almost tasteless. In this way each person gets all the medicaments he needs in one acceptable preparation. We devised a trial to test the efficacy of the powder. In it 12 men and 24 women took part; they were divided into 6 groups each of 2 men and 4 women. We had prepared for us 6 powders, 3 of which were alike but contained no medicaments, the other 3 containing medicaments. Each person in the trial was tested on three occasions with six weeks in between each occasion. The tests were for general appearance, photograph, how they felt, weight, grip, thigh strength, muscle tone, skinfold thickness, assessment of skin elasticity on hand and neck, speed of response, and haemoglobin. The doctors did not know which person was having which powder, nor the composition. The photographs were judged by independent judges. The results clearly separated the two groups of people — those on the medicaments showed great improvement in appearance, strength, haemoglobin level, speed of response, and in general well-being. Artery disease Eight years ago we wondered whether maize oil was any good for the prevention of artery disease. We sold maize oil in the clinic at half price through the generous co-operation of our League of Friends, and advised our people to take 1 fluid ounce (30 ml.) emulsified in the prevention powder. We have records of 272 people who began taking the maize oil and continued for various periods of years. We kept observations on xanthoma, arcus senilis, cataract, retinal arteries and veins, serial electrocardiographs, blood pressure, and the tibial and other arteries. After five years we had 26 people who had taken the oil continuously. We matched them for age, sex, and status with 26 others who had never taken maize oil. When we compared the two groups we were driven to say that we could hardly find any difference at all. In the meantime of course some of those who had taken the oil for years developed angina, coronary disease, stroke, gangrene of the foot, or had died of coronary thrombosis. We are impressed with some work showing the importance of linolenic acid in the prevention of artery disease. We have found a source of refined deodorized linseed oil with a high content of linolenic acid, and we are advising our people to take half a 34 fluid ounce (15 ml.) in the prevention powder or in a skimmed dried milk powder emulsified into a drink. There are some hormone deficiences which are quite common—thyroxine, androgen, anabolic steriod, oestrogen and progestogen. Our experience of using these has thrown up some points of interest. Thyroxine We have found hypothyroidism to be quite common in old people. We believe it requires to be dealt with at a stage earlier than frank myxoedema. The standard textbook description with dry staring hair, and thick myxoedematous skin and other features is a late stage. We have come to rely on four pointers to help us in the diagnosis of this deficiency at an early stage: these are low temperature, low voltage in the electrocardiograph, lengthened ankle-jerk return measured electrically, and radioiodine uptake tests. We use Wayne's index (Wayne, 1960) as a guide to the general symptoms and signs. We measure the temperature with the electric probe, which is quicker and more accurate than the mercury thermometer. A temperature lower than 97-2°F during the day is suspicious. Androgenic and anabolic steroids For some years we gave patients with osteoporosis our prevention powder containing extra calcium and magnesium, together with citrate, vitamin D, and fluoride. On clinical impression only we felt that this supplement to the diet was not sufficient to control the progress of the bone absorption. We believe now that androgens for men and anabolic steriods and oestrogens for women are necessary for the prevention and control of osteoporosis. Some clinical features of androgen deficiency are fatigue, backache, shrinking skeleton, failing strength, loss of muscle tone as in the sagging cheeks; and loss of virulence. We devised a test to try the effect of replacement therapy. We observed 144 people divided into two groups (A and B), each group containing 19 men and 53 women. Each person in Group A was matched for age, sex, and as far as possible for build and status, with a person in Group B. The ages ranged from 55 to 87. All of them showed signs of androgen or anabolic steroid deficiency, and many had other features of the multiple deficiency syndrome. In group A the men were given fluoxymesterone (ultandren) and the women methandienone (dianabol). The trial went on for six months, and at the end we had 18 men and 44 women in each group for comparison. The difference in favour of the treated group was unmistakable: in comparison with the others they improved in strength; the muscle tone improved; aching spines were relieved; they put on weight; their photographs showed fewer wrinkles, so they looked younger; they were able to do tasks which they formerly neglected; in some of the men sex function returned and the whole attitude to life changed for the better. In our prevention powder we include an androgen (for men) or an anabolic steroid (for women) for those people showing signs of deficiency. We are impressed by the usefulness of this procedure. Maintaining the health of older women Oestrogen is one of the hormones devised for the preservation of the human race. It is responsible for the attractiveness of girls. Every girl depends on oestrogen for her glossy attractive hair, beautiful complexion with the clear, translucent, smooth skin, bright sparkling eyes, long lashes, well-shaped eyebrows, graceful neck, and smart figure. We like to think she is always steady and reliable, conscientious and not easily ruffled or upset. Somewhere about the middle forties her oestrogen output begins to fall; the decline goes on for some years until about the middle fifties when it will have fallen to one- 35 third or one-quarter of its earlier output. By the time she gets into the sixties and onwards it will have fallen to one-sixth. During the menopause her gonadotrophins will be increased to try to stimulate her ovaries to keep up the supply of oestrogen with inevitable failure; so she may suffer the unpleasant hot flushes and possibly the drenching night sweats. We may notice a change in her emotional stability; she may be depressed, tearful, anxious, crying for no reason, rather negative, and tending to flare up into angry or catty outbursts for little reason. Her hair, formerly bright, glossy, and pretty, is becoming dull and lifeless, and is made still worse by her own neglect. She may have morbid fears about the future, about growing older, about the children leaving home, about the extent and nature of her husband's outside activities. Her physical strength has declined from what it used to be. Somewhere between 60 and 70 she has passed the stage of emotional instability, but the years are catching up. By degrees she will acquire the drooping eyelids, crow's feet, mouth creases, sagging cheeks, wrinkles in her face, and vertical skinfolds in her neck; on the back of her hands the skin will gradually lose its elasticity, become thin and the veins prominent; her nails may become ridged. Her stature is starting to shrink, she has the beginnings of a buffalo hump at the base of her neck, her lower jaw is slightly shrunken. Her figure has lost its former contour. Her axillary and pubic hair is sparse; the vaginal secretions are drying up; the vulva is becoming atrophic and thin; libido is diminished, and the vaginal cytology shows the changes of old age. Her blood cholesterol is rising, as is possibly also her blood pressure, and arterial disease is advancing. In her seventies and onwards she will turn into the little frail old woman, deeply lined and pigmented, with the pale face, sunken eyes, eyebrows almost gone, thin dry hair, dense rings round her corneae, hairs on her chin and upper lip. Her body is thin and malnourished; there is little muscle substance in her arms and legs; her grip and her strength are feeble; her bones are thin and brittle. She may have obstinate constipation, probably a cystocele. Her temperature is low, her pulse slow, her haemoglobin down and her blood cells abnormal. She has deformities of the feet so that she can only shuffle along, and she has the typical flexed stance of old age. She is miserable, forgetful, querulous; she is often dependent on her relatives and neighbours for her shopping and housework, and is a nuisance to them. She cannot see to read well because her glasses are unsuitable, and she has partial cataracts; she is rather deaf. At this stage of her life she probably has protein malnutrition, nutritional anaemia, deficiency of iron, manganese, copper, vitamin C, vitamin B12 and folic acid. She has deficiency of calcium, magnesium, vitamin D and fluorine. She is deficient in vitamins A, Bj, B2, Bd, and E. She has hypothyroidism, and deficiency of anabolic steroids and oestrogen. She has advanced artery disease affecting her heart and brain. Oestrogen deficiency Much of this deterioration can be traced to deficiency of oestrogen — the effects becoming progressively more noticeable as life goes on. For some time we have been trying to prevent the progress of this deterioration and if possible ameliorate part of the disability. In one experiment, we set out to see the effect of replacement therapy in women just past the menopause, and if possible to find easily observed indications of oestrogen deficiency. We selected 10 women volunteers for the trial; they were all healthy, aged between 49 and 55, and had ceased menstruating for at least a year. They came to the clinic seven times in all at intervals of a fortnight. This covered two cycles of six weeks with three periods of a fortnight in each cycle. They were given tablets thus: First cycle Visit A—beginning : 0.1 mg. ethinyloestradiol daily for a fortnight. Visit B—middle: 0.1 mg. ethinyloestradiol and 4.0 mg. megestrol daily for a fortnight. Visit C—end: nothing for a fortnight. 36 Second cycle Visit D—beginning: 0.1 mg. ethinyloestradiol daily for a fortnight. Visit. E—middle: 0.1 mg. ethinyloestradiol and 4.0 mg. megestrol daily for a fortnight. Visit F—end : nothing for a fortnight. Visit G—end of trial: final tests. At each visit (except the second) they had the following observations: weight, temperature, haemoglobin, serum cholesterol, grip, photograph, re-action time, skin elasticity, blood pressure, electrocardiograph, ankle-jerk time, vaginal cytology, history, and physical examination. Each woman acted as her own control. Every woman showed improvement in various ways at the end of the first cycle (point C). This improvement was partially maintained over the second cycle (F) but fell to the original condition at the end of the trial (G). The photographs were assessed by five judges acting independently. They all agreed that the photographs at the end of the first cycle (point C) looked much more attractive than the ones at the beginning; the women looked younger, brighter, happier, and more alert. The 4th (D), 5th (E), and 6th (F) photographs showed the improvement at C had been maintained, but with some irregularities. Between the beginning and the end of each cycle the hair improved and became glossier, brighter and thicker, and grew better, with dryness and dullness gone. The dry muddy dullness of the eyes recorded in four women at the beginning of the trial seemed to improve and change to brightness at the end. We measured the skin elasticity for each woman on each occasion. On the back of the right hand we defined a point over the prominence at the base of the second metacarpal. On each side of this point we marked two short lines with two pens fastened together 14 mm. apart. The hand was placed on a board over which was fixed a cine-camera set to run at a speed of 64 frames per second. With a pair of forceps the skin between the two lines was pinched up and held; the camera was started and the skin quickly released. The camera photographed the rate of recovery of the two lines to their original position. Photographs were taken twice for each woman for each of the seven occasions they attended. The results showed that in every woman the skin elasticity improved under the influence of oestrogen; it fell during the fortnight between the first and second cycle—C to D; it improved again in the first half of the second cycle D to E; it decreased again in the second half of the cycle during the time when the progesterone was taken—E to F. The elasticity fell still further in the fortnight after the second cycle to the end of the trial—F to G. On each occasion we examined clinically the skin of the face, neck, back of hands, and behind the upper arm for changes in elasticity. On the back of the hand of a young girl the skin when pinched up will fly back into position in less than one-tenth of a second; the skin of an old man or woman will require one second or more. The face of an older person shows loss of elasticity in the creases, lines, wrinkles, crow's feet, and mouth creases; the neck shows vertical skinfolds, and curtain formations; the skin at the back of the upper arm becomes very slack. We noted improvements in the face under the influence of oestrogen by recovery of the youthful oval formation, the fillingout of the lines, the creases becoming less prominent, the skin smoother, and the expression happier. At the end of both cycles the breasts in every case showed changes. From being flabby, pendulous, atrophic, and diminished, they become firmer, enlarged, the nipples more erect and the figure improved. In between the cycles and at the end of the trial the firmness had subsided, the nipples gone smaller, and the whole structure reverted 37 to its previous slackness. In the second half of each cycle and for some days after some of the women had sore erect nipples and vein engorgement. At the beginning all the women complained of miscellaneous symptoms in varying degree, such as fatigue, giddiness, headache, palpitation, muscle weakness, arthralgia, poor concentration, failing memory, abnormal micturition, and general malaise. At the end of the first cycle there were only two complaints. At the beginning of the second cycle some complaints had appeared again and continued to the end of the trial. Seven women were enthusiastic over an improved sense of well-being at the end of the first cycle; but this number fell to two by the end of the second cycle. It is possible that the effect of the tablets, or the excitement of taking part in the trial, or the stimulation given by the enthusiasm of the staff, or the expectation of improved health, or any of these factors in combination might have accounted for the feeling of well-being at the end of the first cycle. But during the second cycle, as the women realized they had to endure some discomfort and inconvenience, the enthusiasm probably waned; or it is possible the medication was not so effective. At the beginning of the trial nine women complained of hot flushes. At the end of the first cycle these had all disappeared. At the beginning two women complained of heavy nocturnal drenching sweats with feelings of coldness and weakness afterwards. These disappeared by the end of the first cycle and did not recur. Three women complained of spasms of the calf muscles at the end of the first cycle and one woman complained in the second cycle. We have noticed this not infrequently with steroid medication. Details of various emotions were given by most of the women at the beginning, practically all of which disappeared by the end of the first cycle. This improvement declined during the two cycles and was only partially restored during the second cycle. By the end of the trial the emotional situation seemed to be no better than when we started. Menstruation occurred at the end of each cycle with all the women except two who had had hysterectomy. It was prolonged in some instances. At the end of the first cycle three women went on for 7 days and one for 13 days. At the end of the second cycle one went on for 7 days, one for 9, and one for 11 days. This is clearly undesirable, being much too long and too heavy. It possibly had an adverse effect on the health of the women in the second cycle and afterwards. We observed the changes in the genital tract both clinically and by cytology. All the women had a heavy vaginal secretion under the influence of oestrogen. It dried up quickly when the tablets were stopped. Midway through the second cycle four women showed swelling and purple discoloration of the cervix, which subsided two weeks after ceasing taking tablets : very likely a progesterone effect. Smears for cytology were taken at every visit and were examined for oestrogen, progestogen, and androgen. At the middle of the first cycle there was an enormous oestrogen response which fell slightly towards the end; between the cycles the oestrogen fell markedly; it was again enormously increased by the middle of the second cycle, and fell again slightly towards the end. After the final two weeks the oestrogen was back again to its initial level at the start of the trial. The progestogen showed a marked increase at the end of the first cycle; it fell back again between the cycles but was high again at the end of the second cycle. It had fallen to its original level at the end of the trial. The androgens tended to fall in the middle of each cycle but the figures are not very convincing. The great influence of oestrogen and progestogen on the genital tract was very apparent. During each cycle some of the women had side-effects such as headache, bloated feeling, and breast discomfort. The most remarkable finding was the manner in which the serum cholesterol level fell from the beginning to the end of the first cycle (A to C); then it rose at the beginning of the second cycle and fell again at the end (D to F); and then it rose again 38 at the end of the trial (G). This effect was consistent throughout the whole of the observations and applicable to every woman. The average cholesterol level was: TABLE 1 Serum Cholesterol — m.g./100 ml. Mean for 10 Women First cycle Second cycle Beginning of cycle 343 347 End of cycle 240 234 End of trial 278 There were no differences in temperature throughout the trial. One or two of the heavier women showed a tendency to decrease in weight during the trial; but generally the weights of the group did not change significantly. We used an instrument for testing grip strength which has a strong spring in the handle. We found no significant differences due to the medicaments. The systolic blood pressure fell on the average by 13 millimetres between the beginning of the trial (A) and the end of the first cycle (C); it remained down continuously through the second cycle to F and then crept back to its original point at the end of the trial G. The diastolic blood pressure followed the same pattern with a fall of 7 millimetres. The haemoglobin was measured on each visit. There was a hint that the mean level for the whole group fell from the beginning of the trial to the end, but we could not prove the fall statistically significant. The reason may have been the blood loss on the two occasions the women menstruated. We took an electrocardiogram of each woman on each visit using the three limb leads, I, II, and III; lead III with deep respiration; and three chest leads. CR1, CR4, and CR7. We examined the leads for differences between the various visits, and found none worth recording. We tested the ankle-jerk reaction time—Woltman's sign—with an instrument which measured electrically the time-interval for the foot to return to its original position after each tap on the tendon. Each woman had three recordings on each visit. We found no significant variation whatever due to the influence of the medicaments. We tested the reaction-time of all the women on all the occasions. The test was to extinguish a small electric bulb by releasing a push-button after it had been lit by the doctor. The time was recorded electrically in hundredths of a second. There was no significant difference between the visits. Oestrogen deficiency in older women We tried the effect of oestrogen therapy on 108 older women whose ages ranged between 54 and 90 with a mean of 72. The very old ones had most of the disabilities mentioned previously. They will accept the therapy even with the possibility of menstruation if the purpose and the possible effects are carefully explained beforehand. We gave them 0.05 mg. of ethinyloestradiol (E.O.) or 0.05 mg. of ethinyloestradiol and 4.0 mg. of megesterol (Meg.) combined, either as tablets or mixed in prevention powder. In some cases we used a 42-day cycle, giving E.O. for 30 days and the combination for 12 days; in other cases we gave the combined medicament continuously. Fifty-two women on continuous E.O. and Meg. combined, for periods varying from three months to one year, reported themselves feeling better and were much improved in general well-being. None of these reported spotting or vaginal bleeding. Generally these women were in the younger age-groups and were the more intelligent and reliable. They were warned they must not cease taking the tablets or powder and for the most part have conformed. Forty-four women have had regular cyclical bleeding or withdrawal bleeding. Most showed improvement in well-being whilst on the medicament. Twelve 39 women, mostly older, have had break-through or irregular bleeding whilst on the medicament; even so, most of these tended to show some improvement. A few have been to hospital for curettage with negative findings. A few of those on the cyclical regime have menstruated once or twice and then either become alarmed or upset by the menstruation and have withdrawn themselves from the treatment. Some others in the younger age-group on the cyclical regime have accepted it for 5 or 6 cycles; but it has taken some persuasion to keep them going. There is no doubt about the improvement in looks and well-being of those who continue. However, we doubt whether a technique based on recurrent menstruation in older women will succeed. Once the women are past the menopause and have ceased to menstruate and hence experienced the relief of not having to bother with it, they are very loath to go back to the former menstrual regime. What we need is some method of giving oestrogen and progestogen without the accompanying menstruation. Our experimental dose of 0.05 mg. of E.O. and 4.0 mg. of Meg. was certainly much too high for the older women. It is quite possible that a maintenance dose of 0.01 mg. E.O. will be sufficient combined with say 1.0 mg. or 0.05 mg. of Meg. We have eight very old women on these doses at present with no bleeding and with great benefit. Most authors on this subject advocate the cyclical menstrual regime for older women, stating that the endometrium needs to be shed and cleared every so often. But in the child-bearing years some women have repeated pregnancies and lactation every year, and may thus have ovulated and menstruated perhaps only once a year, without seeming to do any harm to the reproductive organs. It is possible to vary the length of the induced menstrual cycle almost at will; it is only necessary to vary the day in the cycle at which the progestogen is introduced and the number of days it is continued. The oestrogen can be interrupted, or taken continuously; we have found the continuous method best. We think it may be possible to arrive at a correct combination of oestrogen and progestogen for older women which will avoid menstruation altogether and still confer the benefits of substitution therapy. Care is necessary when commencing oestrogen therapy in women who have ceased menstruating. They seem to react violently to high doses; and especially resent the discomfort, inconvenience, and even misery of the experience. These effects can counteract the benefits. Women need careful preparation beforehand, and constant support and encouragement especially in the early stages. It is important to begin with very small doses and build up slowly. Summary of trial Summarizing the results of this trial, we have found that the best diagnostic tests for deficiency of oestrogen are : absence of menstruation; loss of skin elasticity; recession of the genital tract and changes in the cytology. The effects produced by replacement therapy are : restoration of well-being; improvement in appearance; trophic effect on genital and other tissues; and emotional stability. Notwithstanding this replacement therapy, nothing we have done has contributed to delay of the ageing process. The need for prevention There are many other aspects of our work I have not covered. We should try to push on with the setting up of prevention services for the elderly, or more ideally for the 50s and over, in your own areas. There are various patterns this service can take, and we need lots of experiments to find out the most useful techniques. We know there is a great need, which is constantly increasing and ought to be satified. The maintenance of health in the elderly is as much a challenge to public health as was the challenge of infant welfare fifty years ago. Let us meet it with determination. 40 CHIROPODY SERVICE Prior to the 1st April, 1965, two chiropody schemes run by the Surrey and former Middlesex County Councils were in operation. The main difference between the two schemes was that the majority of treatments in the Barnes and Richmond part of the Borough were carried out in the private surgeries of chiropodists, whereas in the Twickenham, etc. part of the Borough the majority of treatments were carried out in the former Middlesex County Council clinics. Both schemes operated a domiciliary treatment service. For persons who could afford it, the charge made to patients under the Surrey scheme was 3/- per treatment. This charge could be reduced in necessitous cases. Persons in receipt of a National Assistance Board allowance were treated free of charge. Under the Middlesex scheme patients were charged according to a scale which allowed free service to those with low incomes, expectant and nursing mothers, and children. The standard charge was 4/- per foot but this was reduced by half for persons in receipt of unemployment, disablement or sickness benefit, etc. This chiropody service plays a vital part in the care of the aged, who are its main users, as it enables them to remain ambulant. This reduces the demand on other domiciliary services provided by the Borough. From the 1st April to the 31st December, 1965, 7,206 treatments were carried out by private chiropodists in their surgeries and in the homes of patients. A further 874 treatments were given at Borough Council clinics in Hampton, Hampton Wick, and Whitton. In the last nine months of the year, therefore, a total of 8,080 treatments were undertaken. Although the existing arrangements prior the 1st April, 1965 were continued, at the end of the year the Council considered and agreed a revised comprehensive chiropody scheme to cover the whole of the Borough which incorporates the best of the former schemes. This revised scheme is to commence on the 1st April, 1966, and is subject to consultation with the appropriate professional chiropodial bodies. The proposals are as follows: — Method of Provision (a) Treatment at the surgeries of private chiropodists. (b) Treatment at Borough Council Clinics. (c) Treatment at sessions arranged by voluntary societies. (d) Domiciliary treatments. (To be supported by medical certificates). Categories of persons eligible to receive treatment and proposed charges Category. Charge per foot. Men over 65 years 2/- Women over 60 years 2/- Expectant mothers 2/- Nursing mothers (1 year from birth of child) 2/— Registered disabled persons and special medical needs, e.g., Diabetes 2/— School children Free Children under 5 years Free General public with low incomes (see following paragraphs) Free 41 Exemptions from payment of charges Persons in receipt of a National Assistance Board grant. Persons whose total weekly income from all sources does not exceed £6 single and £10 married. The Chairman of the Health Committee is authorised to waive or reduce charges in special circumstances. CONVALESCENT AND RECUPERATIVE HOLIDAYS During 1965 arrangements were made for 88 persons to be admitted to recuperative holiday homes. The following table shows the number of referrals and their source of origin. Family Doctor referrals. Hospital referrals. Children under 5 years of age 4 — Mothers accompanied by children — Mothers 1 — Children 3 — Adults 17 21 Elderly Persons 26 16 Subsequently, arrangements for 1 child, 7 adults, and 8 elderly persons were cancelled. The cases were placed in a variety of homes. HEALTH EDUCATION Health education is recognised to be a very important part of the work of the Health Department. In furtherance of the need to provide information and influence people towards good health, a Health Education Sub-Committee, comprising senior officers of the department under the Chairmanship of the Deputy Medical Officer of Health, has been set up to consider all aspects of health education in the Borough. Poster campaigns on different aspects of the prevention of ill health are held each month and these are supported, wherever possible, by display cabinets. Posters are displayed in clinics, schools, offices and on public notice boards throughout the Borough. The co-operation of the Borough Safety Officer has been very much appreciated where the campaign has a dual purpose, such as Accidents in the Home'. Talks are arranged for voluntary associations, parent and youth groups, etc. and these are invariably supported by films or slides. The health visitors are very active in this field and group teaching is held by them during clinic sessions at welfare centres. Ante-natal relaxation sessions held in association with parentcraft classes are taken by health visitors and midwives. These take the form of a short talk followed by relaxation exercises and finally a discussion. Midwives are concerned with ante-natal care in the mother's home, at welfare centres and at family doctor clinics. (See page 25 — Health Visiting). Arrangements are being made for a booklet to be published giving details of talks which the department will be pleased to arrange. 42 HOME HELP SERVICE Staff Home Help Organiser 1 Assistant Home Help Organisers 2 Home Helps — Whole-time 3 — Part-time 97 — Whole-time equivalent 55.4 (permitted establishment 100) Applications for the home help service are dealt with in the following order of priority:— 1. Acute emergency cases. 2. Domiliciliary Confinements. 3. Tuberculosis. 4. Other cases, i.e., chronic sick, aged, infirm, mentally disordered, etc. Applicants are assessed to pay what they can afford, but persons in receipt of National Assistance Board grants and those suffering from toxaemia in pregnancy receive the service free of charge. The standard charge for the service at the end of the year was 5/- per hour. Cases given help during 1965 were as follows : — Chronic sick and Tuberculosis 103 Aged under 65 Mentally disordered 2 Maternity 176 Others 130 Aged 65 or over 853 Total cases helped 1,264 (included above are 546 cases brought forward from 1964). It is interesting to note that out of every 10 persons receiving the service, approximately 7 receive it free of charge; 2 pay less than full cost, and 1 pays full cost. Figures at the 31st December, 1965, were as follows:— No payment 455 Less than full cost 118 Full cost 69 During the year the home help service, although working to capacity, has had difficulty in meeting all requests for assistance. Generally speaking, cases in the priority classes such as acute emergencies, domiciliary confinements, and the tuberculous were given some assistance but in many instances more assistance than that given was indicated. Despite continued advertising in the local press, display cabinets, etc., the number of home helps has reduced. The lack of recruits may be due in the main to the low rate of pay compared with that obtainable by domestic staff in other fields. At the turn of the year, a fresh pay award was due to be implemented. Hourly payment is made to home helps in accordance with nationally negotiated rates of pay. Additional remuneration is given for work with problem families, dirty homes and certain infectious diseases. Patients are assessed by the Borough Treasurer according to financial circumstances. 43 Neighbourly Help Service The neighbourly help service operated within the Borough has proved successful. Between 1st April, 1965 and the 31st December, 1965, 40 patients (mainly elderly over 65 years of age) received help under this scheme, and at 31st December, 28 persons were being assisted. Good neighbours are paid between 10/- and £2 per week according to the help given by way of shopping, cleaning, preparing meals, lighting fires, etc. MENTAL HEALTH SERVICES Whereas at the 1st April, 1965, some of the new London Boroughs were presented with highly developed and well organised community care services for the mentally disordered, including junior training schools, adult training centres, hostels, day centres, etc., the facilities transferred varied considerably from authority to authority. The London Borough of Richmond upon Thames was unfortunate inasmuch as no establishments for the subnormal, severely subnormal, or the mentally ill were transferred by the former Middlesex County Council or the Surrey County Council. It is necessary, therefore, for the borough to arrange and pay for placements either in other authorities' establishments or in establishments run by voluntary organisations. Mental Illness The Borough is served by two psychiatric hospitals for the mentally ill as follows : Banstead Hospital, Sutton, Surrey. (Districts served: Richmond and Barnes). Springfield Hospital, Beechcroft Road, Upper Tooting, S.W.17. (Districts served : Twickenham, Teddington and Hampton). The following table shows the number of patients admitted to psychiatric hospitals under the Mental Health Act during the year: — Section M F Total Section 5 16 17 33 Section 25 14 15 29 Section 26 1 4 5 Section 29 33 45 78 Section 60 2 — 2 Total 66 81 147 Every effort is made to admit persons to hospital informally and it is disappointing that only 22% were so admitted. It is hoped that with the increasing public awareness of mental ill health that the need for formal action under the Mental Health Act, 1959 will diminish. Co-operation with the hospitals providing psychiatric cover for the borough is considered essential and an effective liaison has been arranged by the attendance of mental welfare officers at the outpatient clinics at the West Middlesex and Richmond Royal Hospitals and at ward conferences at Banstead and Springfield Hospitals. Not 44 only is the mental welfare officer able to advise on after care facilities, etc., but valuable contact is made with the patients at an early stage. The fieldwork in connection with the after care of the mentally ill is carried out by the following officers who were on the staff of the Department at the end of the year:— 1 Chief Mental Welfare Officer. 1 Senior Mental Welfare Officer. 4 Mental Welfare Officers. 1 Mental Health Social Worker. The offices are open from Monday to Wednesday, 9 a.m. to 5.30 p.m., and Thursday and Friday 8.45 a.m. to 5.30 p.m. Outside these hours and at weekends a rota arrangement for urgent calls is organised. I have had the benefit of valuable advice and help from Dr. Alfred Torrie, M.A., M.B., Ch.B., D.P.M., who has held weekly "in service training" sessions for mental welfare officers. From the 1st April, 1965, until 31st December, 1965, mental welfare officers made a total of 726 home visits and approximately 100 office interviews were held during the same period. The total number of mentally ill persons residing in the community and under care as at the 31st December, 1965, was 76 i.e. 8 males and 68 females. The reason for the considerably higher number of females receiving after care at the end of the year is due to the fact that males discharged from hospital seem to settle down to community life much quicker than females. Males develop outside interests through their employment, etc., whereas the females often return home, to the same environment from which they were admitted and need more support in seeking outside interests. Furthermore there is a higher percentage of elderly females than elderly males in the Borough. Referrals to the Mental Health Service During 1965 reports were received under Section 57 of the Education Act, 1944, as amended by the Mental Health Act, 1959, regarding three children who were found unsuitable for education at school. Information was also received about seven educationally sub-normal children who required supervision after leaving school. Community care of the subnormal and severely subnormal Supervision in the Home With support from social workers and health visitors many subnormal and severely subnormal patients of all ages are able to live satisfactorily in the community. It is essential that they and their parents are able to obtain assistance with their problems and this is readily available through visiting officers. I have had the benefit of specialist advice on individual patients from Dr. D. Watterson, M.B., Ch.B., D.P.H. The total number of subnormal and severely subnormal persons under community care at the end of 1965 was 225. This does not include those patients placed in residential accommodation under Guardianship and Informal Foster Care arrangements. 45 Guardianship and informal foster care At the end of 1965 there were 4 patients under the Guardianship of the Council. There were also 12 under informal foster care arrangements, in homes or hostels run by voluntary societies and private homes. In order to avoid formal guardianship procedure informal placements are made wherever practicable. The Guardianship Society, Hove, is most helpful in assisting in the placement of patients in suitable homes. Admissions to hospital The Borough is served by Normansfield Hospital, Teddington, which covers the districts of Twickenham, Teddington, Hampton and Hampton Wick; Botleys Park Hospital, Chertsey, Queen Mary's Hospital, Carshalton, and St. Ebbas Hospital, Epsom, which covers the districts of Richmond and Barnes. The majority of patients from the Richmond and Barnes area are admitted to Botleys Park Hospital. Younger children are admitted to Queen Mary's, Carshalton. The following table shows the number of admissions which have taken place from 1st April, 1965, to the 31st December, 1965, all of which were on an informal basis: Subnormal Severely Subnormal Total Over 16 Under 16 ( Over 16 Under 16 M F M F M F M F Normansfield Hospital — — — — — — — — — Botleys Park Hospital 1 — — — 1 — — — 2 Queen Mary's Hospital — — — — — — — — — St. Ebbas Hospital — 1 — — — — — 1 2 Total 1 1 — — 1 — — 1 4 The number of patients awaiting admission to psychiatric hospitals for the subnormal at the end of the year was as follows : Subnormal Severely Subnormal Total Over 16 Under 16 Over 16 Under 16 M F M F M F M F In urgent need of hospital care — — — — 1 5 6 2 14 Not in urgent need of hospital care — — — — — 2 2 2 6 Total — — — — 1 7 8 4 20 Temporary Care One way in which the parents can be given a measure of relief is for the Borough to arrange short stay care for periods of up to eight weeks in psychiatric hospitals or arrangements may be made with voluntary societies etc. for placement in private homes. During 1965 arrangements were made for 9 patients to be sent to Regional Hospital Board Hospitals; one patient was accommodated in a privately run establishment. 46 Training (a) Attendance at junior training centres. At the present time children from the Borough attend the Hanworth Junior Training Centre, Bear Road, Hanworth, which is operated by the London Borough of Hounslow, and the Kingston Training Centre, Dukes Avenue, Kingston-upon-Thames, operated by the Royal Borough of Kingston-upon-Thames. The numbers attending these centres from the Borough are set out below: Name of Establishment. Area Served. Number attending. Kingston Centre Richmond and Barnes 13 Hanworth Junior Training Centre ... Twickenham, Teddington, Hampton &Hampton Wick 21 Total 34 The older girls at the Hanworth Junior Training Centre are paid monetary rewards up to 15/- per week for helping in the kitchen and with the nursery class children within a ratio of one orderly to every 30 places. Medical inspection and treatment for children attending training centres is provided in the same way as for children attending primary and secondary schools. (b) Attendance at special care units. Certain severely subnormal children are unable because of their unsuitability to attend a junior training centre. These children may be admitted to a special care unit attached to the centres. These care units cater specifically for mentally handicapped children who also suffer from a physical handicap, or are very overactive. These units provide mothers with much needed relief and measure of habit training for the child. (c) Attendance at adult training centres. Adult subnormal and severely subnormal patients from the Borough attend the Acton Lodge and Brentford Adult Training Centres situated within the London Borough of Hounslow, and the Kingston Training Centre situated in the Royal Borough of Kingston. The approximate numbers attending these centres from the Borough are set out below: Name of Establishment Area Served Number attending Acton Lodge Adult Training Centre Twickenham, Teddington, Hampton & Hampton Wick 27 Brentford Adult Training Centre Ditto 5 Kingston Training Centre Richmond and Barnes 12 TOTAL 44 47 The aim of the adult training centres is to train those attending to function at the very highest possible level whether that be to work within the centre or in outside employment. In this way the trainees become more independent and are able to lead as full a life as possible. Work is undertaken at the centres for local firms on a contract basis and includes assembly of electrical components and television parts, toy assembly, carpentry and joinery, involving the use of heavy machinery, gardening, etc., etc. At the Brentford and Acton Lodge Adult Training Centres the Trainees work a 40 hour week, i.e. eight hours daily, Monday to Friday, including a lunch break. They are paid on a scale ranging from 8/- to £2 per week according to diligence, ability, and application to the job. At the Kingston Centre the trainees work a 32½ hour week, i.e. 6½ hours daily, Monday to Friday, including a lunch break. The trainees are paid monetary rewards on a scale ranging from 5/- to 30/- per week. Holiday Camps By arrangement with the London Boroughs of Hillingdon and Hounslow, and the Surrey County Council, arrangements were made for suitable children and adults attending junior and adult training centres from the Borough, to go away for holiday camps of approximately two weeks in duration during the summer of 1965. INCIDENCE OF BLINDNESS I am indebted to Mr. J. B. Elliott, D.P.A., A.I.S.W., Chief Welfare Officer, for the following information : — A. Follow-up of Registered Blind and Partially Sighted Persons for the year ended 31st December, 1965. Cause of Disability Cataract Glaucoma Retrolental Fibroplasia Others (i) Number of cases registered during the year in respect of which Section F of Forms B.D.8. recommends: (a) No treatment 10 9 0 25 (b) Treatment (medical, surgical or optical) 3 - - 6 (ii) Number of cases at (i) (b) above which on follow-up action have received treatment 1 - - 4 B. Other Statistics for the year ended 31st December, 1965. Number of Forms B.D.8. received during the year 53 Number of Registered Blind Persons at 31.12.65 Male 128 Female 196 Total 324 Number of Registered Partially Sighted Persons at 31.12.65 34 71 105 48 Ophthalmia Neonatorum (i) Total number of cases notified during the year — (ii) Number of cases in which:— (a) Vision lost — (b) Vision impaired — (c) Treatment continuing at end of year — MEDICAL ASSESSMENTS Each new entrant to Council service is required to complete a medical questionnaire prior to acceptance, and to undergo a chest X-ray examination. When there is any doubt about the candidate's fitness for the vacant post a full physical examination is carried out, as is done in the case of all entrants to teacher training colleges. During the period under review, 1,032 medical assessments were completed for the Council or training college service, and of this total 350 required full physical examinations. Also 18 Council employees were examined as to their medical fitness to continue in service and 6 of these were recommended for retirement on the grounds of permanent ill-health. NURSING HOMES All registered nursing homes within the Borough are supervised by senior medical officers of the Department and defects and deficiences brought to the attention of the nursing home keepers. No registrations were cancelled during 1965. The number of nursing homes on the register at the end of the year was as follows: — Maternity Homes Nil. Other Homes 8* Total number of beds 308* * These figures include the "Star and Garter" Home, Richmond, which has 200 beds. NURSES AGENCY At the end of the year there were 25 State Registered Nurses and 5 State Enrolled Nurses on the register of one licensed agency. 49 WATER SUPPLY All the dwellings in the Borough are supplied from the Metropolitan Water Board's main, and I am indebted to Dr. E. Windle Taylor, Director of Water Examination, Metropolitan Water Board, for the following report: "I can state that the water supply to the London Borough of Richmond upon Thames has been of satisfactory quality and sufficient quantity during the year. The supply to the area is River Thames—derived water from the Board's Hampton works, and from five wells situated in Richmond and treated at the Petersham works. This well supply was taken over by the Board on 1st April, 1965. The average results of the chemical and bacteriological analysis of these waters are set out on page 51. The water is not subject to plumbo-solvent action; remedial measures are taken at once in respect of the discovery of any form of contamination. The population supplied is 181,116 and the supplies are direct to the houses, no premises being permanently supplied by standpipe. There were no new sources of public water supply instituted in your area during 1965, nor any important extension of trunk mains. There have been some changes in the general scheme of supply following the taking over of the former water supply of the Richmond Corporation; this has involved the use of more River Thames—derived water. The total length of new mains laid during 1965 amounts to 4,367 yards. All new and repaired mains are disinfected with chlorine and the water in them proved satisfactory before the mains are put into service". The following water samples were taken in the Borough by Inspectors of the Health Department: Swimming Baths 60 Satisfactory River Water 12 Satisfactory Domestic Water 63 54—Satisfactory 9—Unsatisfactory The unsatisfactory samples in the domestic water supply were mainly caused by flooding and in each instance the water was allowed to run to waste until repeat samples proved satisfactory. SEWERAGE & SEWAGE DISPOSAL I am obliged to (a) Mr. A. S. Knolles, B.Sc., M.Inst.C.E., M.I.Mun.E., Chartered C.E., the Borough Engineer and Surveyor, and (b) Mr. L. H. Thompson, A.M.I.C.E., A.M.I.S.P., Regional Engineer, Greater London Council for the following reports: — a) The construction of the new gravity sewer in the Hampton area of the Borough is now completed and a number of ejector stations have been closed down as a result. Improvements to the air compressor stations at Bell Hill and Hampton Wick are in hand, which, when complete, will improve the air supply to ejectors in the Hampton and Hampton Wick areas enabling the worn out plant at Hampton works to be closed down. Sewage Disposal for the Twickenham area of the Borough was the concern of the former Middlesex County Council and this function was taken over by the Greater London Council from 1st April, 1965. The disposal works of the former Richmond 50 51 AVERAGE RESULTS OF THE CHEMICAL EXAMINATION of water supplied to the London Borough of Richmond upon Thames Milligrammes per litre (unless otherwise stated) Description of the Sample Number of Samples Day of the month Ammoniacal Nitrogen Albuminoid Nitrogen Nitrate Nitrogen Oxygen abs. from KMn044 hrs. at 27° C. B.O.D. 5 days at 20° C. Hardness (total) CaC03 Hardness (noncarbonate) CaC03 Magnesium as Mg Chloride as C1 Phosphate as P04 Silicate as Si02 Sulphate as S04 Natural Fluoride as F Surface-active material as Manoxol OT Turbidity units Colour (Burgess units) pH value Electrical Conductivity (micromhos) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) Hampton 52 0.041 0.090 4.3 1.20 258 66 4 41 1.9 10 64 0.20 0.09 0.1 15 7.5 550 Richmond wells 4 0.012 0.040 4.7 0.32 314 134 58 0.45 0.1 2 6.9 730 1 1 Source of supply BACTERIOLOGICAL RESULTS — YEARLY AVERAGES, 1965 BEFORE TREATMENT AFTER TREATMENT Number of samples Agar plate count per ml. Coliform count Escherichia coli count Number of samples Agar plate count per ml. Coliform count E. coli count 20-24 hours at 37° C. 3 days at 22° C. Per cent, samples negative in 100 ml. Count per 100 ml. Per cent. samples negative in 100 ml. Count per 100 ml. 20-24 hours at 37° C. 3 days at 22° C. Per cent. samples negative in 100 ml. Per cent. samples negative in 100 ml. Hampton 1,073 7.4 100.0 100.0 Richmond wells 488 1.7 577 64.34 20. 79.51 3.5 189 3.9 38 98.94 99.47 Main Sewerage Board which deals with sewage from the Barnes and Richmond areas have also been taken over by the Greater London Council. b) The sewage from Twickenham, Teddington and Hampton is conveyed through trunk sewers now under the control of the Greater London Council for treatment at the Mogden Works, Hounslow. This plant, serving as it does the whole of the West Middlesex area, receives an average daily flow of 90 million gallons of sewage. Originally constructed between 1931 and 1936, when it was the largest and most advanced of its kind in the world, the works were extended between 1954 and 1961 mainly to counter the deleterious effects on purification of synthetic detergents. The contributing population is now about 1,400,000 and increasing water con sumption, now over 50 gallons per head per day, impurity loading and the changing effects of new synthetic detergents, have caused temporary overloading of some parts of the plant during the last 2 years. This has resulted in periodic smell nuisance, which has been particularly evident in the northern parts of Twickenham. The emergency measures adopted by the G.L.C. have resulted in a gradual im provement in this respect and a programme of constructional work and installation of additional equipment costing nearly £1,000,000 is now in progress. This new plant is designed to give a reasonable margin of spare capacity throughout the works, and should ensure that the odour problem is progressively eliminated. Work recently completed includes: — 1) the construction of 24 acres of new sludge drying beds. 2) the construction of sludge storage lagoons of about 90 million gallons capacity. 3) the removal of 120,000 cu. yds. of consolidated sludge from the site. Work proceeding, and intended to be completed during the next 3 years, includes: — a) further sludge drying beds; b) the provision of further sludge storage capacity; c) additional sludge pumping equipment; d) additional air blowing equipment; e) improvements to existing sludge digestion plant; f) additional sludge digestion tanks — construction to commence March, 1966; g) additional sedimentation tanks — construction planned to commence during 1966. REFUSE DISPOSAL (a) Mr. Knolles also reports: — Refuse Disposal is now a function of the Greater London Council, but the Council have administered the Transfer Station at Barnes and the Twickenham Incineration Plant since 1st April, 1965 by agreement with the Greater London Council. Both plants have operated satisfactorily during the year, but the continued bulking of the refuse has given concern at the Twickenham plant, where a night shift has been instituted to reduce the amount of crude refuse sent direct to the tip. Work has commenced on the installation of a Trade Waste incinerator at the Twickenham plant to deal with furniture and other bulky items received at the works. The Greater London Council will be assuming full control of refuse disposal for the Borough as from 1st July, 1966. 52 SANITARY CIRCUMSTANCES OF THE BOROUGH E. S. HERBERT, M.A.P.H.I. Chief Public Health Inspector. 1. HOUSING (1) Unfit Houses. The Council prepared and submitted to the Minister of Housing and Local Government a programme for dealing with 95 unfit houses in the period 1966-1970, in addition to other individual unfit properties which might require action as the result of routine inspection on complaint. The progress made on existing Clearance Areas comprised : (a) the demolition of 4-10 (consecutive) Wellington Place, Richmond; (b) the confirmation of the Clearance Order in respect of 1-6 (consecutive) St. George's Place, Church Street, Twickenham; (c) the substitution of a Clearance Order for a Compulsory Purchase Order in respect of 1-7 (consecutive), Paradise Cottages, Richmond. Dwellings reported as being unfit for human habitation and not capable of repair at reasonable expense were : 13, Worple Way, Richmond; 93, High Street, Hampton Wick; 18, Princes Road, S.W. 14; 5, Old Bridge Street, Hampton Wick; 3, 3a, 9, 9a, Montague Mews, Richmond; Basement, 20, Haggard Road, Twickenham. The Council made Closing Orders, Demolition Orders or accepted from the owners undertakings in respect of the following premises : 2, Lonsdale Mews, Richmond (Closing Order); 2, 3, 5, 7, 8 & 10, Waterloo Place, Richmond (Closing Orders); Basement, 29, Church Road, Richmond (Closing Order); 7, Albert Road, Richmond (Closing Order); 13, Worple Way, Richmond (Closing Order); 93, High Street, Hampton Wick (Closing Order); 18, Princes Road, S.W. 14 (Demolition Order); Basement, 30, The Green, Richmond (Undertaking). 53 The following properties were made fit for human habitation during the year and in each case a Closing Order was determined or an undertaking cancelled : 3 a, Vine Cottages, Petersham 9, The Terrace, Barnes 10, Waterloo Place, Richmond Closing Order determined. Basement, 31, Kew Green, Richmond 37, Princes Road, Teddington 2, Eleanor Grove, Barnes Undertaking cancelled. All the dwellings included in the above report were dealt with by way of formal action under the Housing Act, 1957; in addition, repairs were effected at 247 dwellings after informal consultation with the owners, and 15 other dwellings were made fit for human habitation after the service of statutory notices under the Public Health Acts. The action taken to remedy unfit houses is summarised in the table below: (a) Clearance Areas represented to Council Nil (b) Dwellings included in (a) above Nil (c) Dwellings demolished after Clearance Orders made 7 (d) Dwellings represented for Demolition or Closing Orders 9 (e) Undertakings received to carry out repairs 1 (f) Closing Orders made in respect of — (i) Whole of building 10 (ii) Part of building 1 (g) Demolition Orders made 1 (h) Closing Orders determined on a building being made fit 3 (i) Undertakings cancelled on a building being made fit 3 (j) Dwellings in which defects were remedied after service of formal notice 15 (k) Dwellings in which defects were remedied after informal action 247 (2) Houses in Multiple Occupation The Council have given consideration to the problems which may arise when a dwelling house is let to more than one family and have set down a standard for the facilities which should be provided for each letting. The standard requires every room used for human habitation to have a window of an area not less than 1/10th floor area (and one-half of the window to be capable of being opened) so as to provide adequate natural lighting and ventilation. Each letting has to have a separate water supply, a sink or wash-hand basin, and a ventilated food cupboard or refrigerator. The house is required to have water closets and baths on a scale which ensures that not more than eight persons need to share each fitting. A copy of the standard has been made available to owners on request, and where houses in multiple occupation are found, on routine visits, to be substandard the owner is required to provide the additional facilities. Apart from the lack of essential amenities, the problems of multiple occupation include overcrowding and bad management; to deal with cases of overcrowding more extensive use is likely to be made of the powers given by the Housing Act, 1961 whereby the local authority limit the number of persons occupying any house or letting by way of a Direction; similarly, cases of bad management can be dealt with by Orders made under the Housing Act, 1961, which render the owner liable to heavy penalties for failure to maintain the dwelling and its fittings in a reasonable state of repair. 54 (3) Certificates of Disrepair The Rent Act, 1957 entitled owners of controlled rented properties to a prescribed rent income provided the dwelling is maintained in a reasonable state of repair having regard to its age, character and locality. The tenant is safeguarded by the Act in that he may resist the rent increase if the owner fails to carry out necessary repairs. For this purpose the tenant applies to the local authority for a certificate of disrepair, which has to be granted if the owner fails to give a satisfactory undertaking to put the house in a proper state of repair within six months, and with this certificate the tenant is entitled to make an adjustment to the amount of rent he pays the owner. The Act seems no longer to be an effective mechanism for ensuring that items of disrepair receive attention, and the following table shows that whereas an average of nearly 100 applications were received annually in the seven years following the introduction of the Rent Act, it was almost completely ignored by landlord and tenant last year. Applications for Certificates of Disrepair : 1957/63 1964 1965 1. Number of applications for certificates 668 10 — 2. Number of decisions not to issue certificates 24 1 — 3. Number of decisions to issue certificates (a) in respect of some but not all defects 520 4 — (b) in respect of all defects 124 5 — 4. Number of undertakings given by landlords under paragraph 5 of the First Schedule 415 7 — 5. Number of undertakings refused by Local Authority under proviso to paragraph 5 of the First Schedule 3 — 6. Number of Certificates issued 232 2 — Applications for Cancellation of Certificates: 7. Applications by landlords to Local Authority for cancellation of certificates 134 2 2 8. Objections by tenants to cancellation of certificates 54 — — 9. Decisions by Local Authority to cancel in spite of tenant's objection 18 — — 10. Certificates cancelled by Local Authority 98 2 2 (4) Medical Priorities Applications for re-housing, supported by Medical Certificates, are received either through the Housing Officer or direct from family doctors or Hospital staff. These applications are divided into three classes —• A — Urgent priority; B — Some medical priority in relation to housing needs; C — No medical priority. In order to preserve continuity and a uniform standard of judgement, the Deputy Medical Officer of Health determines the appropriate socio-medical advice on all these applications. Every case is thoroughly investigated and applicants may be visited either by the Health Visitor or the Public Health Inspector as is appropriate. 55 2. INSPECTION AND SUPERVISION OF FOOD (1) Food Complaints Seventy-three complaints alleging unfitness in food sold or exposed for sale were received during the year. Investigation showed, as in previous years, that many of these complaints arise because of the failure of the food trader to turn over stock in a proper manner. At the beginning of the summer, a letter was distributed to retailers drawing attention to the advantage of adopting a system of visual-aid coding for deliveries of pre-packed perishable foods; the retailer can then be in no doubt as to the day when the "shelf-life" of the article has expired, so that such foods can be withdrawn from sale and destroyed. Legal proceedings were instituted in nine cases with the following results: 1 The case against a grocer for selling unsound bacon was dismissed. 2. A Dairy was fined £10 with £5 5s. Od. costs for selling a bottle of milk con- containing bird droppings. 3. A General Stores was fined £10 with £5 5s. Od. costs for selling a mouldy French Jam Sandwich. 4. A Supermarket was fined £15 with £12 12s. Od. costs for selling a Beef Sausage containing a Surgical Dressing and Finger Stall. 5. A Baker was fined £10 with £3 3s. Od. costs for selling a mouldy Cornish Pasty. 6. A Supermarket was fined £10 with £4 4s. Od. costs for selling a mouldy Steak Pie. 7. A Grocer was fined £20 with £5 5s. Od. costs for selling mouldy sausages. 8. A Butcher was fined £10 with £2 2s. Od. costs for selling a mouldy Steak and Kidney Pie. 9. A General Stores was fined £20 with £5 5s. Od. costs for selling mouldy Sausages. Throughout the year the Inspectors receive requests from food traders to examine doubtful consignments of food, and the following table lists the articles voluntarily surrendered and destroyed after such examinations: Apple Turnovers 200 Frozen Foods 283 pkts. Baby Food 231 tins. Fruit and Fruit Juices 4970 tins. Bacon 43 lbs. Fruit (Fresh) 42 lbs. Beef 1297 lbs. Fruit (Dried) 12 lbs. Biscuits 109 pkts. Lamb and Mutton 308 lbs. Butter 11 lbs. Liquor 26 botts. Cake Decoration 3 pkts. Meat (Tinned) 827 Cereals 72 pkts. Meat Pies 20 Cheese 273 lbs. Milk (Tinned) 287 Christmas Puddings 3 Nuts (Assorted) 81 lbs. Cooking Fat 35 pkts. Offal 82 lbs. Cornish Pasties 389 Other Meats 41 lbs. Cream (Tinned) 12 Pastry 31 pkts. Fish (Tinned) 781 Pickles and Sauces 9 jars. Fish (Fresh) 136 lbs. Pie Filling (Tins) 13 Flour 103 pkts. (2) Food Premises The following table shows the general classification of food premises in the Borough and the total number of visits made to each class of premises. Although the standard of hygiene has been maintained at a reasonably satisfactory level, inspections show that some proprietors have difficulty, because of staff changes 56 and shortage, in establishing the basic cleaning routines which are vitally important if clean and safe food is to be offered to the public. Despite such difficulties it is pleasing to record that no legal proceedings were instituted for breaches of the Food Hygiene (General) Regulations. The control of food hawkers is exercised by registration under the provisions of Section 11, Middlesex County Council Act, 1950, and during the year 7 persons and 3 premises were registered and 114 inspections made. Food Hygiene (General) Regulations, 1960. Type of Premises. No. of Premises No. of Premises which comply with Reg. 16* No. of Premises to which Reg. 19 appliest No. of Premises which comply with Reg. 19 No. of Visits carried out. Bakehouses 25 25 25 25 258 Butchers' Shops 125 125 125 125 624 Confectioners (Flour) 60 60 — — 133 Confectioners (Sugar) 282 282 — — 208 Dairies 4 4 4 4 44 Fishmongers and Poulterers 39 39 39 39 106 Fried Fish Shops 16 16 16 16 101 Greengrocers and Fruiterers 143 143 143 143 319 Grocers 321 321 321 321 1013 Ice Cream Premises—Manufacture 4 4 4 4 Ice Cream Premises—Sale and Storage 518 518 — — 171 Public Houses and Licensed Premises 72 72 72 72 170 Restaurants, Cafes and Canteens 222 222 222 222 738 1831 1831 971 971 3885 * Regulation 16 deals with the provision of wash-hand basins for the use of all persons engaged in the handling of food. † Regulation 19 deals with the provision of facilities for washing food and equipment. (3) Food Sampling. Under the powers of the Food and Drugs Act, 1955, and in conjunction with the regulations and orders made thereunder, samples are procured for the purpose of chemical analysis and for bacteriological and other examination. Chemical analysis ensures that foods are in fact, what they are proclaimed to be; that no injurious substances have been added and no constituents extracted so as to injuriously affect the nature, substance, or quality of the food; that no colouring matter nor preservatives have been added, except in the foods permitted and within the maximum quantities allowed. Bacteriological and other examination includes the tests employed to ensure that foods are free from pathogenic organisms and, with regard to milk and ice cream, that the heat treatment processes have been carried out satisfactorily. Samples for chemical analysis are submitted to the Public Analyst, D. D. Moir, Esq., M.Sc., F.R.I.C., and those for bacteriological and other examination to the Public Health Laboratory Service, Epsom. The invaluable help and advice given by the Public Analyst, and the co-operation received from the staff of the Public Health Laboratory Service have contributed in great measure to the effectiveness of food sampling in the Borough. During the year one hundred and ninety-nine samples were procured for chemical analysis and of these, fourteen were considered to be irregular. The following table shows the various types of food sampled and the results obtained. 57 Number Analysed Number Irregular Articles. Formal Informal Total Formal Informal Total Butter, Margarine and Fats 4 2 6 — — — Cereals 2 9 11 — — — Cream and Cream Products 1 3 4 — — — Coffee 1 2 3 — — — Drinks and Beverages 4 14 18 — 2 2 Fish and Fish Products — 9 9 — — — Flavourings and Essences — 8 8 — 1 1 Flour Confectionery 1 11 12 — 1 1 Fruit and Vegetables 4 7 11 — 1 1 Health Foods — 4 4 — 1 1 Herbs and Spices 1 15 16 — 2 2 Ice Cream 1 — 1 1 — 1 Jams and Marmalades — 7 7 — 1 1 Jellies 1 3 4 — — — Meat and Meat Products 8 13 21 — 1 1 Medicinal Preparations — 7 7 — — — Milk and Milk Products 7 15 22 — 2 2 Pickles and Sauces 1 12 13 — 1 1 Soups — 2 2 — — — Sugar Confectionery 2 8 10 — — — Syrups — 8 8 — — — Yeast — 2 2 — — — Total 38 161 199 1 13 14 The irregular samples comprised : — (a) Carrot Juice. The manufacturers of this product claimed that the food was a source of Vitamin A. Such a claim is not justified unless the amount of the food that would ordinarily be consumed in one day contains at least one-sixth of the daily requirements of the vitamin and the Public Analyst reported that this product was deficient in Vitamin A. Representation was made to the manufacturers with the result that the labelling was altered and the reference to the product being a source of vitamin A was removed. (b) Honey Kola. Under the provisions of the Labelling of Food Order, a compound food, for which there is no statutory standard, should state on its label the appropriate designation of each ingredient. Unless the quantity or proportion of each ingredient is specified, the ingredients have to be printed in the order of the proportion in which they are used, the ingredients used in the greatest proportion being specified first. The label of this product contravened these requirements as some of the ingredients were not declared and others were not specified in the order of their proportions. The manufacturers, on being informed of the contravention, arranged for the re-labelling of the product so as to comply with the Order. (c) Pure Almond Milk. This was a product consisting of a number of ingredients which were not correctly defined on the label. When the manufacturers were informed of the irregularity they decided to withdraw stocks and discontinued the sale of the article. (d) Pork Sausages. Under the terms of the Preservatives in Food Regulations, sulphur dioxide to the extent of 450 parts per million is permitted as a preservative in sausages, provided the sausages are labelled as containing preservative, or a notice to this effect is conspicuously displayed in the shop. Neither of these requirements was observed at the time of purchase although the sausages were found to contain preservative. The retailer, on being informed of this contravention, displayed an appropriate notice in a conspicuous place in the shop. 58 (e) Honey and Sesame Spread. This article was sold with a label claiming that the food was naturally rich in proteins and calcium. It was found that the proportion of proteins was small and that the calcium content was equivalent only to one-twentieth of the body's daily requirement. To justify the claim that the food was rich in this mineral, the amount of calcium should have been one half of the daily requirement. The retailer and the manufacturers were notified of the misleading claim and, as a result of this, the product was re-labelled and the reference to proteins and calcium were removed from the label. (f) Dairy Topping. This was a sample which was found to consist of homogenised and sterilised top of the milk. Under the provisions of the Labelling of Food Order, the designation of an article of food must be specific and not generic so as to indicate to a prospective purchaser the true nature of the ingredient to which it is applied. The description of this article was not considered to be an appropriate designation for the purposes of the Order. The manufacturers were accordingly informed and subsequently introduced new labels on which was added the words "a pure dairy product made solely from milk". The amended labels were accepted as indicating a truer description of the product. (g) Scotch Whisky Flavoured Marmalade. This sample was found to contain no whisky nor alcohol. It was ascertained, however, that the ingredients of the product included whisky and whisky flavour essence but as these were added prior to the boiling process the alcohol evaporated during the boiling. Following correspondence with the manufacturers, new amended labels were brought into use. (h) Strawberry Pie Filling. This was an article containing more than two ingredients. Although the ingredients were listed on the label as required by the Labelling of Food Order, one of the ingredients "vegetable gum" was considered to be a generic and not a specific name. The importers of the product which was manufactured in Canada were notified of the contravention and they arranged with the manufacturers to print new labels altering the generic term "vegetable gum" to the specific one of "locust bean gum". (i) Tumeric. This article is a plant of the ginger family used as a condiment especially in curry powder. The article itself was considered genuine but there was an infringement of the Labelling of Food Order in so far as the address of the packer was not specified on the label. Representation was made to the importers and new appropriate labels were introduced. (j) Black. Olives. The ingredients of this article were given in minute lettering as olives, salt, vinegar. It was considered that the word "vinegar" was a generic and not a specific name and that the lettering was so small as to be inconspicuous. The importers were informed of the contravention and they arranged for the manufacturers in Italy to print appropriately amended labels. (k) Strawberry Puffs. This informal sample was sold in a container labelled "Strawberry Puffs—Filling contains butter and strawberry jam". Upon analysis it was found that the sample was a pastry containing a filling of imitation cream and strawberry jam but no butter. Efforts to obtain a formal sample were unsuccessful as the retailer had discontinued selling the product. The Health Department of the Authority in whose area the strawberry puffs were being manufactured were notified of the report and a formal sample taken by them resulted in the manufacturers being prosecuted and fined £20. 59 (1) Mushroom Cubes. This was a sample of "cubes" intended to be added to meat dishes and gravy to impart a flavour resembling mushrooms. In the opinion of the Analyst, the designation "mushroom cubes" was not considered to be an appropriate one in so far as the proportion of mushrooms was so small that the flavour produced was predominantly that of a mixture of artificial flavour of onion, monosodium glutamate and garlic, and bore little resemblance to genuine mushrooms. Correspondence with the manufacturers resulted in agreement being reached regarding an appropriate designation for this product. (m) Vine Leaves. This was an article of food containing two ingredients namely, vine leaves and brine, but the ingredients were not specified on the labelling as required by the Labelling of Food Order. Following investigation with the retailer and suppliers it was ascertained that the supply of this product had been discontinued. (n) Ice Cream. This was a sample contained in a carton with an illustration depicting a dish of ice-cream surrounded by sections of mandarin oranges. Because of the range of ice-cream sweets now sold which include fruit-ice made to resemble fruit, this illustration was reported to be misleading as to the contents of the article. The manufacturing company were informed of the Analyst's observations and they agreed to introduce new illustrated cartons for their range of ice-cream products which would be approved by the Public Analyst. (4) Milk Supplies and Sampling. By virtue of the Milk (Special Designation) (Amendment) Regulations, 1965, a new special designation "Ultra Heat Treated" was prescribed for milk which is heated to a temperature of 270°F. for a period of not less than one second. The processed milk has to satisfy the prescribed colony count test. The conditions, subject to which a Licence is granted, require the milk, immediately after treatment, to be put into sterile containers for delivery to consumers under such conditions as will ensure the protection of the milk from risk of contamination. Unless the aseptic precautions are taken the milk will lose its long-keeping attribute and post treatment contamination will result in it failing the test. The regulations regarding the special designations in relation to "Pasteurised", "Sterilised" and "Untreated" milk remain in force. The designation "Untreated" has replaced "Tuberculin Tested" as the special designation for raw milk. The following Licences have been granted authorising dealers to store and sell designated milks: Ultra Heat Treated 11 Pasteurised 59 Sterilised 49 Untreated 39 There are no processing plants in the Borough but there is one Dairy which is registered bv the Ministry of Agriculture. Fisheries and Food. 60 Sixty samples of milk were submitted for examination and all were found to satisfy the prescribed tests, including the following samples examined for the presence of Brucella Abortus: — Number of samples of raw milk examined 4 Number of positive samples found Nil Action taken in respect of positive samples Nil (5) Ice Cream Manufacture and Sampling. The Ice-Cream (Heat Treatment, etc.) Regulations, 1959, defined the methods to be adopted for the heat treatment of ice-cream mixes. Mixes must be subjected to one of three recommended processes of pasteurisation or to the process of sterilisation. After heat treatment the mix must be reduced to a temperature of not more than 45°F., and finally, after freezing, must be kept at a temperature not exceeding 28°F. There is also an alternative method to the final one of freezing by which a mixture which has been sterilised is immediately placed in sterile air-tight containers under sterile conditions at the premises where the sterilisation process is carried out. This product is known as a complete cold mix which can be made into ice-cream by adding water only, and by freezing. There are four premises registered in the Borough for the manufacture of ice-cream — one where the ice-cream is pasteurised by heating to a temperature of 160°F. for a period of 10 minutes, the other three where the ice-cream is manufactured by using the complete cold mix method. There are also five hundred and eighteen premises registered for the storage and sale of ice-cream. During the year one hundred and seventy-eight samples were taken and upon examination were graded as follows : Grade 1 — 112 Satisfactory. Grade 2 — 19 Grade 3 — 25 Unsatisfactory. Grade 4 — 22 The unsatisfactory samples were those which had been taken from opened cans from cafes and restaurants. It is the practice in these premises for ice-cream to be received in cans, which are kept in refrigerators so that the ice-cream can be served as necessary It is essential however, that sterilised utensils are used for serving, otherwise contamination of the ice-cream is likely to occur. Where unsatisfactory samples had been obtained it was found that the contamination had arisen due to the use of improperly sterilised utensils. In each instance the appropriate investigation was carried out and advice given on the use of sterilising agents, resulted in the subsequent samples being satisfactory. (6) Other Foods. One hundred and two samples of foods were taken for bacteriological examination, five of which were found to be unsatisfactory. Certain] types of foods such as meat, milk and fish products are recognised as suitable media for the development of bacterial organisms, and sampling was concentrated on these classes of food. The samples found to be unsatisfactory were of dairy cream cake and fresh cream. The dairy cream cake, which was manufactured in the Borough, was found to contain S. aureus. A thorough investigation was carried out at the bakehouse concerned and subsequent samples were found to be satisfactory. The samples of fresh cream were taken on the same day from opened cans in two different bakehouses. The cream had been obtained from the same manufacturing source and both samples failed to satisfy the prescribed test. As soon as the results were known, repeat samples were taken from sealed cans on arrival at the respective bakehouses. These samples also failed to satisfy the prescribed test and the results were referred to the Authority in whose area the Creamery was situated. The processing and handling methods at the Creamery were investigated by the Authority concerned as the result of which subsequent samples proved to be satisfactory. 61 (7). The Liquid Egg (Pasteurisation) Regulations, 1963. There are no egg pasteurisation plants in the district and the eight samples of liquid egg taken were submitted only for bacteriological examination and not to the Alpha-Amylase test. 3. ATMOSPHERIC POLLUTION (a) The Clean Air programme continued satisfactorily and the following Smoke Control Orders came into operation during the year : Area Dwellings Other Premises Barnes No. 6 Order 110.6 acres 1,609 174 Richmond No. 6 Order 108.0 „ 2,007 125 Twickenham No. 4 Order 875.0 „ 3,058 147 In addition, the following Orders were made by the Council and are planned to come into operation in 1966 : Area Dwellings Other Premises Barnes No. 7 Order 453 acres 1,288 89 Richmond No. 7 Order 152 „ 1,330 41 Twickenham No. 5 Order 630 „ 3,077 156 The revised grant arrangements continued without further amendment. Householders are given freedom of choice between the various smokeless fuels and where solid smokeless fuel is selected, applicants are encouraged to install the more efficient closed appliance rather than the open coke firegrate; where electricity is selected for space heating, a grant is not paid for direct heating appliances, the use of which places undue strain on power resources at peak periods, but a grant is available for the installation of electric storage heaters. Inevitably the new policy has resulted in more costly although more efficient adaptations and the Council have given sympathetic consideration to many cases of financial hardship so that, where need is shown, a 100% grant has been paid instead of the statutory 70%. (b) Complaints of smoke emission were not numerous and in general referred either to garden bonfires or to isolated factory chimneys. The burning of garden refuse, even in a smoke control area, is permitted by law so long as a nuisance is not caused to the inhabitants of the neighbourhood. When complaints have been received the householder concerned has accepted the advice given on the disposal of garden waste matter so as not to give offence to nearby residents. Complaints of smoke from industrial chimneys have required a more thorough technical investigation, and in the case of a local laundry the proprietors have agreed to apply for the Council's town planning consent to enable the boilerhouse to be reconstructed and to install a modern mechanically fired boiler which will replace the existing unsatisfactory hand fired boiler. 4. OFFICES, SHOPS AND RAILWAY PREMISES ACT, 1963 The Act came into force in 1964 and sets standards for the health, welfare and safety of employees in offices, shops and railway premises. All office workers are within its scope whether they work in separate office buildings or in offices forming part of other buildings (e.g. schools, factories, hotels, etc.). Shops are widely defined to include wholesale and retail trade premises, restaurants, launderettes, dry-cleaning receiving premises and fuel storage depots. 62 The Act does not apply to premises (a) where only self-employed persons work, or (b) used for "family businesses" i.e. where no-one is employed other than close relatives of the employer or (c) where the total time worked by employees is less than 21 hours weekly. Premises to which the Act applies are required to be registered by the local authority and the principal matters on which standards are laid down relate to cleanliness — overcrowding — temperature — ventilation — lighting — sanitary accommodation — washing facilities — drinking water — clothing accommodation — seats for sedentary work — first aid facilities — safety and operation of machinery — fire precautions. During the year 444 additional premises were registered under the Act and the total number of premises registered and inspected at the end of the year is summarised below: Total number of registered premises. Number inspected during year. Offices 606 323 Retail Shops 1,074 640 Wholesale Shops 53 29 Catering Establishments 166 97 Fuel Storage Depots 5 1 1,904 1,090 A great measure of co-operation has been received from employers in the Borough in implementing the new standards and no legal proceedings were instituted for contraventions of the Act; in addition, the Council granted no certificates exempting premises from the standards laid down. A special survey was made in the last quarter of the year on both natural and artificial lighting in offices and shops to enable the Minister to consider whether more precise lighting standards are required, and the following narrative was submitted. (1) General Impression of the Standard of Lighting. Artificial Lighting. The standard of artificial lighting in shops and offices was found almost always to be good in the sections open to the public, but sometimes less satisfactory in other parts. Offices were more satisfactory than shops. Natural Lighting. This was sometimes inadequate and varied considerably. Most shops had adequate light only near the large display window and this did not reach to the rear of the larger shops. Staircases, landings, wash places, etc., which generally had filament lamps were sometimes inadequate, and w.c.'s, especially external ones in yards, occasionally had no artificial or natural light. (2) Unsatisfactory Lighting. Certain trades such as retail builders merchants and hardware shops where the goods were of a less attractive kind, and where drab surroundings reduced the reflected light, had unsatisfactory lighting, but these were few. A more disquieting cause of unsatisfactory lighting was due to an effort by owners to reduce the cost of lighting. The explanation given by a Manager for this was that 63 where a standing charge with a fixed wattage had been agreed with the Electricty Board; the lamps in the working parts were of low wattage to justify a low standing charge. This feature in the case of a large firm of multiple shops, was to the detriment of employees working in the extensive stockrooms, where lamps were limited to 40 watts (under six lumens), and with bad light arrangement due to high shelves. Where a large number of lamps serving stockrooms having fair natural lighting are only required during two quarters of the year, it was found advantageous to avoid the necessarily high standing charge by adopting the higher tariff. This step created a tendency on the part of owners to use low powered lamps which they considered adequate, but when employees were questioned they complained emphatically that the light was insufficient (2/4 lumens). Lighting appears to be installed without any ordered scheme and with only limited — if any — professional advice. Comments have been made by employees on the unpleasant effect on the eyes of facing filament light after long exposure to fluorescent light, and newly installed fluorescent light had to be subdued owing to excessive harshness after complaints by customers in a hairdressing salon. Only one instance was found where insufficient light existed in the vicinity of machinery (Supermarket conveyor belt). Generally the lighting was adapted to the requirements of the trade varying from the brightly fluorescent lighted supermarkets to the dimly filament lit antique shops and restaurants. Inadequate lighting in working areas was attributable either to economy on the part of owners, or to a lack of awareness of the deficiency. In the latter case the deficiency was readily remedied when pointed out. A standard is required for stockrooms and guidance is needed in the arrangement of light and in the creation and use of reflected light. (3) Standard Recommended to Occupiers. Advice given so far limited to fitting higher powered lamps where required, based on the Illuminating Engineering Society's Code. It seems that standards cannot be applied to stockrooms without distinction, and need to be related to the particular business; in the case of the multiple shops quoted in section 2, the work involved reading the small print on labels of bottles and required a higher standard than usual. (4) Instances of Excessive Glare. Glare does exist to some extent and Venetian blinds and adjustment of lights was advised as a remedy, but it was found that complaints by employees of glare were dealt with quickly by employers. Assessment was made by questioning employees on the effect of the light on them. 64 5. PUBLIC HEALTH INSPECTIONS The following table shews the multitudinous duties carried out during the year and I am pleased to pay tribute to the work done by senior and district inspectors and by the technical and general assistants and to record their achievements. Despite staff shortages, they made every endeavour, and with considerable skill and technical ability, to ensure that the department's services were maintained, and my appreciation of their efforts must include mention of the assistance given by the pupil inspectors. Bacteriological sampling — IceCream 194 — Milk 72 — Other Foods 65 Clean Air Act — Inspections and Observations 9178 Control of Caravans 109 Diseases of Animals Act: Waste Food Order 21 Drainage and Sanitary fittings examination 3504 Food and Drugs Sampling 178 Houses inspected—Housing Act 669 Houses Let in Multiple Occupation 152 Housing Applications 336 Houses inspected —Public Health Act 4875 Houses inspected re Permitted Numbers 152 Houses inspected re Vermin and Disinfestation 399 Infectious Diseases enquiries, disinfection, etc. 1233 Merchandise Marks Act 22 Noise Abatement Act 510 Offices, Shops and Railway Premises Act— General Inspections 1090 Offices, Shops and Railway Premises Act — Other Visits 2383 Pet Animals Act 116 Prevention of Damage by Pests Act 258 Rag Flock and Other Filling Materials Act 6 Rent Act, 1957 36 Swimming Baths — Sampling 30 Unsound food examination 677 Water Supply—Inspection 103 Water Supply — Sampling 99 Agricultural Holdings 5 Animal Boarding Establishments 27 Bakehouses 258 Butchers Shops 624 Confectioners (Flour) 133 Confectioners (Sugar) 208 Dairies 44 Factories (Mechanical) 185 Factories (Non-Mechanical) 12 Factory Canteens 80 Fishmongers and Poulterers 106 Fried Fish Shops 101 Greengrocers and Fruiterers 319 Grocers 1013 Hawkers 114 Hairdressing Establishments 39 Ice-Cream premises 171 Massage and Chiropody establishments 26 Outworkers 6 Places of Public Entertainment 1 Public Houses and Licensed Premises 170 Restaurants and Cafes 658 Riding Establishments 16 Schools 102 Scrap Metal Dealers 21 Interviews 876 Miscellaneous Visits 3300 Inspections other than Houses — Public Health Act 838 Total number of visits and inspections 35920 65 The complaints received during the year are classified in the table below and they reflect a pattern similar to that of previous years. Nature of Complaint. Number Received Housing Defects 261 Choked and defective drains and sewers 432 Defective water closets 37 Accumulations of offensive matter 61 Unsound food 73 Verminous and other Infested premises : Bugs 18 Rats and Mice 959 Wasps 8 Fleas 9 Others 53 Keeping of Animals 4 Keeping of Bees 2 Nuisance from Pigeons 15 Smoke Nuisances 53 Noise Nuisances 30 Miscellaneous 81 Total 2096 Every effort is made by inspectors to carry out their work through informal action, and to seek co-operation by interview and letter; in certain cases recourse to statutory proceedings is unavoidable, and a summary of notices served during the year is given below: — Subject of Notice. Public Health Act. Food and Drugs Act. Number of Informal Notices served 363 52 Number of Informal Notices complied with 241 49 Number of Statutory Notices served 24 — Number of Statutory Notices complied with 12 — It was found necessary to institute legal proceedings against the owner of premises in the Hampton Hill area for non-compliance of statutory notices served under Sections 39 and 45 of the Public Health Act, 1936. These notices were served on the 27th November, 1964 and in March 1965 the owner was fined £2 plus £3 3s. Od. costs. Again in June, 1965 the owner was fined 1s. Od. per day for 68 days + £3 3s. Od. costs and then again in October, 1965, 1s. Od. per day for 113 days + £5 5s. Od. costs. The notices were then complied with. 6. DISINFECTION AND DISINFESTATION Disinfection of premises and articles after infectious disease is carried out at the expense of the Local Authority and in cases other than after infectious disease at the cost of the individual. Disinfestation of premises for the eradication of bed bugs, fleas, etc. is carried out and the cost charged to the individual. There is no provision for the destruction of wasps, ants, cockroaches, beetles and other insects whose treatment requires a specialist service. By arrangement, all persons suffering from scabies or infested with lice are sent to the Hammersmith Medicinal Baths for treatment. During the year 1 person suffering from scabies and 3 persons infested with lice were treated. 66 The following table gives details of the number of premises disinfested during the year. Disinfestation. Bugs Wasps Fleas Lice Miscellaneous Total Dwelling Houses 25 — 7 — — 32 Workplaces 1 — — — 1 2 Food Shops — — — — — — Miscellaneous — 3 — 1 — 4 26 3 7 1 1 38 Total Income from D.D.T. and other special treatments £54 17s. 4d. 7. RODENT CONTROL The rodent control staff have continued to do much useful work in eradicating rats and mice from premises. No. of complaints received 959 No. of infestations found 738 Total number of visits 4,853 The treatment of foul sewers in the former Richmond area was carried out in May, but the second treatment normally due in November had to be postponed through illness and difficulties with transport. Every effort will be made to complete this treatment early in 1966. The anti-coagulent, Warfarin, was used and baiting was concentrated in specific areas known to be persistently infested with rats. In the Twickenham area, four treatments per year using Fluoracetamide (direct poisoning) are normally carried out, but by the end of the year under review, only three treatments were possible and arrangements have been made to complete the programme early in 1966. No serious problems are presented in the Barnes area and the Ministry of Agriculture, Fisheries and Food have suggested no further action in this district until 1966. The Ministry have been kept informed of the two methods of sewer treatment in operation and have advised its continuation. They are of the opinion that if present progress is maintained it is possible that the whole of the sewage system could be free of rats in the not too far distant future. 67 8. FACTORIES ACT, 1961, Part I of the Act. (1.) INSPECTIONS, for purposes of provisions as to health. Premises Number on Register Number of Inspections Written Notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4, and 6 are to be enforced by Local Authorities 60 12 — — (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 585 185 — — (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) — — — — Totals 645 197 — — (2.) Cases in which DEFECTS were found. Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness (S. 1) 4 4 — 3 — Overcrowding (S. 2) — — — — — Unreasonable temperature (S. 3) — — — — — Inadequate ventilation (S. 4) 2 4 — 2 — Ineffective drainage of floors (S. 6) — — Sanitary Conveniences (S.7) (a) Insufficient 1 1 1 — (b) Unsuitable or defective 5 4 — 3 — (c) Not separate for sexes 1 — — 1 — Other offences against the Act (not including offences relating to outwork) 8 6 — 3 — Totals 21 19 — 13 — Part VIII of the Act, Outwork. Nature of Work Section 110 Section 111 No. of outworkers in August list required by Section 110 (1) C No. of cases of default in sending lists to Council No of prosecutions for failure to supply lists No. of instances of work in unwholesome premises Notices served Prosecutions Wearing Apparel 94 — — — — — Electrical Fuse Makers 70 — — — — — Artificial Flowers 11 — — — — — Feather Sorting 1 — — — — — Stuffed Toys 11 — — — — — Textile Weaving 2 — — — — — Lampshades 51 — — — — — Total 240 — — — — — 68 9. MORTUARIES There are two mortuaries in the Borough; one provided by the former Richmond Borough Council on a site close to the Petty Sessions Court and the other provided by the former Twickenham Borough Council in the grounds of the Public Library at Hampton. In recent years the Mortuary at Hampton has been upgraded to recommended standards. Due to inherent difficulties of siting and congestion the Richmond Mortuary is not up to this standard and the need for further deliberation as to its future has been demonstrated. The number of bodies admitted to the two Mortuaries during the year was: — Richmond 276 Hampton 565 10. LAUNDRY SERVICE A laundry service for incontinent patients is provided. The service is confined exclusively to incontinent patients, and articles laundered are limited to sheets and draw sheets. The service is provided twice weekly throughout the year. Soiled sheets are collected and at the same time an appropriate number of laundered sheets is delivered to the patient. The service is of great benefit to those who use it and is expanding. Early in the year it became apparent that the former Richmond Corporation Laundry (Baths department) and the private laundry at Staines which carried out a comparatively small amount of work for the former Richmond and Twickenham Bor oughs would not be able to cope with the increased load; arrangements were accordingly made with a local private laundry to deal with all the soiled sheets throughout the Borough. These arrangements are working satisfactorily. At the end of the year under review there were 29 cases on the books. Incontinent pads are used where the degree of incontinence does not require the sheet service and where the patient is doubly incontinent thus reducing the laundering of soiled bed linen. The pads are normally distributed by the district nurses, but where a laundry service for incontinent persons is also in operation, pads are sometimes delivered by the van driver. Used pads are collected and destroyed whenever disposal is requested because the householder has difficulty in dealing with this type of refuse. Soiled dressings (including maternity debris) are also collected and disposed of in the same manner, generally on the request of the domiciliary nursing staff. There is an increasing call for this service and during the year nearly 900 col' lections were made. 11. DISEASES OF ANIMALS ACT, 1950 The Council accepted the offer from the Corporation of London to act as agents for the Council in respect of their responsibilities under the above Act and I am indebted to Mr. G. S. Wiggins, M.R.C.V.S., Veterinary Officer, Corporation of London, for his observations as follows:— "Duties were concerned solely with the Diseases of Animals Act and not with any of the allied Acts. 69 In the London Borough of Richmond there are some six premises where livestock are kept, plus one Kosher Butcher and Poulterer, and routine visits were made to these to a total of 16½ hours. Visits were made by the Veterinary Officer to the Pet Shop at 148, Heath Road, Twickenham, on the 2nd, 6th, 9th and 12th August, 1965, in respect of a suspected source of psittacosis. Appropriate steps were taken to see that where psittacine birds were kept the pens were emptied, cleaned and properly disinfected. (See page 11 — Psittacosis). During the above period no case of notifiable disease under the terms of the above Act was reported in the area of the London Borough of Richmond". 12. ANIMAL BOARDING ESTABLISHMENTS ACT, 1963 This Act provides for a system of licensing by the Local Authority of any establish' ment at which a business of providing accommodation for cats and dogs is carried out. During the year 27 inspections were made and 5 establishments licensed. 13. PET ANIMALS ACT, 1951 No person is allowed to keep a pet shop except under the authority of a licence granted in accordance with the provisions of this Act. During the year 15 licences were issued and 116 inspections made. 14. RIDING ESTABLISHMENTS ACT, 1964 This Act came into force on 1st April, 1965, and from that date it is an offence to keep a riding establishment except under the authority of a licence granted for the purpose. The Council are the responsible licensing authority and among the factors which they are obliged to take into account in deciding whether to grant a licence in any particular case are: 1. that the applicant for the licence appears to them to be suitable and qualified, either by experience in the management of horses or otherwise, to be the holder of such a licence, and to the need for securing; 2. that there will be available at all times, for horses, accommodation suitable as respects construction, size, number of occupants, lighting, ventilation, drainage and cleanliness; 3. that in the case of horses maintained at grass, there will be maintained for them at all times during which they are so maintained adequate pasture and shelter; 4. that horses will be adequately supplied with suitable food, drink and — except in the case of horses maintained at grass, so long as they are so maintained — bedding material, and will be adequately exercised and rested and so far as necessary visited at suitable intervals; 5. that all reasonable precautions will be taken to prevent and control the spread among horses of infectious or contagious diseases; 6. that appropriate steps will be taken for the protection of horses in case of fire; 7. that horses will be maintained in a good state of health and that, in the case of a horse kept for the purpose of its being let out on hire for riding or a horse kept for the purpose of its being used in providing instruction in riding, the horse will be suitable for the purpose for which in that case it is kept; 8. that adequate accommodation will be provided for forage, bedding, stable equip' ment and saddlery. 70 Where an application is received for a licence the Local Authority shall not proceed to a decision in the matter unless they have received and considered a report by a Veterinary Surgeon or Veterinary Practitioner authorised by them to carry out inspections. During the year 4 establishments were licensed and 16 inspections made. The Council's appointed Veterinary Officers are Messrs. M. A. P. Simmons and J. A. Morris, and I am most grateful to them for their assistance in the administration of this Act. 15. ESTABLISHMENTS FOR MASSAGE and/or SPECIAL TREATMENT Establishments where massage or special treatment is carried on in the Twickenham area were licensed under the Middlesex County Council Act, 1944, by the former Twickenham Corporation. These licences expired on 31st March, 1965. In the Richmond and Barnes areas this type of establishment was licensed by the Surrey County Council and the licences expired on 31st July, 1965. Under the provisions of The Local Law (North West London Boroughs) Order, 1965 all premises in the Council's area were, from 1st April, 1965, licensed under the Middlesex County Council Act, 1944. Where applicable all applicants for a licence are now required to possess the qualifications necessary for registration by the Board established under the Professions Supplementary to Medicine Act, 1960. Certain approved conditions are incorporated in every licence granted. During the year 21 licences were issued and 26 inspections made. 16. SWIMMING POOLS I am obliged to Mr. T. Lindley, F.Inst.B.M., Baths Manager for the following report: — Swimming facilities are provided within the Borough at the three Open Air Pools during the summer period and at one Indoor Swimming Pool throughout the year, all properties being owned by the Council. The Twickenham Open Air Pool has a capacity of 280,000 gallons of water; Hampton Pool has a capacity of 206,000 gallons of water and the Teddington Pool has a capacity of 180,000 gallons of water; the Parkshot Indoor Pool has a capacity of 96,000 gallons of water. The water for all pools is supplied by the Metropolitan Water Board and is filtered by sand pressure filters at all Pools. Sterilization is achieved by chlorination gas treatment operating as a "marginal" principle at the Open Air Pools and "breakpoint" principle at the Parkshot Pool. The rates of turnover at both Twickenham and Teddington Pools is every 6½ hours; that at Hampton every 4 hours; that at Parkshot Pool, approximately every 6 hours. Tests are taken three times daily for free-available and residual chlorine in the water, the pH values, also the shallow end and deep end water temperatures, the results being recorded in a standard log-book. Bacteriological tests of the water at all Pools are made each month and all such analyses during the past year have proved entirely satisfactory. Private bath suites for ladies and gentlemen are constructed in the Parkshot Establishment. 71 FUTURE SCHEME — 1966 A New Baths Establishment, of a "combination" nature, is under construction in the Old Deer Park at the present time and should be opened in mid 1966. The establishment consists of one main Indoor Pool 110ft. long by 42ft. wide, water capacity of 210,000 gallons and a turnover rate of 3 hours; one Indoor Learner's Pool 42ft. long by 24ft. wide, water capacity of 17,000 gallons and turnover rate of 1½ hours, and an Open Air Pool 110ft. long by 42ft. wide, water capacity of 160,000 gallons and a turnover rate of 4 hours. The filtration of all Pools water will be through Pre-coat filters, and sterilization will be carried out by chlorine gas treatment on "breakpoint" principle. A Plenum heating system will be installed and the whole establishment will be operated electrically. A private baths suite consisting of baths for 12 males and 12 females — with the necessary waiting rooms, toilets, etc. — is included in the scheme. The site is landscaped and well laid out, providing some two acres of grass and banked areas which will be available for sun-bathing, games, etc. 72 LONDON BOROUGH OF RICHMOND UPON THAMES ANNUAL REPORT of the PRINCIPAL SCHOOL MEDICAL OFFICER A. M. NELSON M.B., Ch.B., D.P.H. 1965 HEALTH DEPARTMENT, ELMFIELD HOUSE, HIGH STREET, TEDDINGTON, MIDDX. June, 1966. To His Worship the Mayor, Aldermen and Councillors of the London Borough of Richmond upon Thames. MR. MAYOR, LADIES AND GENTLEMEN, I have the honour to present my Annual Report on the work of the School Health Service for the year 1965. The main aim has been to maintain the established systems of working from the two County Authorities. A rationalization of the clinical and administrative procedures is being undertaken all the time. One can report that the general physical condition of our children is in good shape. However, I would direct your attention to the pertinent comments of the Principal School Dental Officer, that of all the children examined approximately half required treatment. The trend of such treatment is a conservative one in that the ratio of fillings to extractions in your service is more than thirty to one whilst the national figure is five to one. I feel that a child who fails to make progress at school is worthy of all the help that we can muster. The causes of this slow development are multiple and need all the skills of teachers, doctors, and others. Therefore the School Health Service would like these children brought to their notice as soon as possible because the child concerned may be suffering from either poor vision, impaired hearing, limited mental endowment, or emotional trauma. A child who is not learning at the same pace as his fellows is a challenge to the dedicated teacher. However, I would make the plea to all teachers that the resources of the School Health Service are at their disposal for aid if it is sought. I wish to record the considerable interest and support of the Education Schools Sub-Committee and their Chairman, Councillor Mrs. H. A. M. Champion, also that of the Chairman of the main Committee, Alderman E. Bostock. I wish to acknowledge the co-operation and collaboration of my colleague, Mr. W. R. Wainwright, Chief Education Officer, and his staff. Yours respectfully, A. M. NELSON, Principal School Medical Officer. 1 EDUCATION COMMITTEE as at 31st December, 1965. Alderman E. BOSTOCK, MA., F.C.A. (Chairman). Councillor R. A. J. ALCOCK (Vice-Chairman). Alderman L. Defries-Porter, LL.B., M.B.I.M. Councillor J. H. Bedford. Councillor Mrs. H. E. Bell-Wright. Councillor B. Bligh, B.A. Councillor E. H. Campion, B.A., Dip.Ed. Councillor Mrs. H. A. M. Champion. Councillor F. D. Christian, F.I.B., G.L.C. Councillor F. L. Eslick, F.C.C.S. Councillor F. D. Gilday-Fox, B.A. Councillor H. Hall, M.P.S., F.S.M.C. Councillor A. B. Hart. Councillor S. Hayes. Councillor A. M. Leaney. Councillor R. H. Mitchison. Councillor Mrs. M. E. Owen. Councillor J. Paskin, M.B.E. Councillor B. W. C. Pride. Councillor B. L. Royle, J.P., A.M.I.E.R.E. Councillor G. J. Samuel, M.A. Councillor C. W. Sewell, M.A., F.R.Econ.S. Councillor Mrs. G. D. Smith. Councillor R. H. Stevens. Councillor S. D. Wade. Councillor G. A. Watson. Councillor Miss O. J. Wilkins. Councillor D. K. Winslow. Councillor J. E. Woodward, O.B.E. Councillor Mrs. M. A. Woodward, J.P. F.V.I., M.R.S.H. Rev. F. J. Davys; Rev. T. F. Valentine, M.A.; Rev. D. Landreth, M.A.; Mrs. M. B. Davies; Dr. J. D. Mortimer, M.A.; Mr. F. A. W. Counter; Mr. R. C. Feather, M.A., B.Sc.; Mr. C. Holman; Mr. L. F. Holmes, Mr. T. Telling. EDUCATION SCHOOLS SUB-COMMITTEE as at 31st December, 1965. Councillor Mrs. H. A. M. CHAMPION (Chairman). Alderman L. DEFRIES-PORTER, LL.B., M.B.I.M. (Vice-Chairman). Councillor Mrs. M. A. Woodward, J.P. Councillor B. Bligh, B.A. Councillor F. D. Christian, F.I.B., G.L.C. Councillor H. Hall, M.P.S., F.S.M.C. Councillor Mrs. M. E. Owen. Councillor G. J. Samuel, M.A. Councillor Mrs. G. D. Smith. Rev. F. J. Davys. Mrs. M. B. Davies. Mr. C. Holman. Mr. L. F. Holmes. Alderman E. Bostock, M.A., F.C.A. (ex-officio). Councillor R. A. J. Alcock (ex-officio). 2 SCHOOL HEALTH SERVICE STAFF as at 31st December, 1965. Principal School Medical Officer A. M. Nelson, M.B., Ch.B., D.P.H. Deputy Principal School Medical Officer J. K. Craig, M.B.E., M.A., M.D., B.Ch., B.A.O., D.P.H., D.C.H., D.I.H. Senior Assistant Medical Officers Margeurite E. M. James, M.B., Ch.B., D.P.H. Elizabeth Wales, M.B., B.S., D.C.H., D.P.H., D.R.C.O.G. Medical Officers Enid G. Carson, M.B., B.Ch., B.A.O., D.C.H Vivienne Simmons, M.R.C.S., L.R.C.P., D.C.H. Elizabeth M. Williams, B.A., M.B., B.Chir., D.R.C.O.G. Consultants in School Health Service Helena B. Casey, M.B., B.Ch., B.A.O., D.O.M.S. R. Higgins, M.A., M.B., B.Chir., D.P.M. Agnes M. Main, M.B., B.S. R. H. Maudsley, M.B., Ch.B., F.R.C.S., L.R.C.P. Principal School Dental Officer. G. H. Tucker, L.D.S., R.C.S. Dental Officers ... R. Green, L.D.S., R.C.S. Elsa M. Johnson, L.D.S., R.C.S. T. A. McVey, L.D.S., R.F.P.S. Doreen M. Stapleton, B.A., B.Dent.Sc. Speech Therapists Miss K. S. Buckman, L.C.S.T., A.R.C.M., A.T.C.M., L.T.C.M. Miss P. A. Knight, L.C.S.T. Mrs. S. A. Thrift, L.C.S.T. Physiotherapists Mrs. J. B. Y. Appleton, C.S.P. Miss L. M. Caink, F.C.S.P. Mrs. M. M. Waters, C.S.P. Chief Nursing Officer Miss G. M. Francis, S.R.N., S.C.M., H.V.Cert. Superintendent Health Visitor . Miss D. W. Woods, S.R.N., S.C.M., H.V.Cert. Dental Surgery Assistants Miss M. Antcliff. Mrs. S. N. Briggs. Miss M. D. Crosbie. Miss S. F. Doult. Mrs. M. Goss. Miss A. Puntin. Mrs. D. Quinney. Audiometer Operators . Mrs. C. W. Mathias. Mrs. I. Corteen. 3 The population of Richmond upon Thames at mid 1965 was 181,130 of which 19,759 were school children in maintained schools. Table I. SCHOOL POPULATION (As at 20.1.66) No. of schools Number on Registers Total Boys Girls Secondary Grammar 5 1,680 1,627 3,307 Secondary Modern 15 2,716 2,405 5,121 Primary 51 5,688 5,429 11,117 71 10,084 9,461 19,545 Nursery 2 61 39 100 Day Special Schools for E.S.N. children 2 55 21 76 Day special School for Maladjusted children 1 28 8 36 Autistic Unit 1 2 - 2 6 146 68 214 Total 77 10,230 9,529 19,759 4 MEDICAL INSPECTION AND TREATMENT Year ending 31st December, 1965 Table II. Medical Inspection of Pupils attending Maintained Primary and Secondary Schools (including Nursery and Special Schools). A. — PERIODIC MEDICAL INSPECTIONS. Year of Birth Number of pupils inspected Physical Condition of Pupils Inspected Satisfactory Unsatisfactory Number %of column 2 Number %of column 2 (1) (2) (3) (4) (5) (6) 1961 and later 40 40 100 — — 1960 553 549 99.27 4 0.73 1959 351 348 99.15 3 0.85 1958 85 84 98.82 1 0.18 1957 451 449 99.56 2 0.44 1956 61 61 100 — – 1955 32 32 100 – — 1954 206 206 100 – — 1953 436 435 99.77 1 0.23 1952 158 158 100 – — 1951 159 158 99.37 1 0.63 1950 and earlier 1310 1307 99.77 3 0.23 TOTAL 3842 3827 99.61 15 0.39 B. — OTHER INSPECTIONS. Number of Special Inspections 1,848 Number of Re-Inspections 1,955 3,803 Periodic Medical Inspections. The local education authority has a duty, by statute, to arrange for school children at maintained schools to be medically examined on at least three occasions during the child's school life. These arrangements can be flexible as to time and method. The orthodox and historical approach is three periodic examinations: — at school entry, on transfer from junior to senior school, and prior to leaving school. Timing is critical and can be 5 debated. Some people hold the view that the child should be seen as soon as he enters a fresh school, others maintain that the child should have been sufficiently long in the school to be known by the staff and thus in a position to make comments to the examining school medical officer. Again there is a body of opinion that advocates selective medical examinations after judicious scrutiny of a parental questionnaire instead of a routine medical inspection. My own view is that a controlled trial in a limited number of schools would be advisable before a defined policy was enunciated. Physical Condition of Pupils Inspected. The general physical condition of school children remains at a very high level. Out of 3,842 children examined only 15 were found to be of unsatisfactory physical condition. The co-operation and collaboration of the teaching staff is gratefully acknowledged. Without their help and understanding it would not have been possible to arrange these routine medical inspections. Table III. TABLE A. — Pupils found to require treatment at Periodic Medical Inspections (excluding Dental Diseases and Infestation with Vermin). Year of birth For defective vision (excluding squint) For any of the other conditions in table IV(A) Total individual pupils (1) (2) (3) (4) 1961 and later — 9 9 1960 11 74 84 1959 12 28 39 1958 5 13 16 1957 32 68 93 1956 4 6 10 1955 2 8 9 1954 14 23 35 1953 45 54 95 1952 15 21 34 1951 10 18 27 1950 and earlier 195 169 333 TOTAL 345 491 784 6 Table IV. Defects found by medical inspection in the year ended 31st December, 1965. TABLE A. — PERIODIC INSPECTIONS. Defect code number Defect or disease Periodic inspections Entrants Leavers Others Total (T) (O) (T) (O) (T) (O) (T) (O) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 4 Skin 11 16 50 65 30 51 91 132 5 Eyes: a. Vision 15 52 201 134 129 170 345 356 b. Squint 10 14 6 7 19 20 35 41 c. Other 5 7 8 25 8 31 21 63 6 Ears: a. Hearing 6 26 6 16 12 40 24 82 b. Otitis media 6 35 7 9 2 11 15 55 c. Other 2 2 11 4 16 10 29 16 7 Nose and throat 15 127 6 32 14 122 35 281 8 Speech 10 26 – 5 10 26 20 57 9 Lymphatic glands — 49 – 5 – 26 – 80 10 Heart 1 20 1 27 2 31 4 78 11 Lungs 2 29 1 24 1 49 4 102 12 Developmental: a. Hernia — 3 1 1 3 3 4 7 b. Other 3 22 1 34 5 42 9 98 13 Orthopaedic: a. Posture 1 10 7 18 20 20 28 48 b. Feet 28 50 15 38 30 69 73 157 c. Other 1 35 55 51 17 49 73 135 14 Nervous system: a. Epilepsy 1 6 — 5 5 5 6 16 b. Other — 1 2 9 – 9 2 19 15 Psychological: a. Development – 15 – 10 3 59 3 84 b. Stability 2 57 1 38 6 161 9 256 16 Abdomen 4 15 6 21 7 26 17 62 17 Other 7 22 17 53 12 60 36 135 (T) Requiring treatment. (O) Requiring observation. 7 Table IV. — continued. TABLE B. — SPECIAL INSPECTIONS. Defect code number Defect or disease Pupils requiring Treatment Pupils requiring Observation (1) (2) (3) (4) 4 Skin 415 37 5 Eyes: a. Vision 87 38 b. Squint 3 2 c. Other 15 6 6 Ears: a. Hearing 65 122 b. Otitis media 13 10 c. Other 34 2 7 Nose and throat 32 33 8 Speech 20 15 9 Lymphatic glands 1 4 10 Heart 3 12 11 Lungs 4 19 12 Developmental: a. Hernia — — b. Other 16 12 13 Orthopaedic: a. Posture 3 3 b. Feet 18 21 c. Other 35 26 14 Nervous system: a. Epilepsy 3 1 b. Other 1 7 15 Psychological: a. Development 7 34 b. Stability 41 53 16 Abdomen 8 8 17 Other 45 24 8 Table V. Recorded incidence of certain defects found to require treatment at periodic inspection per 1,000 pupils examined. 1965. Total children examined 3,842 Skin 23.7 Eyes : a. Vision 89.8 b. Squint 9.1 c. Other 5.5 Ears : a. Hearing 6.2 b. Otitis media 3.9 c. Other 7.5 Nose and Throat 9.1 Speech 5.2 Lymphatic Glands 0.0 Heart 1.0 Lungs 1.0 Developmental : a. Hernia 1.0 b. Other 2.3 Orthopaedic : a. Posture 7.3 b. Feet 19.0 c. Other 19.0 Nervous System : a. Epilepsy 1.6 b. Other 0.5 Psychological : a. Development 0.8 b. Stability 2.3 Abdomen 4.4 Other 3.1 Table VI. Number of children examined other than at Periodic Medical Inspections: — Pupils examined for any condition, ailment or defect 1,411 Other special examinations, freedom from infection, employment byelaws, etc. 437 1,848 Re-inspections of pupils previously found to have some defect 1,955 9 Table VII. CLINICS. School Health Service facilities available. BARNES Essex House, Station Road, Barnes, S.W.13. Minor Ailments Orthopaedic (physiotherapy) Speech Therapy Vaccination and Immunisation HAM Ashburnham Road, Ham, Richmond, Surrey. Back Lane, Ham, Richmond, Surrey. (Closed 1966). Dental Minor Ailments Ophthalmic Orthopaedic (physiotherapy) Speech Therapy Vaccination and Immunisation HAMPTON 24, Station Road, Hampton, Middlesex. Dental Minor Ailments Vaccination and Immunisation HAMPTON WICK 20, Seymour Road, Hampton Wick, Kingston-upon-Thames, Surrey. Dental (including X-ray) Minor Ailments Orthopaedic (Consultant) Orthopaedic (Physiotherapy) Vaccination and Immunisation MORTLAKE North Worple Way, Mortlake, S.W.14. Dental Minor Ailments Ophthalmic Orthopaedic (physiotherapy) Speech Therapy Vaccination and Immunisation RICHMOND Kings Road, Richmond, Surrey. Minor Ailments Orthopaedic (Physiotherapy) Speech Therapy Vaccination and Immunisation Windham Road, Richmond, Surrey. Child Guidance Service Dental Minor Ailments Ophthalmic Orthopaedic (physiotherapy) Speech Therapy Vaccination and Immunisation TEDDINGTON Church Road, Teddington, Middlesex. Dental (Orthodontic Only) Stanley Road, Teddington, Middlesex. Minor Ailments Ophthalmic Vaccination and Immunisation TWICKENHAM York House, Richmond Road, Twickenham, Middlesex. Dental Minor Ailments Ophthalmic Vaccination and Immunisation 58, Hampton Road, Twickenham, Middlesex. Child Guidance Service Speech Therapy WHITTON Hospital Bridge Road, Twickenham, Middlesex. Dental Minor Ailments Vaccination and Immunisation 10 OPHTHALMOLOGY. Dr. Helena Bridget Casey, M.B., B.Ch., D.O.M.S., Ophthalmologist, reports on the work of the ophthalmic clinics : — The ophthalmic clinics have been well attended. Statistics are available separately. (See Table VIII). One comes to the conclusion that an eye examination is an admirable thing in the first school year. The hereditary defects of myopia, hypermetropia and the accompanying astigmatisms are detected. Some parents are quite relieved to find eye defects, especially when there has been slowness of learning. I do think that parents are much more amenable to spectacles today. The development of axial myopia from the age of ten or eleven years onwards is a problem. I feel that it is on the increase, though doubtless, with the excellent eye screening in schools, more children were presented who might otherwise not have been detected. The amenity of the clinics is no mean factor, as well as the increasing confidence of the parents, and perhaps not least the cosmetic attraction of the new types of spectacles; all are factors which help us to see the myopes. Most of the children over the age of eleven, who attend the clinics are of the nature of myopics. Treatment of inflammatory conditions is usually limited to blepharitis or conjunctivitis with the odd foreign body presenting for removal. Injuries are rare, though a traumatic cataract in a boy of fourteen, due to a snowball injury, was presented recently at Windham Road Clinic. Table VIII. Eye Diseases, Defective Vision and Squint. Number of cases known to have been dealt with External and other, excluding errors of refraction and squint 53 Errors of refraction (including squint) 1944 1997 Number of pupils for whom spectacles prescribed 526 Defective Vision : The Keystone Telebinocular Vision Screener is replacing the card testing method. This is used to check near point and distance seeing ability and appears to be more efficient than the older methods. Children who are found to suffer from defective vision can either be referred to the Ophthalmic Clinics within the School Health Service where refraction is completed by an ophthalmic surgeon, or to the family doctor. During the year 205 sessions were held. Total number of cases dealt with was 1,997. There were 351 new cases (including squints). Glasses were prescribed for 526 patients. 11 Table IX. DISEASES AND DEFECTS OF EAR, NOSE AND THROAT. Number of cases known to have been dealt with Received operative treatment : (a) for diseases of the ear —- (b) for adenoids and chronic tonsillitis 34 (c) for other nose and throat conditions — Received other forms of treatment 262 Total 296 Total number of pupils in schools who are known to have been provided with hearing aids : (a) in 1965 12 (b) in previous years 22 12 AUDIOMETRY. At the end of 1965 two audiometer operators were on the staff of the department. Children have their hearing tested by audiometer three times in their school lives. The first routine test is done before the age of seven; the next in the third year in junior school, and finally in the second year in the senior school. Special instances, for example, children who are failing to make progress in school, are dealt with expeditiously. Audiometers are kept in condition by regular calibration by the manufacturers. Children who fail the audiometric test are referred for further investigation. Fifty five new cases were seen and 117 re-examinations were carried out in 1965, at the Heston Hearing Clinic to which the majority of referrals are made. Table X. (a) Audiometer Tests — Routine Age Group 1st Tests * Re-tests. Failures. Total % of Col. 1 (1) (2) (3) (4) Up to 7 yrs. 2252 308 248 11.0 10 to 11 yrs. 3776 333 282 7.5 12 to 13 yrs. 3165 241 213 6.7 Totals 9193 882 743 8.1 * In Schools. (b) Audiometer Tests — Specials Age. 1st Tests. Re-tests. Failures. Total. % of Col. 1 (1) (2) (3) (4) Under 5 29 8 15 51.7 5 119 32 51 42.9 6 174 59 125 71.8 7 220 96 116 52.7 8 142 54 64 45.1 9 133 40 73 54.9 10 103 30 54 52.4 11 55 10 17 30.9 12 53 12 26 49.1 13 67 35 37 55.2 14 43 19 27 62.8 Over 14 60 24 29 48.3 Totals 1198 419 634 52.9 13 Table XI. INFESTATION WITH VERMIN. (i) Total number of individual examinations of pupils in schools by school nurses or other authorised persons 12,120 (ii) Total number of individual pupils found to be infested 47 (iii) Number of individual pupils in respect of whom cleansing notices were issued (Section 54(2), Education Act, 1944) 1 (iv) Number of individual pupils in respect of whom cleansing orders were issued (Section 54(3), Education Act, 1944) – Table XII. DISEASES OF THE SKIN (excluding uncleanliness — see Table XI.). Number of cases known to have been treated. Ringworm : (a) Scalp — (b) Body — Scabies 1 Impetigo 4 Other skin diseases 381 Total 386 Table XIII. OTHER TREATMENT GIVEN. Number of cases known to have been dealt with. (a) Pupils with Minor ailments 1367 (b) Pupils who received convalescent treatment under School Health Service arrangements 5 (c) Pupils who received B.C.G. vaccination 735 (d) Other than (a), (b) and (c) above — Heart 3 Lungs 1 Developmental 15 Nervous — Epilepsy 1 Abdomen 3 Total 2130 14 Table XIV. HANDICAPPED PUPILS. Pupils ascertained during the year requiring education at a special school: (a) Blind 1 (b) Partially sighted 2 (c) Deaf — (d) Partially hearing 4* (e) Educationally sub-normal 18 (f) Epileptic — (g) Maladjusted 24 (h) Physically handicapped 7 (i) Speech — (j) Delicate 11 * Includes 2 recommended for Nursery Class for Partially Hearing Pupils. 15 Table XV. Handicapped Children maintained by the Richmond upon Thames Education Committee in Residential Special Schools as at 31st December, 1965. Blind Partially Sighted Deaf Partially Hearing Educationally Subnormal Maladjusted Delicate Physically Handicapped Speech Defects Epilepsy TOTAL Recognized Schools All Souls 1 1 Camphill, Rudolph Steiner 1 1 East Quinton 7 7 Edith Edwards House 1 1 Elmers Court 2 2 Exhall Grange 1 1 Gosden House 2 2 Ingfield Manor 1 1 Linden Lodge 1 1 Meath 1 1 Needwood 2 2 Ovingdean Hall 1 1 Park Place 3 3 Palingswick 1 1 Red Hill 1 1 Red House 1 1 Royal Cross School for Deaf 1 1 Royal School for the Deaf 1 1 St. Michael's 1 1 St. Nicholas 5 5 Starhurst 1 1 Suntrap 3 3 Swaylands 4 4 Tylney Hall 1 1 Wishmore Cross 1 1 Worcester College for the Blind 1 1 Independent Schools Arts Educational Trust 1 1 Bylands 1 1 Caterham 1 1 Crusaders 1 1 Falcon Manor 1 1 Farmhouse 2 2 Gaveston Hall 1 1 Grangewood 1 1 Kings 3 3 New 1 1 Normansal 3 3 Peredur Home 3 3 Philpotts Manor 1 1 Royal Wanstead 1 1 St. Christopher's 1 1 St. Mary's 2 2 4 St. Thomas More 1 1 Sandon House 2 2 Sheiling Curative 1 1 Sherrardswood 1 1 Spinney 1 1 Staddles 1 1 Stanbridge 1 1 2 Stinsford 1 1 Stokelake House 1 1 Walton Elm 2 2 Wells Cathedral 1 1 Wennington 2 2 2 2 2 3 15 51 11 2 88 16 DAY SPECIAL SCHOOLS. St. Hilda's Day Special School for Educationally Sub-normal Children, Barnes. Admissions during 1965 10 Discharges during 1965 6 Transferred to ordinary schools 2 Transferred to senior day E.S.N, school 2 Transferred to residential E.S.N, school 1 Left district 1 No. of children on roll as at 31st December, 1965 23 Clarendon Day Special School for Educationally Sub-normal Children, Twickenham. Admissions during 1965 26 Discharges during 1965 13 Transferred to senior day E.S.N, school 7 Transferred to ordinary schools 4 Transferred to Athelstan House Autistic Unit 1 Left district 1 No. of children on roll as at 31st December, 1965 47 Oldfield House Day Special School for Maladjusted Children, Hampton. Admissions during 1965 13 Discharges during 1965 17 Transferred to ordinary schools 8 Transferred to senior day E.S.N. school 2 Transferred to residential schools 4 Transferred to Junior Day E.S.N. school 1 Transferred to Day Special School for physically handicapped 1 Emigrated 1 No. of children on roll as at 31st December, 1965 33 Athelstan House Autistic Unit, Hampton. Admissions during 1965 3 Discharges during 1965 1 Discharged as unsuitable (referred to hospital for further investigation) 1 No. of children on roll as at 31st December, 1965 2 Handicapped Pupils. Mental disorders, including maladjusted and educationally sub-normal children, constitute the greatest proportion of handicapped children who require special educational facilities. Many of the children deemed delicate suffer from pyschosomatic disturbances which make it difficult for them to cope with the stresses of normal school life. In other words many such children suffer from more than one defect. It is not an easy task to define the category of handicap for the purposes of special educational treatment. Therefore a child on entering a special school is ono trial, and a change of school may be indicated when a secondary defect becomes dominant. All handicapped children attending special schools, either day or residential, are medically reviewed by the School Health Service at least once a year, and sometimes more frequently so that their progress and special educational treatment can be assessed. During 1965 reports were issued to the Local Health Authority under Section 57 (4) of the Education Act, 1944, regarding three children who were found unsuitable for education at school. Information was passed to the Local Health Authority about seven educationally sub-normal children who required supervision after leaving school. 17 CHILD GUIDANCE SERVICE. The Directors of the Child Guidance Clinics, Dr. Robin Higgins, M.A., M.B., B.Chir., D.P.M., and Dr. Agnes Main, M.B., B.S., report as follows: — Dr. Robin Higgins — The main brunt of the work in the Child Guidance Clinic at Richmond has followed the familiar pattern: namely the detection, assessment and where possible resolution, of the more acute and overt tensions affecting primarily school-age children. In this sense we have continued to function as a psychological first-aid post, analysing where possible personal and habitual ploys that have strained a family or individual to breaking point, and advising on more immediate moves which can sometimes be taken to forestall such breakdowns or to minimise their effects when they have occurred. In addition, we are seeking to lay increasing emphasis on ways of building up psychological resilience among a wider section of the child population. Painting and play groups made up of a mixture of children with very varying degrees of disturbance represent one mode of this preventive work. Here under supervision children are given opportunities of discovering for themselves perspectives, talents and achievements they never believed they were capable of. We are at present exploring ways of combining groups with more orthodox individual treatment and already the results are promising. When the time permits we propose to extend these opportunities suitably adjusted to the pre-school child and the adolescent. Dr. Agnes Main — From the medical point of view the work of the Twickenham Child Guidance Clinic has continued more-or-less unchanged within the new London Borough of Richmond upon Thames. However, we have noticed an increase in the number of referrals in more recent months and we have been aware for some time that the severity of disturbance in some children seems to be of a higher degree than in the past. During the year we have been trying to extend the work of the Clinic to provide a service for disturbed infants and toddlers by way of regular visits on the part of one psychiatric social worker to the Maternity and Child Welfare Clinic at Whitton with visits of the psychiatrist from time to time. We would very much like to be able to extend this work still further, believing that if we are to provide a service in preventive medicine, this is where the work of the Child Guidance Clinic should start but owing to the shortage of sessions available to the psychiatric social workers, psychotherapist, and psychiatrist, it is almost impossible at the present time to contemplate working along these lines. Oldfield House Day School for Maladjusted Children is of enormous help and benefit to those children who both require this form of special education and are lucky enough to have had it provided for them by the Borough. Co-operation between the School staff and the Clinic is high and is maintained by monthly conferences and regular visits of the psychiatrist to the school. Since April last we have been fortunate in opening a small Unit for severely disturbed children at Athelstan House, Hampton where we hope, not only to be able to help these children but to learn something from them which will contribute to the wider field of work with these so severely handicapped pupils. Weekly visits are made to the Unit by the psychiatrist and regular contact with the parents of these children is maintained. We have had visits from paediatricians undertaking the D.C.H. Course and from overseas psychiatrists: Dr. Issroff from the Psychiatric Department of West Middlesex Hospital has also frequently attended our weekly Case Conference. 18 During the year, numerous mature students, seconded to Courses at the Institute of Education, the Maria Grey Training College and St. Mary's College have attended here weekly. We hope that they benefited from their work here. In addition, we would mention that it has been of some help to us to know that the children concerned were provided with remedial help in the Clinic setting when they would otherwise have remained as a name on the Clinic waiting lists. Table XVI. Child Guidance Treatment. Number of cases known to have been treated. Pupils treated at Child Guidance Clinks 343 ORTHOPAEDIC CLINIC. Mr. R. H. Maudsley, F.R.C.S., Consultant Orthopaedic Surgeon reports: — Mr. Michael Colwill, F.R.C.S., Senior Orthopaedic Registrar, has been visiting at Hampton Wick regularly during 1965, where 382 children were seen at the Orthopaedic Clinic, many of them on more than one occasion. Of these, 90 were new cases and the remainder follow-ups. The majority of these children had minor conditions, such as mild flat feet, knock knees and intoeing gaits. There were a few more serious problems which might have been better referred directly to a hospital with X-ray facilities, etc. Table XVII. Orthopaedic and Postural Defects. Number of cases known to have been treated. (a) Pupils treated at clinics or out-patient departments 538 (b) Pupils treated at school for postural defects — 538 19 SPEECH THERAPY. The year was divided into two, the first part being a transitional period before the establishment of the new London Borough of Richmond upon Thames. During the first three months of the year 39 children were having treatment in Twickenham, and in the same period 103 were attending clinics in Richmond, Mortlake, Barnes and Ham. During the year ended 31st December, altogether 199 children attended speech clinics, and the year ended with 170 on the registers, with 14 awaiting admission. Miss Buckman, formerly senior speech therapist of Middlesex Area 10, was appointed to be in charge of Richmond upon Thames, and Miss Millhouse, who previously had worked in Barnes, Mortlake and Ham, continued as part-time therapist in those areas. During the year two additional therapists were appointed. Mrs. Thrift joined the staff at the end of June, and Miss Knight at the beginning of September. The following shows the work and districts of each therapist: Miss Buckman (Senior Therapist). Headquarters: The Child Guidance Clinic, Twickenham. Visits other clinics in her charge. Attends Oldfield House School for Maladjusted Children three times weekly. Miss Knight (Full-time Therapist). Work is divided between Twickenham and Windham Road Clinic. She visits also Darrell Road Infants School and St. Elizabeth's School, Richmond. Miss Millhouse (Part-time Therapist) working three days only. Has clinics at Mortlake, Barnes, Ham, and visits St. Hilda's School (E.S.N.) once weekly. Mrs. Thrift (Part-time Therapist). Visits Clarendon School (E.S.N.) three times weekly, and has one session at King's Road, Richmond. Most referrals came from school medical officers and child welfare clinics. Others were from head teachers and a few were transfers from hospital clinics. Types of cases were: dyslalia, delayed speech development, stammering, sigmatism, cleft palate, dyslexia and cerebral palsy. It seems that children are tending to be referred to speech clinics at a younger age than in the past. This is a step forward, for although formal therapy cannot be used, the contact of parents with a speech therapist does much to allay anxiety, which in time is passed on to the child, and often it is possible to discover causes for retarded development of speech. When a child approaches school age and cannot be understood parents feel he will be at a disadvantage. Many preschool children referred to the speech therapist have been quite incomprehensible. 20 Table XVIII. Number of pupils treated by Speech Therapist under arrangements made by the Authority. Number of Children treated 199 Number of New Patients 77 Total Number of Attendances 3,385 Number on Waiting List, 31.12.65 14 Number of Children Discharged 29 Normal Speech 18 Improved 6 Own Discharge (non-attendance) 1 Left District or Left School 4 Table XIX. Types of cases treated during the year. Dyslalia 129 Delayed Speech and Language Development 24 Stammering 15 Dysarthria 6 Lisp 6 High Frequency Deafness 5 Sigmatism 5 Cleft Palate 3 Dysphasia 3 Cluttering 2 Cerebral Palsy 1 21 REPORT OF PRINCIPAL SCHOOL DENTAL OFFICER. During the year 91 sessions were devoted to dental inspection and the mouths of approximately half the school children in the Borough were examined. Of these children again approximately half needed treatment. The number of sessions devoted to treatment numbered 2,045. Some measure of the extent of dental treatment required in the Borough may be gained if these figures are related to the fact that there are also in the Borough over 50 dental practitioners providing general dental services. All children found to require treatment at periodic school inspections whose parents wished them to be seen at a school clinic were able to be treated. No. of pupils inspected at school 7738 No. of pupils inspected at clinic 3349 No. of pupils offered treatment 4324 No. of pupils requiring treatment 5769 The discouraging condition of the teeth of the young school child is reflected in the number of fillings and extractions performed on children in the 5—9 year old group. Age 5—9. Age 10—14. Age 15 + First Visits 1612 1538 443 Subsequent visits 2433 3659 1026 Total visits 4045 5197 1469 Additional courses commenced 269 213 84 Fillings in permanent teeth 880 3036 1355 Fillings in deciduous teeth 2793 298 Permanent teeth filled 738 2352 1024 Deciduous teeth filled 2332 312 Permanent teeth extracted 29† 378* 80$ Deciduous teeth extracted 759 263 General anaesthetics 345 208 20 Emergencies 194 132 33 No. of pupils X-Rayed 317 Prophylaxis 552 Teeth otherwise conserved 562 No. of teeth root filled 10 Inlays or crowns 13 Courses of treatment completed 2586 † this figure includes 6 teeth extracted for orthodontic reasons. * this figure includes 252 teeth extracted for orthodontic reasons. ‡ this figure includes 21 teeth extracted for orthodontic reasons. 22 A measure of the success of the combined attack on dental disease by dental health education and conservative treatment is shown by the ratio of fillings (5271) to extractions (254) due to decay of the permanent dentition of more than 30: 1, whilst the national figure is 5:1. Four clinics in convenient parts of the borough have a session devoted to the extraction of teeth under a general anaesthetic once a fortnight. For three of these sessions a consultant anaethetist is employed on a sessional basis and for the other a medical officer who is an experienced anaesthetist. The orthodontic surgeon treated 498 cases with 237 appliances and completed treatment for 71 children. Twelve courses of treatment were discontinued and 15 patients were referred to a hospital consultant. Ten school children were supplied with 11 dentures. The dental laboratory which has a staff of 1 chief technician, 7 senior technicians and 2 apprentices, supplies the needs of not only this borough but also of the London Boroughs of Brent, Ealing, Harrow, Hillingdon and Hounslow. The output from the dental laboratory is as follows — Dentures Ortho. appliances Inlays and Crowns Misc. 355 1983 167 469 A visit by Messrs. A. G. Smith and J. Rodgers of the Department of Education and Science to the clinics in the borough was made in the early summer and Mr. K. C. B. Webster, a dental adviser to the Greater London Council, paid several visits with special reference to the dental laboratory service. Two full'time students at the Chiswick Polytechnic course for dental surgeryassistants attended clinics at Hampton and York House on Wednesdays during the Spring and Summer terms to gain the practical training necessary for their examination. Mrs. Briggs, a dental surgery assistant, gained the Diploma of the British Dental Nurses Association as a result of evening study at Chiswick Polytechnic. 23 NUTRITION. I am indebted to Mr. W. R. Wainwright, B.A., D.P.A., for the following: — Meals and Milk. The number of children receiving midday dinners and milk at maintained schools on a selected date in 1965 was as under: — Date Number of dinners 1/3 pints milk Number of children at school % of children having dinners 21st September, 1965 *14,393 15,151 17,841 81 * In addition approximately 1000 meals per day to Kitchen and Cooking Staff. The number of children receiving milk at non-maintained schools on 21st September, 1965 was 2,493 (3,157 children in school). In December, 1965, meals were being cooked at 36 schools and at three central kitchens. ROAD ACCIDENTS TO SCHOOLCHILDREN, 1965. Killed Seriously Injured Slightly Injured Total January – – 9 9 February – 3 6 9 March – 3 9 12 April – 3 27 30 May – 3 25 28 June – 5 16 21 July – 3 10 13 August – 1 21 22 September – 2 9 11 October 1* 5 9 15 November – 4 4 8 December – 3 8 11 1 35 153 189 * Under escort by parent. DEATHS OF SCHOOLCHILDREN. It is with regret that I include the following details of local schoolchildren who died in 1965. Sex. Age. Cause of death. M 8 Acute Leukaemia. M 9 Haemolytic Anaemia. Uraemia. M 5 Drowning (Accidental). F 8 Contusions of brain due to fracture of skull (road accident). 24 J. H. Broad & Co. Ltd. ( Printers). 8. King Street, Richmond. Surrey.