TW1046 Twickenham Urban District Council. ANNUAL REPORT OF THE School Medical Officer, ON THE MEDICAL INSPECTION AND TREATMENT OF CHILDREN IN THE PUBLIC ELEMENTARY SCHOOLS, TOGETHER WITH THE ANNUAL REPORT OF THE Medical Officer of Health, FOR THE YEAR 1914, BY GEORGE H. DUPONT, M.D., D.P.H., Medical Officer of Health and School Medical Officer. Twickenham : Printed by H. & C. Franklin, King Street, 1915. Twickenham Local Education Authority. Annual Report of the SCHOOL MEDICAL OFFICER, on the Medical Inspection and Treatment of Children in the Public Elementary Schools, for the year ended December 31st, 1914. School Attendance and School Management Sub-Committee : Mr. Councillor W. Poupart (Chairman). „ J. H. Broad. „ G. A. Farrer. „ F. H. Nash. ,, W. A. Slade. „ G. Townsend. ,, T. Wheelhouee. ,, H. W. Wreford-Glanvill. Mrs. E. Palmer. Mrs. C. Leeson. Rev. E. English. Mr. J. A. Anderson. Mr. S. Poole. Public Health Department, Radnor House, Twickenham, February 28th, 1915. To the Chairman and Members of the Education Committee. Sir, Ladies and Gentlemen, I have the honour to submit my report upon the work of Medical Inspection and treatment of children in the elementary schools during the year 1914. The most notable features of the year's work appear to be:— (7) The increasing number of children in attendance at the schools. (2) The large and still increasing numbers attending the inspection clinic and for treatment of minor ailments at Radnor House. (3) The commencement of the work of dental inspection and treatment. (4) The commencement of systematic home visitation of the children stated to be absent on account of non-notifiable infectious disease. I am Sir, Ladies, and Gentlemen, Your obedient Servant, George .H. Duponk. 4 GENERAL. There are eight schools in Twickenham, comprising eighteen departments after the separation of the boys' and girls' departments at Orleans School at the end of the year. Taking the average for the year there were 4183 scholars on the registers, the number for December being 4252, an increase of 430 compared with the number on the registers at the beginning of 1911. The average daily attendance was 3770, being 90.08 per cent. TABLE I. Numbers on registers and in daily attendance. Month. Number on Register. Daily attendance. Attendance. January 4134 3683 89.11 February 4124 3719 90.18 March 4111 3720 90.49 April 4172 3870 92.76 May 4216 3907 92.67 June 4255 3917 92.07 July 4173 3811 91.33 September 4096 3800 93.83 October 4231 3745 88.52 November 4250 3682 86.62 December 4252 3628 85.32 Average 4183 3770 90.08 At the end of the year the new Orleans School accommodating the boys' and girls' departments was used for the first time. The following description of this very fine building has been kindly supplied by Mr. Pearce, the Surveyor to the Education Committee, who was the architect of the building. 5 ORLEANS SCHOOL. Accommodation. The new building has been designed to accommodate 420 boys on the first floor and 420 girls on the ground floor, and together with the building for the infants' department, which was erected in 1911 on the same site, will provide accommodation for a total number of 1,230 children. The accommodation consists of separate assembly hall for boys and girls (each 50 feet by 28 feet 6 inches), sixteen class rooms, teachers' rooms, cloak rooms, and lavatories, stock and store rooms, and basement for heating apparatus with coal and coke stores. Lighting and Ventilation. The class rooms are placed so as to obtain direct and ample light by means of windows carried to the full height of the rooms, and are so planned that in every case the desks are lighted from the left hand side of the scholars. All class room windows are fitted with centre hung fanlights at the top and glazed removable hoppers at the bottom as well as the ordinary double hung sashes. In addition to the window ventilation, special inlet and outlet ventilators are provided in each class room, arranged so as to secure adequate ventilation at different levels above and below the breathing line, and ventilating radiators, fitted with regulating valves are also provided next to the external walls for the supply of warm fresh air during the winter months. The assembly halls, corridors and cloak rooms are also provided with special extract flues connected with ventilating turrets in the roof, and the cloak rooms are fitted with wrought iron lattice folding gates which serve as a protection against theft and at the same time materially assist the ventilation. Heating. The school is heated throughout by an accelerated low pressure hot water system, with two radiators placed at opposite sides of each class room, under separate control, in order that the heat may be regulated as required. Provision has also been made for the heating of the cloak rooms by pipe coils placed at the floor level. 6 Artificial Lighting. The school is lighted throughout with electric light, and each class room is lighted by means of six single points. Walls and Floors. Internally the walls are finished with plastolith dados up to a height of three feet six inches and sirapite plaster for the remainder of the height. The floors in the hall on the ground floor and in the corridors throughout are of pitch pine blocks, and in the class rooms batten flooring nailed to the joists on the first floor, and on the ground floor to dovetailed fillets bedded in the concrete. The floors of the cloak rooms, basement and latrines, are finished in granolithic paving, and the entrance halls are paved with terrazzo. All external angles in the brickwork, woodwork, and plaster are rounded in order to prevent unnecessary damage to the fabric, and to avoid risk of accident to the children. Internally hollow rounded mouldings are used as far as possible, and the internal angles at the junction of the walls and ceilings are also rounded to a radius of inches in order to prevent unnecessary accumulation of dust. Playgrounds. Two playgrounds are provided, one for the joint use of the girls' and infants' departments, with a total area of 1,680 square yards, and one for the boys' department, with a total area of 2,150 square yards, and a separate range of latrines is provided for each department. The sanitary arrangements and hygienic conditions of the schools were practically the same as in the previous year, but it is a matter for congratulation that the ample increase in accommodation provided by the new Orleans departments will diminish the overcrowding in some of the schools which has recently been inevitable. CO-RELATION OF SCHOOL MEDICAL AND OTHER DEPARTMENTS. It has again been possible for the Medical Officer of Health to undertake the duties of medical inspection in the schools, and consequently co-relation between the Public Health and School Medical services was complete. 7 Arrangements for Medical Inspection. These have been on the same lines as in previous years. The lists of children for inspection being compiled with the assistance of the head teachers. Inspection Hards of children admitted from other schools have been written for, and sent when requested. The Inspection Cards, after the examination, have been returned to the Office and the details entered into registers which are then returned to the schools, where they are kept for reference after the necessary particulars have been extracted, the Cards being retained at the Office. Assistance given by School Nurse and Teachers. As in previous years the School Nurse has been present at the inspections and undertaken the preliminary dressing and undressing of the children., the taking of heights and weights and the preliminary testing of vision. With two exceptions it has been necessary to use class rooms for medical inspection and to displace the class or classes usually in that room. The School Medical Officer desires to express his appreciation of the assistance given by the head teachers in every case and their endeavours to diminish the difficulties incidental to medical inspection, especially in the older schools. Medical aspects of School Attendance. As it has been realised that school attendance is in a large number of cases a question of ill-health, every endeavour has been made to inform the head teachers and attendance officers of the reasons for, and likely duration of, absence from school of any children coming under our notice. In this connection it may be noted that about 1186 of the 2686 attendances at Radnor House were made by children who were absent on account of ill-health. The desirability of visiting the homes of the children reported to be absent on account of infectious disease, was referred to at some length in last year's annual report. 8 The Council decided in July to appoint a second nurse whose work would principally be in connection with school medical work Since she commenced her duties in September it has been possible to visit the homes of a very considerable number of children reported by the teachers to be absent on account of measles, whooping cough, mumps or tonsilitis. From September to December 31st, 177 homes were thus visited. It has not been possible altogether to exclude infectious cases from attendance at the Inspection Clinic at Radnor House, as the nature of these cases is frequently not recognisable by the teachers. Especially does this apply to whooping cough, but the number of infectious cases sent to the Clinic has much diminished of late, and arrangements have been made for suspected cases to be separated while waiting, from the children attending for other reasons. In many instances the diagnosis of infectious disease sent by parents to the head teachers was not confirmed on visitation by the nurse, and the children were in consequence able to return to school at a much earlier date than would otherwise have been the case. In every case visited by the nurse or seen by the School Medical Officer at Radnor House in which children were absent from school, certificates were sent to the head teachers as to their fitness or otherwise to attend school. Eight hundred and ninety-six certificates were thus issued and in each case a copy was sent to the School Attendance Officer. Eight hundred and forty-seven of the new cases attending the clinic were sent by the head teachers to ascertain whether the children were lit to attend school, and 76 by the attendance officer, the head teachers, as a rule, preferring to submit the cases to the School Medical Officer for opinion before placing the matter in the hands of the attendance officers. These facts indicate that Medical Inspection bears a very important and close relationship to the question of school attendance, and it should considerably assist the work of the Committee in this respect. 9 EXTENT AND SCOPE OF THE INSPECTION. Following the methods adopted in the latter part of 1913, the children were examined (1) on entrance as infants, (2) at 8 years, and (3) after reaching the age of 12. The schedule of medical inspection has been closely followed in every case. The number examined at routine inspections in the schools during the year was 1,527, as shown in Table II. :— TABLE II. Name of School. Entrants. Intermediates. Leavers. Total. Trafalgar boys 1 68 91 160 „ girls 2 79 80 161 ,, infants, B. 68 14 — — „ „ G. 59 35 — 176 Orleans boys 3 44 32 79 „ girls — 32 30 62 „ infants, B. 40 3 — — „ „ G. 20 3 - 66 Nelson infants, B. 19 2 - - „ „ G. 27 2 - 50 St. Mary's boys 1 32 37 70 „ girls — 30 30 60 ,, infants, B. 35 — — — „ „ G. 27 — — 62 Arch. Cam. boys 3 43 35 81 „ girls 4 44 61 109 ,, infants B. 25 2 - — „ „ G. 30 4 - 61 St. Stephen's boys — 15 38 53 ,, girls — 12 23 35 ,, infants B. 26 14 - - „ „ G. 31 20 - 91 Whitton mixed, B. - 14 23 - „ „ G. 2 17 27 83 St. James' mixed, B. 10 16 15 - „ „ G. 10 12 5 68 Total 423 577 527 1527 In addition, 93 children were specially examined at the schools, but the great majority of special examinations were carried out at the clinic at Radnor House. 10 TABLE III. Age and sex distribution of Children inspected. Entrants. Intermediates Leavers. Tot. G.T. 5 6 Oth. Tot. 8 Oth. Tot. 12 13 14 — — Boys 147 50 34 231 170 97 267 205 64 2 271 769 Girls 123 50 39 212 155 135 290 168 84 4 256 758 Total 270 100 73 443 325 232 557 373 148 6 527 1527 CONDITIONS FOUND ON INSPECTION. Weights and Heights. In every case the heights and weights have been carefully taken and entered on the record card. In past years these have been averaged and recorded according to the ages. Much useful information has thus been obtained, and it may be considered sufficient for local use. For comparative purposes with other districts such measurements are of but little value unless all are taken on the same basis as regards clothing, and consequently the tables previously published in the Annual Report are discontinued. TABLE IV. Numerical Statement of Conditions found on Inspection. Condition. Entrants. Leavers. Intermediate Group. Total. Boys. Girls. Total. Per cent. Boys. Girls. Total. Per cent. Boys. Girls. Total. Per cent. Boys. Girls. Total. Per cent. Total inspected. 231 212 443 29.01 271 256 527 34.51 267 290 557 36.48 769 758 1527 100.0 Clothing Satisfactory 225 210 435 28.49 255 253 508 33.27 250 281 531 34.77 730 744 1474 96.53 Unsatisfactory 6 2 8 0.52 16 3 19 1.24 17 9 26 1.70 39 14 53 3.47 Footgear Satisfactory 223 210 433 28.36 245 245 490 32.19 248 273 521 34.12 716 728 1444 94.56 Unsatisfactory 8 2 10 0.65 26 11 37 2.42 19 17 36 2.36 53 30 83 5.43 Cleanliness of Head Clean 229 192 421 27.57 262 198 460 30.12 254 243 497 32.55 745 633 1378 90.24 Nits 2 20 22 1.44 9 58 67 4.39 12 45 57 3.73 23 123 146 9.56 Pediculi - - - - - - - - - 2 2 0.13 - 2 2 0.13 Dirty — - - - - - - - 1 — 1 0.07 1 - 1 0.07 Cleanliness of Body Clean 229 211 440 28.81 270 254 524 34.32 263 288 551 36.08 762 753 1515 99.21 Dirty 1 1 2 0.13 1 1 2 0.13 3 2 5 0.33 5 4 9 .59 Pediculi 1 — 1 0.07 — 1 1 0.07 1 — 1 0.07 2 1 3 0.19 Nutrition Excellent 92 99 191 12.51 143 156 299 19.58 94 117 211 13.82 329 372 701 45.91 Normal 130 102 232 15.19 126 93 219 14.28 157 164 321 21.02 413 359 772 50.56 Below normal 9 11 20 0.65 1 7 8 0.52 16 9 25 1.63 26 27 53 3.47 Bad — — — — 1 — 1 0.07 — — — - 1 - 1 0.07 Nose and Throat No defect 178 172 350 22.92 232 216 448 29.34 225 235 460 30.12 635 623 1258 82.38 Mouth breathers 2 3 5 0.33 5 2 7 0.45 4 1 5 0.33 11 6 17 1.11 Tonsils (slight) 33 28 61 3.99 30 22 52 3.41 24 40 64 4.19 87 90 177 11.59 ,, (marked) 12 6 18 1.18 5 14 19 1.24 10 8 18 1.18 27 28 55 3.60 Adenoids (slight) 3 8 11 0.72 2 3 5 0.33 6 9 15 0.98 11 20 31 2.03 „ (marked) 7 1 8 0.52 2 — 2 0.13 — 2 2 0.13 9 3 12 0.78 External Eye Disease No disease 224 203 427 27.96 270 256 526 34.44 260 282 542 35. 49 754 741 1495 97.90 Blepharitis 2 7 9 0.59 1 — 1 0.07 2 5 7 0.46 5 12 17 1.12 Conjunctivitis - - - - - — — - 1 - 1 0.07 1 - 1 0.07 Corneal opacity 1 2 3 0.20 - - - - - 2 2 0.13 1 4 5 0.33 Other disease 4 — 4 0.26 — — — — 4 1 5 0.33 8 1 9 0.59 Ear Disease No disease 229 206 435 28.49 270 255 525 34.38 263 288 551 36.08 762 749 1511 98.95 Otorrhœa R. 2 5 7 0.46 1 - 1 0.07 4 2 6 0.39 7 7 14 0.92 ,, L. 1 1 2 0.13 - 1 1 0.07 2 1 3 0.19 3 3 6 0.39 Other disease - 1 1 0.07 — — - - — - - — - 1 1 0.07 Teeth Sound 71 65 136 8.91 118 97 215 14.08 85 91 176 11.53 274 253 527 34.51 Less than 4 59 57 116 7.59 119 138 257 16.83 106 130 236 15.46 284 325 609 39.88 4 or more 100 90 190 12.44 34 20 54 3.54 76 67 143 9.36 210 177 387 25.34 Other conditions 1 — 1 0.07 — 1 1 0.07 — 2 2 0.13 1 3 4 0.26 Heart and Circulation No disease 216 197 413 27.05 259 238 497 32.55 251 277 528 34.57 726 712 1438 94.17 Organic 9 5 14 0.92 4 8 12 0.79 5 5 10 0.65 18 18 36 2.36 Functional 1 4 5 0.33 4 4 0.26 2 3 5 0.33 3 11 14 0.92 Anæmic 8 8 16 1.05 8 6 14 0.92 10 5 15 0.98 26 19 45 2.95 Other defects — - — — 2 1 3 0.19 — — - - 2 1 3 0.19 Lungs No disease 221 207 428 28.03 268 254 522 34.18 259 285 544 35.63 748 746 1494 97.84 Bronchitis - — - - — — - - — — — — — — — — Bron, Catarrah 8 4 12 0.79 1 — 1 0.07 6 4 10 0.65 15 8 23 1.50 Tuberculosis — — - - - - - - - - — — — — — — „ (suspected) — — — — 2 — 2 0.13 1 1 2 0.13 3 1 4 0.26 Other disease 2 1 3 0.19 1 2 3 0.19 1 1 0.07 4 3 7 0.45 Nervous System No disease 227 211 438 28. 68 266 252 518 33.92 263 284 547 35.82 756 747 1503 98.42 Epilepsy — 1 1 0.07 2 — 2 0.13 1 — 1 0.07 3 1 4 0.26 Chorea - — - — — 1 1 0.07 — - - — — 1 1 0.07 Other disease 4 — 4 0 .26 3 3 6 0.39 3 6 9 0.58 10 9 19 1.24 Skin No disease 225 210 435 28.49 269 255 524 34.32 263 286 549 35.95 757 751 1508 98.76 Ringworm, body — — — — — — - - - — — - — — — — „ head 1 — 1 0.07 — — - - — — — — 1 — 1 0.07 Impetigo 4 2 6 0 .39 — 1 1 0.07 3 3 6 0.39 7 6 13 0.85 Scabies - - - - - - - - - - - - - - - - Other diseases 1 — 1 0.07 2 — 2 0.13 1 1 2 0.13 4 1 5 0.33 Rickets No disease 224 212 436 28.55 270 256 526 34.45 267 287 554 36.28 761 755 1516 99.28 Slight 4 — 4 0.26 - - - - - 1 1 0.07 4 1 5 0.33 Marked 3 — 3 0.19 1 — 1 0.07 — 2 2 0.13 4 2 6 0.39 Deformities No deformity 230 212 442 28.94 270 256 526 34.44 267 288 555 36.35 767 756 1523 99.74 Deformities 1 - 1 0.07 1 — 1 0.07 — 2 2 0.13 2 2 4 0.26 Tuberculosis Non.Pulmonary Glandular 1 1 0.07 - - - - - - - - 1 - 1 0.07 Bones and Joints - - - - - - - - - - - - - - - - Other forms - - - - - - - - - - - - - - - - No disease 230 212 442 28.94 271 256 527 34.51 267 290 557 36.48 768 758 1526 99.93 Speech Not defective 228 211 439 28.75 268 256 524 34.32 261 289 550 36.02 757 756 1513 99.08 Def. articulation 1 — 1 0.07 1 1 0.07 1 1 2 0.13 3 1 4 0.26 Stammering 2 1 3 0.19 2 — 2 0.13 5 — 5 0.33 9 1 10 0.65 Mental condition Normal 230 212 442 28.94 263 254 517 33.86 258 281 539 35.39 751 747 1498 98.10 Dull or backward 1 1 0.07 7 1 8 0.52 8 9 17 1.11 16 10 26 1.70 Mentally defective — — — — 1 1 2 0.13 1 — 1 0.07 2 1 3 0.19 Vision No defect 224 207 431 28.22 239 215 454 29.73 212 231 443 29.01 675 653 1328 86.96 Wearing glasses 2 4 6 0.39 11 18 29 1.90 6 8 14 0.92 19 30 49 3.21 6/9 R. 6 4 10 0.65 12 23 35 2.29 23 25 48 3.14 41 52 93 6.09 L. 4 4 8 0.52 11 18 29 1.90 26 30 56 3.67 41 52 93 6.09 6/12 R. - - - - 3 - 3 0.19 6 5 11 0.72 9 5 14 0.92 L. - - - - 3 3 6 0.39 4 5 9 0.59 7 8 15 0.98 6/18 R. 1 - 1 0.07 3 7 10 0.65 7 8 15 0.98 11 15 26 1.70 L. 1 1 2 0.13 2 10 12 0.79 5 11 16 1.05 8 22 30 1.97 6/24 R. - 1 1 0.07 2 4 6 0.39 8 9 17 1.12 10 14 24 1.57 L. - - - - 3 3 6 0.39 8 6 14 0.92 11 9 20 0.65 6/36 R. - — - - 2 - 2 0.13 1 - 1 0.07 3 - 3 0.19 L. - - - - 1 - 1 6.07 2 2 4 0.26 3 2 5 0.33 6/60 R. - - - - - - - - - - - - - - - - L. — — — — 1 — 1 0.07 — 1 1 0.07 1 1 2 0.13 Total children with defective vision 7 5 12 0.79 32 41 73 4.78 55 59 114 7.47 94 105 199 13.03 Squint, „ R. 2 9 11 0.79 1 - 1 0.07 5 - 5 0.33 8 9 17 1.12 L. 3 6 9 0.59 1 — 1 0.07 3 — 3 0.19 7 6 13 0.85 Hearing (whisper) No defect 231 211 442 28.94 269 243 522 34.18 266 284 550 36.02 766 748 1514 99.15 20ft. R. - - - - - 2 2 0.13 - 5 5 0.33 - 7 7 0.46 L — — — — 1 — 1 0.07 - - - - 1 - 1 0.07 10ft. R. — — — — 1 - 1 0.07 - — — - 1 - 1 0.07 L. — — — — — - - - - - - - - - - - 5ft. R. - 1 1 0.07 - 1 1 0.07 1 1 2 0.13 1 3 4 0.26 L. — — — — — — — - - — — - - - - - Total children with defective hearing — 1 1 0.07 2 3 5 0.33 1 6 7 0.46 3 10 13 0.85 Note. References to the methods adopted to follow up and obtain treatment will be given under the respective headings. 11 Clothing and Footgear. The percentage of those noted as imperfectly clothed was 3'4 and very defective boots 5'4. However, it must be remembered that the boots are not infrequently borrowed from another member of the family for the occasion of the inspection and the figure stated is rather more favourable than that normally existing, but Twickenham children, are on the whole well clad. It is much to be regretted, that the Trustees of the charitable fund which has in the past supplied many slippers for the use of children arriving at school with wet feet, have not felt that they were able to continue to supply these during the year under review. They were a gift of great value and one which added not only to the comfort but also helped to safeguard the health of many children. The same fund has, however, lent several pairs of boots to necessitous children. Verminous Children. The subject of verminous conditions of either the head or body has attracted some attention locally during the past year. It cannot be too clearly stated that the number of children found verminous at routine inspection bears no relationship to that normally existing. Children attending the elementary schools in Twickenham are relatively free from this trouble in comparison with many districts, and it is because there are so many children from clean homes in the schools that considerable attention has been paid to this matter. The school nurse has made frequent "visits to the schools and given notices to parents of children found to be affected. When attention is thus drawn to what is only a comparatively slight case, an opportunity is given to the parents to deal with it at once, and such advice is usually acted upon promptly although perhaps in some cases it may not have been appreciated. If parents could see some of the cases which eventually come to the clinic as a consequence of neglected verminous conditions, there would, it may be safely asserted, be none to resent advice which, at any rate, is meant in the kindest way. 12 Thirty children were formally excluded during the year on account of their verminous condition and their parents were prosecuted in three cases, under the attendance bye-laws, and convictions obtained. Defective Nutrition. On the whole the children were well fed and few showed signs of persistent under-feeding, although in many cases the nutrition was below average, mostly on account of some recent illness or other morbid condition. The Provision of Meals Act has not been adopted, but through voluntary agencies free meals were provided in several schools. Carious Teeth. Of the 1527 children inspected in the schools 996 had carious teeth either temporary or permanent or both, being 70 per cent, of the children examined. This number is probably less than the real figure as it includes only decay visible to the eye without the assistance of the probe and dental mirror. At the end of 1913, the scheme for providing dental treatment (which was contained in the special report, printed as an appendix to last year's report), had been adopted by the Council and awaited the sanction of the Board of Education. This sanction was received in due course, and the Medical Officer again reported in May as to the necessary arrangements, accommodation and staff. The suggestions contained in that report were acted upon and Mr. Edward Thorne, L.D.S. (R.C.S. Eng.), was appointed School Dentist. With alterations of a comparatively slight character the rooms at Radnor House used for the inspection clinic have been most excellently adapted for the purpose by the Surveyor. The children enter at a side entrance in Cross Deep into a lobby (where perambulators can be left), and then pass into the 13 waiting room. This communicates direct with the Consulting Room where treatment is carried out. On the days selected for extractions, the process is reversed. The children to be treated enter by the main door, wait in the main hall at a considerable distance from the consulting room, and after treatment pass into the rinsing room and out by the side entrance. In this way children waiting for treatment do not come into contact with those who have been operated upon. The arrangements made have worked excellently. As this is the first year in which dental inspection and treatment has been undertaken by the Committee, the work being commenced after the summer holidays, special reference may not be out of place. In the first place the Committee will be interested to know that out of 150 authorities in England and Wales which have instituted a dental clinic, there are only 20 districts having a school population of the same size or less which have undertaken this work, and it may also be noted that with one exception Twickenham is the smallest place in England and Wales where treatment for adenoids and enlarged tonsils, defects of vision, dental disease and X-ray treatment for ringworm are carried out at the expense of the Local Education Authority. It is intended that the Dental Surgeon shall visit the schools in rotation, and a commencement was made at the Trafalgar Schools Infants' Department, the procedure being as follows:— Every child between the ages of six and eight years was examined, and a record taken of each mouth and a note of any treatment required. On each occasion the school nurse accompanied the dentist and by marking the cards at his dictation a considerable saving of time was effected. These record cards were then returned to the Health Department from whence a letter was sent to the parent or guardian drawing attention to the conditions found and offering, if necessary, assisted treatment. 14 Parents who applied for such treatment filled up a consent and guarantee form, and arrangements were then made for the child's attendance at the Clinic for treatment. Pursuing this course, 250 children were inspected by the Dental Surgeon in the schools, and in addition 61 specially recommended by the School Medical Officer, were inspected at the Dental Clinic, making in all 311 inspections. The dental clinic was held on 11 occasions at weekly intervals, one half day being occupied on each occasion, and 129 children received treatment. Three days were set aside for extraction cases under a general anæsthetic, and gas was administered to 57 children by the School Medical Officer. The following table shows the ages of the children who were examined by the School Dentist at the ordinary routine inspections, and also the number of children with defective teeth. TABLE V. Ages at Inspection. Total children inspected. Total children with defective teeth. Total recommended for treatment. 5 6 7 8 9 Boys — 57 56 3 — 116 102 83 Girls 1 56 69 7 1 134 115 89 Totals 1 113 125 10 1 250 217 172 One hundred and forty-five children made 187 attendances at the Dental Clinic. The following table is a summary of the treatment carried out at each attendance of the School Dentist. 15 TABLE VI. Total No. of attendances. No. of new cases. Special examinations. No. receiving treatment. Fillings. Extractions. Other treatment. Temp. Perm. Temp. Perm. 7 7 - 7 2 9 - - - 12 12 — 12 5 8 1 - 2 Dressings, 5 5 1 4 2 1 2 — - 25 13 1 24 - - 92 13 - 11 10 5 7 1 8 - - 3 Dressings. 12 11 4 8 4 5 1 - 1 Dressing. 18 17 9 10 3 0 - - 3 Dressings. 20 9 1 19 - - 68 9 - 23 22 13 11 9 7 2 Dressings. 23 21 10 13 10 11 - - 18 Dressings. 31 18 17 14 — - 58 4 — 187 145 61 129 36 55 222 26 29 Dressings. Of the 61 children specially examined, 3 received treatment at the same time. In seven cases the parents have obtained private treatment for their children, and in four instances the parents refused to obtain any treatment. Diseases of Nose and Throat. Two hundred and thirty-two children had some enlargement of the tonsils, but in only 55 was the enlargement marked. Adenoids only were noted in 43 children or (2.8 per cent, of the children examined), the condition being marked in 12 cases. In the Report from the principal medical officer to the Board of Education for the year 1913, (issued at the end of 1914) it is suggested that the subject of the incidence, causes, previous history, associated conditions and treatment of adenoids, should specially be reported upon. 16 It is important, however, first to define precisely what is meant by adenoids. They may be generally described as hypertrophy of the lymphoid tissue in the naso-pharynx. This condition may exist in any degree, from some slight thickening producing perhaps a tendency to catarrh, to a mass of vegetations causing marked obstruction to respiration, mental dulness, or discharging ears. Adenoids are not invariably to be recognised with accuracy in the somewhat hurried and imperfect examination which is possible under the conditions under which medical inspection is usually carried out. If symptons alone are relied upon, the diagnosis must frequently be fallacious. If further measures such as posterior rhinoscopy or digital examination are to be employed, special light and other conditions are necessary. With but few exceptions, every case of suspected adenoids seen in school during the year has been referred for subsequent examination at the inspection clinic, where the nose can also be carefully examined, and several other cases have been sent by the teachers for special examination at the Inspection Clinic. Under the arrangement with the St. John's Hospital, sanctioned by the Board of Education, 51 cases of enlarged tonsils or adenoids or both, were operated upon, and in addition 54 cases were operated on at Hospitals elsewhere or privately, making a total of 105 cases operated on during the year. All cases operated on at the expense of the Committee, and the majority of cases operated on by private arrangement were seen afterwards by the School Medical Officer before their return to school and instructions given as to breathing exercises. Eye Diseases and Defective Vision. Nearly all the cases of conjunctivitis or blepharitis were sent by the teachers to the inspection clinic and dealt with there ; the number seen at routine examination was in consequence comparatively small and these only slight in degree. 17 One hundred and ninety-nine children were found to have defective vision being 12.3 per cent, of the total examined during routine. Forty-nine children were already wearing glasses. Several cases of suspected defective vision were also examined specially at the inspection clinic and treatment recommended. Seventy-five cases were examined by the Committee's Opthalmic Surgeon, Mr. Blair, while in addition 40 received treatment at Hospitals or privately. In all, therefore, 115 children received treatment, for defective vision, fifteen of this total being re-examinations of children for whom glasses had been previously prescribed. Considerable effort has been made to follow up those children who are supposed to be wearing glasses. Spectacles are unfortunately very fragile and the excuse that glasses do not fit or are broken, is too tempting to be neglected as a reason for not wearing glasses which have been prescribed after considerable trouble, and the value of which is not apprciated. Deafness and Otorrhcea. The best test for defective hearing which can be satisfactorily carried out in a elementary school has yet to be determined. That suggested by the Chief Medical Officer for the Board of Education is the whisper at varying distances up to 20 feet, but with the noises that usually surround the Medical Inspector at work in the schools, the results of this test are very very liable to be erroneous. This appears to be the common experience among those engaged in the work, and our practice has been to accept the normal conversational voice at ordinary distances as evidence of satisfactory hearing, reserving those cases which are unable to hear the ordinary voice and all cases of otorrhaea for subsequent exainition at the Clinic. 18 Diseases of the Heart. In 50 cases murmurs were recognised and in 36 cases the condition appeared to he organic in character and such were referred for subsequent examination and seen at intervals. Slight functional conditions were not specially noted. Diseases of the Lungs. Bronchial catarrh noted in 1.5 per cent of the children examined. Many cases were referred for subsequent examination at the Clinic and in a considerable number of instances the County Tuberculosis Officer kindly examined doubtful cases and, besides giving his opinion, kept the cases under observation. The assistance of the Tuberculosis Officer proved of much value and has to a considerable extent solved the question of the treatment of the tuberculous school child as far as this district is concerned, but it has not unfortunately remedied the domestic and economic conditions which contribute so markedly to the production of the disease. Three children were found to be affected with tuberculosis, two being pulmonary and one extra pulmonary. The former being found as a result of re-examination of suspected cases. In all, including those not fit to attend school, seven children are definitely known to be affected with pulmonary tuberculosis, being 0.16 per cent, of the total school population. Infectious Diseases in Schools. The system of notification by the head teachers of children believed to be suffering from infectious disease has been continued and the exclusion of contacts has been regularly carried out in accordance with the memorandum of 1909. Since September 1st, when the second nurse was appointed the returns have been more complete, and it has been possible to visit the homes of a considerable number of these absentees. 19 Several of these were found to be suffering from diseases of a non-infectious character and were thus enabled to return to school at once, while some were apparently quite well. Ringworm of the Scalp. From the year 1913 five cases, all under treatment, were carried over as uncured, and 36 new cases were discovered during the year. All the new cases found were treated during the year. Thirty were cured and six remained under observation on December 31st. Thirty-two cases were treated by X-rays by the Committee's Radiologist, Mr. Blake, under the superintendence of the School Medical Officer. In only two of these X-ray cases was a second application necessary; in all the other cases one application sufficed and the results have again been extremely satisfactory, and the cures rapid. Exceptional Children. Blind.—Two boys are attending schools for the blind. Deaf Mutes.—There is one deaf and dumb child attending one of the infants' departments. Epileptics.—Five cases of major epilepsy and four of epilepsy in the minor form are under observation by the School Medical Officer. Mentally Deficient. Excluding some of the epileptic cases above mentioned, there are six feeble minded children attending the elementary schools, and who are not incapable of receiving some benefit there. Seven children in the area are believed to be imbeciles or idiots and two of these have been reported during the year to the Middlesex County Council, which is the local control authority under the Mental Deficiency Act, 1913. 20 TABLE VII. Numerical Return of all exceptional children in the area, on Dec. 31st:— Defect. Remarks. Boys. Girls. Total. Blind Attending certified Schools for the blind 2 - 2 Deaf and Dumb Attending Public Elementary Schools - 1 1 Mentally Feeble Attending Public Elementary Schools 2 4 6 Minded Notified to Local Control Authority 1 1 2 Deficient Imbeciles Not at School 1 1 2 Idiots — 3 2 5 Epileptics: (including Minor Epilepsy). Attending Public Elementary Schools 4 3 7 Not at School 2 — 2 Pulmonary Tuberculosis Attending Public Elementary Schools 3 3 6 Not at School — 1 1 Other forms of Tuberculosis Not at School — 4 4 Cripples Attending Public Elementary Schools 1 3 4 ,, Non-Tuberculous Not at School 1 1 2 Parents Present at Inspection. It is gratifying to record that 87 5 per cent, of the children were accompanied by parents or guardians at the inspections. This not only indicates the considerable interest displayed by the parents but the care shewn by the head teachers in arranging the inspection, as far as possible, on days suitable to the parents. Vaccination. Of the 1527 children examined at routine inspection, 216 bore no evidence of having been vaccinated, being 141 per cent. This is an interesting and important condition in view of the fact that small-pox will probably be more prevalent as a result of the war. 21 FOLLOWING UP AND TREATMENT. It has been possible to follow up cases recommended for treatment during the past year even more closely than in the preceding years, and the proportion of cases receiving adequate and completed treatment is again gratifying, being 8T5 per cent, of those recommended. Four hundred and forty-two visits were paid by the school nurse to the homes of children recommended for treatment in addition to the many visits paid to the schools for the same purpose, not including visits in connection with inspected infectious disease. Some of the parents still, however, seem to think that necessity for obtaining treatment for their children is rather a mild form of delusion on the part of the School Medical Officer, than a matter of importance to the child. Thirty-seven boys and twenty-five which on being seen at the routine inspection were considered to require subsequent examination, were referred to the inspection clinic and dealt with there. These are therefore included in the total number of cases seen at Radnor House. 22 TABLE VIII. Treatment of defects of children during 1914. Conditions. Defects requiring treatment. Defects treated. Defects untreated. Per centage treated. From 1913. New cases. Total. Left district, refused or improved. Carr. for. to 1915. Total. Cleanliness of head and body - 30 30 28 - 2 2 93.3 Nose and throat 36 110 146 122 11 13 24 83.5 Ear diseases 1 5 6 6 - - - 100.0 Hearing - 4 4 3 - 1 1 75.0 Exteral eye disease - 5 5 5 - - - 100.0 Vision and squint 27 129 115 115 20 20 40 73.7 Lungs - 5 5 5 - - - 100.0 losis pul. - 2 2 2 - - - 100.0 Non-pul. - 5 5 4 1 - 1 80.0 Heart - 1 1 - 1 - 1 0.0 Nervous system 2 12 14 11 3 - 3 78.5 Skin 3 37 40 40 - - - 100.0 Deformities 2 1 3 2 1 - 1 60.6 Other 4 50 54 41 7 7 14 75.9 Total 75 396 471 384 44 43 87 81.5 Recommendations in reference to carious teeth are not included in the above table of cases recommended for treatment, being dealt with separately in the table of work carried out by the school dental surgeon, nor does it include the cases of minor ailment treated by the school nurse at Radnor House in which efficient treatment was carried out in every case. 23 INSPECTION CLINIC AND TREATMENT BY SCHOOL NURSE. In last year's report, reference was made to the increasing number of children attending the inspection clinic at Radnor House which hitherto had been held on two mornings each week. By the end of 1913 the numbers attending had already exceeded the limit of those that could be dealt with in this way and the past year has seen a further marked increase, the attendances numbering 2686, as compared with 1618 in 1912, and 2385 in 1913. The Inspection Clinic is probably the most important branch of school medical work and is carried out in Twickenham on a more complete scale than in most places. Very soon after the commencement of statutory medical inspection in the elementary schools, in the year 1908 it was realized that without some additional arrangements for re-examination, inspection on entrance and on leaving the schools was almost useless. At the inspections in school, certain morbid conditions could be recognised and treatment recommended, but in many cases satisfactory diagnosis was impossible. The surroundings under which the examinations on school premises took place, the necessarily somewhat rapid examination, the absence of proper light and special instruments, especially for ear and throat cases, and the obscure nature of some cases rendering the diagnosis often faulty. When again the question of following-up arose, it was necessary to call repeatedly at the schools or for the school nurse to call at the homes, and as children were frequently absent from school on the day on which the call was made or not at home when the nurse visited, much time was thereby wasted. The Inspection Clinic was therefore commenced at the beginning of 1910, and its progress may be judged from the figures given above. The sources from which the cases attending the inspection clinic are derived are :— 24 (1) Cases referred by the Medical Inspector from routine inspection for special examination or re-examination. These include heart murmurs. To attempt to decide definitely in school, the organic or functional nature of many of these is usually to court disaster. Again, taking adenoids, one refers nearly all cases where this condition is supected to the Inspection Clinic where only complete examination can be thoroughly carried out. Lung cases, perhaps more than any, require quiet surroundings for their accurate recognition, and it is invariably our practice to refer these cases to the clinic for periodic observation, while it is practically imposible to recognise the cause of deafness and the conditions causing otorrhœa (discharging ears) without special apparatus, such as could not be used in a school room. (2) Cases recommended for treatment. The value of a few minutes' quiet persuasion in the case of many parents cannot be overestimated when the stage of recommending treatment has been reached, and the Clinic is of great value in watching the progress of cases after treatment has been received. The preceding classes of cases are those therefore which attend on the instructions of the School Medical Officer himself, but the largest number of new cases are— (3) Those which are sent for opinion by the head teachers when they are in doubt as to a child's fitness to be in class. Until it was possible to visit such cases at home, many cases of suspected infectious disease were sent to the Clinic, but during the last quarter there was a marked diminution in the number of these cases sent for opinion. (4) The next class of cases are those sent by the School Attendance Officers or by the Education Committee, the usual question being the fitness to attend school, and the children excluded on account of their verminous state may be included in this class. 26 (5) It is not possible or desirable to exclude treatment of minor ailments from the Inspection Clinic and it has been found necessary for the school nurse to be in attendance not only to assist with the preparation of the children but to treat such conditions as septic sores, discharging ears and the cases of ringworm after the application of X-rays. The best indication of the value of School Inspection Clinics is the fact that they are being established generally throughout the country, although the difficulties in scattered areas are considerable. The premises at Radnor House, especially since the alterations necessitated by the establishment of the dental clinic, are excellently adapted for the purpose and leave but little to be desired. In the earlier days of the work a considerable number of the cases were brought by the parents without reference to the head teachers, but for the past two years only those children have been seen who attended with a ticket signed by a head teacher or attendance officer. On account of the increased attendances, it has been necessary to see children on each morning of the week, two mornings however, still being entirely set aside for this work. It will probably be necessary in the future to institute a waiting list and only send for a given number on each day. This however curtails the advantage, by excluding many acute conditions or affections in their early stage and will not be adopted if it can be avoided. Reference to the number of certificates issued as to fitness to attend school has already been made. The children sent to the seaside under the King Edward Middlesex Memorial Fund were duly examined and a considerable number for convalescent homes. The children continue to be much indebted to the Ministering League, through which agency no less than 35 delicate children were sent to Brighton for periods of three weeks and upwards, free of expense. 26 The staffs of not only the local hospitals but many of the London hospitals have received many requests from the Medical Officer for assistance during the year and he desires to tender his thanks to them for services without which the year's work would have been greatly diminished in value. At the same time however, it must be pointed out that by far the greater and more important portion of the treatment has been that carried out under the arrangements made by the Education Committee, and that without this merely a fringe of the cases requiring attention would have received the treatment which was needed. 27 Twickenham Urban District Council. Annual Report of the MEDICAL OFFICER OF HEALTH For the Year ending 31st December, 1914. Health Committee: Mr. Councillor G. A. Farrer (Chairman). „ E. C. Dyer. „ S. S. Earle. „ H. C. Eldred. „ W. H. Kempson. „ F. H. Nash. „ W. J. Palmer. „ W. Poupart (ex-officio). „ W. A. Slade, J.P. (ex-officio) „ G. A. Wade, B.A. „ A. Watkins. 28 Public Health Department, Radnor House, Twickenham, March 23rd, 1915. Mr. Chairman and Gentlemen, I have the honour to submit to you my Fifth Annual Report on the health and sanitary condition of the district. The following points appear to call for special mention:— Population, Census 1911, 29,376. Estimated population, June 1914, 32,000. Birth rate, per 1,000 living, 24.4. Death rate, per 1,000 living, 12.7. Infantile Mortality, per 1,000 births, 80.5. Total Rainfall, 26.47 inches. NATURAL AND SOCIAL CONDITIONS. Physical Features.—The district is 2,477 acres in area, inclusive of that portion covered by water. It is bounded on the north by Heston and Isleworth, on the south by Teddington, on the east by the Thames, which separates it from Surrey, and on the west by Hanworth. Twickenham stands upon a porous subsoil of gravel and sand from twelve to twenty feet in depth, the gravels which lie on the London clay being efficiently drained by the rivers Thames and Crane, which run almost parallel throughout the district. The addition to the population produced by the advent of the motor 'bus has been maintained. A considerable number of adult males are absent from the district on active service, but these were 29 more than counter-balanced towards the end of the year by the influx of Belgian workmen employed at the Pelabon Works in the eastern portion of the district. The public parks and recreation grounds are not only extensive, but well distributed throughout the district, the total acreage (199 acres) being composed of the following:—Marble Hill, 66½ acres; Moor Mead, 11¾ acres; The Green, 7½ acres; Radnor House Gardens, 3¾ acres; and Murray Park, Whitton, 9 acres, which was opened during the year. The rainfall amounted to 26.47 inches as compared with 21'56 inches in 1913. VITAL STATISTICS. Population. Estimated to Midsummer, 1914 32,000 At census, 1911 29,367 „ 1901 20,991 „ 1891 16,026 Up to Midsummer, to which time the estimate of the population was made, there had not been any marked increase in the population, which has been estimated at 32,000. The estimated populations of the different wards to the middle of 1914 were :— South 6,130 East 8,203 West 8,867 Central 6,755 Whitton 2,045 Whole district 32,000 30 The average number of persons per inhabited house was 4.3 at the census of 1911. Taking into consideration the rates given below, it is possible that the estimate of the population is somewhat lower than the real figure. Births. Nett number 782 Rate per thousand 24.4 Seven hundred and seventy-two births were registered as occurring in the district and ten were transferred from outside. This is the highest number that has been registered since 1906, and, despite the increase of the population, the birth rate shows a slight tendency to recovery, being one per thousand above that of the preceding year. Of the nett births 364 were males and 418 were females. Deaths. Nett number 406 Rate per thousand 12.68 The death rate was 1.68 per thousand above the rate for 1913. The number of deaths of persons said to have their fixed or usual residence in Twickenham, but who died outside the district, was 107, and these have to be added to those registered in the district. This is an unusual number, being twenty-seven more than in the preceding year and almost double the average number for the preceding nine years. The transfer of these deaths by the Registrar General to the district to which they are supposed to belong has become keener during recent years, while the increasing number may also be accounted for by an increasing tendency on the part of the public to go to Hospitals and nursing homes for more serious illnesses, especially those of a surgical character. 31 The number of deaths from all causes at different ages were:— Under Over 1 year 1-2. 2-5. 5-15. 15-25. 25-45. 45-65. 65. 63 7 7 25 14 44 98 148 There has not been a marked increase in the deaths from any one cause, except for organic disease of the heart, but the deaths among infants, due to wasting or atrophy, were less than half those occurring in 1913. The deaths from respiratory diseases, excluding tuberculosis, were practically the same, as were those from diarrhoea and enteritis. There were, however, eight deaths from diphtheria as compared with three during the preceding year. Pneumonia in all forms accounted for 71 per cent. of the total deaths, a slightly lower percentage than that of the previous year, while the percentage of deaths from pulmonary tuberculosis was the same as the preceding year. Percentage of total deaths due to certain diseases. Year. Pneumonia (all forms). Pulmonary tuberculosis. Cancer. Rate Per 1,000 of persons living. 1909 6.9 7.4 6.9 0.9 1910 6.0 8.5 7.6 0.8 1911 6.0 9.4 10.5 1.2 1912 7.1 7.3 10.6 1.7 1913 8.5 5.9 10.8 1.1 1914 7.1 5.9 8.1 1.0 The deaths of all residents occurring in or out of the district were distributed among the wards as follows:— West. East. Central. South. Whitton. 132 112 72 60 30 32 The death rate per thousand for each ward was:— West. East. Central. South. Whitton. 13.7 13.6 10.8 9.7 14.4 Inquests.—Inquests have been held during the year on thirtyfive bodies, the causes of death being:—Suicide, four; violence, other than suicide, seventeen; natural causes, fourteen. Six of the deaths were due to drowning, one being suicidal. Deaths in Institutions.—Twenty-two deaths occurred in public institutions in the district. Of the deaths transferred to Twickenham from outside, sixty occurred in the Isleworth Infirmary; fourteen at the Royal Hospital, Richmond; five at the Middlesex County Asylum, and the rest in various institutions in London and elsewhere. Infant Mortality. Nett deaths under 1 year of age 63 Rate per thousand births 80.5 The infant mortality rate was practically the same as in the preceding year. 33 INFANT MORTALITY RATE CHART, 1897-1914. 34 The following table shows the number of the infant deaths in 3ach ward, and the rate per thousand of the estimated living population Wards. Central. South East. West. Whitton. Total. 1st quarter 3 5 8 5 1 22 2nd „ 1 1 1 3 2 8 3rd „ 1 2 7 10 - 20 4th „ 1 1 3 7 1 13 Total 6 9 19 25 4 63 Rate per 1000 of estimated population 0.8 1.4 2.1 2.8 1.9 1.9 In subsequent years, it will be possible to calculate ward rates of Infant Mortality on the registered births as the names and addresses are now received weekly from the Registrar. Of the infant deaths, the number due to diarrhoea and enteritis were practically the same as last year, there was, however, a slight increase in the deaths of premature infants and the deaths due to diphtheria were higher. The West and East Wards show the highest rates calculated on the estimated total ward population. 36 Chart showing number of deaths of children under one year of age, per 1,000 Registered Births with proportion (in black), caused by diarrhcea. 36 RAINFALL IN INCHES DURING JULY, AUGUST AND SEPTEMBER. 1910. 1911. 1912. 1913. 1914. July 2.94 0.70 1.76 1.83 1.97 August 2.83 1.50 5.24 1.44 2.53 September 0.46 1.23 1.40 1.60 0.87 Totals 6.23 3.43 8.39 4.87 5.37 SANITARY CIRCUMSTANCES OF THE DISTRICT. Water Supply. The water from wells supplying thirteen dwellings has been analysed during the year and in each case was found to be so polluted as to be unfit for use for domestic purposes. In eleven of these, the wells have been closed voluntarily by the owners, and the supply from the Metropolitan Water Board substituted. With few exceptions the rest of the dwellings in the district have the supply from the Water Board laid on. Eel Pie Island. The insanitary conditions existing at this island have been under consideration by the Committee, and the matter is to receive farther consideration. The conditions referred to in the last annual report remain much the same, but owing to the war, the island was much less frequented by the public during the summer and the nuisances were not so marked. Collection and Disposal of House Refuse. With the exception of Eel Pie Island the house refuse is collected weekly in covered carts by the Council's own employees and all is burnt in the destructor. Daily collection is however made from some of the flats where the storage for a longer period is undesirable. I am indebted to the Surveyor for the following and several other figures:— Quantity collected during the year 15,790 cubic yards. Average quantity collected per day 52½ „ 37 Schools. Of the cases of scarier fever notified during the year, sixtyeight were children attending schools in Twickenham and the cases were distributed fairly evenly throughout the district. Although a few cases occurred as the result of contact in school on more than one occasion, there was never anything approaching an epidemic affecting any particular school. Fifty-eight cases of diphtheria occurred among school children, thirty-eight of these occurring in the last two quarters of the year, and the schools in East Twickenham were specially affected. Examination of the throats of every child in the affected class, for ten days after the occurrence of a case, has been carefully and systematically carried out during the year and swabs taken where suspicion arose. In this way entire classes were examined on 154 occasions. Twenty-nine swabs were taken, and fifteen proved to be cases of diphtheria, not including positive contacts who had no symptoms. There was a considerable outbreak of measles during the second quarter chiefly affecting the infants' department of the Archdeacon Cambridge Schools. In no instance was it considered necessary to advise closure of any school during the year. Following is a table of the cases of infectious disease among school children which have come under the notice of the School Medical Officer during the four quarters, but doubtless there were other cases which were not reported. Quarter Sc. fe. Diph. Typhoid Fever. Measles. Wh. C. Chicken pox. Mumps. Rotheln. 1st 18 12 - - 39 7 10 - 2nd 10 8 - 38 10 12 15 31 3rd 19 19 2 3 24 2 42 - 4th 21 19 2 3 3 23 287 - Total 68 58 4 44 76 44 354 31 38 Drainage and Sewerage. The district is sewered on the separate system and the disposal of sewage carried out at the Mereway works. SANITARY INSPECTION OF THE DISTRICT. The figures and other details of the work of the Sanitary Inspectors have been supplied to me by the Inspector of Nuisances as required by the order of the Local Government Board. Considerable activity has been displayed and much useful work has again been accomplished. The work of inspection has perhaps been performed with more energy than method, but at the end of the year the system was organised more carefully and although the results may not be so obtrusive the work will be carried out in a more systematic manner in future. It has been the practice hitherto to carry out what may be described as general sanitary inspections of considerable numbers of dwellings. The result of this has been that, as a rule, drainage matters have received an undue proportion of attention and other defects were apt to be overlooked. It is intended in future to remedy any obvious cause of complaint where necessary, but to devote as much time as can be spared to complete systematic inspections under the Housing and Town Planning Act, and to follow up closely the intimations which are sent as the result of such inspections. Much of the work of the Sanitary Inspectors is included in the County Council Tables, pages 62 to 67. Notices.—Four hundred and • seventy-nine intimations were sent, most of these referring to several separate defects. A large number of these have been complied with, but it was considered necessary to ask for authority to serve 160 statutory notices. These were not all complied with by the end of the year, but all are being carefully kept under observation and will be reported upon in due course. Drainage.—The smoke test was applied to the drainage and plumbing work of 155 houses of which 131 were found to be defective. 39 Overcrowding. This very difficult problem has cropped up at times and intimations were served on the occupiers of several houses, to reduce the number of the inmates. In three instances statutory notices were required and were duly complied with, but it must be confessed the improvement is by no means always permanent. Dirty Tenants.—An endeavour has been made to deal, to a small extent, with the problem of the dirty tenant, both the persuasive methods on the part of the Health Nurse and Sanitary Inspectors, and also by somewhat stronger methods by the service of notices on the tenant himself. It is in these cases that the advantage of combining the School Medical and Health Departments under one head is specially felt, many very dirty homes being discovered as the result of finding persistent dirty or verminous conditions among some of the school children. Such tenants make a pig sty of any clean cottage in a few weeks and many intimations, and eleven statutory notices were served during the year. The improvement in many cases was striking, but it would be taking too optimistic a view of the cases to believe that the change for the better would be permanent. Sloth, poverty, alcohol, want of proper knowledge of how to clean up thoroughly, all contribute towards the production of the dirty tenants, but an occasional example has a wonderfully good effect in the immediate neighbourhood for a time, at any rate. Refreshment Houses.—Systematic visits have been made to restaurants and places where food is prepared. Altogether 226 visits were made. No food was seized in any of these places, but instructions as to cleanliness were given and in one case very marked defeets in the drainage of the premises were discovered and duly rectified. Premises Controlled by Bye-laws. Inspection of Slaughterhouses.—There are eight registered slaughterhouses and two are licensed annually, one of the latter 40 being newly licensed during the year. Of the slaughterhouses 3 are in use regularly, the remainder being less frequently used. Three hundred and eighty visits have been paid to slaughterhouses during the year, and 177lbs. of diseased or unsound meat have been voluntarily surrendered and sent to the destructor. Some of the butchers now readily send for advice when conditions of a doubtful character are met with. Offensive Trades.—Under the appropriate byelaws, five persons carry out the trade of fish-frying. Their premises have been frequently visited and inspected. During the year permission was granted in one case to establish the business of a fish fryer. Disposal of Manure.—Several manure pits have been constructed or re-constructed so as to bring them into compliance with the Byelaws, and five large accumulations of manure were removed. Cowsheds, Dairies and Milkshops.—The state of the register on December 31st was:— Cowkeepers, 6; purveyers of milk, 29; total persons registered, 35. Added during the year. Cowkeepers, nil; Purveyors, 11. As a result of representations made, the premises of the two largest cowkeepers in the district, keeping altogether 85 cows, have been brought into a condition more in accordance with modern requirements. The drainage was completely reconstructed, the floors of the sheds relaid, ventilation of the sheds improved, the yards paved, and a new cooling shed built. The disposal of manure in the neighbourhood of cowsheds in such a way as to discourage the breeding of flies, and the prevention of the contamination of the milk by, at any rate, some cleansing of the udders of the cows and the hands of the milker are all points of which the value is not yet appreciated by the majority of cowkeepers, although some progress may be reported in this direction. 41 Inspection of Meat and other Foods.—In addition to the inspection of slaughterhouses, the following are reported to have received systematic visits:— Description. No. of visits. Butchers' shops 833 Fish shops (including fried fish shops) 746 Restaurants 226 The shops were principally visited on Saturday evenings. The restaurants were on the whole well kept and clean; the meat in the butchers' shops was generally of very fair quality. All the unsound food disposed of was surrendered voluntarily ; the total weight surrendered amounting to about 227 pounds. Bakehouses.—These have been visited throughout the year. The statutory whitewashing has been carried out in each, but in some cases it was necessary to draw the attention of the occupier to the neglect of this duty before the works were undertaken. Sale of Food and Drugs Acts. The duties in connection with these Acts in this district are carried out by the officers of the County Council of Middlesex. The following particulars of samples taken in Twickenham have been received from the Chief of the Weights and Measures Staff. Article. Taken. Adulterated. Butter 71 4 Milk 227 18 Cream 14 3 312 25 Prosecutions, 3 42 Workshops and Workplaces, etc.—The record of the work done in this connection is set out in the special tables of the Home Office which follow. 1.—INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Premises. Number of Inspections. Written Notices. Prosecutions Factories (Including Factory Laundries) 58 - Nil. Workshops (Including Workshop Laundries) 199 15 Nil. Workplaces (Other than Outworkers' premises included in Part 3 of this Report) - - Nil. Total 257 15 Nil. 2.—DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts:— Nil. Nil. Want of cleanliness 5 5 Want of ventilation - - Overcrowding 1 1 Want of drainage to floors 1 1 Other nuisances 1 1 Sanitary accommodation- Insufficient - - Unsuitable or defective 6 6 Not separate for sexes - - Total 14 14 - - 3.—HOME WORK. Nature of Work. Outworkers' Lists, Section 107. Lists received from Employers. Sending twice in the year. Sending once in the year. Lists. Outworkers. Lists. Outworkers. Contractors. Workmen. Contractors. Workmen. Wearing apparel— Making, &c. 3 ... 3 8 ... 8 Cleaning and washing ... ... ... ... ... ... Household linen ... ... ... ... ... ... Lace, lace curtains, and nets ... ... ... ... ... ... Curtains and furniture hangings ... ... ... ... . . Furniture and upholstery ... ... ... ... ... ... Electro-plate ... ... ... ... ... ... File making ... ... .. ... ... ... Brass and brass articles ... ... ... ... ... ... Fur pulling ... ... ... ... ... ... Cables and chains ... ... ... ... ... .. Anchors and grapnels ... ... ... ... ... ... Cart gear ... ... ... ... ... ... Locks, latches and keys ... ... ... ... ... ... Umbrellas, &c. ... ... ... ... ... ... Artificial flowers ... ... ... ... ... ... Nets, other than wire nets .. ... ... ... ... . Tents .. ... ... ... ... ... Sacks .. .. ... ... ... ... Racquet and tennis balls ... ... ... ... .. ... Paper, &c., boxes, paper bags .. ... ... ... ... . Brush making ... ... ... ... ... ... Pea picking ... ... ... ... ... ... Feather sorting .. ... ... ... ... ... Carding, &c., of buttons, &c. ... ... ... ... ... ... Stuffed toys ... ... ... ... ... ... Basket making .. ... ... ... ... ... Chocolates and sweetmeats ... ... ... ... ... ... Cosaques,Christmas crackers, Christmas stockings, &c. ... ... ... ... ... ... Textile weaving ... ... .. ... .. ... Total 3 ... 3 8 ... 8 44 4.—REGISTERED SHOPS. Workshops on the Register (s. 131) at the end of the year. Number. Bakehouses 18 Dressmakers 15 Laundries 8 Milliners 5 Motor and Cycle Works 10 Tailors 4 Other 22 Total number of Workshops on Register 82 5.—OTHER MATTERS. Class. Number. Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Acts (s. 133, 1901) 3 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshps Acts (s. 5, 1901) Notified by H.M. Inspector 3 Reports (of action taken) sent to H.M. Inspector 3 Other .. — Underground Bakehouses (s. 101) :— Certificates granted during the year — In use at the end of the year 3 Housing. Considerable progress has been made with the systematic housing inspection of the district, under the Housing (Inspection of the district), Regulations. Two hundred and five dwellings have been inspected in this way and proper records made, during the year. As will be readily understood it is an easier matter to make inspections than to see that all the defects to which attention is drawn, are remedied by the owner, and inspection is apt to get too far ahead of following up. Still, much useful work has been done. The details of the housing work accomplished are shown in the following table:— HOUSE-TO-HOUSE INSPECTIONS. Premises. No. of houses inspected. General character of Defects. Water Supply. Closet accommodation. Sink and Drainage. Dampness. Roof. Light and Ventilation. Yard Paving. Ashes accommodation. Other. Chapel Road, 1, 1a, 2, 2a, 3, and 3a 6 - - 2 1 - 3 3 - 1 Cole's Buildings, 2, 4, 5, 9, and 10 5 5 5 5 5 - - 5 4 - Colne Road, 46, 54 to 70 (even nos.) 73, 82, to 100 (even nos.) 21 1 7 16 21 15 20 19 10 21 Douglas Road, 1 to 32, 34, 35, 36, 38, 40, 41, 42, 43, 44, 46, 47, 48, 50, 52 to 61, 63, 65, 67, 73, 75, 77, 79, 81, 83, 89, 91, 93, 97 , 99, 101, 103, 105, 107, 109, 113, 115, 119, 123, 125, 129, 131, 133, 135, 137, 139, 141, 145, 147, 149, 151, 153, 159, 161, 163, 165, 167, 169, 173, 175, 177, 179, 181, 185, 187, 189, and 191 103 66 36 29 44 34 11 71 63 76 Lion Road, 11 to 49 (odd nos.) 20 15 16 18 20 14 19 17 8 20 Orleans Road, Ivy Cottage, 2, 3, 4, 5, 6, 8, 12, 14, 16, 18, 20, 22, 23, 24, 25, 26, 28, 29, 32, 33, and 35 22 10 6 16 17 4 17 9 2 19 Richmond Road, 89 1 - 1 1 1 1 1 1 1 1 South Western Road, 2 to 28 (even nos.) 14 - - 8 14 1 - 14 12 12 Staines Road, 16 1 1 1 1 1 1 - - 1 - Tower Road, Tower Cottage 1 1 1 1 1 1 - 1 1 - Warwick Road, 3, 4, 5, 49 to 56 11 3 7 5 - 1 1 9 4 1 Totals 205 102 80 102 125 72 72 149 106 151 46 TABLE OF HOUSES IN REFERENCE TO WHICH CLOSING ORDERS WERE MADE. Premises. Date when represented by M.O.H. Date of Closing Order. Date of determination of Closing Order. Date of demolition order. Remarks. 5, Sion Row July 15th, 1912 July 25th, 1912 March 21st, 1914 .. Rendered habitable. Mann's Cottages A (8 cottages) July 14th, 1913 Sept. 25th, 1913 ... Sept. 10th, 1914 Voluntarily demolished. B „ „ ... „ „ C „ „ ... „ „ D „ „ ... „ „ E „ „ ... „ „ F „ „ ... „ „ G „ „ Dec. 31st, 1914 ... Rendered habitable. H „ „ ... Sept. 10th, 1914 Voluntarily demolished. Colne Road 24—34 (Even numbers) Oct. 12th, 1913 Jan. 8th, 1914 June 25th, 1914 ... Rendered habitable. Bell Lane No. 2 Nov. 17th, 1913 „ .. ... Work in hand. „ 4 „ „ ... ... Work in hand. „ 8 „ „ ... Sept. 10th, 1914 .. „ 12 „ „ ... ... Voluntarily demolished. Colne Road „ 166 „ „ ... ... Demolished by Council for street improvement purpose. „ 168 „ „ .. ... „ 170 „ „ ... ... Lion Road „ 15 Sept. 28th, 1914 Nov. 26th, 1914 ... ... Work in hand. „ 17 „ „ ... ... „ „ 19 „ „ ... ... „ „ 27 „ „ .. ... „ „ 37 „ „ ... ... „ 47 The building of house3 for the working classes has been almost at a standstill and only four houses completed during the year would be included under the term "houses for the working classes." Several of the local house agents have been good enough to furnish information as to the demand for and supply of houses for the working classes. From these it appears, as would be supposed, that the demand varies somewhat in different parts of the district. Cottages from 7s. to 10s. per week have been in considerable demand especially towards the end of the year, and in the eastern portion of the district, as also were small villas under £32 per annum. There is also some demand for dwellings of the cheapest character, and sub-letting of portions of a cottage is somewhat frequently met with. Separate dwellings at a rent of 6/- per week or less are becoming less numerous. They hitherto consisted chiefly of old cottages, many in a condition of dilapidation, and as such are those which are dealt with by closing orders under the Housing and Town Planning Act. In many cases such extensive works are necessary to render them habitable that demolition is usually preferred. As a matter of fact, forty-six such dwellings have been demolished, voluntary or otherwise, during the last three years, and dwellings at a similar rent have not been built to replace them. The displaced tenants unable to find separate cottages at the same rent as they formerly paid are compelled, as a rule, to share a more modern cottage with another family, and although the drainage and construction are more modern, overcrowding not infrequently results and is an extremely difficult problem to deal with. There has again been a decided tendency to divide up larger houses, especially basement houses, into dwellings for two or more families. In some cases proper provision is made for the separation of the families, but in a large number of cases the houses are merely 48 occupied by two families without special separation or without any separate or adequate sanitary convenience. Where application was made for exemption under the Customs and Inland Revenue Acta, 1890 and 1903, it is possible to draw attention to such shortcomings, but the majority of cases have not been brought to the knowledge of the Health Department. SANITARY ADMINISTRATION OF THE DISTRICT. Staff.—The sanitary staff has remained the same as at the end of the preceding year, but as the result of illness the department was deprived of the services of Mr. Knight for several months. On account of the great increase in the clerical work of the department, especially that involved by the work of medical inspection and treatment of the children in the elementary schools, a junior clerk was appointed to the department. Hospital Accommodation and Administration.—The Isolation Hospital has again been used for the reception of scarlet fever and diphtheria and has been well occupied throughout the year. In last year's report reference was made to the fact that the building was only intended for the treatment of scarlet fever and that the attempt to treat diphtheria also was surrounded with many difficulties and some dangers. A report on the subject of accommodation at the Isolation Hospital was presented in March, 1914, and considered by the Committee, and this was still under consideration at the end of the year. The total admissions to the Hospital during 1914 was 167. This is the largest number of cases treated since the hospital was opened, and is an increase of eighteen on the previous year, which in its turn was a record year for admissions. There is practically no opposition to removal either on the part of the relations or the medical practitioners, in fact the difficulty frequently has been to decline cases when the hospital has been more than sufficiently filled. 49 The small block in the grounds has again been used as a discharge block for scarlet fever. To this convalescent cases have been sent during the last fortnight of their stay, where they have been in charge of an attendant, who does not come into contact with the acute cases. Four return cases of scarlet fever occurred during the year, and these were during the early part of the year when there was much pressure on the accommodation. Four cases of diphtheria developed scarlet fever during their stay in the hospital. There were five cases of double infection, three of the scarlet fever cases developing whooping cough and two chickenpox. In seven cases operations were required, tracheotomy being performed on four occasions, one case of diphtheria developed acute appendicitis necessitating operation, and two were operated on for glandular suppuration. Many of the cases admitted were of an extremely serious character and required much attention. The nursing staff have carried out their duties in an entirely satisfactory manner. The more serious cases, especially the more septic cases of scarlet fever, were treated as far as possible in the open air. There is unfortunately, no verandah on which beds can be placed, and in consequence such treatment was only possible on fine days, and beds had frequently to be hurriedly dragged under cover in the event of rain. The results, as in the past two or three years, have been so encouraging that the nurses have cheerfully faced the difficulties which were inevitable. It would, however, be advisable, either in connection with a new block or separately, to provide a verandah to the scarlet fever wards where cases can be more efficiently treated in this manner. Seven deaths occurred in the hospital during the year, six being cases of diphtheria and one of scarlet fever. Following is a table of the notifications of scarlet fever and diphtheria, and the percentages of cases removed during the past six years. 50 Year. Scarlet Fever. Diphtheria. Total admissions to Hospital. Cases notified. Number removed. Percent. removed. Cases notified. Number removed Per cent. removed. 1909 102 81 79 30 - - 81 1910 65 59 82 31 — - 59 1911 41 34 82 97 52 63 86 Mar-Dec 1912 28 16 57 89 61 68 105 1913 119 107 90 52 40 78 159 1914 98 90 91 92 77 83 167 Bacteriological Work.—During the year 246 swabs were taken for examination, seventy being taken by medical practitioners, twenty-nine by the School Medical Officer or the School Nurse, the remainder being taken at the Isolation Hospital to ascertain the fitness of patients for discharge. Three specimens of sputum were examined for tubercule bacilli and six specimens of blood for the widal reaction for typhoid fever. In twenty-four cases of suspected ringworm, the hairs were examined microscopically by the Medical Officer. Adoptive Acts in force in the district. The Infectious Diseases (Prevention) Act, 1890, excepting section 5. The Public Health Acts (Amendment) Act, 1890, excepting parts 5 and 6. *The Private Street Works Act, 1892. The Baths and Wash-houses Acts, 1846—1899. The Public Health Acts (Amendment) Act, 1907, sections 15—31, both inclusive, and section 33 in part 2. The whole of the parts, 3, 4, 5 and 6, together with sections 81 down to the word "offensive," 83, 86, 87 and 88 of part 7; the whole of parts 8 and 9, and sections 92, 93 and 95 of part 10. 55 Byelaws in force in the district. *New Streets and Buildings. Dairies, Cowsheds and Milkshops. Nuisances. Sanitary Conveniences. Removal of Noxious and Offensive Matters. Offensive Trade (Fish Fryer). Slaughter Houses. *Pleasure Grounds and Parks. Allotments. Common Lodging Houses. *Libraries. Those marked * are not administered by the Health Committee. PREVALENCE AND CONTROL OVER INFECTIOUS DISEASE. Two hundred and thirty notifications were received relating to cases of acute infectious disease, the figures for each disease being as follows:— Scarlet Fever 98 Puerperal Fever 6 Diphtheria 92 Enteric Fever 9 Erysipelas 22 Ophthalmia Neonatorum 3 The attack rates per 1,000 of the population compared with those of the whole of England (excluding London) are indicated in the following table :— Scarlet Fever. Diphtheria. Year. Twickenham. England. Twickenham. England. 1911 1.39 2.84 3.30 1.33 1912 0.91 2.95 2.90 1.24 1913 3.75 3.51 1.64 1.39 1914 3.06 4.38 2.87 1.60 The number of notifications of acute infectious diseases was higher than in the previous year. Scarlet fever was somewhat less 52 prevalent, but the cases of diphtheria were considerably more numerous, while in addition nine cases of typhoid fever were notified. Scarlet Fever. - Of the ninety-eight cases of scarlet fever, thirty-nine occurred during the first half and fifty-nine during the second half of the year ; the notifications for each month being :— January 9 July 6 February 7 August 8 March 4 September 14 April 6 October 12 May 10 November 13 June 3 December 6 39 59 98 The cases of this disease, which was prevalent towards the end of 1913, continued to be somewhat numerous, but the notifications received during 1914 were twenty-one less than those of the preceding year. No extensive or localized outbreak occurred, but the majority of the cases were in the Central and East Wards. Although successive cases arose among children attending some of the public schools, no particular school was specially involved. Slight cases of the disease, which had not been recognised by the friends, were discovered on more than one occasion and were doubtless the cause of many cases the origin of which was otherwise inexplicable. The type of disease was not, on the whole, of so mild a character as in recent years, and several very septic cases were admitted to the hospital, the one fatal case being of a particularly virulent and hæmorrhagic character. Diphtheria.—The number of cases notified has been forty more than during the preceding year, cases occurring in each month as will be seen by the following list: — Diphtheria.—The number of cases notified has been forty more than during the preceding year, cases occurring in each month as will be seen by the following list: — 53 January 11 July 10 February 6 August 7 March 5 September 11 April 5 October 11 May 4 November 10 June 2 December 10 33 59 92 On the whole, the disease was of a somewhat more severe type, eight deaths being registered as due to diphtheria. Of these six occurred in the Hospital, the case mortality rate being 7'7 per cent. of cases admitted to the hospital, while the mortality rale among eases nursed at home was 13.3 per cent. These figures are interesting, because as a rule the hospital mortality rate is higher than that among home cases, as the more severe cases are usually removed to hospital for treatment. The total case mortality was 8'6 per cent. Practically half the cases occurred in the East Ward. A limited outbreak occurred among the boys of the Fortescue House School, in November and December, six cases being notified and removed to Hospital. Typhoid Fever.—Nine cases of typhoid fever were notified during the year. As this was a somewhat unusual number for this district, as a rule only one case being reported during each year, a somewhat detailed report of the cases is necessary. An isolated case (1) occurred in April and the patient being in comfortable circumstances was nursed at home. No preceding or subsequent case could be traced in connection with this and there was no local cause in the house to arouse suspicion. The patient had frequently to go away on business, and it is possible the disease was contracted elsewhere. 54 The next case (2) was notified on August 8th, and was in no way connected with the first. This patient was also in good circumstances, was engaged in London and enquiries did not elicit information as to an unrecognised case or to any article of diet which might have been a possible cause. The case was efficiently nursed at home and no further case arose in connection with it. On August 18th, a case (3) was notified from a cottage in the Second Cross Road. The patient was seen by the Medical Officer of Health and the diagnosis verified bacteriologically. Neither his occupation, diet nor sanitary surroundings were open to suspicion. The only feature in common between cases (2) and (3) being that both were in the habit of bathing in the river regularly, and frequently swallowed river water. As Hospital accommodation for typhoid cases has not been provided by the Council, the patient remained at home and was nursed by his mother. On September 9th a second case (4) was notified from the same house and died after a few days. On September the 24th, the mother (5) of these cases was found to be suffering from the disease and after considerable difficulty was admitted to a London hospital. Three other members of the same family (6), (7), (8), had by this time however been infected although one was a very mild case, the other two were of a very severe type and died after removal to a nursing home. A subsequent case (9) was notified from a cottage in another road and was also removed to a nursing home. She was a friend of case (6) and in all probability a contact case. After removal and isolation of these cases, no further cases arose in the district, which has since been entirely free from the disease. Altogether, therefore, there were seven cases at or in connection with the cottage in the Second Cross Road, and there is no doubt that six were due to infection from the first case (3) arising there. 55 The impossibility of getting these cases admitted into isolation hospitals belonging to other authorities emphasises the necessity for the provision by the Council of hospital beds for any case of typhoid fever that might arise. This outbreak was reported to the Council, who after consideration instructed the Medical Officer of Health to furnish the Mereway Hospital (which was vacant and had been reserved for small-pox) and to treat cases of typhoid fever there, subject to satisfactory arrangements being made with other authorities for the reception of small-pox cases should such occur. Such arrangements for the treatment of small-pox elsewhere having failed, the Mereway Hospital is still reserved for small-pox, but the provision of accommodation for typhoid fever has been included in the scheme outlined in the report presented to the Committee on additional hospital accommodation which was under consideration at the time of writing this report. On September 1st a circular letter was received from the Local Government Board on the co-operation between the civil and military services especially in view of the possibility of outbreaks of typhoid fever or small-pox. No troops were billeted in the district during the year, but on account of the presence of a considerable number of refugees and soldiers on leave, the questions were considered by the Council, but owing to the difficulty of arranging for the reception of smallpox elsewhere than at the Mereway, no hospital accommodation for typhoid fever had been arranged at the time of writing this report. Whooping Coughs, Measles and Mumps.—The prevalence of these diseases is to a certain extent indicated by the notifications which were received from the teachers in the elementary schools. Whooping Cough was somewhat prevalent in the first and third quarters of the year, and six deaths were registered as due to this disease, five of which were children under 1 year of age. Measles was not present in excess of the usual amount and was apparently of mild type, no death being recorded. 56 Mumps assumed an epidemic character in the last quarter of the year and affected practically every elementary school. Three hundred and fifty-four cases came under the notiee of the Medical Officer of Health. The control of the spread of the infection in the non-notifiable infectious diseases presents many difficulties, the chief being the fact that these cases cannot be recognised in the earlier stages. It is no uncommon experience in a school, when drawing attention of a teacher to a cough which is very suggestive of whooping cough, for one to be told that the child has had a similar cough for a week or more but that the child has never "whooped," and consequently was not sent home. Frequently one is placed in the same position of uncertainty when asked for a definite opinion as to whether a child is, or is not, suffering from whooping cough and the difficulty which the teachers experience in coming to a decision can be well understood. Again, in the case of measles, the pre-eruptive symptoms and signs being only those of a severe "cold," a definite diagnosis cannot be made before the rash appears As both diseases are, without doubt, highly infectious in the earliest stage, it follows that many other children may be infected before the first case is definitely recognised. There is a good deal of ignorance and carelessness on the part of parents as to the necessary care in dealing with these cases, but on the whole parents are willing to keep the child away from school if they are suffering from either of these diseases. Whatever arrangements may be made to secure notification of these cases, it is probable that many will still reach school, and in the event of subsequent enquiries being made, ignorance as to the nature of the disease will always be advanced as an excuse by the parents, and of course it is well-known that the majority of these cases do not come under the care of a medical practitioner. Still, even although immunity from whooping cough may not be secured by notification and subsequent exclusion from 57 school of patients and contacts, the majority of the cases will become known to the health authority and visiting by the nurses could be carried out and advice given both as to the care of the patient and the necessity for medical advice, especially in the case of children under school age. Although mumps is a definite infectious disease and is fairly easily recognisable by the more experienced, practically every child with glandular enlargements under the jaw from whatever cause is stated by the parents to be suffering from mumps. As in the past cases of diphtheria have frequently been considered by parents to be mumps until the patient was very seriously ill, serious effort was made to have the cases of mumps visited during the outbreak towards the end of the year. As a result of this some three cases of diphtheria were discovered, and several of the other cases were found not to be mumps, but some other glandular enlargement of a non-infectious character. The necessity for continuing to make the provision for visiting, and if necessary, providing treatment for cases of whooping cough will be appreciated more when it is remembered that, in Twickenham, forty-one children have died from this disease during the past seven years. Puerperal Fever.—Six cases were notified during the year. In each case where a midwife was in attendance, the Medical Officer of the County Council of Middlesex was communicated with and all necessary disinfection carried out. No case either of acute Poliomyelitis or Cerebro-spinal Meningitis was notified during the year. Ophthalmia Neonatorum.—Thisdisease became compulsorily notifiable from April 1st under regulations of the Local Government Board. Three cases were notified and visited by the Health Nurse. In each case recovery was complete. 58 Small-pox.—On September 1st a circular letter was received from the Local Government Board drawing the Council's attention to the importance of having in immediate readiness adequate arrangements for dealing with any cases of small-pox which might appear, and enclosing memorandum on the steps requisite to be taken where small-pox was prevalent. Now that the Mereway Hospital has been partially furnished it would be possible to make arrangements to deal with a case at very short notice. Prevalence of and control over Tuberculosis.—Seventytwo notifications of tuberculosis were received during the year, sixty-two referring to pulmonary and ten to non-pulmonary cases. As many of these related to patients who had moved into Twickenham after the onset of their illness, the figures afford no indication of the amount of tuberculosis originating in the district. Every new case has been visited by the Health Nurse and full particulars obtained. Advice has been given as to the necessary precautions, and regular subsequent visits have been paid at such intervals as were thought advisable. All children attending the elementary schools who were residing in any house from which a case of pulmonary tuberculosis were notified, were examined by the Medical Officer of Health in his capacity as School Medical Officer. The County of Middlesex, which is the authority with which the Middlesex Insurance Committee have made arrangements for the treatment of tuberculosis among insured persons, opened a local dispensary in July, and a very considerable number of persons, both insured and uninsured, have received advice and treatment. The Medical Officer of Health is much indebted to Dr. Norton, the County Tuberculosis Medical Officer for the area which includes Twickenham, for much assistance, especially in reference to the opinions concerning and the treatment of school children. Dr. 59 Norton has kindly supplied the following particulars of new cases dealt with during the year :— Number of persons seen who were either tuberculous or suspected of being tuberculous 61 Number of contacts, chiefly children 33 A certain amount of overlapping of visits by the Officers of the County and Local Authorities appears to be inevitable. Where two authorities are concerned, one with the prevention of the spread of infection and the other with the treatment of the patients, overlapping must occur, but every endeavour is being made to diminish this as far as possible by arrangements with the tuberculosis officer. The control of tuberculosis is beset with many difficulties, and on the whole must be considered somewhat disappointing. On account of the length of the illness and the fact that many patients are sufficiently well to be able to follow some employment, they frequently change their residence often without warning and other persons occupy the house or rooms before any disinfection can be carried out. Considerable discussion has taken place for some years past as to the ultimate value of treatment in Sanatoria. Unfortunately almost every patient treated in a Sanatorium has to return after varying periods into surroundings which are unsatisfactory both hygienically and economically. The patient, if a wage earner, is either unable to work or if able to be employed has to choose an occupation other than that previously followed. The result is that the weight gained while in the sanatorium is usually lost and the money expended on sanatorium treatment is practically thrown away. This has been our experience in numerous cases, and one cannot help thinking that, given fair surroundings, a similar sum of money expended in 60 assisting the patient to remain at home with efficient nursing and medical supervision would be more efficacious in the long run. Investigation of and disinfection after Infectious Diseases.—In all cases homes were visited and full inquiries made, these being subsequently tabulated in the register. Home cases were also systematically visited by the Inspectors. Disinfection by formaldehyde vapour, soaking bedclothes and personal clothing in disinfectant solution, and removal where necessary of bedding to the steam disinfecting apparatus were regularly carried out, both after recovery of home cases and after removal of patients to hospital or death of cases of pulmonary tuberculosis. Several disinfections after cases of cancer were also carried out at the request of occupiers of premises when such cases had died. MEANS OF PREVENTING MORTALITY IN CHILDBIRTH AND IN INFANCY. The subject of infant mortality is dealt with on page 32. The Council having applied for permission to adopt the Notification of Births Act, 1907, this was received in April. It was, however, not found to be possible to commence work under the Provisions of the Act until the school summer holidays had ended when the Health Visitor who was also School Nurse, was able to devote the necessary time to the duties. The work was then continued until the end of the year, but was considerably interfered with, first by the illness of the Health Visitor and later when she left to take up nursing duty with the French Red Cross Society, and although an excellent temporary Health Visitor was obtained she was unable to remain until the end of the year. 61 In consequence of these changes some dislocation was inevitable, but in spite of these, much useful work was carried out, three hundred and fifty-three visits being paid to births notified. Summer Diarrhœa.—The Medical Practitioners in the town again kindly sent voluntary notifications of some of the cases of Summer Diarrhœa coming under their notice during August and September, in all twenty-seven notifications being received. Nine of these were received during August and eighteen during September. It was found possible to visit thirteen of these cases and advice was given. As only eight deaths occurred as the result of this disease during August and September, including those transferred from other districts, it may be assumed that the type, was on the whole mild, and this was borne out by the observations and reports of the Health Nurse. It is intended that fuller reference to this very important portion of the work of the department will be made in the next year's report. The question of storage and disposal of manure is closely connected with this subject, as it is obviously useless to employ a Health Nurse to give advice and to visit summer diarrhoea, if old standing accumulations of manure are allowed to exist in immediate proximity to the more crowded streets. During the past two years considerable attention has been paid to this subject, which is especially important now that the possibility of flies as carriers of disease is recognised. Although the Byelaws dealing with manure receptacles have been in force since 1898, compliance has not apparently been very strictly enforced in reference to existing receptacles, and in many cases no receptacle at all has been provided. Long continued immunity in this respect has produced a feeling of security among the keepers of horses which is not justified by the condition of their manure receptacles. It is fair, 62 however, to state that when attention of occupiers of premises where horses were kept, has been drawn to the absence of suitable receptacles for manure they have, almost invariably, agreed readily to make proper provision. Following this Report will be found the statistical tables required by the Local Government Board and the Middlesex County Council. I am, Mr. Chairman and Gentlemen, Your obedient Servant, Medical Officer of Health. COUNTY COUNCIL TABLE No. 1. Inspections. Number of Premises Inspected on Complaint. (1) 106 Number of Premises Inspected in connection with Infectious Diseases (2) 211 Number of Premises under periodical Inspection. (3) 145 Houses inspected from House-toHouse (H. and T.P. Act). (4) 205 Total number of Inspections and re-inspections made. (5) 3333 COUNTY COUNCIL TABLE No. 1—continued. Action taken. (Other than under H. and T.P. Act). Cautionary or Intimation Notices given 364 Statutory Orders Issued. 124 Summonses Served. — Convictions Obtained. — Dwelling Houses and Action under H. and T.P. Act, 1909. Number of Houses dealt with under Sect. 15. — Number of Houses found to be in a state dangerous or injurious to Health (Sect. 17). 6 Number of Representations made by M.O.H. (Sect. 17), with a view to the making of Closing Orders. 6 Number of Houses made Habitable without Closing Orders. 1 Number of Closing Orders made by L.A. (Sect. 17), (including premises previously represented). 12 Number of Houses closed Voluntarily. 1 Number of Closing Orders determined after Repairs (Sect. 17). 8 Number of Houses Demolished (а) by order of L.A. (Sect. 17). (b) Voluntarily. a — b 12 Illegal Underground Rooms Vacated. — Houses let in Lodgings (Tenement Houses). Number Registered under Bye-laws. — Number of Contraventions. — Common Lodging Houses. Number Registered under Bye-laws. — Number of Inspections made. — Number of Contraventions. — COUNTY COUNCIL TABLE No. 2. Bakehouses. Number in District. 21 Contraventions of Factory Acts. — Slaughterhouses. Number on Register. 10 Number of Inspections made. 380 Frequency of inspection. weekly Contraventions of Bye-laws. — Cow-sheds. Number on Register. 7 Number of Inspections made. 83 Frequency of inspection. monthly Contraventions of Regulations. — Number of Milch Cows in District. 120 Dairies and Milkshops. Number on Register. 39 Number of Inspections made. 266 Frequency of Inspection. monthly Contraventions of Regulations. — Unsound Food. Meat (including organs) surrendered. (Approximate weight in pounds). 177 Poultry and Game surrendered. (Approximate weight in pounds). — Fish surrendered. (Approximate weight in pounds). 421bs. and 4 boxes of kippers. Fruit and Vegetables surrendered. (Approximate weight in pounds). — 65 COUNTY COUNCIL TABLE No. 2—continued. Unsound Food continued. Other Articles surrendered. (Approximate weight in pounds). Method of disposal. Refuse Destructor. Offensive Trades. Number of premises in District. 5 Nature of Trades. Fish Fryer. Number of Inspections made. 240 Contraventions of Bye-laws. — Water Supply and Water Service. Wells. New, Sunk. — Cleansed, Repaired, &o. — Closed as Polluted. 3 Percentage of Houses supplied from Public Water Service. 99.9 Cisterns. New, Provided. 79 Cleansed, Repaired, Covered,&c. — Draw-Taps placed on Mains. 20 Percentage of Houses supplied on Constant System. 99.9 Number of Samples obtained for analysis. From Local Wells. 3 From Public Supply. — COUNTY COUNCIL TABLE No. 3. Water Closets Number of Water Closets substituted for Dry Receptacles. — Repaired, Supplied with Water, or otherwise Improved. 76 Percentage of Houses provided with Water Closets. 99.9 Drainage and Sewerage of existing Buildings. Drains. Examined, Tested, Exposed, &c. 43 Unstopped, Repaired, Trapped, &c. 28 Waste Pipes, Rain Water Pipes, Disconnected, Repaired, &c. 83 New Soil Pipes or Ventilating Shafts fixed. 47 Existing Soil Pipes or Ventilating Shafts repaired. - Disconnecting Traps or Chambers inserted. 114 Reconstructed. 100 Cesspools. Rendered Impervious. Emptied, Cleansed, &c. — Abolished, and Drain connected to Sewer. — Percentage of Houses Draining into Sewers. 99.9 Disinfection. Rooms Disinfected. Ordinary infectious diseases. 193 Phthisis. 18 Rooms Stripped and Cleansed. — Articles Disinfected or Destroyed. Ordinary infectious diseases. 1085 Phthisis. COUNTY COUNCIL TABLE No. 3—continued. Dust. New bins provided. 52 How frequently is dust removed from each house. weekly. In a few cases daily. Number of complaints of nonremoval received. 10 Method of Disposal. Destructor. All. By Tipping. Sundry Nuisances Abated. Overcrowding. 7 Smoke. — Accumulations of refuse. 6 Foul ditches, ponds, &c., and stagnant water. — Foul pigs and other animals. 21 Dampness. 92 Yards repaved or repaired. 164 Other nuisances 207 Canal Boats used as Dwellings. Number Registered under the Acts. Nil Number of Contraventions of Regulations. Nil | Moveable Dwellings, Caravans, Tents, &c. Number Observed during the Year. 5 Number of Nuisances therefrom Abated. — Number Removed from District. 5 68 LOCAL GOVERNMENT BOARD TABLE 1. Vital Statistics of whole District during 1914 and previous Years. Year. Population estimated to middle of each year. Births. Total Deaths Registered in Transferable Deaths. Nett Deaths belonging to the District. Uncorrected Number. Nett. the District. of Non-residents registered in the District. of Residents not registered in the District. Under 1 Year of Age. At all Ages. Number. Rate. Number Rate. Number. Rate per 1,000 Nett Births. Number. Rate. 1909 27696 703 ... ... 311 11.2 5 56 56 79.6 362 13.2 1910 28643 696 ... ... 251 8.8 2 50 62 89.08 299 10.4 1911 29622 684 698 23.7 288 9.7 8 70 78 111.7 350 11.9 1912 30634 693 713 23.3 238 7.8 8 81 49 68.7 311 10.1 1913 31681 722 734 23.15 277 8.7 6 80 52 79.0 351 110 1914 32000 772 782 24.4 314 9.8 15 107 63 80.5 406 12.7 Area of District in acres (land and inland water), 2477. Total population at all ages, 29,367 At Census Total families or separate occupiers, 6799 1911. 69 LOCAL GOVERNMENT BOARD TABLE 2. CASES OP INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1914. Notifiable Disease Number of Cases Notified. Total Cases Notified in each Locality. Total Cases removed to Hospital. At all Ages. At Ages—Years. Central Ward. South Ward. East Ward. West Ward. Whitton Ward. Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to 65. 65 and upwards. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera Plague . ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous croup) 92 ... 15 68 6 3 ... ... 22 12 44 11 3 77 Erysipelas 22 ... ... 1 2 11 6 2 6 1 5 9 1 ... Scarlet fever 98 ... 16 69 7 6 ... ... 33 12 36 15 2 90 Typhus fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric fever 9 ... ... 4 2 2 1 ... 1 5 ... 3 ... 5 Relapsing fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... Continued fever 1 ... ... 1 ... ... ... ... ... ... 1 ... ... ... Puerperal fever 6 ... ... ... 1 5 ... ... 1 1 2 ... 2 ... Cerebrospinal Meningitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... Poliomyelitis Ophthalmia ... ... ... ... ... ... ... ... ... ... ... ... ... ... Neonatorum ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pulmonary Tuberculosis 62 ... 1 9 8 32 12 ... 11 11 18 19 3 ... Other forms of Tuberculosis 10 ... 1 3 1 3 1 1 1 1 1 7 ... ... Totals 300 ... 33 155 27 62 20 3 75 43 107 64 11 172 Isolation Hospitals:-Twickenham Urban District Council's Isolation Hospital, Nelson Road, Whitton (for scarlet fever and diphtheria). Mereway Hospital (for small pox). Sanatoria, Ac., Tuberculosis cases treated through the Middlesex County Council. 70 LOCAL GOVERNMENT BOARD TABLE 3. CAUSES OF, AND AGES AT DEATH DURING THE YEAR 1914. CAUSES OF DEATH. Nett deaths at the Subjoined Ages of "Residents" whether occurring within or without the District. Total deaths whether of "Residents" or "NonResidents" in Institutions in the District. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and upwards All causes:— Certified 408 62 7 7 25 14 44 99 150 ... Uncertified 1 1 ... ... ... ... ... ... ... ... Enteric Fever 2 ... ... ... 1 ... ... 1 ... 2 Small-pox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... Scarlet Fever 1 ... ... ... 1 ... ... ... ... 1 Whooping Cough 6 5 ... 1 ... ... ... ... ... ... Diphtheria & Croup 8 ... ... 2 6 ... ... ... ... 6 Influenza 4 ... ... ... ... ... 1 1 2 ... Erysipelas 2 ... ... ... ... ... ... 1 1 ... Phthisis (Pulmonary Tuberculosis) 24 ... ... ... 1 3 8 11 1 ... Tuberculous Meningitis 6 2 ... ... 2 ... 2 ... ... ... Other Tuberculous Diseases 5 1 ... ... 2 ... 2 ... ... ... Cancer, Malignant Disease 33 ... ... ... ... ... 1 20 12 2 Rheumatic Fever 1 ... ... 1 ... ... ... ... ... 1 Meningitis 6 1 ... 1 2 1 ... 1 ... 1 Organic heart disease. 50 ... ... ... ... 1 7 17 25 1 Bronchitis 19 ... 1 ... ... ... ... 3 15 ... 71 LOCAL GOVERNMENT BOARD TABLE 3-continned. Pneumonia (all forms) 29 6 1 ... 1 1 6 6 8 ... Other diseases of respiratory organs 5 1 ... ... ... ... ... 3 1 1 Diarrhoea and Enteritis 12 10 1 ... 1 ... ... ... ... ... Appendicitis and Typhlitis 3 ... ... ... 2 ... ... 1 ... ... Cirrhosis of Liver 4 ... ... ... ... ... ... 3 1 ... Alcoholism ... ... ... ... ... ... ... ... ... ... Nephritis and Blight's disease 10 ... ... ... ... ... 1 4 5 ... Puerperal Fever 3 ... ... ... ... 1 2 ... ... ... Other accidents and diseases of Pregnancy and Parturition 2 ... ... ... ... ... 2 ... ... ... Congenital Debility and Malformation, including Premature Birth 28 28 ... ... ... ... ... ... ... ... Violent Deaths, excluding Suicide 13 4 ... 1 3 2 1 1 1 1 Suicide 3 ... ... ... ... ... ... 2 1 ... Other Defined Diseases 125 5 4 1 3 5 11 23 73 6 Diseases ill-defined or unknown 2 ... ... ... ... ... ... ... 2 ... Totals 406 63 7 7 25 14 44 98 148 22 72 LOCAL GOVERNMENT BOARD TABLE 4. INFANT MORTALITY. Nett Deaths from stated causes at various Ages under 1 Year of Age. CAUSES OF DEATH. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 1 Month. 1-3 Months. 3-6 months. 6-9 months. 9-12 Months. Total Deaths under 1 Year. All causes. Certified 12 6 6 3 27 14 13 7 1 62 Uncertified 1 ... ... ... 1 ... ... ... ... 1 Small-pox ... ... ... ... ... ... ... ... ... ... Chicken-pox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... 3 1 ... 4 Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... Tuberculous Meningitis ... ... ... ... ... ... 1 1 ... 2 Abdominal Tuberculosis ... ... ... ... ... 1 ... ... ... 1 Other Tuberculous Diseases ... ... ... ... ... ... ... ... ... ... Meningitis (not Tuberculous) ... ... ... ... ... ... ... ... ... ... Convulsions 1 ... ... ... 1 ... ... ... ... 1 Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... 1 ... ... 1 Pneumonia (all forms) ... ... 1 1 2 2 1 1 ... 6 Diarrhoea ... ... ... ... ... 1 2 1 ... 4 Enteritis ... ... ... ... ... 3 2 2 1 8 G1stritis ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... 1 ... ... 1 Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlaying l ... ... ... 1 1 ... ... ... 2 Injury at Birth ... ... ... ... ... ... ... ... ... ... Atelectasis ... ... ... ... ... ... ... ... ... ... Congenital Malformations l 3 1 ... 5 3 ... ... ... 8 Premature Birth 7 1 4 1 13 1 1 ... ... 15 Atrophy, Debility and Marasmus 1 1 ... 1 3 1 1 1 ... 6 Other Causes 2 1 ... ... 3 1 ... ... ... 4 Totals 13 6 6 3 28 14 13 7 1 63 Nett Births in the year, 782. Nett Deaths in the year of infants, 63. INDEX To Annual Report of Medical Officer of Health and School Medical Officer for 1914. PAGE. Adenoids, Diagnosis of 15 „ Treatment of 16 Adoptive Acts in force in the District 50 Annual Report of Medical Officer of Health 27 Appointment of School Dentist 12 Attendance, Average in Schools 4 Attendance Officers, Assistance given by 7 Bacteriological Work 50 Bakehouses 41 Births and Birth rate 30 Blind Children 19 Byelaws in force in the District 51 „ Premises controlled by 39 Cancer, Death Rate from 31 Certificates of Absence from School 8 Clinic, Dental 13 ,, Inspection 23 Closing Orders (H. & T.P.A., 1909) 46 Clothing 11 Convalescent Homes, Children sent to 25 Co-relation of School Medical and other Departments 6 County Council Tables showing full details of Sanitary Work for 1914 62 to 67 Cowsheds 40 Dairies 40 Deafness 17 Deaf Mutes 19 Death Rate from Cancer 31 „ Pneumonia 31 „ Pulmonary Tuberculosis 31 Deaths and Death Rate 30 ii. PAGE. Deaths in Institutions 32 „ in Wards 31, 32 „ of Infants due to Diarrhoea 35 „ Transferable 30 Defects Treated, Table of 22 Dental Clinic 13 „ Premises for 13 Dental Treatment 13 „ Number Inspected 14 „ Summary of 15 Dentist, Appointment of School 12 Diarrhoea, Deaths of Infants due to 35 „ Summer, in Infants 61 Diphtheria, Deaths from 49, 53 Diphtheria, Notifications of 52 Disinfection after Infectious Diseases 60 Drainage and Sewerage 38 Drainage, Testing of 38 Eel Pie Island 36 Epileptics 19 Estimated Population of Wards 29 Exceptional Children, Table of 20 Extent of Medical Inspection 9 Eye Diseases 16 Following Up and Treatment 21 Following Up, Statement of Results of 22 Foot Covering 11 Health Committee, Members of 27 Heart, Diseases of 18 Heights 10 Home Office Tables showing full details of Inspection of Factories, Workshops and Workplaces 42 Hospital Accommodation and Administration 48 Hospital Treatment of Small-pox 58 House Refuse, Collection and Disposal of 36 Houses for the Working Classe 47 iii. PAGE. Housing and Town Planning Act, 1909, Closing Orders 46 Housing. Inspection of District 44 Infant Deaths due to Diarrhoea 35 Infant Deaths in Wards 34 Infant Mortality 32 Infant Mortality Rate, Chart of 33 Infectious Diseases, Disinfection after 60 Infectious Diseases in the Schools 18, 37 Infectious Diseases, Investigation and Disinfection after 60 Infectious Diseases, Prevalence and Control over 51 Infectious Diseases, Visits by School Nurse 8 Inspection Clinic 23 Institutions, Deaths in 32 Inquests 31 Local Government Board Tables:— Table I. Vital Statistics: Population, Births and Deaths, since 1909 68 Table II. Cases of Infectious Disease notified 69 Table III. Causes of and ages at death 70 Table IV. Infantile Mortality under one year:— Causes of Deaths 72 Lungs, Diseases of 18 Manure, Disposal of 40, 61 Measles 55 Meat and other foods, Inspection of 41 Meat, unsound or diseased 40 Medical Inspections, arrangements for 7 Medical Inspection, Conditions found on Table IV. Medical Inspection, Extent and scope of 9 Medical Inspection, Parents present at 20 Medical Officer of Health, Annual Report of 27 Mentally Deficient Children 19 Milkshops 40 Mortality in Childbirth and in Infancy, Means of preventing 60 Mumps 56 iv. PAGE. Natural and Social Conditions 28 Notices, Preliminary, numbers of 38 Notices, Statutory, numbers of 38 Nose, Diseases of 15 Notification of Births Act, 1909, Adoption of 60 Notifications of Diphtheria 52 Notifications of Scarlet Fever 52 Nurse, Assistance given by 7 Nurse, Treatment by 25 Nutrition 12 Offensive Trades 40 Ophthalmia Neonatorum 57 Orleans School, Description of 5 Otorrhœa 17 Overcrowding 39 Parents present at Inspection 20 Physical Features of District 28 Pneumonia, Death Rate from 31 Poliomyelitis 57 Population 29 Premises Controlled by Byelaws 39 Public Health Committee, Members of 27 „ Staff 48 Public Parks and Recreation Grounds 29 Puerperal Fever 57 Pulmonary Tuberculosis, Death Rate from 31 Pulmonary Tuberculosis in School Children 18 Rainfall 29, 36 Recreation Grounds and Public Parks 29 Refreshment Houses 39 Ringworm of the Scalp 19 Ringworm X-ray treatment of 19 Sale of Food and Drugs Acts 41 Sanitary Administration of the District 48 V. PAGE. Sanitary Circumstances of the District 36 „ Inspection of the District 28 Scarlet Fever 52 Scarlet Fever, Notifications of 52 Scarlet Fever, Open air treatment of 49 Scarlet Fever, Return cases of 49 School Attendance, Medical Aspects of 7 School Attendance Sub-Committee, Members of 1 School Dentist, Appointment of 12 School Medical Service, Co-relation of, with Public Health Service 6 School Registers, Number on 4 Schools, Certificates of absence from 8 Schools, Hygienic conditions of 6 Schools, Infectious diseases in 18, 37 Scope of Medical Inspection 9 Sewerage and Drainage 38 Slaughterhouses, Inspection of 39 Small-pox, Hospital treatment of 58 Staff, Sanitary 48 Summer Diarrhœa in Infants 61 Teachers, Assistance given by 7 Teeth, Arrangements for treatment of 13 Teeth, Condition found at Routine Inspection 12 Throat, Diseases of 15 Tonsils, Treatment of 16 Transferable Deaths 30 Treatment by School Nurse 25 Treatment of Smallpox 58 Tuberculosis, Prevalence and control over 58 Tuberculosis, Pulmonary, Death Rate from 31 „ ,, in School Children 18 Typhoid Fever 53 ,, Arrangements for treatment of 55 Vaccination 20 Verminous Conditions 11 ,, Exclusions for 12 vi. PAGE. Vision, Number found defective 17 „ Treatment of 17 Vital Statistics of the District 29 Wards, Deaths in 31, 32 Wards, Estimated Population of 29 „ Infant Deaths in 34 Water Supply 36 Weights 10 Whooping Cough 55 Workshops, Workplaces, &c. 42 X-Ray treatment of Ringworm of the Scalp 19