TWI 048 Twickenham Urban District Council. ANNUAL REPORTS of the School Medical Officer and Medical Officer of Health FOR THE YEAR 1920. GEORGE H. DUPONT, M.D., D.P.H., Medical Officer of Health & School Medical Officer. twickenham: printed by walker & co., heath road. Twickenham Urban District Council. Annual Report OF THE School Medical Officer, 1920. Twickenham Urban District Council Public Health Department, Radnor House, Twickenham, May, 1921. To the Chairman and Members of the Education Committee. Mr. Chairman, Ladies and Gentlemen, I have the honour to present my Annual Report for the year 1920, on the medical inspection of the children attending the Public Elementary Schools, on the defects found and on the measures taken to prevent disease and to remedy defects. Reference is also made to the hygienic and sanitary conditions of some of the schools. The report is arranged in accordance with the plan suggested by the Board of Education in the circular issued at the beginning of the year. The conditions now treated under the arrangements made by the Committee include minor ailments, ophthalmic and dental defects, tonsils and adenoids and ringworm of the scalp, and it is to these provisions that the success of the work is largely due. The transfer of the records from the Infant Welfare Centres to the School Medical Department has been continued. As many of the defects found among the school population have commenced during infancy, it may be predicted confidently that when the same facilities for treatment of cases of early disease are extended to infants at Infant Clinics, many of the diseased conditions 4 now found among the children at their entrance to school life will have been remedied before that stage is reached. A serious attempt to discover in school classes, cases of illness at the earliest possible stage, and especially cases of early infectious disease, has been made by the institution of a daily visit to all the Infant Departments by the School Nursing Staff, and by the subsequent visiting of the homes of those reported to be absent on account of suspected infectious disease. With the active co-operation of the Head Teachers, this should prove a valuable measure. I am Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, School Medical Officer. 5 GENERAL. Estimated civil population of district (Registrar General) 36,406 Number of schools 9 Number of separate departments 20 Average number of children on registers 4,650 Average attendance 88.99 per cent The number of children on the registers was 57 more than during the previous year, the average attendance being 0.71 per cent lower. There was no alteration in the number of schools or departments. STAFF OF SCHOOL MEDICAL SERVICE. The staff consists of the following:— (1) The School Medical Officer, who is also Medical Officer of Health, undertakes the duties in connection with administration, the clinical duties of the inspection and minor ailment clinics, acts as dental anaesthetist and shares the work of medical inspection in the schools. (2) School Medical Inspector, part time, who is engaged in general medical practice in the district. (3) Ophthalmic Surgeon, part time, who is also Ophthalmic Surgeon to Royal Hospital, Richmond, and engaged solely in consulting practice. (4) Dental Surgeon, part time. (5) School Nurse, whole time, trained nurse. (6 & 7) Two Health Visitors, trained nurses, who devote part of their time to the work of the School Medical Service and part to Maternity and Child Welfare. 6 (8) Clerical. The clerical work is carried out in the Offices of the Public Health Department, and the services of one clerk are specially devoted to School Medical and Maternity and Child Welfare Work. CO-ORDINATION. Arrangements for the co-ordination of the work of the School Medical Service with that of the Health Services:— (а) Infant and Child Welfare. The records obtained by visiting under the Notification of Births Act and consultations at the Infant Welfare Centres are transferred to the School Medical Department and are filed with subsequent school records. A continuous history of the child from birth is thus obtained in the case of children born in the district. As the School Medical Officer acts as Medical Superintendent of the Maternity and Child Welfare work, and two Health Visitors also act as part time School Nurses, the co-ordination between the two branches is satisfactory. (b) Nursery Schools. There are no nursery schools in the district. (c) Debilitated Children under school age. No clinic exists for the treatment of children under school age, but the services of the epidemic nurse are utilized not only for epidemic disease but for ordinary illness when the incidence of infectious disease is light. 7 THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. A careful inspection of the hygienic conditions of the Schools has been made in conjunction with the Chief Sanitary Inspector. All Schools have a water supply and water closet accommodation, but as may be expected, the conditions as to lighting, ventilation, and cloak room accommodation are unsatisfactory in many of the Schools, especially in the older non-provided Schools. Details of these defects are before me, and it would be an easy matter to put forward a long list of recommendations for alteration and improvement. As in many cases they would involve radical alteration and even reconstruction of various schools to such an extent as to be an impossibility, either at the present time or in the near future, no good purpose would be served by referring to them in detail now, and it is proposed, from time to time, to bring the more urgent points to the attention of the Committee in the hope that they may be remedied gradually. As mentioned above, nothing but the replacement of the older buildings by new ones designed in accordance with modern requirements will remedy the conditions existing at several of the older schools. Medical Inspection (Table I., p. 25). Description of arrangements made and methods adopted for the medical inspection of the children:— All children in the three usual age groups are examined, i.e., (1) all entrants ; (2) those who have reached the age of eight years; (3) those who have reached the age of twelve years; and (4) those of 8 intermediate ages coming from other schools for whom there is no evidence of recent medical inspection at other schools. The Schedule laid down by the Board of Education has been closely followed in every particular, and on account of the facilities offered by the Clinic at Radnor House, there is ample opportunity for further or more complete examination where such is required. In addition to the opportunities offered by the routine inspections at the schools, parents are allowed to bring any child (by consent of the Head Teachers) to the Clinic at Radnor House for opinion, and full advantage is taken of this; a large number of defects are thus recognized at an early stage, which would certainly not receive treatment unless the Clinic existed. As mentioned in previous reports, there is very little disturbance of school routine by medical inspection in the schools where the Head Teacher has a separate room, as this has invariably been placed at the disposal of the School Medical Inspector. Where no such room exists, classes have to be displaced and desks moved, and considerable dislocation is occasioned thereby. Findings of Medical Inspection (Tables, pp. 26, 27. 32). Review of facts disclosed by medical inspection:— (a) Uncleanliness. The condition as to cleanliness of the heads of girls, both in the infants' and senior departments, leaves a good deal to be desired. Cut of, approximately, 1,000 girls examined at routine inspections, 24% were found to have evidence of vermin in the head. Of the girls in the senior departments 27% were verminous, and in the junior and infant departments 21%. As may be expected, varying conditions of cleanliness were found in different schools; 9 in one girls' school 65% were found to be infested, while in one infants' department only 10% were not clean. The only way to reduce this number is by frequent and persistent visitation of the schools, exclusions and prosecutions following where necessary. To be quite candid, this has not been energetically pursued during the year. The increasing time taken up by the minor ailment, dental and ophthalmic clinics, and the increasing numbers who have to be medically inspected, have rendered it necessary to drop some of the work, and beyond sending notices and repeated notices to parents no more bellicose measures have been adopted. In some of the worst cases, and especially those complicated by septic sores, impetigo of the head and scabies, the use of the Bathing Centre established at Radnor House has been invaluable, and reference to its activities is made under the heading of treatment of minor ailments. (b) Minor Ailments. It is a tribute to the value of the Minor Ailment Clinic to find that the number of minor ailments discovered during routine inspection is comparatively small, while the number dealt with at the Clinic, whether they are sent by the School Nurses and Head Teachers, is large. Taking for example infectious skin disease and external eye disease, the percentage of children found affected at routine inspection was approximately 1% of each, while at the Clinic these cases constituted 11% and 10% respectively of the 1300 children specially seen. Again, taking the cases of otorrhœa or discharging ears, 2% of the routine inspections were found to have this disorder, while at the clinic 5% of children seen, attended for this condition. 10 The explanation is simple and satisfactory ; nearly all the cases of minor ailments are found by special inspections and referred for treatment at the Clinic or elsewhere immediately, instead of having to wait for routine inspection or, what is more likely, not being properly treated at all. (c) Tonsils and Adenoids. Some enlargement of the tonsils was found in approximately 30% of the children under 8 years and 24% of the seniors, or 27% of all seen at routine inspection. As is well known, a certain amount of tonsillar enlargement is compatible with perfect health. Ninety-one children were found to require operations for enlargement of the tonsils, with or without adenoids, and in eleven cases of adenoids only, operation was indicated, in all one hundred and two being referred for operation. The theory that heart disease or defect may be due to septic infection from unhealthy tonsils is one that has received considerable attention. The figures obtained from the results of medical inspection during the past year may be given, although they do not tend to support or rebut the contention. Among 769 entrants, 14 had heart defects as indicated by definite murmurs, but in only three of these 14 children was the heart defect associated with enlarged tonsils. Among 713 seniors examined, 16 had heart defects, but in only one of these children were enlarged tonsils present. In all, out of the 30 children found to have heart murmurs, four were found to have enlarged tonsils. (c) Tuberculosis. One definite case of pulmonary tuberculosis was discovered during the year, and three cases of non-pulmonary tuberculosis. Several cases of suspected tubercle of the lungs were kept under observation and referred if necessary to the Tuberculosis Medical Officer for opinion. 11 (d) Skin disease. Diseases of the skin are by far the most frequently met with condition, and, unpalatable as the fact may be, it cannot be denied that the majority of the cases are due to a low standard of personal cleanliness. Sixty-four cases of scabies (Itch), 57 cases of impetigo and a large number of septic sores were found and referred for treatment. The number of cases of ringworm of the scalp, 21, was practically the same as last year. Eighteen cases of ringworm of the body were also found. (e) External eye disease. Ten cases of inflamed eyelids and six of conjunctivitis were found. (f) Vision. One hundred and forty-three children were found to have defective vision, and in addition 22 suffered from strabismus (squint), making in all 165 cases. Of these, 97 were discovered during routine examination of the intermediates and leavers, approximately 10.7%, the figure last year being 15%. In all, 133 cases were referred for examination with a view to glasses being obtained if necessary. (g) Ear disease and hearing. Persistently defective hearing is usually caused by middle ear suppuration, or is associated with adenoids or enlarged tonsils. During the routine examination of 1,700 children, 39 were noted as having defective hearing, 23 of these being cases where ear discharge was present or there was a history of this condition having existed recently. At the lowest estimate therefore rather more than 2% of children suffered from deafness of a persistent character. 12 In addition to the 23 cases of middle ear suppuration found at routine inspection, 65 cases were sent direct to the Clinic for treatment; in all, therefore, 88 cases of suppurative ear discharge were met with. By the assistance of the teachers and as a result of some propagandism, there would appear to be an increasing tendency on the part of parents to treat ear discharge more seriously and to take advantage of the facilities for treatment which are offered. (h) Dental defects. Of the children examined by the School Dentist, below the ages of 6 and 9 years, 85% were found to have dental defects sufficiently marked to require the services of a dentist. It is, however, very gratifying to find at the medical inspection of the older children, from 8 to 12 years, an increasing number of children who have healthy mouths as the result of previous treatment by the School Dentist. As would be expected, this is most noticeable in the children between 8 and 9 years, the good results having worn off to a considerable extent by the age of 12 years. It has not been found possible, up to the present, to find sufficient time for the School Dentist to re-examine and treat at a later age those children already treated by him between 6 and 8. Even with the present restricted opportunities for treatment, the improvement is quite noticeable, and its value cannot be overstated. (i) Crippling defects. The usual causes of crippling defect are infantile paralysis (poliomyelitis), tubercular disease, and accident or congenital defect. The number of children of school age in the district who are crippled to a varying extent from these causes are as follows:— 13 Poliomyelitis 14 Tubercular disease 5 Rickets 2 Other 3 Six of these cases were discovered for the first time on medical inspection during the year. (j) Acute infectious disease. The incidence of acute infectious disease in the Schools is indicated in the following table:— Cases of Acute Infectious Diseases in Schools, 1920. School Measles Wh. C. Ch.Pox Mumps Diphth. Sc. fever Trafalgar Boys 2 — — 1 3 2 „ Girls 12 — — — 1 — „ Infants 72 — — 1 2 1 Orleans Boys 11 — 1 — — 1 „ Girls 36 1 — — 2 1 „ Infants 153 15 8 1 3 1 Whitton Mixed — — — 2 1 — Nelson Infants 7 — — — — — St. Mary's Boys 6 2 — — 1 — „ Girls 1 — — — 1 1 „ Infants 26 2 2 — 4 — Arch. Cam. Boys — — — — — 1 „ Girls 1 — — — 5 — „ Infants 55 — 3 — 4 1 St. Stephen's Boys — — 1 — — 1 „ Girls 1 — 1 — — 1 „ Infants 31 — 4 — 1 1 St. James' R.C. 7 — 1 — 2 — Gould Road 9 — — — 2 — Other schools 9 — — — 14 3 Total 439 20 21 5 46 15 The cases of measles were much more numerous than during the preceding year, during which this disease was almost absent from the district. The schools chiefly affected were the Infants' departments of Orleans, Trafalgar, St. Mary's and Archdeacon Cambridge. 14 The number of children suffering from other infectious diseases was not in excess of the normal average. As in previous years, in all cases where the Head Teacher has reported that a child has been absent from school and the absence was believed to be due to Measles, Whooping Cough, or Mumps, the School Nurses have visited the home, and when the diagnosis was verified contacts from the same household have been excluded, in accordance with the Joint Memorandum of the Medical Officers of the Local Government Board and Board of Education, issued in 1909. Although this had been carried out as thoroughly as possible—and of course it could only apply to cases coming to the knowledge of and reported by the Head Teachers—it had not the desired result in preventing the spread of those diseases in the Infants' Schools, although at times extensive exclusions made serious inroads on the attendance. After careful consideration, it was decided to cease routine exclusion of contacts of Measles, Whooping Cough Chicken Pox, or Mumps, and to substitute a system of daily visits to the Infant Schools by the School Nursing Staff. For several years past, the School Nurses have visited daily for ten days classes where a case of Diphtheria has occurred, and examined the throats of the children. The method of daily visits to all Infants' Departments was therefore an extension of this procedure. The Committee approved the course suggested and a commencement was made at the end of the year. Certain schools were allotted to each Nurse, corresponding as far as possible to the district usually covered by her in the course of her duties as Health Visitor. The following instructions were issued to the Nursing Staff:— 15 " The Nurse will visit the school each morning, taking with her a list of children who are known to require special observation, and will also receive from the Head Teacher a list of any children who are absent on account of any suspicious illness. "The Nurse will specially examine known contacts in the classes, will generally look through the other children in the class, and will also examine children who are brought to her notice by the teacher. " The Nurse will advise the Head Teacher as to the children who may appear unfit for school and will report such to the Medical Officer. " In case of children reported absent on account of infectious disease the Nurse will visit the home or transmit the name to the Nurse in charge of the portion of the district where the child resides, so that the child may be visited. " The Medical Officer will arrange for certificates of exclusion to be sent where necessary." It may be hoped that this daily supervision of classes, and visiting of homes, may tend to prevent the retention in class of any child who is unfit, either for his own sake or for fear of infection to others, and may also enable illness to be recognised and treated at the earliest possible moment. The success of the measure largely depends on the willing co-operation of the teachers and should be of much assistance to them in deciding as to whether a child is fit to remain in or to return to school. Under the arrangements above referred to, by which daily examination of throats were made after the occurrence of diphtheria in a class, all the children in affected classes were examined on 136 occasions and 6 swabs were taken from doubtful throats. 16 Following up. Following is a description of the methods employed. If on routine or special examination a child is found to require subsequent examination, a definite date for the re-examination is given to the parents for attendance at the Clinic, as almost all re-examinations are carried out at the School Clinic. If attendance is not made on the appointed date, the School Nurses visit the school and if necessary the home. It will be obvious that re-examination may frequently be necessary before the precise treatment necessary may be clear, and thus many children referred for subsequent observation were subsequently recommended for treatment. All cases recommended for medical treatment are entered in the Treatment Register, and the entry is not closed until either satisfactory treatment has been obtained or has been refused or the child has left the district. In the last case, if the address can be obtained, information has been sent to the School Medical Officer of the district to which the family has moved. It is significant to note, however, that in no case has such information been received from a School Medical Officer of any other district in reference to children moving into Twickenham. The success of following up is entirely dependent on the activity and tact of the Nursing Staff, and I take this opportunity of acknowledging the value of their work, an indication of the extent of which is given by the following figures:— Visits to schools in connection with Medical and Dental Inspections, 90; class examination of throats, 136 ; daily visits, 278 ; treatment, etc., 41. Visits to homes in connection with suspected infectious disease, 513 ; treatment, 122 ; other, 56. Total number of visits to schools and homes, 1,236. 17 In addition the Nurses' duties include attendance at the Minor Ailment and Inspection Clinic (daily), and at the Dental and Ophthalmic Clinics. Medical Treatment. The number of cases treated and the results of the treatment obtained have again been very gratifying, and this satisfactory state of affairs is largely due to the opportunities given by the arrangements made by the Committee for the treatment of minor ailments, adenoids and tonsils, dental defects, ringworm and ophthalmic defects. During the year, 1,189 children were recommended for treatment, Of these, 963 received completed or satisfactory treatment during the year. Excluding dental treatment only 31 cases were given up on account of refusal by the parents or other reasons. In 6 cases only partial treatment was carried out, and three left the district before treatment could be given. The remainder were under treatment at the end of the year or were carried forward. A tabular statement of the various diseases and the number of children treated will be found in Table IV. A, B. C, and D, at the end of this report (pp. 30, 31). (a) Minor ailments. The treatment of these at the Clinic at Radnor House now occupies the whole of every morning, and extends practically throughout the holidays, one or more of the School Nurses and the Medical Officer being present on each occasion, while the services of a clerk are in frequent requisition. The total attendances of children at the Clinic for observation or treatment numbered 6,472, again constituting a record ; of these 4,674 attendances were for the treatment of minor ailments. Cases of Otorrhoea or discharging ears, still form a large proportion of the cases treated, and again 18 every effort has been made to secure regular attendance for treatment. I am satisfied that the serious results from neglect of this condition are becoming much more widely appreciated by the parents, and more willingness to continue treatment until a cure is effected is now shown. The usual " hospital " method of giving " lotion or drops " to be used by the parents with occasional attendance for supervision, has long ago been found by us to be almost useless, and daily attendance for adequate treatment by the School Nurses has been substituted, and has produced most excellent results. Septic skin disease, including impetigo and septic sores, boils and abscesses, are still the most frequent type of illness dealt with at the Clinic, and until the whole standard of personal cleanliness is raised and the facilities for satisfactory ablution in the houses of those who send their children to the public elementary schools are increased, these conditions will continue to be widespread. In dealing with these, and especially with scabies, the Cleansing Centre has been invaluable. It is in the same building as the School Clinic and is consequently immediately available, and its establishment has added in no small extent to the good results obtained. The number of individual children bathed at the Cleansing Centre was 70, and the number of baths given was 1,463. (b) Tonsils and Adenoids. With the approval of the Board of Education, the Committee has paid to St. John's Hospital, Twickenham, a fee of £1 10s. per case for 70 cases operated upon each year. The majority of the remaining cases were treated either at Richmond Hospital or other hospitals, chiefly in London by subscribers' recommendation. In November a letter was received from the Richmond Hospital stating that Elementary School Children would 19 not in future be treated on a subscriber's recommendation, but only by arrangement with a Local Education Authority. In consequence of this, the Committee decided to increase the number of cases treated at St. John's Hospital to 100 cases per annum. It will still be necessary to refer to special hospitals cases which present particular difficulty or complication. (c) Tuberculosis. Unless they are already receiving attention, all cases of this disease are referred to the local Tuberculosis Officer for treatment where such appears necessary. Cases where the disease is inactive and where the child can attend school are periodically examined by the School Medical Officer, and in addition, child contacts of all new cases are examined by the School Medical Officer and kept under observation where necessary. (d) (e) Skin diseases and External Eye diseases. The treatment of these cases is almost entirely carried out at the minor ailment Clinic and has already been referred to. Cases of external eye disease which do not yield to treatment readily are referred to the School Ophthalmic Surgeon for opinion. (f) Vision. 1 he Ophthalmic Clinic has been held at Radnor House every alternate Thursday afternoon during the School terms, and the Ophthalmic Surgeon has attended on each occasion. The Optician also attends to measure for new glasses and adjust those ordered at the previous, session. (g) Ear disease and Hearing. As above mentioned, cases of Otorrhoea are treated at the Minor Ailment Clinic. Cases of catarrhal deafness are also dealt with, and cases not yielding satisfactorily "O treatment are referred to special hospitals. 20 (h) Dental defects. The Dental Clinic for treatment has been held every Thursday morning, and additional morning sessions have been held for inspection in the Schools as required. The School Medical Officer acted as dental anaesthetist. Following a letter from the Board of Education in March, 1920, the Committee sanctioned an additional session weekly. As this would necessitate additional attendance by a medical practitioner for the administration of anaesthetics, sanction was also given for this. For this increased work at the Dental Clinic, more adequate accommodation would be necessary, and a report as to this was put before the Committee and was under consideration at the end of the year. A detailed statement as to the children inspected and the treatment carried out by the School Dentist is given in Table IV. D. (1) and (2) (p. 31). (i) Crippling defects and Orthopaedics. These have been dealt with by reference to Hospitals in London and especially to the Royal National Orthopaedic Hospital, to the staff of which Hospital much thanks is due. The great difficulty of obtaining proper apparatus on account of the cost, was referred to in last year's report, and is still a problem requiring solution. As this class of defect is not treated at the expense of the public funds, it is still necessary to struggle to obtain letters from the Surgical Aid Society subscribers, and much valuable time is lost. Open Air Education. Beyond holding a certain number of classes in the playgrounds in the summer and the teaching of gardening at some schools, no open air education is carried out, nor are any of the schools adapted for the purpose. Physical Training. There is no association of the School Medical Service with the work of physical training in the schools. 21 Provision of Meals. The Education Committee devoted considerable attention to the question of providing meals for underfed children. After consideration of a report by the Clerk to the Committee on the legal aspect of the position, a Conference of the Head Teachers and the School Medical Staff was called at the request of the Committee. The Conference reported that the approximate number of children which appeared underfed was 350, and made various recommendations as to the nature of the meals, the most suitable centres and probable cost. This report was adopted by the Education Committee and a recommendation made to the Council that the Act be adopted. This recommendation was rejected by the Council, and in consequence the matter was left to voluntary effort. Co-operation of Parents. Notice of intended medical inspection is always sent to parents, and attendances were secured in 84.4% of the number of children inspected. Where treatment is required very little reliance is placed on written communications, personal interview by the School Medical Officer or School Nurse being secured wherever possible, and to this method of procedure, much of the success of the work is due. Co operation of Teachers. Acknowledgment may be made here of the willing co-operation of the teachers in medical inspection and in sending up cases requiring treatment. Following up and medical treatment are carried out by the School Nursing staff, and the assistance of the teachers is less required in connection with these. In almost every instance the same remarks as to willing co-operation applies to the daily visits of the Nurses to the schools, although in connection with the exclusion of children who appear unfit the question is looked at from a 22 somewhat different viewpoint, and differences of opinion are almost inevitable. Co-operation of Attendance Officers. The assistance of the School Attendance Officers in seeing attendance at the Clinic of children who are not attending regularly, has been considerable, and the services of these Officers have also been utilized in obtaining signatures to consent forms for dental treatment, and thus the time of the School Nurse formerly devoted to this work has been rendered available for more purely technical duties. On the other hand, many of the visits of the School Nurse to homes, especially visits to children reported to be absent through infectious disease, has been of much value from a school attendance point of view. In each case where exclusion is considered necessary or where it is found on visiting that there is no reason for further absence, a certificate is sent to the Head Teacher. In this aspect of the work, the advantage of visits by an experienced Nurse is obvious. She can see the patient, take the temperature if necessary, and advise as to length of exclusion, whereas the ordinary School Attendance Officer has to take the word of the parent, and cannot verify this. In consequence, there has been a natural tendency on the part of the Head Teachers to derive information from the Nurses' visits and reports for the purposes of school attendance, and in order to prevent overlapping this appears to be a side of the question to which the Education Committee might pay attention with advantage. Co-operation of Voluntary Bodies. There is no School Care Committee, and the work of giving recommendations to hospitals, to relieving officers, or convalescent homes, has again fallen to the lot of the School Medical Staff. 23 In connection with sending children to convalescent homes at the seaside, grateful acknowledgment is again made of the valuable assistance rendered by the local branch of the Ministering League, through which agency no less than 15 children were sent to Brighton for periods of three weeks and upwards. Blind, Deaf, Defective and Epileptic Children (pp. 28, 29). The routine and special inspections are quite sufficient for the purposes of ascertaining and keeping under observation children in the above categories. Places in residential schools have been found for those children who are blind or deaf mutes. There is no special school or arrangement for dealing with markedly dull or higher grade defectives, and these are taught in the ordinary elementary school classes, with such special attention as is possible. Cases of imbecility or idiotism are referred to the Local Control Authority. Nursery, and Continuation Schools, have not been provided. The arrangements for medical inspection, etc., in the secondary schools for girls are carried out by the County Council, and beyond receiving medical record cards of such girls as have been examined in the public elementary schools, no further co-operation has been requested. Employment of Children and Young Persons. Byelaws to regulate the conditions of employment of children and young persons in this district received approval during the year. Although most of the provisions of these byelaws are framed to safeguard the health of employed children, the section which chiefly concerns the School Medical Service is as follows:— "The Local Authority, if they are satisfied by a report of the School Medical Officer or otherwise, that any child is being employed in such manner as to be 24 prejudicial to his health or physical development, or to render him unfit to obtain the proper benefit from his education, may either prohibit or attach such conditions as they think fit to, his employment in that or any other manner, not with standing that the employment may be authorised under the provisions of this Act or any other enactment." At the time of writing this report, the Authority had not laid down the procedure to be adopted to decide whether the child was fit for the occupation intended and whether, during his employment, his health remained in such a condition as to enable him to continue to follow such employment without ill effects, nor has the relationship between the Juvenile Employment Committee, the Certifying Factory Surgeon and the School Medical Service been determined. Up to the present, the discovery of children who were engaged in occupations for which they were medically unfit has been left to chance, although several such cases have been found and advice given to the parents. One child, excluded for scabies, was found to be helping an itinerant greengrocer! It is to be hoped that such an occurrence will not be possible when the byelaws are being enforced. Miscellaneous. Many examinations have been made and certificates signed in connection with children sent to the Seaside Convalescent Home at Herne Bay under the King Edward Memorial Fund; to Brighton through the Ministering League, and for admissions to various institutions and orphanages. Further examinations have also been made of children for whom applications have been made for performances in theatrical entertainments. 25 TABLE I. Number of children inspected 1st January, 1920, to 31st December, 1920. A—Routine Medical Inspection. Entrants. Intermediate Group. Leavers. Grand Total. 3 4 5 6 Oth. T't'l 8 12 13 14 Oth. T't'l Boys - 30 225 92 40 387 191 144 7 3 44 389 776 Girls 1 24 244 115 22 406 230 192 27 2 67 518 924 Totals 1 54 469 207 62 793 421 336 34 5 111 907 1700 B.— Special Inspections. Special Cases. Re-examination (i.e., No. of children re-examined). Boys 659 604 Girls 640 643 Totals 1299 1247 C—Total number of individual children inspected by the Medical Officer, whether as Routine or Special cases (no child being counted more than once in one year). 2999. 26 TABLE II. Return of Defects found in the course of Medical Inspection in 1920. Defect or Disease. Routine Inspections. Specials. Number referred for treatment. Number requiring to be kept under observation, but not referred for treatment. Number referred for treatment. Number requiring to be kept under observation, but not referred for treatment. (1) (2) (3) (4) (5) Malnutrition 1 5 2 2 Uncleanliness— Head - - 3 5 Body - - - - Skin Ringworm— Head 1 - 20 - Body - - 12 6 Scabies 5 - 59 - Impetigo 1 - 56 Other diseases (non tubercular) 5 4 93 26 Eye Blepharitis 2 8 Conjunctivitis __ 6 1 Keratitis - - - - Corneal Ulcer - - - - Corneal Opacities - - - - Defective vision 30 53 50 10 Squint 6 8 7 1 Other conditions — — 3 2 Glasses renewed or repaired — — 15 — 27 Ear Defective hearing 1 4 2 13 Otitis media 5 11 64 1 Other diseases 3 2 2 3 Nose and throat Enlarged tonsils 56 27 22 13 Adenoids 5 14 6 10 Enlarged tonsils and adenoids 10 9 3 2 Other conditions — - 4 6 Enlarged Cervical glands (non tubercular) — 1 — 9 Defective speech — — — — Teeth—Dental diseases - - - — Heart and Circulation Heart disease— Organic — 1 — 1 Functional - 3 - 1 Anaemia - 1 1 5 Lungs Bronchitis — 2 2 12 Other (non tubercular) — 2 2 4 Tuberculosis Pulmonary— Definite — 1 — — Suspected — 4 — 4 Non-Pulmonary— Glands Spine — 1 - — Hip — — — — Other bones and joints — — — — Skin — - 1 — Other forms — — — — Nervous System Epilepsy 1 4 2 1 Chorea — — — 3 Other conditions - 2 5 12 Deformities Rickets 1 3 — 1 Spinal curvature - - — — Other forms 1 2 2 5 Other defects and diseases 11 8 79 80 Number of individual children having defects which required treatment or to be kept under observation—943 28 TABLE III. Numerical return of all exceptional children in the area in 1920. Boys. Girls. Total. Blind (including partially blind) within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893 Attending Public Elementary Schools 1 - 1 Attending Certified Schools for the Blind 1 - 1 Not at school — - — Deaf and Dumb (including partially deaf) within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893 Attending Public Elementary Schools - - - Attending Certified Schools for the Deaf 1 1 2 Not at school - 1 1 Mentally Deficient Feeble minded Attending Public Elementary Schools 7 3 10 A ttendingCertified schools for Mentally Defective Children 1 - 1 Notified to the Local Control Auth'y by Local Education Authority during the year 1 - 1 Not at school 1 — 1 Imbeciles At school 1 — 1 Not at school 1 — 1 Notified to local ControlAuth. 1 2 3 Idiots 2 2 [ Epileptics Attending Public Elementary Schools 5 3 8 Attending Certified Schools for Epileptics ... - 1 1 In Institutions other than Certified Schools - - - Not at school — — — 29 Physically Defective Pulmonary Tuberculosis Attending Public Elementary Schools - 3 3 Attending Certified Schools for Physically Defective Children - - - In Institutions other than Certified Schools 1 - 1 Not at school — 3 3 Crippling due to Tuberculosis Attending Public Elementary Schools 2 - 2 Attending Certified Schools for Physically Defective Children - - - In Institutions other than Certified Schools 1 - 1 Not at school 1 — 1 Crippling due to causes other than Tuberculosis, i.e., Paralysis, Rickets, Traumatism Attending Public Elementary Schools 8 9 17 Attending Certified Schools for Physically Defective Children 1 - 1 In Institutions other than Certified Schools - 1 1 Not at school 1 1 2 Other physical defectives, e.g., delicate and other children suitable for admission to openair schools; children suffering from severe heart disease Attending Public Elementary Schools 1 - 1 Attending Open-air Schools — — — Attending Certified Schools for Physically Defective Children, other than Openair Schools - - - Not at school 1 5 6 30 TABLE IV. Treatment of defects of Children during 1920. A—Treatment of minor ailments. Disease or Defect. Number of children. Referred for Treatment. Treated. Under Local Education Authority's Scheme. Otherwise. Total. Skin:— Ringworm—Head 22 21 1 22 „ Body 4 3 1 4 Scabies 76 70 6 76 Impetigo 64 61 3 64 Minor Injuries 28 28 1 29 Other skin disease 52 45 7 52 Ear disease 88 43 7 50 Eye disease (ex ternal and other) 29 21 7 28 Miscellaneous 63 41 11 52 B—Treatment of Visual Defects. Referred for Refraction. Number of Children. Submitted to Refraction. For whom glasses were prescribed. For whom glasses were provided. Recommended for treatment other than by glasses. Received other forms of treatment. For whom no treatment was considered necessary. Under Local Education Authority's Scheme, Clinic or Hospital. By Private Practitioner or Hospital. Otherwise. Total. 133 119 6 Nil. 125 121 *144 Nil. Nil. 4 *Includes 13 cases of renewal of lost or broken glasses. C—Treatment of defects of nose and throat. Referred for Treatment. Number of children. Received other forms of Treatment. Received Operative Treatment. Under Local Education Authority's Scheme, Clinic or Hospital. By Private Practitioner or Hospital. Total. 137 67 52 119 Nil. 31 D—Treatment of Dental Defects. 1. Number of children dealt with. Age groups. "Spec'ls" Total. 5 6 7 8 9 10-14 (a) Inspected by Dentist 10 141 140 127 8 - 31 457 (b) Referred for Treatment 9 113 122 119 8 - 31 402 (c) Actually treated 1 61 80 68 5 - 31 246 (d) Re-treated (result of periodical re-exam). - - - - - - Nil. Nil. 2. Particulars of time given and of operations undertaken. No. of half-days devoted to inspection. No. of half-days devoted to treatment. Total No. of attendances made by the children at the Clinic. No. of Permanent Teeth. No. of Temporary Teeth. Total No. of fillings. No. of Administrations of General Anaesthetics included in (4) and (6) No. of other Operations. Extracted Filled Extracted Filled Perm. Teeth. Temp. Teeth. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) 5 36 489 35 288 1401 Nil. 288 217 2 Nil. TABLE V. Summary of Treatment of defects as shown in Table IV. (A, B, C, D, and F, but excluding E). Disease or Defect. Number of Children. Referred for Treatment. Treated. Under Local Education Authority's Scheme. Otherwise. Total. Minor Ailments 426 339 44 383 Visual defects 133 119 6 125 Defects of nose and throat 137 67 52 119 Dental defects 402 246 — 246 Other defects 91 — 90 90 Total 1189 771 192 963 32 TABLE VI. Summary relating to children medically inspected at the routine inspections during the year 1920. (1) The total number of children medically inspected at the routine inspections 1700 (2) The number of children in (1) suffering from:— Malnutrition 178 Skin disease 35 Defective vision (including squint) 144 Eye disease 14 Defective hearing 14 Ear disease 38 Nose and throat disease 433 Enlarged cervical glands (non-tubercular) 153 Defective speech 8 Dental disease 1087 Heart disease:— Organic 4 Functional 31 Anaemia 23 Lung disease (non-tubercular) 67 Tuberculosis:— Pulmonary (definite) 4 (suspected) 8 Non-pulmonary 1 Disease of the nervous system 20 Deformities 7 Other defects and diseases 56 (3) The number of children in (1) suffering from defects (other than uncleanliness or defective clothing or footgear) who require to be kept under observation (but not referred for treatment) 172 (4) The number of children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, etc.) 145 (5) The number of children in (4) who received treatment for one or more defects (excluding uncleanliness, defective clothing, etc.) Included in Table V, not kept separately from Specials. 33 Twickenham Urban District Council. Public Health Department, Radnor House, Twickenham, June, 1921. To the Chairman and Members of the Twickenham Urban District Council. Gentlemen, I have the honour to submit my Annual Report on the health and sanitary conditions of the District, together with the measures taken to safeguard and improve the health of the inhabitants. The report has been written in accordance with the form and under the headings directed by the Ministry of Health, and a perusal of these will indicate the many and varied aspects of public health administration which is now entrusted to the Local Authority. The Housing Scheme has at last reached the stage of erection of houses and a small number were nearing completion at the end of the year. The work of caring for the health of mothers and young children has been actively followed up and the transfer of the Heath Road Maternity and Child Welfare Centre to Radnor House has much facilitated and improved the conditions under which the duties of that Centre were carried out. A house and grounds have been bought for adaptation for the purposes of a Maternity Home, but arrangements for its use had not been completed when the year ended. 34 The older but none the less important features of Public Health work such as the supervison of the sanitation of dwellings, of the supplies of milk and other foods, and the prevention and treatment of infectious disease have continued to receive adequate attention and one can look back upon a year of satisfactory health conditions, with steady effort towards the improvement of the health of the community which is the aim of all concerned. I am, Sir and Gentlemen, Your obedient Servant, George. H. Dupok. Medical Officer of Health. 35 NATURAL AND SOCIAL CONDITIONS. As these have been referred to in previous reports, it is only necessary to mention a few points. General. The district is 2478 acres in area, of which practically 200 acres are public parks. The population has reverted to its pre-war character and only a very small number of Belgians remain. The existing economic conditions have not been such as to lead to an expansion of the industrial population and as the year progressed the number of unemployed men had much increased. St. John's Hospital with its 17 beds, still provides the only general hospital accommodation in the district. In the recently issued report of that institution it is stated that 385 patients were admitted during the year, of which 183 were only detained for one day. The hospital has no out-patient department in the ordinary sense of the term, but 845 casualties and emergencies were treated in addition to those detained. It is impossible to speak too highly of the valuable work done by this little hospital, but its size is obviously inadequate for the needs of the district. I am not aware of the existence of any other institution within the district which provides gratuitous medical relief. VITAL STATISTICS. Population. For the year 1920, the population of the district was estimated by the Registrar-General at 36,406, the nett civil population being estimated at 36,077 Taking the district as a whole. the density of the population is therefore 14.5 per acre. The growth of the 36 population is indicated by the census figures for the past 30 years: 1891 16,026 1901 20,991 1911 29,367 1920 Estimated 36,406 The excess of births over deaths was 444, as compared with 214 and 36 in the two preceding years. Births. Number of births registered 807 Increase compared with 1919 204 Birth rate per 1,000 of the population 22.1 Increase in birth rate compared with 1919 5.4 Comparison with rates of the preceding 5 years: Year No. of births Rate per 1000 of population 1915 678 20.5 1916 723 19.9 1917 559 14.2 1918 553 14.3 1919 603 16.7 1920 807 22.1 The illegitimate births numbered 51. One out every fifteen of the total births was illegitimate, the proportion being the same as last year. Deaths. Number of deaths 363 Decrease compared with 1919 26 Death rate per 1000 of the population 10.61 Decrease compared with 1919 0.6 Death rate for England and Wales 12.4 37 Comparison with preceding 5 years: No. of Rate per 1000 deaths of population 1915 395 11.96 1916 423 12.69 1917 370 10.34 1918 517 15.04 1919 389 11.21 1920 363 10.61 As compared with 1919, there was, by the number indicated in brackets an increase in deaths from the following diseases : Zymotic diseases (which include the common infectious diseases) (7); Pneumonia (8); violence and suicide (8); Alcoholism and cirrhosis of the liver produced three deaths, as compared with two last year, and an average of 7.3 for the 10 years prior to 1916. There was (by the number indicated) a diminution in the deaths from influenza (25), pulmonary consumption (7) and cancer (11). Following were the principal death rates per 1,000 of the population: Zymotic Diseases 0.33 Tuberculosis (All forms) 0.83 Cancer 1.19 Infant deaths. Nett deaths under one year of age 47 Rate per 1,000 births 58.2 Average for preceding 5 years 89.6 Death rate per 1,000 births of legitimate infants 48.9 Death rate per 1,000 births of illegitimate infants 196.0 38 The infant mortality rate was only 58.2 and was 8.1 per 1,000 births less than the preceding year, which in its turn was the lowest infant death rate recorded in this district. The average death rate of infants in 148 towns of England and Wales of populations between 20,000 and 50,000 during 1920, was 80. To put it in another way, out of every 1000 babies born in other towns of approximately the same population 80 died during the first year of life, while in Twickenham only 58 failed to reach their first birthday. Following are the infant mortality rates for Twickenham during the past 20 years: Year Rate Year Rate 1901 118.0 1911 111.7 1902 139.0 1912 68.7 1903 115.4 1913 79.7 1904 150.7 1914 80.5 1905 122.0 1915 100.2 1906 133.1 1916 85.6 1907 112.4 1917 82.2 1908 93.2 1918 113.9 1909 79.6 1919 66.3 1910 89.0 1920 58.2 An analysis of the causes of death of children under five years of age is given in Table III, page 75. SANITARY CIRCUMSTANCES. Water supply. The water supply is that of the Metropolitan Water Board and is constant. Only a few wells exist in connection with outlying cottages. None were closed during the year. As a result of notices served, 19 cisterns used for the supply of water for drinking and domestic purposes were 39 efficiently covered and 108 draw-off taps were placed on the house mains in substitution for the supply from uncovered and often inaccessible cisterns. Drainage, Sewerage, and Closet Accommodation. The sewerage system is arranged on the "separate" system, and the sewage is dealt with at the Council's Sewage Disposal Works. Practically all the houses in the district are connected with the sewerage system and 99.9 per cent. have water closets. The satisfactory condition which obtains in the district generally, does not apply to the considerable area known as Eel Pie Island. On the Island there is an hotel, 20 bungalows and week-end residences, besides tea gardens, and in addition to the regular summer residents, many thousands of persons resort to the island for short periods of one day or less. The island is not sewered and no collection of house refuse is arranged by the Council. This unsatisfactory state of affairs has been brought to the attention of the Council on several occasions. Scavenging. Scavenging is efficiently carried out by the Local Authority under the supervision of the Surveyor. Collection is made once weekly except in a few instances where a special daily collection is made. The refuse is destroyed by burning in the Council's destructor, and during the year 5,712 tons were thus disposed of. 178 sanitary dustbins were supplied in place of those found defective. 40 Sanitary Inspection of the District. The Sanitary Inspectorial staff consists of a Senior Sanitary Inspector and an Assistant Sanitary Inspector, both of whom hold Certificates of the Royal Sanitary Institute as sanitary inspectors and also the Certificates for inspectors of meat and other foods. In addition to the duties of finding nuisances and taking appropriate action in connection therewith, the work of the Sanitary Inspectors includes inspection of dwellings under the Housing Acts, the making of enquiries into and disinfection after infectious disease, the supervision of the sanitary conditions of workshops and workplaces, the supervision of slaughter houses, of restaurants and other places where food is prepared, and of shops where food is sold, especially the shops of butchers, fishmongers, greengrocers and bakehouses, the supervision of the condition of dairies, cowsheds, milkshops and of piggeries, of stables and manure receptacles and of van dwellings. In addition, there are numerous duties of inspection in connection with offensive trades, under the Acts which regulate the storage of petroleum and under the Shops Acts. Inspections. For all purposes the Inspectors made 5350 visits of inspection and re-inspection during the year. A tabulated statement of these visits will be found at the end of the report, table V, page 77. Notices served. The Intimation Notices served during the year numbered 572 and the majority were duly complied with. The Statutory Notices carried forward from the preceding year were 22, and it was found necessary to serve 171 legal notices during the year. Of this total of 193 Statutory Notices 177 were complied with during the year. 41 Premises controlled by Byelaws, etc. Fish Frying. This is the only scheduled "offensive trade" in the district and is carried out at 6 premises. 41 visits were paid to these during the year by the Inspectors. Pig-keeping. In order to encourage food production during the war, permission was granted to several persons to keep pigs in places such as the gardens of small houses which were not in accordance with the terms of the nuisance byelaws. This permission was given in the form of licences for one year, and during the year under review 19 such licences were issued, and 111 visits of inspection were made to the piggeries. On the whole the sties and surroundings were well kept, but the situation in many cases was obviously unsuitable for permanent occupation for this purpose. Underground Sleeping Rooms. Owing to the scarcity of housing accommodation, a very considerable number of rooms are being used both for living and sleeping, the floors of which are 3 feet or more below the surface of the street adjoining, but practically all are at least 7 feet in height and consequently do not fall within the definition of dwellings unfit for human habitation as defined by Section 17 of the Housing, Town Planning etc., Act, 1909. Those in use are basement rooms in old houses which, although unlettable before the war, are now regularly and fully occupied. No regulations have been made by the Local Authority to secure proper lighting or ventilation of these rooms. 42 Tents, Vans and Sheds. For the past two years, there have been intermittent camps of itinerant van dwellers on the vacant land adjoining Hounslow Road, Whitton. No sanitary accommodation existed and water supply was obtained from neighbouring cottages. At first, three or four caravans stayed for short periods, and as usual when inspections were made and notices served, the caravans moved to another district. During the year 1920, the camp became permanent and the number of vans at any one time varied considerably between 4 and 24, with approximately 100 occupants for whom the owner of the land provided some water closet accommodation and water supply from a stand pipe. The interiors of the vans were, as is usually found, kept in a cleanly condition, but there was much littering of the surrounding ground with rubbish and even if no actual public health nuisance arose, the existence of these camps was unsightly, and doubtless also the behaviour and language of the van dwellers were not at times altogether refined and were undoubtedly a source of acute annoyance to the residents in the neighbourhood. The Council accordingly applied to the Ministry of Health for approval of Byelaws to regulate the sanitary condition of these moveable dwellings and after some delay, these were allowed by the Ministry in December, 1920. As soon as these Byelaws were in force, notices were immediately served on the owner of the land to provide adequate sanitary accommodation, but on account of the behaviour of the occupiers of the vans, it was found possible to proceed under a Byelaw dated 1893, against the owner of the land for permitting "any such land, within one hundred yards of any street, or of any dwelling house, to be 43 occupied so as to cause annoyance, injury or disturbance to residents in the neighbourhood, by any tent dweller, squatter or gipsy, or other person dwelling in a tent, van, or other similar structure." Action under this Byelaw was contemplated at the end of the year. Schools. Sanitation. All the schools have been visited and reported upon by the Inspector of Nuisances during the year. All have a sufficient water supply and the sanitary accommodation is adequate. All the schools are provided with water closets, but these are of an obsolete character in several of the schools where the old trough closets still exist. Infectious Diseases. With the exception of Measles, the incidence of infectious disease in the schools was comparatively light, only 32 cases of diphtheria and 12 of scarlet fever occurring among 4,650 children attending the Public Elementary Schools. The greatest number of cases of diphtheria occurring in any single department of a school was five, and these were distributed over a period of several months. Measles was very prevalent during February, March, April, May and June, after which this disease was practically absent for the rest of the year. The administrative measures taken to deal with the spread of infectious disease in the schools were in accordance with the suggestion of the "Joint Memorandum" and are referred to in the appropriate portion of this report and in the report of the School Medical Officer, page 14. FOOD. Milk Supply. There are 4 cowkeepers in the district and the number of cows is usually 92, the largest number kept at one farm being 70. The cows are inspected quarterly by the Council's 44 Veterinary Surgeon who has sent in an invariably satisfactory report as to the condition of the cows inspected. In addition, the Sanitary Inspectors paid 17 visits of inspection to the cowsheds and no contraventions of the Byelaws were found. From the number of cows given above, it follows that the greater part of the milk consumed is produced outside and brought to the district by rail. There are 20 milkshops in the town and 25 persons are registered as purveyors of milk. 67 visits of inspection were made to the milkshops and 10 contraventions of the Regulations were found and remedied. Meat. Following is a statement of the Slaughterhouses in use: 1914 Jan. 1920. Dec. 1920. Registered 8 8 8 Licensed 2 1 1 10 9 9 There is no public abattoir and no system of notification of time of slaughtering which takes place irregularly. The Inspectors paid 28 visits to slaughter houses and three contraventions of Byelaws were discovered and remedied. No seizure of unsound meat was made during the year, but 2,037 lbs. were surrendered voluntarily. In addition, 14 lbs. of bacon, 7 lbs. tinned meat, and 42 lbs. rabbits were surrendered voluntarily. 196 visits of inspection were paid to butchers shops. Fish and other Foods. In the month of June. 146 tins of tomatoes were seized and condemned by a magistrate. They were a part of surplus army stock and were in a state of decomposition. The Council, after consideration, decided not to take legal proceedings in the matter. 45 222 lbs. of unsound fruit and vegetables were voluntarily surrendered and 11 lbs. condensed milk. The following visits of inspection were also paid:— Fish shops, 115; Greengrocers shops, 90; Restaurants, &c., 28. Bakehouses. There are 17 bakehouses in the district, two being underground bakehouses. Fifty-six visits of inspection were made. Twenty-one breaches of requirements were found and remedied in due course. PREVALENCE AND CONTROL OF INFECTIOUS DISEASE. The following table gives the number of notifications of cases of infectious diseases received during the year 1920, and the preceding nine years:— 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Small-pox - - - - - - - - - 1 Scarlet Fever 41 28 119 98 30 42 26 19 55 39 Diphtheria 97 89 52 92 46 43 32 24 131 77 Enteric Fever — 2 1 9 4 — — — 3 2 Puerperal Fever 2 - 4 6 1 - 2 2 6 6 Erysipelas 7 10 6 22 9 10 3 4 7 14 Measles † † † † † 459 323 528 39 506* German Measles † † † † † 79 544 23 8 - Ophthalmia Neon † † † 3 7 — 8 4 11 8 Cerebrospinal Fever † † † † 3 - 5 1 2 - Pneumonia— Primary † † † † † † † † 8 28 Influenzal † † † † † † † † 18 9 Malaria † † † † 4 † † † 14 5 Trench Fever † † † † † † † † 1 — Dysentery 1 † † † † † † † — 1 Tuberculosis: Pulmonary 52 97 66 62 49 52 43 57 48 39 Non-pul- monary - 29 31 10 6 19 18 18 8 9 † Not notifiable. * Voluntary notifications. 46 Small-pox. In the year 1902, ten cases of small-pox occurred in Twickenham. For eighteen years the disease was absent from the district, but on April 22nd, 1920, I was asked to see an adult female patient in consultation with one of the local medical practitioners, and agreed with him that the case was one of Small-pox. The onset of the disease was on the 15th April, and the rash appeared on the 18th April. The patient, a middle-aged woman, had been vaccinated in infancy but not subsequently, and the scars were faintly visible. The nature of the illness had not been recognised and the patient had moved freely about the district during the first two days after the appearance of the eruption. The source of the infection was obvious. The patient's husband had an attack of what was supposed to be malaria which commenced on March 25th, while he was in Spain and was probably contracted in Barcelona. This illness was not recognised as small-pox and he travelled from Spain to his home in Twickenham without let or hindrance. When seen by me on April 22nd, he had evidence of recent fading scars and the distribution of these on the face, limbs and body, together with the history, removed any doubt as to his having suffered from recent small-pox. The patient was immediately removed to the small block at the Infectious Diseases Hospital, Whitton, which is usually reserved for convalescent cases of scarlet fever, and was treated there until recovery. The immediate contacts were quarantined at home and vaccinated at once. Full enquiries into the patient's movements showed that she had mixed freely with a number of persons and had been into several shops while the eruption was present. Immediate notice of the occurrence of the 47 case was sent to the Ministry of Health and to the medical officers of health of all neighbouring districts, including London. As Medical Officer of Health, I vaccinated 21 contacts under the Public Health (Small-pox Prevention) Regulations and a considerable number were vaccinated by private practitioners and by the Public Vaccinator, to whose authority notice of the occurrence of the case was sent. The case was seen in consultation with me by one of the Medical Officers of the Ministry of Health and the diagnosis confirmed. As slated above, the patient was removed to the small separation block at the Hospital for Infectious Diseases at Whitton, all members of the staff of which were revaccinated. The Council expressed their appreciation of the services of the Sanitary Inspectors and of the Matron and nursing and domestic staff who all volunteered for smallpox duty, and to whose efforts the satisfactory result was chiefly due. Fortunately at the time, there were only a very small number of cases of ordinary infectious disease at the Hospital and these, with the remainder of the staff, were removed to the small Hospital at the Mereway which was last used for small-pox in 1902, and which was partially furnished in anticipation of the occurrence of cases of typhoid fever some years ago. The case of small-pox was not removed to this little Hospital for the following reasons. It was considered likely that several cases might arise and the amount of accommodation for patients at the Mereway Hospital is very limited. The staff accommodation only allows for two nurses and there is no provision for resident domestic staff, and in addition, no staff, either nursing or domestic, was available 48 at the Mereway Hospital. Again the hospital is in the immediate proximity to the Sewage Disposal Works and dust destructor and is approached through and is only two hundred yards away from, one of the poorest and most congested parts of the district. Fortunately no other case of small-pox arose, although all known contacts were kept under observation and fortunately also the number of ordinary infectious disease. remained so low as not to exceed the limited accommodation at the Mereway Hospital. This can only be attributed to good fortune and the possibility of dealing with patients in the same easy way cannot be relied upon in the event of the occurrence of another case of small-pox. The Health Committee considered reports from the Surveyor and myself on the question of making satisfactory and adequate provision for small-pox, but no definite decision had been arrived at by the end of the year. Scarlet Fever. The number of cases notified was 39, being 6.8 below the average for the preceding nine years. The attack rate was 1.07 per thousand of the population. There were two deaths from scarlet fever, the mortality rate being 5.1 per 100 cases. The monthly incidence of cases was:— January 3 July 5 February 1 August 2 March 4 September 1 April 1 October 4 May 3 November 3 June 3 December 9 Total 39 49 Diphtheria. The number of notifications was 77, being 54 less than during the preceding year, and 10 higher than the average for the preceding nine years. Deaths from diphtheria numbered four. The mortality rate per 100 cases was 5.2. The monthly incidence of cases was:— January 18 July 3 February 11 August 1 March 13 September 3 April 4 October 6 May 4 November 4 June 7 December 3 Total 77 As mentioned in last year's report, there had been a considerable prevalence of diphtheria in the last three months of the year 1919. In December of that year, 45 cases were notified but from that time there was a rapid fall in the number of notifications. In January, 1920, eighteen cases were notified and after March, only 35 cases occurred during the remainder of the year. The cases notified were distributed fairly evenly throughout the district, except in the Whitton ward, where only one case occurred during the year. Administrative measures, bacteriological examinations, etc. All school classes in which a case of diphtheria had occurred were visited daily by the nursing staff for ten days after the occurrence of a case, and the throats of all the members examined. 50 For this purpose classes were examined on 136 occasions. In addition the homes of the children stated to be absent on account of sore throat or other doubtful infectious disease have been visited. The facilities thus offered have been appreciated by the parents, the nurses are frequently called in to see children who have doubtful symptoms, and by these measures, several cases have been discovered early and medical treatment obtained. Free use is made of swabs for bacteriological diagnosis of diphtheria. Fifty-nine swabs from doubtful throats were taken by the School Medical Staff, either at the schools, at the school clinic, or at the homes of children, and 21 of these were found to contain the bacillus of diphtheria. Routine examination of swabs from the throats of home contacts with diphtheria, prior to return to school, has not been undertaken. No restriction is placed on the use of swabs by medical practitioners, and diphtheria anti-toxin has been freely available, a charge only being made in cases where the patients were considered to be able to pay the cost price. Disinfection has been carried out by spraying rooms with formaldehyde solution and soaking the bedclothes in disinfectant solution. Removal of bedding, etc., for steam disinfection in the Washington-Lyons disinfector, has been carried out after small-pox, typhoid fever, home cases of scarlet fever and diphtheria, and advanced cases of tuberculosis. The services of the nurse appointed by the Council to nurse cases of epidemic disease in the patients' own homes, have been of great value. This has been noted especially in connection with measles, ophthalmia neonatorum and pneumonia. 51 Measles. This disease is no longer compulsorily notifiable and in consequence it is not possible to give the exact number of cases, but by information received through the schools and the nursing staff, it has been evident that there was a marked prevalence in March, April, May and June. The age and ward incidence are set out in table IV, page 76, at the end of this report. In all, 506 cases came to the knowledge of the department and the majority of these were visited and verified by the nursing staff. As only one case proved fatal, it may be assumed that the type was mild. Typhoid Fever. Two cases of this disease occurred during the year, one in July and one in November. The first was a travelling railway official, who probably contracted the disease outside the district. The case proved fatal the day after the notification was received. The other case was also apparently an isolated one and beyond a history of the patient having partaken of oysters on several occasions, no definite cause could be ascertained. As this patient could not be nursed at home, and as there is no provision at the Twickenham Isolation Hospital for the reception of cases of typhoid fever, the patient was removed to the London Fever Hospital and treated there. It should be noted that each case thus dealt with costs at least £50. In neither case was there any extension of the disease. Encephalitis Lethargica. One case of this disease was notified and notification of the death of the patient was received at the same time. 52 The practitioner in charge of the case informed me that the diagnosis was confirmed by an eminent specialist. On careful enquiry no source of infection could be traced. Particulars of the case were sent to the Ministry of Health. Cerebro-spinal Fever and Acute Poliomyelitis. No cases of these diseases occurred during the year. Ophthalmia Neonatorum. Eight cases of acute inflammation of the eyes of newborn babies were reported, and in each case the services of the Council's home nurse were given. All ended in complete recovery. The births were attended as follows:— By midwife only, 4; doctor and midwife, 2; doctor and untrained nurse, 2. Puerperal Fever. Six cases of puerperal fever were notified, being one case in every 134 births. Three of the cases were fatal. The confinements were attended as follows:— By midwife, 3 ; doctor and midwife, 3. Anthrax. Notice having been received from the City of London that certain shaving brushes had been found infected with anthrax, and that brushes from the same consignment had been delivered to two retailers in Twickenham, arrangements were immediately made to stop the sale of these brushes, and all were returned to the wholesaler with the exception of one brush which had been sold and could not be traced. 53 In December, 1920, the Council decided to make human anthrax a notifiable disease, and application was made to the Ministry of Health for approval. Pneumonia. Thirty-seven cases were notified, of which 28 were acute primary pneumonia and nine were influenzal pneumonia. The services of the epidemic nurse were of much assistance in nursing these cases. Malaria and Dysentery. Five cases of malaria were notified, all being men who had contracted the disease while on active service in the East. One notification of dysentry was received, the disease being contracted during military service in India. This man was found to be a milk carrier for a well known firm of dairymen. In accordance with the Public Health Regulations, 1919, I gave him notice to discontinue this occupation. He was kept under close observation and after an interval was admitted to a military hospital where he was detained for three months. On his discharge he received a certificate from the military hospital stating that he might resume his work as a milk carrier and on enquiry later, appeared quite well. No further case arose. Tuberculosis. Of the notifications received, 48 related to cases which had not been previously notified in this distiict. Of these, 39 were cases of pulmonary disease and nine of the non-pulmonary form. 54 All new notifications were visited and all cases on the register visited periodically throughout the year. With the consent of the notifying practitioner, many new cases were referred to the Tuberculosis Officer and the School Medical Officer arranged to examine all contacts of school age in the affected households. MATERNITY AND CHILD WELFARE. The duty of caring for the health of mothers and young children offers more scope for valuable work of a true preventive character than any of the other efforts which are being made to preserve life and health. It may be predicted with confidence that many of the defects which are now met with during medical examination of children of school age, will not be found when supervision of the children between the ages of two and four years is carried out in a manner equal in efficiency to that now available for school children and young infants. This, no doubt, will come in time, and merely requires some expansion of the medical and nursing staff for its satisfactory realisation. A description of the scheme as at present developed in the district shows that although much valuable work is being done, there are gaps which are either entirely unbridged, or over which the bridges are of a somewhat slender character. This is specially seen in connection with the care of expectant mothers and the provision of beds in a maternity home or hospital. Committee. The Maternity and Child Welfare Committee is the Health Committee of the Council. Three lady members are co-opted and a sub-committee attends to matters of detail. 55 Midwives. There are eight midwives in the district, five trained and three untrained. The number appears to be sufficient, although some appear to take on more cases than can be attended personally with complete efficiency. The control of midwives in this district is in the hands of the Middlesex County Council and not the local district council. Care of Expectant Mothers. The arrangements for consultations for expectant mothers were continued by Dr. Hatton and advantage was taken of the opportunities, but to a somewhat limited extent, there being 65 of these consultations during the year. It is unlikely that this aspect of the work will develop very rapidly until the opening of the long expected Maternity Home, where consultations for expectant mothers will become a routine preliminary to admission and can with advantage be continued with the other work of the Home. Maternity Home. As mentioned in the report for 1919, the Maternity and Child Welfare Committee had devoted considerable attention to the question of providing a maternity home and were endeavouring to find suitable premises. The possibility of joint action with neighbouring districts had been suggested and representatives from the Council attended a conference with the Teddington District Council, on January 12th, 1920, at which the representatives of both Councils unanimously agreed upon the principle of establishing a maternity home, managed by a joint committee of the two Councils. About the same time, a conference of representatives of various authorities in South Middlesex was convened by the 56 Middlesex County Council, and it was suggested that a maternity home should be established in Twickenham and should receive patients from Twickenham, Teddington, Hampton, and adjacent portions of the County in which the County Council is the authority for the administration of the Maternity and Child Welfare Act. Assurances were received from the Teddington Council and the Middlesex County Council that they would agree to joint action in maintaining a maternity home if established in Twickenham. Hampton Urban District Council later declined to enter into the scheme. The Twickenham Council then purchased the private house with grounds of about two acres, known as Hedingham House, which is situated in the Hampton road, close to the boundary, where the Twickenham and Teddington districts join. The house consists of a basement with three stories above and, when adapted, will provide accommodation for 12 beds for patients and the necessary isolation beds. A report on the suggested adaptation and staffing was presented to the Council in November, 1920, in which it was estimated the cost would be as follows:— Capital—House and grounds £2,600 Alterations, etc. 3,600 Furnishings 1,500 £7,700 Annual—Maintenance £1,800 Repayment of loans and interest 1,000 £2,800 57 It was pointed out that a sum of approximately £900 per annum should be received from patients, and that a grant of 50% of approved nett expenditure might be expected from the Ministry of Health. A caretaker was placed in the house, but as negotiations were not completed a commencement of the work of adaptation of the house had not been made at the commencement of the year. Notification of Births. The number of births of living children registered during the year was 807, and as there were only 20 failures to notify births, it would seem that the constant reminders to doctors and nurses which have been sent from the Health Department have not been in vain. Twenty still births were also notified. Five hundred and sixty-one first visits were paid to notified births. Care of Infants and Young Children. The Health Visitors have actively continued the work of visiting homes where births have occurred and their assistance and advice have been much appreciated. Two Health Visitors are now engaged on duties connected with home visiting and the Infant Consultation Centres. The following visits were paid by the Health Visitors:— To expectant mothers (special visits) 13 To infants under 1 year: first visits, 561; Total 3133 To children 1-5 years 677 In addition, visits of enquiry were made to notified cases of puerperal fever, ophthalmia neonatorum and to infants and young children suffering from measles, whooping cough and epidemic diarrhoea. 58 Home Nursing. The services of the home nurse have been of the greatest value. Her duties have been chiefly those of nursing in their own homes infants and young children under the age of five years and especially those suffering from ophthalmia neonatorum, measles, whooping cough and summer diarrhoea. Nursing assistance has also been given in those cases of puerperal fever where the patient has been nursed at home. The remainder of the nurse's time has been occupied in assisting in the work of the School Medical Service. Infant Consultation Centres. Arrangements were made at the end of 1919 to transfer to Radnor House, the work carried on for the previous three years at the Heath Road Centre. This has been a much appreciated change. It has been possible, not only to see a much larger number of children and mothers at each session, but the more commodious premises and the fact that the building is also the offices of the Public Health Department have much facilitated and increased the efficiency of the work, whilst it has been possible to develop still further the social side. The second centre at St. Margaret's has more than fulfilled expectations and has proved a great convenience to mothers in the eastern portion of the town. The attendance throughout the year has been excellent. The attendances for consultations during the year were as follows:— Children under one year 2336 Children over one year 645 Total children 2981 Mothers 80 3061 59 It has not been found possible to arrange a Centre to serve the Whitton portion of the district. The existing Centres are so situated that the distance is too great for mothers or young children to attend from Whitton, and the same difficulty arises in connection with the attendance of the younger school children at the school Clinic. The matter was reported upon to the Maternity and Child Welfare Committee and to the Education Committee and both expressed approval of the suggestion that, if suitable premises could be obtained, a combined Child Welfare Centre and branch school Clinic should be established in Whitton. Unfortunately, it has not been possible to secure suitable accommodation and the matter is therefore still in abeyance. The necessity, however, is as great as ever and the need will be more insistent when the partially erected municipal houses are completed in Whitton. In addition to the more strictly medical aspect of the work of the Centres, the other activities have been continued and the nursing staff have been much helped in these matters by the lady members of the Committee and the voluntary helpers who have attended in turn throughout the year. The baby garments made by the elder girls in several of the schools have been eagerly sought after by the mothers attending the Centres who have been enabled to buy them at the prime cost of the material, while the girls have also had the advantage of a valuable training. Cod Liver Oil Emulsion, Marylebone Cream, and similar additions to the diet of bottle-fed children have also been supplied at cost price. Dried milk has been 60 upplied under the powers conferred by the Milk (Mothers and Children) Orders, 1919 and in accordance with the terms of that Order, and the milk thus supplied has been of the greatest possible value in providing a supply at a comparatively moderate cost, and especially when the amount of ordinary milk obtainable was much restricted. In the large majority of cases the full cost price of the milk was paid by the recipients, but in certain cases, after enquiry into their circumstances, dried milk was supplied at less than cost price or free. During the year 5838 lbs. of dried milk were supplied, approximately equivalent to 58380 pints of milk when reconstituted. The distribution at less than cost price was very carefully safeguarded, all applications being recommended by the Medical Officer to the Centre, countersigned by the Medical Officer of Health, and subsequently submitted to the Committee. The recipients of dried milk at less than cost price were:— Mothers, expectant or nursing—Free, 10; reduced prices, 6; total, 16. Children under 3 years—Free, 21; reduced prices, 32; total, 53. Following is a summary of articles supplied:— Dried milk in 1 lb. packets 5838 Bottles of Cod Liver Oil Emulsion, Petroleum Emulsion, &c., 467 Woollen vests, binders, &c. 255 Virol and chymol, cartons of 965 Other articles 85 A "Babies' Garden Party" and gathering of Mothers attending the Centres, which was again held in the grounds of Radnor House, was extremely successful. Competitions 61 for babies were arranged and tea and entertainment provided through the kindness of the lady members of the committee and other friends, to all of whom thanks were duly conveyed. Infectious Disease under five years. Reference to this is made under the respective diseases, but the action taken may be summarized as follows:— Infectious Disease. No. of cases notified. No. of cases visited. No. of cases nursed. Ophthalmia Neon. 8 8 5 Puerperal Fever 6 4 2 Measles 92 66 6 Epidemic Diarrhœa 6 6 6 STAFF OF THE HEALTH DEPARTMENT. As several of the officers are engaged in duties connected with both the School Medical Service and general Public Health Administration, these are included in the list given below:— Medical Officer of Health: G. H. Dupont, who is also School Medical Officer, Dental Anæsthetist, Medical Superintendent of Maternity and Child Welfare, Medical Officer to one of the Centres, and Medical Superintendent with charge of Patients at the Isolation and Small-pox Hospitals. Medical Officer to Radnor House Infant Welfare Centre (part time): Dr. Helen Hatton. Health Visitors: Miss M. Herron and Miss T. Stubbs. Both are trained Nurses and hold the Central Midwives Board Certificate and the Certificate of the Royal Sanitary Institute for Health Visitors and School Nurses. School Nurse : Miss H. Franklin. Trained. 62 Home (Epidemic) Nurse : Miss L. Manning. Trained. Sanitary Inspectors: L. Marsden (Chief Sanitary Inspector), M. V. Sutcliffe. Both Inspectors hold Certificates as Sanitary Inspectors and as Inspectors of Meat and other foods. Chief Clerk: W. Brearley. Sanitary Inspectors' Certificate, R.S.I. Assistant Clerk: J. W. Cronk. Sanitary Inspectors' Certificate, R.S.I. Assistant Clerk (for Maternity and Child Welfare and School Medical Service): Miss V. Williams. HOSPITAL ACCOMMODATION FOR INFECTIOUS DISEASES. The Hospital for Infectious Disease is situated in Whitton and consists of one large ward block of two wards, respectively eight and six beds, with two observation wards to accommodate one bed each. The ward on the first floor, originally intended for a play room, is now converted into a ward and can take four beds. There is also a small separate block of two wards in the grounds, which can accommodate four patients, and is used for convalescent cases of scarlet fever. The total number of beds available is therefore twenty for acute cases and four for convalescent patients. Cases of diphtheria and scarlet fever are received and cases of cerebro-spinal fever and Erysipelas have had to be admitted also. On the accepted basis of one bed for each thousand of the population, it will be seen that available beds should be at least 36 in number, without making any allowance for the growth of the town. When scarlet fever or diphtheria is prevalent, the accommodation is at once found to be insufficient, and, in 63 addition, there is insufficient accommodation for the observation of doubtful cases or the proper separation of septic cases, and, at these times of pressure, considerable difficulty has been experienced in effectually separating the sexes. With the present limited accommodation, cases of typhoid fever, complicated measles or epidemic diarrhœa cannot be admitted. The inadequacy of the arrangements for small-pox has been referred to on page 47. The small building at the Mereway, which is supposed to be reserved for small-pox> is that which was used for ordinary infectious disease before the new hospital was built at Whitton twelve years ago. The two small wards could receive two patients of each sex ; there is fair accommodation for two nurses, but none for domestic staff, and in consequence it is extremely undesirable, if not impossible, to use it for the purpose of receiving cases of small-pox. The inadequacy of the hospital accommodation for infectious diseases generally has been reported upon to the Council on several occasions, but the difficulties of erecting new buildings or extending existing buildings during the past few years and at present, are obvious. Nelson Road Hospital. There were 103 admissions to the Hospital during 1920, the diagnose before admission being:— Scarlet fever, 33; Diphtheria, 69; Small-pox, 1—103 In three cases the diagnosis of diphtheria was not verified after observation. Deaths. Scarlet fever, 2; Diphtheria, 4. BACTERIOLOGICAL WORK. Every facility is given to practitioners to send specimens for bacteriological examination and no charge is made for these, nor for the supply of anti-toxin in necessitous cases. 64 The following specimens were sent for examination during the year:— Throat swabs by practitioners and from schools 150 „ „ from isolation hospital 151 Sputum for tubercle bacilli 8 Blood specimen for tubercle and malaria 2 Water for analysis 3 Total 314 HOUSING. General. The shortage of houses, of which details were given in the previous year's report, was no less acute during 1920. The cry has been raised more recently that the demand for houses has been exaggerated. This cannot be truthfully said in reference to Twickenham even although it may apply elsewhere, and it is probable that in this, as in other instances, the "wish is father is to the thought." The call for new houses may not be so loud; people get accustomed, too soon, to living in unsatisfactory surroundings, but the need for more houses is as great as ever. It is by no means certain, however, that the want will be met by supplying houses to let at 20/- to 25/- per week. The majority of those who most require better housing are entirely unable to afford any such sum, and while such rents are necessary, they will continue to live with three or four families packed in a house only suitable for one or two and, in many instances, only one room for each family. It is not easy to see any way out of the difficulty until building costs are materially diminished. During the year 1920, the Council commenced the erection of 68 houses as a first instalment of the scheme. Of these, twenty-four were to be situated in Tower Road 65 and Riverview Gardens, leading to Cross Deep, and 44 in Prospect Crescent and Kneller road, Whitton. None of the houses were ready for occupation by the end of the year, but the work was in progress on 24 of the houses in the Cross Deep estate, and on 44 houses in Whitton. The Council, by the termination of the year, had authorised the erection of 145 houses. I am indebted to the Surveyor for the above figures and the following particulars. The types of houses in the Council's Housing Scheme include:— Type A. Flatted houses. Each house containing living room, scullery and two bedrooms. Type B. Living room, scullery and three bedrooms. Type D. Parlour, living room, scullery and three bedrooms. Type E. Parlour, living room, scullery and four bedrooms. All the houses are provided with w.c., separate bathroom, larder, and inside coal store, and are fitted with dresser, cupboards and ample shelving. The plans of the various houses are arranged so as to secure as far as possible the maximum amount of sunlight to the living rooms and bedrooms. The stairs, which start from a small entrance lobby with space under for cycle or perambulator, are lighted by landing windows, and the larders are placed on the north and east side of the house. The houses generally are erected in blocks of four with a passage on the ground floor between the second and third houses of of each block, in order to provide separate means of access to the back, and are constructed of 9-inch brickwork, finished with cement roughcast or stucco, and the roofs covered with tiles. 66 In order, however, to secure variety, some of the houses are erected in pairs, and mottled facing bricks and small slates are used instead of roughcast and tiles. All the houses are fitted with casements and hopper lights, and the joinery finished with wood preserving stain. Gas is used throughout for lighting and hot water supplies, the living rooms fitted with "Servall" stoves, which can be used either as a cooking stove or open fire, and a gas cooking range is provided in the scullery. Nine houses had been erected by private enterprise, but as these were apparently for sale and could not be rented, they were vacant at the end of the year. Overcrowding. Practically no action has been possible in reference to overcrowding; the impossibility of finding any alternative accommodation has immobilised families under whatever circumstances they might find themselves. Fitness of Houses. The general standard of housing may be described as unsatisfactory, and as regards the older property, is poor. With the present cost of repairs, these are, in most instances, put off until compulsion is brought to bear, and however much one's sympathy may be with some of the owners of small property, it must be remembered that ownership brings with it responsibilities as well as profits. It will surely be conceded that, for the health of the inmates, the following at least are essential in a town like Twickenham:— The dwelling should be (1) free from dampness, (2) efficiently lighted and ventilated, (3) should have a water supply free from the possibilities of contamination, (4) should have an efficient dustbin, (5) should possess effective 67 and satisfactory closet accommodation and drains, and (6) should be provided with satisfactory arrangements for cooking and washing. These should be the minimum requirements, and it must be confessed that a large number of the smaller dwellings in the district fall short of this moderate standard of efficiency. Most of the defects found on housing inspection are included under dampness, uncovered water supply cisterns, and defective dustbins. Section 28 of the Housing and Town Planning, etc., Act, 1919, provides that if the owner of any house suitable for occupation by persons of the working classes fails to make and keep such house in all respects reasonably fit for human habitation, the Local Authority may serve a notice on the owner requiring him to execute such works as may be necessary to make the house in all respects reasonably fit for human habitation. There is, however, a proviso that if the house is not capable, without reconstruction, of being rendered fit for human habitation, the owner may declare his intention of closing the house for human habitation. If the Local Authority do not agree, the difference is to be determined by the Ministry of Health. As a commencement, representation was made in July in reference to a dwelling that was obviously unfit for habitation. Notice was served on the owner, who stated that he was unable to carry out the repairs, and he declared his intention of closing the house. The Council having differed as to the question of reconstruction, the matter was referred to the Ministry and was not settled by the end of the year. In another instance, voluntary closure was accepted, the tenants ultimately left the cottage and, in consequence, two dwellings were rendered vacant at a time when cottages were unobtainable. 68 The result of representations of extensive dilapidations for actions under Section 28 was not therefore encouraging, and it was found more efficacious to deal with conditions which were nuisances under the appropriate sections, and to represent under Section 28 other conditions, such as defective windows and doors, cooking stoves and washing arrangements, which, added together, render the dwelling not in all respects fit for human habitation. This was found much more successful and has been continued since. No representation as to unhealthy areas was made during the year. Reference to Byelaws as to tents, vans, sheds, &c., and to underground rooms used as sleeping rooms, will be found on page APPENDICES AS TO HOUSING CONDITIONS. 1. General. Estimated population, for birth rate 36,406 „ „ for death rate 36,077 General death rate 10.61 Tuberculosis death rate 0.83 Infantile mortality, per 1000 births 58.2 Number of dwelling houses of all classes 6,832 Number of working class dwelling houses 3,768 Number of new working class dwellings erected during 1920 9 2. Unfit Dwelling Houses. 1. Inspection. (1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 207 69 (2) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 6 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 5 2. Remedy of Defects without Service of formal Notices. Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their Officers 130 3. Action under Statutory Powers. A. Proceedings under section 28, of the Housing, Town Planning, etc., Act, 1919. (1) Number of dwelling houses in respect of which notices were served requiring repairs 5 (2) Number of dwelling houses which were rendered fit— (а) by Owners 3 (b) by Local Authority in fault of owners - (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by Owners of intention to close 1 70 B. Proceedings under Public Health Acts. (1) Number of dwelling houses included under 1 (1) in respect of which notices were served requiring defects to be remedied 77 (2) Number of dwelling houses in which defects were remedied— (a) by Owners 77 (b) by Local Authority in fault of Owners nil C. Proceedings under Sections 17 and 18 of the Housing, Town Planning. etc. Act, 1909. (1) Number of representations made with a view to the making of Closing Orders nil (2) Number of dwelling houses in respect of which Closing Orders were made nil (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit nil (4) Number of dwelling houses in respect of which Demolition Orders were made nil (5) Number of dwelling houses molished in pursuance of Demolition Orders made in 1914 2 71 3. Unhealthy Areas. Areas represented to the Local Authority with a view to improvement schemes under (a), Part I., or (6), Part II., of the Act of 1890 nil 4. (1) Number of houses not complying with the building Byelaws erected with consent of Local Authority under Section 25 of the Housing, Town Planning, &c. Act, 1919 1 5. (2) Staff engaged on housing work with briefly the duties of each officer. Sanitary Inspectors 2 73 TABLE I. Vital statistics of district during 1920 and previous years. Year. Population estimated to middle of year. Births nett. Deaths nett. Number Rate. Under 1 year. At all ages. Number Rate per 1,000 births. Number Rate. 1914 32,000 782 24.4 63 80.5 406 12.7 1915 33,000 678 20.5 68 100.2 395 11.9 1916 36,154 723 19.9 68 85.6 423 12.6 1917 39,867 559 14.2 46 82.2 370 10.3 1918 38,508 553 14.3 63 113.9 517 15.0 1919 36,142 603 16.7 40 66.3 389 11.2 1920 36,406 807 22.1 47 58.2 363 10.6 Area of district in acres 2478 Total population at all ages 29,367 Number of inhabited houses 6,803 Average persons per house 43 At Census of 1911. 74 TABLE II. CAUSES OF DEATH AT ALL AGES DURING THE YEAR, 1920.—(Civilians only.) Causes of death. Males. Females. All causes 190 173 Total 363 1. Enteric Fever 1 — 2. Small-pox — — 3. Measles 1 — 4. Scarlet Fever l 1 5. Whooping Cough — — 6. Diphtheria and Croup 1 3 7. Influenza 3 2 8. Erysipelas 1 — 9. Pulmonary tuberculosis 15 7 10. Tuberculous meningitis 2 1 11. Other tuberculous diseases 3 1 12. Cancer, malignant disease 14 29 13. Rheumatic Fever 1 — 14. Meningitis 1 — 15. Organic heart disease 19 15 16. Bronchitis 12 14 17. Pneumonia (all forms) 13 14 18. Other respiratory diseases 4 1 19. Diarrhœa, etc. (under 2 years) 3 1 20. Appendicitis and typhlitis 3 — 21. Cirrhosis of liver 1 — 21a. Alcoholism 1 1 22. Nephritis and Bright's disease 7 4 23. Puerperal fever — 3 24. Parturition, apart from puerperal fever — 2 25. Congenital debility, etc 11 10 26. Violence, apart from suicide 7 5 27. Suicide 3 1 28. Other defined diseases 62 58 29. Causes ill-defined or unknown — — Special causes (included above)— Encephalitis lethargica 1 — 75 TABLE III. Causes of death among children under 5 years of age. CAUSES OF DEATH. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under one month 1-3 months 3-6 months 6-9 months 9-12 months Total under one year 1-2 years 2-3 years 3-4 years 4-5 years Total under five years Measles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... 1 1 2 Whooping Cough ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Erysipelas ... ... ... ... ... 1 ... ... ... 1 ... ... ... ... 1 Tuberc. Abdominal ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 Bronchitis ... ... ... ... ... 1 1 ... ... 2 ... ... 1 1 4 Pneumonia ... ... ... 1 1 ... 2 4 ... 7 1 ... ... ... 8 Enteritis ... ... ... ... ... 2 1 ... ... 3 ... ... ... ... 3 Gastritis ... ... ... ... ... ... ... 1 1 2 ... ... ... ... 2 Syphilis ... ... ... 1 1 ... 1 ... ... 2 ... ... ... ... 2 Atelectasis 2 ... ... ... 2 ... ... ... ... 2 ... ... ... ... 2 Congenital Malformations 2 ... ... ... 2 ... 1 ... ... 3 ... ... ... ... 3 Premature birth 11 2 1 1 15 1 ... ... ... 16 ... ... ... ... 16 Debility from birth ... 1 ... ... 1 1 ... ... ... 2 ... ... ... ... 2 Atrophy & Marasmus ... ... ... ... ... ... 2 ... ... 2 ... ... ... ... 2 Other diseases 4 ... 1 ... 5 ... ... ... ... 5 1 ... ... 1 7 Total ... 19 3 2 3 27 6 8 5 1 47 2 ... 4 3 56 76 TABLE IV. Notifications of Infectious Disease during 1920. Disease. Under 1 year 1-5 5-15 15-25 25-45 45-65 65 and over South East West Cent. Whitt. Total Scarlet Fever 1 7 20 6 4 1 — 8 12 15 4 — 39 Diphtheria — 9 52 6 10 — — 22 11 29 14 1 77 Enteric Fever — — — 1 1 — — — 1 — 1 — 2 Puerperal Fever — — — — 6 — — 1 — 3 2 — 6 Erysipelas 1 — — 2 3 6 2 4 3 7 — — 14 Measles and German Measles 3 92 411 — — — — 52 173 183 87 11 506 Opth. Neon. 8 — — — — — — — 3 1 4 — 8 Cerebro-Spinal Fever — — — — — — — — — — — — — Encephalitis Letfiargica — — — — — — 1 — 1 — — — 1 Pneumonia P. — 5 2 5 7 7 2 4 6 11 6 1 28 „ Influenzal — — — 3 2 1 3 1 1 2 5 — 9 Malaria — — — — 5 — — — 4 — 1 — 5 Tuberculosis, pulmonary — — 5 9 20 4 1 — 17 16 6 — 39 „ non-pulmonary — 2 4 — 3 — — — 2 3 4 — 9 Small-Pox — — — — 1 — — — 1 — — — 1 Dysentery — — — 1 — — — — — 1 — — 1 77 TABLE V. Visits of Inspectors. Visits and Inspections. No. Premises after complaint 567 Premises after notified infectious disease (not including disinfections) 128 Disinfections after notified infectious disease 155 Dwelling houses (other, including H.T.P.A. and Rent Restriction Act) 37 Factories 36 Workshops, Workplaces and Outworkers 64 Schools 9 Stables 133 Slaughterhouses 28 Bakehouses 56 Cowsheds 17 Dairies and Milkshops 67 Piggeries 111 Restaurants, etc. (including Grocers'shops) 28 Butchers' Shops 196 Fish Shops 115 Greengrocers' Shops 90 Offensive Trades 41 Van Dwellings 13 Properties under notice and work in progress 2,766 Visits under Shops Acts 27 Visits under Petroleum Acts 78 Other visits 588 Total Visits and Inspections 5,350 78 Annual Report of the Medical Officer of Health for the year 1920 on the administration of the Factory and Workshop Act, 1901, in connection with Factories, Workshops and Workplaces. TABLE I.—Inspection of Factories, Workshops and Workplaces. (Including Inspections made by Sanitary Inspectors or Inspector of Nuisances.) Premises. Number of Inspections Written Notices Prosecutions Factories (including Factory Laundries) 36 6 — Workshops (including Workshop Laundries 58 23 — Workplaces (other than Outworkers' premises included in Part 3 of this Report) 2 — — Total 96 29 — TABLE II.—Defects found in Factories, Workshops and Workplaces. Particulars. Number of defects. Number of Prosecut'ns Found Remedied Referred to H.M. Insp'r Nuisances under the Public Health Acts;— Want of cleanliness 14 12 — — Want of ventilation 1 1 — — Overcrowding — — — — Want of drainage of floors — — — — Other nuisances 9 8 — — Sanitary accommodation Insufficient 2 — — — Unsuitable or defective 15 13 — — Not separate for sexes — — — — Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouses — — — — Breach of special sanitary requirements for bakehouses 21 21 — — Other offences 3 3 — — Total 65 58 — — 79 TABLE III.—Home Work. Nil. TABLE IV.—Registered Workshops. Workshops on the Register at the end of the year. Number Bakehouses 13 Bootmaking and Repairing 12 Cycle Repairing 9 Dressmaking 26 Tailors' Workshops 10 Laundries 6 Other 39 Total 115 TABLE V.—Other Matters. Class. Number Matters notifid to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshops Act 3 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshops Acts Notified by I I.M. Inspector 10 Reports (of action taken) sent to H.M. Inspector... 9 Other — Underground Bakehouses in use at the end of the year 2 GEORGE H. DUPONT, Medical Officer of Health, June 1st, 1921.