AC 439(1) Twickenham TWI 31 Borough of Twickenham ANNUAL REPORT OF THE Medical Officer of Health 1933 GEORGE H. DUPONT, M.D., D.P.H., Medical Officer of Health and School Medical Officer. Twickenham : Printed by Walker & Co. (Printers) Ltd., Heath Road. 73032 Borough of Twickenham. Public Health Department, Municipal Offices, Twickenham. June, 1934. To the Mayor, Aldermen and Councillors of the Borough of Twickenham. Ladies and Gentlemen, I have the honour to submit my Report on the health and sanitary conditions of the Borough during the year 1933, and on the measures taken to safeguard and improve the health of the inhabitants. The increase in the population continues at a rate which would have occasioned surprise a few years ago, but which is now accepted as a regular occurrence. The Registrar General's estimate of the population to the middle of the year was 11,550 and the figure at the end of the year had probably reached 42,000. The Whitton portion of the district, which a year or two ago was almost rural in character, is now becoming covered with houses and their attendant shops, the Chertsey arterial road has reached Twickenham, the centre of the populated area of the Borough is rapidly moving westwards and, at the present rate of building, Twickenham, if restricted to her present borders, will soon become a built-up area. The regular work of safeguarding the health of the town has been continued actively in all its various branches. From the pages which follow, it will be seen that the representation and demolition of dwellings, which are no longer fit for habitation, has been a matter which has received special attention. Many of these have been demolished and their occupants re-housed in modern dwellings, but there are still too many houses which are occupied by two, three or more families without the provision of adequate and separate conveniences, both domestic and sanitary. The necessity for the solution of this problem is more urgent, as far as Twickenham is concerned, than that of overcrowding, at any rate as judged by the present accepted standards. I am, Ladies and Gentlemen, Your obedient servant, George. H. Duport. Medical Officer of Health. 3 SUMMARY OF CONTENTS. Page Section A.—General and Vital Statistics 3 Section* B.—General Provision of Health Services 6 Section7 C.—Sanitary Circumstances of the Area 11 Section D.—Housing 13 Section E.—Inspection and Supervision of Food . 15 Section F.—Prevalence of and Control over Infectious Disease 15 SECTION A. GENERAL STATISTICS. Area of district in acres (exclusive of portion covered by water, including 20 acres added under revision of boundaries) 2,435 Population at Census, 1931 39,980 Population, estimated by Registrar General, 1933 41,550 Number of separate dwellings, end of 1933 10,389 Rateable value, December, 1933 £369,393 Sum represented by a penny rate, gross £1,566 SOCIAL CONDITIONS. The Borough continues to be largely residential in character and, in common with the greater part of the County of Middlesex, the fields are being covered rapidly with houses which sell for prices varying from £'600 to £800 upwards. Many of the older houses, not only the larger three-storied houses, but also many two-storied smaller dwellings, have been let to two or more families, either after adaptation or entirely without any special measures being taken to fit them for the altered use. A new tendency which has now appeared, is the erection of new blocks of flats suitable for persons who are prepared to pay a rent from about £90 per annum upwards. There was no special industrial development in the Borough, the largest local industry being that of fruit preserving in which approximately 145 persons are employed. There are also engineering and engraving works, while the motor garage industry, as elsewhere, employs a considerable number of persons. The Chertsey Arterial Road has now crossed the Thames and has reached Twickenham, and such development as has occurred in its neighbourhood has been of a residential character. VITAL STATISTICS. Population. The population as estimated by the Registrar "General at the middle of 1933 wa s 41,550. This figure, which I believe to be approximately correct, has been used in calculating the various rates based on the total population of the Borough. The estimated increase of the population during the year was therefore 650, and as the natural increase, i.e., the excess of births over deaths was only 24, the balance of 626 consigted of persons who had moved to Twickenham from other places. From general observation a considerable number of families appear to be removing to Twickenham from the South Western parts of London and the intervening suburbs. Births. Total births registered 604 Number of live births 591 Decrease in total births compared with 1932 22 Birth rate (live births) per 1,000 of the population 14.2 The birth rate of 14.2 again shows a decline of 0.5 per thousand of the population below the rate for the preceding year and may be compared with birth rates of 14.4 for England and Wales and of 14.5 for 132 smaller towns with populations of comparable size. The sex and legitimacy of the live births was Male. Female. Total. Legitimate 273 289 562 Illegitimate 13 16 29 286 305 591 The number of still births registered was 13, of which 11 were legitimate and two illegitimate. The still birth rate was 21 per thousand of the total births. The proportion of illegitimate births was 1 in every 20 of the total births registered. 4 Deaths. Nett number of deaths 467 Increase compared with 1932 40 Death rate per 1,000 of the estimated population 11.2 Increase compared with 1932 0.8 The (uncorrected) death rate was somewhat higher than that for the preceding year, but was 1.0 per thousand less than that for England and Wales generally, and practically the same as that for towns of comparable size. CAUSES OF DEATH AT'ALL AGES. Year 1933. Registrar General's figures. Causes of Death. Males. Females. Total. All causes 217 250 467 1. Typhoid and Paratyphoid Fevers - - - 2. Measles — — — 3. Scarlet Fever — 1 1 4. Whooping Cough 9 1 3 5. Diphtheria 1 — 1 6. Influenza 7 13 20 7. Encephalitis Lethargica — — — 8. Cerebro-spinal Fever — — — 9. Tuberculosis of respiratory system 18 16 34 10. Other tubercular diseases - 1 1 11. Syphilis 4 — 4 12. General paralysis of the insane, tabes dorsalis 3 — 3 13. Cancer, malignant disease 29 29 58 14. Diabetes 1 4 5 15. Cerebral haemorrhage, etc. 8 9 17 16. Heart disease 19 65 114 17. Aneurysm 1 I 2 18. Other circulatory diseases 13 13 26 19. Bronchitis ti 14 20. Pneumonia (all forms) 10 18 28 21. Other respiratory diseases 5 7 22. Peptic ulcer — 2 2 23. Diarrhoea, etc. (under 2 years) — — — 24. Appendicitis 1 1 2 25. Cirrhosis of liver 1 1 2 26. Other diseases of the liver, etc. 1 2 3 27. Other digestive diseases i 15 28. Acute and chronic nephritis 6 t) 15 29. Puerperal sepsis — — — 30. Other puerperal causes — — — 31. Congenital debility, premature birth, malformations, etc. 7 8 15 32. Senility 1 10 11 33. Suicide 2 3 5 34. Other violence ... 12 8 20 35. Other defined diseases 21 16 37 36. Causes ill-defined or unknown 1 1 2 Compared with the preceding year, there was an increase in the deaths from Influenza, Tuberculosis of the lungs, Bronchitis, Cancer and diseases of the heart and circulation. The deaths from Violence, excluding suicide, numbered 20, exactly double the number for the previous year. Of the total deaths of Twickenham residents, 142 occurred in the County Council Institutions of Isleworth and elsewhere, 38 in hospitals in Twickenham, Richmond, London and elsewhere, 8 in Sanatoria and 17 in Nursing Hemes. This means that approximately 44 per cent, of the deaths of Twickenham persons occurred in hospitals and other institutions for the reception of the sick, excluding mental hospitals. Deaths from Infectious Diseases. Disease 1932 1933 Number Rate per 1000 of population. Number Rate per 1000 of population. Measles 1 0.02 — — Whooping cough 2 0.04 3 0.07 Scarlet fever — — 1 0.02 Diphtheria 1 0.02 1 0.02 Enteric fever 1 0.02 — — Influenza 11 0.27 20 0.48 Tuberculosis (pul.) 27 0-66 34 0.81 5 It is a source of satisfaction to note that no woman died in or in consequence of childbirth during the year. The causes of maternal deaths during the past five years have been as follows :— 1929 1930 1931 1932 1933 From Sepsis 2 — — 1 — From other causes.2 1 1 3 — Infant Deaths. Nett deaths of infants under 1 year of age 31 Infant death rate per 1,000 live births 52 Infant death rate per 1,000 legitimate births 48 Infant death rate per 1,000 illegitimate births 137 Deaths from diarrhoea (under 1 year) per 1,000 live births Nil The infant death rate was practically the same as that for the previous year and compares favourably with 64 for England and Wales generally and with 56 for towns of comparable size. While deriving satisfaction from these figures, it must always be remembered that calculating the rates for a comparatively small town such as Twickenham, a small variation in numbers causes a marked difference in the rates and conclusion should only be drawn for comparisons over a relatively long period. This is shown in the table of death rates per thousand live births ot infants in Twickenham during the past 25 years. Year. Rate. Year. Rate. Year. Rate. 1909 79.6 1917 82.2 1925 70.1 1910 89.0 1918 113.9 1926 49.0 1911 111.7 1919 66.3 1927 55.4 1912 68.7 1920 58.2 1928 52.0 1913 79.7 1921 84.7 1929 61.1 1914 80.5 1922 70.2 1930 40.3 1915 100.2 1923 72.2 1931 39.2 1916 85.6 1924 54.6 1932 1933 51.4 52.0 The number of infants who died before the end of the first month of life was 19, giving a neonatal death rate of 32 per thousand live births. The neonatal death rate for the past five vears has been:— Year 1st week 2nd week 3rd week 4 th week Rate 1929 14 1 1 1 30.5 1930 12 — 2 2 28.5 1931 8 1 — 3 19.6 1932 8 o — 1 18.1 1933 15 1 2 1 32.1 The following table shows the deaths of infants and children under 5 years of age which occurred during 1933:— Causes of death of children under 5 years of age. 1933. CAUSES OF DEATH. 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 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... ... 2 2 1 ... ... ... 3 Diphtheria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculosis ... ... ... ... ... ... ... ... 1 1 ... ... ... ... 1 Bronchitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pneumonia 1 ... ... ... 1 2 1 1 ... 5 ... 1 ... ... 6 Enteritis& Gastritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Atelectasis 1 l ... ... 2 ... ... ... ... 2 ... ... ... ... 2 Accident or injury at birth ... ... ... ... 2 ... ... ... ... 2 ... ... ... ... 2 Congenital malformations 2 ... ... 1 3 ... ... 1 ... 4 ... ... ... ... 4 Premature birth 2 ... 1 ... 3 ... ... ... ... 3 ... ... ... ... 3 Debility 3 ... ... ... 3 ... ... ... ... 3 ... ... ... ... 3 Atrophy and Marasmus ... ... ... ... ... ... 1 ... ... 1 ... ... ... ... 1 Other diseases 2 ... 1 ... 3 ... 1 ... ... 4 ... ... 1 ... 5 Violence ... ... ... ... ... 1 l ... ... 2 1 ... ... ... 3 Inattention at birth 2 ... ... ... 2 ... ... ... ... 2 ... ... ... ... 2 Total 15 1 2 1 19 3 4 2 3 31 2 1 1 ... 35 6 Public Mortuary. During the year 44 bodies were brought into the Mortuary. Twenty-four post-mortem examinations were made and 24 inquests were held. A refrigerating cabinet capable of receiving two bodies was provided during the early part of the year, and the improvement effected by this change, which would have been a striking one during an ordinary summer, was particularly welcome during the prolonged heat which was experienced during the summer of 1933. The provision of the refrigerating cabinet not only improves the conditions under which post-mortem examinations of bodies can be carried out, but the fact that it is now possible to preserve almost indefinitely the conditions of bodies brought in might be of very great value in medico-legal cases. The other minor alterations which were carried out have also improved to a certain extent the conditions under which the necessarily unpleasant work of post-mortem examinations has to be carried out. SECTION B. GENERAL PROVISION OF HEALTH SERVICES. Public Health Officers of the Local Authority. (a) Medical:— Medical Officer of Health, School Medical Officer, Medical Superintendent of Infectious Diseases Hospitals, and Medical Officer to the Maternity and Child Welfare Committee : George H. Dupont, M.D., C.M., D.P.H. Whole time. Assistant to Medical Officer of Health and Medical Officer to the Ante-Natal Clinic ; Ethel Richmond Emslie, M.D., D.P.H. Whole time. Ophthalmic Surgeon : C. J. Longworth Blair, M.R.C.S. Part time. Dental Surgeon : G. Woolford, L.D.S., R.C.S. Part time. (b) Other:— Senior Sanitary Inspector: Leonard Marsden, Cert.R.S.I., Sanitary Inspector and Inspector of Meat and Other Foods. Whole time. Sanitary Inspector: Major Vincent Sutcliffe, Cert.R.S.I., Sanitary Inspector and Inspector of Meat and Other Foods. Whole time. Health Visitor (Principal): Beatrice Pilkington, S.R.N., Cert., Central Midwives Board and Health Visitors' Certificate, R.S.I. Whole time. Health Visitor: Ethel Dunkley, S.R.N., Cert., Central Midwives Board and Health Visitors' Certificate, R.S.I. Whole time. Health Visitor: Matilda G. Heath, S.R.N., Cert., Central Midwives Board and Health Visitors' Certificate, R.S.I. Whole time. School Nurse : Laura Manning, S.R.N. Whole time. Matron at Isolation Hospital: Gertrude Hunter, S.R.N. (General and Fever). Chief Clerk : Walter Brearley, Cert., Sanitary Inspector, R.S.I. Whole time. Second Clerk : Barbara R. Heslett. Whole time. Clerk for Maternity and Child Welfare and School Medical Service : Violet Williams.. Whole time. Mortuary Attendant: W. Parsons. There was no increase in the number of the staff of the Public Health Department, the only change in the personnel being the appointment of Dr. Ethel R. Emslie, M.D., D.P.H., in place of Dr. P. M. Linnell, who resigned on account of her marriage. Nursing in the Home. General. The Nurses of the Twickenham Nursing Association continued the home nursing of persons who were suffering from those diseases for the nursing of which the Council is able to make provision. Two whole-time nurses are now employed and the part-time services of a third nurse are requisitioned at times. The Council contributed £100 to the Association for these services. 7 From the monthly returns received, the following visits were recorded as paid to patients who came under the Council's scheme :— Visits paid to patients under 5 years, 487 ; over 5 years, 384. Total visits paid, 871. Nursing of Infectious Cases. Cases of Pneumonia, Measles, Whooping Cough and Ophthalmia Neonatorum, were nursed in their own homes. Home nursing of cases of puerperal fever has not been necessary. Midwives. The number of Midwives who declared their intention of practising in the district during the year was 11, and this number appeared to be sufficient for the needs of the Borough. The question of provision by the Corporation, of Midwives for women in necessitous circumstances was considered after receipt of a letter from the Middlesex County Council in which attention was drawn to the principle underlying Section 5 of the Local Government Act, 1929, and suggesting that the Twickenham Maternity and Child Welfare Committee, as a Maternity and Child Welfare Authority, should make provision for the supply of midwives for such necessitous women as are confined in their own homes. The Middlesex Countv Council found themselves unable to enter into an agreement with the Corporation in the matter and requested the Corporation to provide the service in question without any agreement. The Council acceded to this request and approved the scheme of which the following is an outline :— (1) The assistance to be restricted to women desiring to be confined at home. (2) Contributions to be on a scale approved by the Council and based on the nett income and the number of persons in family. (3) The patient to select her own midwife. (4) The fee payable by the Council to the midwife to be £2 10s. Od. for a first confinement and £2 0s. Od. for a second or subsequent confinement. (5) If the patient, who has selected a midwife, is sent into Hospital before or during confinement, a proportion of the fee to be payable to the midwife. (6) The midwife's fee to be payable after a report from the Health Visitor that the case has been completed and satisfactory. As this scheme was only approved at the end of the year, no opportunity has arisen for testing it or estimating the number of applications. From past experience it has been found that almost all mothers in this position in life desire to obtain admission to the Maternity Block of the West Middlesex Hospital. It would be surprising if this were otherwise when one takes into consideration the advantages which admission to such a well equipped hospital confers both in the way of efficient treatment for the patient and the release from the cares of a home where both money and comforts are lacking. Nursing Homes. The Middlesex County Council are the supervising authority for Midwives and for Maternity and Nursing Homes in the Borough. The number of Nursing Homes in the Borough at the end of the year was 7. LEGISLATION IN FORCE. The adoptive acts and the Bye-Laws in force were set out in detail in the report for the preceding year and remain unaltered. HOSPITALS. Smallpox. The provision of hospital treatment for smallpox is made by the Middlesex County Council. For Other Infectious Diseases. Other infectious diseases are treated at the Borough Hospital, Nelson Road. The total number of beds available is:—scarlet fever, 12; diphtheria, 12; special or complicated cases, 6; total, 30. In my reports for 1931 and 1932, reference was made to a series of Conferences which had been held among local authorities in South Middlesex, in connection with the proposal to form a joint hospital district for the area. Further conferences were held during the year and, after many vicissitudes, it appears to be decided that a joint hospital district is to be formed comprising the Boroughs of Heston and Isleworth, Richmond (Surrey) and Twickenham, together with the Urban Districts of Hampton, Hampton Wick and Teddington. The proposal to include the districts of Feltham, Staines and Sunbury in the joint district did not materialise, but the success of the new joint district does not appear likely to be jeopardised by the secession of the three districts last named. 8 Admissions. The total number of admissions to the Hospital during the year was 147, the number admitted during the previous year being 139. Of the admissions, 96 were cases of Scarlet Fever; 27 Diphtheria; 1 Erysipelas; 1 Measles; 1 Meningitis; while of the remaining 21 cases, "the diagnosis was not confirmed on observation. There was 1 death from Diphtheria and 1 death from Meningitis secondary to old standing middle ear suppuration. The greatest number of occupied beds on any one day was 23. The cases of Scarlet Fever exceeded the accommodation officially available for this disease on thirty days, but by use of the cubicle block it was possible to deal satisfactorily with all cases admitted. Twickenham was fortunate throughout the year in experiencing a somewhat low incidence of infectious disease, and in consequence it was possible to admit thirty-two cases from other Authorities who were less fortunate. The number of cases admitted from the Borough of Twickenham was therefore 115. The necessity for the provision of additional accommodation both for patients and staff has been mentioned repeatedly in the reports for recent years, but as this question will have to be faced by the Joint Hospital Board as soon as it is established, no useful purpose would appear to be served by referring to it in detail now. The equipment of the wards and administration block has been maintained in a state of efficiency, but in view of the uncertainty of the position which the hospital may occupy in the future, no structural alterations or additions have been made. It must be pointed out, however, that although the amount of infectious disease occurring in the Borough was small during 1933, the same fortunate condition cannot be expected to continue, and the question of the provision of additional accommodation should be considered without waiting for the actual formation of the proposed Joint Board, otherwise it may be found that even a comparatively moderate outbreak of Scarlet Fever or Diphtheria in Twickenham or the neighbouring districts will find the hospital accommodation for infectious diseases entirely inadequate to deal with the situation. Other Hospitals. The only general hospital in the Borough is St. John's Hospital. The management is by voluntary Committee and there is no resident medical staff. The new X-Ray department was opened during the year and the number of beds has now been increased to 34. Although there is no outpatient department, casualties and emergencies are dealt with in large numbers. The other hospitals largely used by Twickenham residents are the West Middlesex County Hospital, Isleworth, and the Royal Hospital, Richmond. In addition to these, extensive use is made of the general and special hospitals in London. The Corporation again made a subscription of £105 to the Royal Hospital, Richmond, during the year. Maternity and Nursing Homes. There is no municipal maternity home in the Borough, but there are private nursing homes to almost all of which maternity cases are admitted. CLINICS AND WELFARE CENTRES. Following is a list of clinics and treatment centres within the borough :— Name. Address. Davs of Attendance. Bv whom provided. Maternity and Child Welfare Clinic. York house Tuesday, Wednesday, Thursday, at 2 p.m. Twickenham Council Infant Welfare Centre and Branch School Clinic Murray Park hall, Whitton Mondays, 2.30 p.m. ditto Ante-natal Clinic York house Second and last Friday in each month ditto School Clinic, including minor ailments, dental and ophthalmic clinics York house Daily Twickenham Education Committee Tuberculosis Dispensary 1 Staines Road Wednesdays, 10 a.m. Middlesex County Council Ambulances. Two motor ambulances are provided by the Council, one for non-infectious and casualty cases and one for the removal of patients to the Infectious Diseases Hospital. Both are staffed and maintained by the Fire Brigade, and the services in connection with both ambulances have been entirely satisfactory. . 9 Following is a table of the use of the casualty ambulance during the vear 1933:— Total calls. Casualty calls. Patients carried. Mileage Calls during 1932 1st quarter 99 41 102 499.2 108 2nd quarter 125 68 121 544.8 98 3rd quarter 106 63 108 535.9 125 4th quarter 105 47 100 559.1 104 435 219 431 2139.0 435 The casualty calls amounted to 50 per cent, of the total calls during the year. For several years it has been the practice to take to their homes in the neighbouring districts, without charge, persons not residing in Twickenham who have met with accidents in a public place or street in the Borough. In addition, a formal arrangement had been made with the Teddington Urban District Council for the reciprocal use of the ambulances on any occasion on which the ambulance of either district might not be available. In the case of one district, without a municipal ambulance service, although calls to casualties in that district were being attended to by the Twickenham ambulance, the Authority in question were not prepared to enter into an agreement in the matter. This incident was apparently one of the causes of the issue of circular 1356 of the Ministry of Health, in which the Minister desired to be assured that satisfactory arrangements were made between adjoining districts for the reciprocal use of ambulances. The matter has now been placed on a satisfactory footing, and agreements have now been entered into with the Borough of Richmond and the Urban Districts of Teddington and Feltham. Laboratory Facilities. The bacteriological examination of specimens was carried out as usual by the Virol Pathological Research Laboratories in London. The number of specimens sent for examination during the year was as follows :— For Diphtheria, 277; for Tuberculosis, 104; Other, 8. MATERNITY. The total number of births which occurred in the Borough during the year was 594, of which 10 were still births. 98.8 per cent, of the births being notified. Of the 594 births which occurred, 415 were notified by midwives and 172 by parents or doctors. Midwives were present at 70.6 per cent, of the births, but it is possible that a medical practitioner was also present in some of the cases notified by midwives. The scheme for promoting Maternity and Child Welfare as far as it had been developed in the Borough was set out in full in my report for the year 1932, and it is only necessary therefore to give particulars of the services rendered under the various headings during 1933. Care of the expectant mother. The Ante-Natal Clinic has been held every fortnight throughout the year. The total attendances of expectant mothers was 450, of which 133 were first attendances. Calculated on the births which occurred in Twickenham during the year, 22.4 per cent, of the total number of expectant mothers attended at the Ante-Natal Clinic, but as many of the women confined in Twickenham came to nursing homes here for their confinement only, and on the other hand several Twickenham mothers were confined at the West Middlesex Hospital at Isleworth, it is impossible from these figures to draw any accurate conclusion as to the total number of expectant mothers who obtained Ante-Natal care or the degree of Ante-Natal supervision received. Under the scheme for dental treatment, 40 expectant or nursing mothers received dental treatment, principally extractions of carious teeth, and 7 were supplied with sets of artificial teeth. In accordance with requests received from the Public Assistance Authority, enquiries were made into the home conditions of a considerable number of women who had applied for admission to the Maternity block at the West Middlesex Hospital for their confinements, and reports furnished to the Public Assistance Committee. Care of the mothers during confinement. The Corporation have not established a Maternity home, nor have any arrangements been made with any institution for the reception of complicated or difficult cases. If such institutional treatment is required, it is necessary for the medical practitioner in charge of the case to make such arrangements as he can for the admission of the patient to a hospital. The arrangements'under which medical practitioners can obtain the services of a consultant in complicated cases is still in force, but was not utilised during 1933. 10 Subsequent to Confinement. In cases of puerperal pyrexia, the services of a consultant are available when necessary. Nursing mothers, who are in necessitous circumstances, are provided with a supply of milk to supplement their diet. Dental treatment is provided at a nominal charge to nursing mothers who are unable to afford necessary treatment, and they are also provided with artificial teeth in suitable cases in accordance with an approved scale. No provision has been made for examining and advising mothers who have not recovered their proper health after the birth of their children. A number of women in this condition are met with at the Infant Consultations, but the circumstances do not permit any examination of the mother. The necessity for the provision of a clinic for such examinations is as great, if not greater, than that for providing dental or other treatments, and there is no doubt that much ill health could be avoided if such a clinic were established. Child Welfare. Home Visiting. The Health Visitors call at the homes where a birth has occurred in all cases where such visits are considered to be advisable. If deference to the wishes of a very limited number of medical practitioners in the town, home visiting was not offered in certain cases where the doctor indicated that such was not desired. It was found, however, that in many of the cases so indicated, the mother either brought her baby to the Centre on her own initiative or sent a request for the Health Visitor to call. It is now found that these requests that the Health Visitor should abstain from visiting have now been abandoned even by those doctors who raised the question in the first instance, as they have no doubt found by experience, what was pointed out to them in the first instance, that the visits of the Health Visitors are complementary and in no way antagonistic to the services of medical practitioners in caring for the health of mothers and infants. The visits paid to homes by the Health Visitors during the year were as follows:— To expectant mothers 222 To children under 1 year 3,240 To children under 5 years 4,586 Other visits 1,646 Winter School. In accordance with the arrangement which has been in force for several years, one of the Health Visitors attended a short revision course during the winter. By this means one Health Visitor has an opportunity, every third year, of refreshing her knowledge of the work and of becoming acquainted with any modern developments in connection with Maternity and Child Welfare. Infant Welfare Centres. The infant consultations were held on four afternoons weekly, that at Murray Park, Whitton, being held on Monday and those at York House on Tuesday, Wednesday and Thursday afternoons. The total attendances at all the centres numbered 7794, only those attending for consultation or weighing being included. New cases. Centre No. 1. York House. Centre No. 2. Whitton. Totals. Under 1 Year 263 52 315 1 to 5 years 49 18 67 Mothers 11 4 15 Total Attendances:— Under 1 year 3949 784 4733 1 to 5 years 2394 640 3034 Mothers 21 6 27 Total attendances at all the Centres 7794 Treatment is not carried out at the Welfare Centres. When medical or surgical treatment is required the cases are referred to private practitioners or to hospitals. Treatment was advised for 75 children during the year and was obtained in 70 cases. 11 Dental treatment for children under 5 years of age was given to 31 children. This consisted almost entirely of extractions of carious teeth, which were carried out under "gas" anaesthesia in all cases. Infant Life Protection. The Health Visitors are also appointed as infant life protection visitors under the Children Act, 1908. The details as to registration during 1933 were as follows :— Number of foster children on register at beginning of year 73 Number removed from register 57 Number registered for first time during year 42 Number on register at end of 1933 58 Deaths of foster children 1 Failure to give notice of reception of nurse children was detected in three instances and warnings sent. Proceedings were taken against one foster mother who had moved from the Borough taking two foster children with her without having given notice of removal. She was traced to a neighbouring district and, on proceedings being taken a penalty was not inflicted, but the foster mother was ordered to pay 20/- as costs. At the commencement of the year it was noted that two advertisements offering to receive infants for reward appeared in a local paper without giving the name and address of the person offering to receive the children. These persons were traced with the assistance of the editor of the newspaper concerned, and both expressed their ignorance of the provision of the Act. No further action was taken, and an assurance was received from the newspaper that such advertisements would not appear again. Prevention of Deafness. On receipt of circular 1337a from the Minister of Health, in which attention was drawn to the serious results arising from deafness in young children and emphasising the necessity for early treatment of ear disease in infants, a report was submitted on the subject. In this it was pointed out that the number of cases of ear disease in infants would not justify the establishment of a special ear clinic, but that if these cases in infants could attend at an ear disease clinic at the same time as those children of school age for whom special opinion and treatment were also required, there would be sufficient material to occupy the attention of an aurist during one session each month. It was decided to approach the Education Committee with a view to the establishment of a joint clinic, and this arrangement had just been completed at the end of the year. Orthopaedic treatment. No child was dealt with under the scheme for the treatment of crippling defects in children under school age, during the year. Such cases as arose appear to have received treatment at hospitals either locally or in London. SECTION C. SANITARY CIRCUMSTANCES OF THE AREA. There was no important change in the water supply of the district. The few wells which remained are gradually disappearing and all the new houses erected receive their supply from that of the Metropolitan Water Board. The cesspools which still remain on the Heathfield Farm Estate were emptied at regular intervals by the employees of the Corporation, but it is anticipated that before long all cesspools will be replaced by connection with sewers. The collection of house refuse is carried out weekly under the direction of the Borough Engineer and Surveyor, from whose reports it appears that 8,380 tons of refuse were collected and disposed of in the destructor. A number of complaints were received during the year indicating that annoyance was caused to the occupiers of flats over business premises, arising from the burning of paper and similar articles of trade refuse by shop keepers in the yards behind their shops. The smoke and particles arising from this method of destruction of the refuse, however carefully carried out, are bound to cause annoyance to those living above. It is regrettable that no more satisfactory way of dealing with this refuse appears to be practicable at present, for there can be no doubt that many householders have a real grievance in the matter. 12 Sanitary Inspection. The multifarious duties now included in the daily work of sanitary inspection have been carried out satisfactorily during the year. The details of the work, which include domestic sanitation, housing inspection, supervision of food supplies (including milk, meat and other foods), the investigation and abatement of nuisances, the sanitation of workshops and factories, the supervision of offensive trades, the investigation of and disinfection after the occurrence of cases of infectious disease and the storage of petrol and carbide of Calcium, will be found under the appropriate headings, but the mere figures give but little indication of the attention needed to secure effective supervision over the many sided activities of this branch of public health work. The total number of inspections and re-inspections carried out during the year was 7,660. The visits paid in respect of each branch of the duties of the inspectors are set out under the appropriate heading. In consequence of these visits, notices were served on owners or occupiers as follows:— Informal notices (intimations) served . 361 Informal notices complied 312 Statutory notices served 13 Statutory notices complied 12 Domestic Sanitation. Included under this heading will be found the visits paid by the Sanitary Inspectors, under the Housing Regulations, to premises where nuisances were suspected and visits for the purpose of enquiry and disinfection after the occurrence of infectious disease. The extent of the work clone in this department of the Inspector's duties will be noted from the list which follows:— Visits to premises after complaint 537 Visits after the occurrence of infectious disease 270 Visits under Housing Regulations 72 Total visits and inspections 7660 The following works were carried out in consequence of the above visits:— Drains tested 17 Drains unstopped and repaired 93 Waste pipes disconnected or repaired 29 Soil pipes provided or repaired 9 Inspection chambers inserted 1 Complete drainage reconstructions 6 Water supply cisterns repaired 5 Draw taps from main provided 45 Gutters repaired 41 Roofs repaired . 101 W.c. apartments repaired or re-built 36 W.c's repaired 68 Dustbins provided 97 Damp walls remedied 129 Ventilation provided . 16 Yards paved or repaired 25 Rooms stripped and cleansed 195 Offensive accumulations removed 15 Other works carried out . 499 Schools. The sanitary conveniences, water supply and lavatories were inspected quarterly throughout the year and found to be satisfactory. The amount of infectious disease among the scholars was comparatively small, measles being absent almost throughout the year. Offensive Trades. The following offensive trades which have been established were kept under regular supervision :— Fish fryers 8 Fat melters 2 Rag and bone dealers 2 No new offensive trade was established during the year, one application for the commencement of a fish frying business being refused. The number of visits paid by the sanitary inspectors to premises where offensive trades were carried on was 114. 13 Petroleum Acts. Forty-six licences to keep petrol were issued to 43 persons, and 8 licences to 6 persons to keep carbide of calcium. The number of visits paid bv the Inspectors in connection with these premises was 204. FACTORIES AND WORKSHOPS. Number of factories in the district 62 Number of workshops 95 Number of workplaces 4 In accordance with the requirements of the Factory and Workshops Act, 1901, a statement of inspections is submitted, together with the defects found, and the result of action taken. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES, Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. (1) Number of Inspections (2) Written Notices (3) Prosecutions (4) Factories (including Factory Laundries) 133 4 - Workshops (including Workshop Laundries) 143 4 — Workplaces (other than Outworkers'premises) 4 1 — Total 280 9 — DEFECTS FOUND IN" FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. (1) Number of Defects. Number of Prosecutions. (5) Found. (2) Remedied. (3) Referred to H.M. Inspector. (4) *Nuisances under the Public Health Acts:— Want of cleanliness — — — — Want of ventilation — — — — Overcrowding — — — — Want of drainage of floors — — — — Other nuisances 1 1 — — Sanitary accommodation— insuflicient 1 — — — unsuitable or defective 2 2 — — not separate for sexes ... — — — — Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (s. 101) — — — — Other offences ... 5 5 — — (Excluding offences relating to out-work and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factory and Workshops Transfer of Powers) Order, 1921) Total 9 8 — — ♦Including those specified in sections 2, 3, 7 and S of the Factory and Workshop Act, 1901, as remediable under the Public Health Acts. SECTION D. HOUSING. The work of inspection of the district with a view to representing the houses which are unfit for human habitation, and which are repairable at a reasonable expense or not so repairable, has been actively continued. It will be seen from the tables which follow that, in consequence of this activity, demolition orders have been made in reference to a considerable number of unfit dwellings, while extensive repairs have been carried out in order to render the remainder fit for occupation. 14 The condition of families occupying the basements of the older dwelling houses has been a matter of special concern as, in my opinion, this is the most unsatisfactory form of dwelling especially where children are concerned. In all cases the procedure has been to deal with individual unfit houses or parts of houses separately occupied, and in no case has the Corporation declared either for improvement or a clearance area. Following are the details of houses inspected during the year and action taken in connection therewith:— 1. Inspection of Dwelling-houses during the Year :— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 361 (6) Number of inspections made for the purpose (excluding re-inspections) 760 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 37 (b) Number of inspections made for the purpose (excluding re-inspections) 72. (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 6 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 335 2. Remedy of defects during the Year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 312. 3. Action under Statutory Powers during the Year:— A.—Proceedings under sections 17, 18 and 23 of the Housing Acts, 1930 : (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners Nil (ib) By local authority in default of owners Nil B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were 13- served requiring defects to be remedied (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 12. (b) By local authority in default of owners 1 C.—Proceedings under sections 19 and 21 of the Housing Act, 1930 :— (1) Number of dwelling-houses in respect of which Demolition Orders were made 13 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 6- D.—Proceedings under section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 1 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit 2 15 SECTION E. INSPECTION AND SUPERVISION OF FOOD. Milk. It is with a note of regret that the departure of Twickenham's sole remaining milch cow has to be recorded. When this is contrasted with the 145 cows, which provided the greater part of the milk consumed in the district in the year 1910 when I first became your Medical •Officer of Health, the change in the character of the area can be appreciated. Milk is now delivered almost entirely in glass bottles, but the number of persons who have applied for registration to sell milk in sealed cartons tends to increase. No bacteriological examinations of milk samples were made. At the end of the year the register was as follows:— Cowkeepers 2 (No cows kept) Dairymen 15 Purveyors of milk 31 Milk under special designations was sold by dairymen as follows:— Certified milk 9 Grade " A" milk 1 Grade " A " tuberculin tested 9 Pasteurised 9 Licensed to bottle Grade "A" T.T. milk 1 Licensed to pasteurise milk 1 Meat. Although some registered slaughter-houses remain in the Borough, most of them have not been used for a very considerable period, and the amount of slaughtering done locally is negligible. No sei7Aire of unsound or diseased meat was made, but 101 lbs. of beef was surrendered during the year. There are 41 butchers' shops in the Borough, which were kept under close supervision, 290 visits being paid for this purpose by the Sanitary Inspectors. Other Foods. Regular supervision of other shops from which foodstuffs were sold was also exercised, the following visits being paid for this purpose:—restaurants and eating house kitchens and grocers' shops, 323 visits; greengrocers' shops, 193 visits; fish shops, 95 visits. SECTION F. PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. The number of cases of notifiable infectious disease which occurred during 1933 is set out in the following table. Cases in which the diagnosis was not confirmed on observation subsequent to notification are not included. Of those not confirmed on observation thirteen were notified as diphtheria, two as scarlet fever and one as ophthalmia neonatorum. Month Diphtheria Scarlct Fever Puerperal Fever Puerperal Pyrexia Pneumonia Primary Pneumonia Iniluenzal Ophthalmia Neonatorum Erysipelas Typhoid Fever Acute Poliomyelitis Malaria January 0 7 — - 3 3 — — — — February 3 8 1 2 — 1 — — — March 3 12 1 1 — 1 — — April — 7 - - 2 1 — 2 -- - — May 2 10 — — 2 - — 1 — — June 2 4 — — - — 1 — — — July 1 5 1 — — — — — — — August 5 2 — 1 1 — — 1 — 1 — September 2 10 — — — — — — — — — October 4 14 — — — — - — — — — November 1 4 - - — — — 1 — — — December 1 8 — — 1 — — — — — 1 TOTALS 29 91 1 2 17 6 — 8 — 1 1 16 Infectious Disease, 1933. Ages at notification. Disease Total Notifications Under 1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-25 25-35 35 45 45 05 (55, etc. i Admitted to Hospital Deaths Diphtheria 29 - 1 4 2 - 9 1 4 2 3 — 1 — 24 1 Scarlet Fever 91 — — 3 4 10 40 28 1 2 1 1 1 — 69 1 Puerperal Fever 1 — — — — — — 1 — — — — — 1 — Puerperal Pyrexia 2 — - — — — — — 1 1 — 1 — Pneumonia :— Primary 17 1 — — — 2 — — — 2 2 3 6 1 3 28 Influenzal 6 — — — — - 1 — — 1 1 1 — 9 — Ophthalmia Neonatorum - - - - - - - - - - - - - - - Erysipelas 8 - - - - - - - - 1 2 1 4 - - - Acute Polio-myelitis 1 - - - - - - 1 - - - - - 1 — Malaria 1 - - - - - - - - - 1 - - - 1 — The district was again fortunate in experiencing a comparatively light incidence of infectious disease, and the number of cases of scarlet fever and diphtheria notified did not differ to any appreciable extent from those notified during the previous year. Scarlet Fever. Most of the cases admitted to the hospital were of a mild or moderate type. Scarlet fever anti-toxin was administered to 30 out of the 35 cases classed as moderate, and its effect in producing a rapid fall to normal of the temperature, fading of the rash, increased comfort on the part of the patient, and marked diminution of the desquamation stage, was too evident to be merely accidental. The influence of the scarlet fever anti-toxin in reducing the tendency to complications is not easy to estimate accurately. Of the total cases of scarlet fever admitted during the year, the percentage of patients in whom middle ear suppuration developed was 4.7 ; of those to whom scarlet fever anti-toxin was not administered the figure was 4 per cent., and of those to whom scarlet fever anti-toxin was administered, 6.6 per cent, developed ear complications. It must be pointed out, however, that scarlet fever anti-toxin was only given to the moderately severe cases, which would be those among whom ear complications would be more likely to occur, while, in addition, the undesirability of attempting to draw conclusions from percentages based on small numbers must also be borne in mind. The adminstration of scarlet fever anti-toxin did not appear to have any influence in reducing the occurrence of cervical adenitis. Its use, however, has certainly enabled us todischarge patients at an earlier stage than was formerly the practice. Excluding cases in which the diagnosis of scarlet fever was not confirmed on admission, three-fifths of the cases were discharged from hospital between 21 and 30 days after admission. Diphtheria. Of the cases of diphtheria admitted to the hospital, three were of severe type, twomoderately severe and the remainder mild in character. Other Diseases. One severe case of erysipelas, one of chicken-pox and one of complicated measles were admitted, but the limited accommodation at the hospital does not permit the admission of more than occasional cases. Fortunately, however, measles was almost entirely absent from the district during the year and, in consequence, requests for admission of cases of this disease were not numerous. Information as to the occurrence of cases of infectious diseases which are not compulsorily notifiable is obtained satisfactorily from the schools and the Health Visitors and is acted upon as far as possible. No arrangements were made to provide immunization against diphtheria or scarlet fever either in schools or elsewhere. No special steps have been taken to investigate or deal with cases of cancer. Cases of inflammation of the eyes in infants (ophthalmia neonatorum) are visited by the Health Visitors, nursed, if necessary, by the Nursing Association Nurses and re-visited until the termination of the case. No definite case was met with during the year. 17 Table of notifications of Infectious Disease during the past ten years. 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 Anthrax - — - 1 — — — — — — Small-pox — — — i — — — — - Scarlet l ever 27 36 25 49 71 124 173 102 96 91 Diphtheria 20 37 60 88 J17 93 136 64 27 29 Dysentery — - — - — 28 ~~ - - Enteric Fever 1 3 4 3 3 3 - 1 1 - Puerperal Fever — 2 2 — 3 4 9 6 1 1 Pvrexia † † 3 6 2 8 2 6 4 2 Ophthalmia Neonatorum 1 6 6 3 1 3 1 6 5 — Pneumonia:— Primary 18 43 19 24 15 22 6 19 14 17 Influenzal 13 5 5 10 5 17 4 6 5 6 Erysipelas 12 13 13 10 17 9 11 7 12 8 Malaria 1 — — 1 — — — 2 1 Encephalitis lethargica 7 4 1 — — 1 — — — - Acute Polio Encephalitis 9 - — — — — — — — 1 Poliomyelitis 3 1 — — — — — Cerebro-spinal Fever — — — — — —- — — Tuberculosis:— 27 Pulmonary 56 45 36 42 40 44 49 44 51 Non-pulmonarv 10 11 13 16 11 13 14 2 9 11 † Not notifiable Tuberculosis. Following is a table of the notifications of new cases of tuberculosis received during the year, with the ages at the time of notification and a table of the deaths which occurred as the result of tuberculosis, with the ages at which death occurred. Age Periods New Cases Deaths Pulmonary XonPulmonary Pulmonary NonPulmonary M. F. M. F. M. F. M. F. 0 - - - - 1 - - - 1 - - - 1 - - - - 5 - - 1 - — — — - 10 1 — - 1 — — - - 15 1 1 — — — — — ' ' 20 3 — — 1 2 3 — - 25 0 6 — 2 5 3 — 1 35 1 1 — — 2 5 - - 45 3 — 1 — 4 2 - - 55 2 3 — — 3 3 — 03 and upwards - - - - 1 - - - Totals 16 11 6 5 18 16 — 1 The treatment of cases of tuberculosis is carried out by Officers of the Middlesex County Council, but all cases residing in the Borough were visited at regular intervals by the Health Visitors of the Corporation. :-7