Tw12 Borough of Twickenham ANNUAL REPORT OF THE Medical Officer of Health 1934 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. Borough of Twickenham. Public Health Department, Municipal Offices, Twickenham. July, 1935. 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 1934, and on the measures taken to safeguard and improve the health of the inhabitants. The town is rapidly increasing in size and now has a population of at least 45,000. The erection of large blocks of flats appears to indicate a change in the attitude of the somewhat better-off inhabitants towards the family house with its front and back gardens which has been the characteristic type of suburban dwelling for generations. While the established branches of the work of protecting the public health have been continued, the establishment of a Clinic for immunization, especially of children, against diphtheria marked a very important development in the campaign against disease, while the arrangements which have been made to provide midwives for necessitous women and home helps for those women who, during their confinement, have no one to attend to the domestic duties of the home, are two measures which add materially to the effectiveness of the scheme for safeguarding the health of the mothers. A further indication of progress is shown in the completion of the scheme for the formation of a Joint Hospital Board to unite Twickenham with five neighbouring authorities for the purpose of providing one hospital for the reception of cases of infectious disease in place of the disconnected small units which have served for this purpose in the past. I am, Ladies and Gentlemen, Your obedient servant. Medical Officer of Health. 3 SUMMARY OF CONTENTS. Page. Section A.—General and Vital Statistics 3 Section B.—General Provision of Health Services 6 Section C.—Sanitary Circumstances of the Area 10 Section D.—Housing 12 Section E.—Inspection and Supervision of Food 14 Section F.—Prevalence of and Control over Infectious Disease 14 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 Register General, to mid 1934 43,477 Number of separate dwellings, end of 1934 12,316 Rateable value, December, 1934 £414,509 Sum represented by a penny rate, gross £1,728 SOCIAL CONDITIONS. While the building of new houses, principally of a semi-detached character, has continued without abatement, the erection of handsome blocks of flats has again been a feature of the building programme of the year. Up to the present this type of dwelling has not been provided for the weekly wage earner. It is interesting to speculate as to whether flats will appeal to him in the same way that they have attracted those who are able to pay a higher rent. There is no tendency to further industrialisation of the Borough, which still remains largely residential. VITAL STATISTICS. Population. The population as estimated by the Register General to the middle of 1934 was 43,477, and this estimate may be accepted as approximating closely to the actual figure. By the end of the year it is probable that the population had reached 45,000. This would indicate an increase in the population of 1,927 during the year, and as the natural increase, i.e., the excess of births over deaths was 138, the balance of 1,789 consisted of persons who had moved to Twickenham from other places. Births. Total births registered 656 Number of live births 629 Number of still births 27 Increase in total births compared with 1933 52 Birth rate (live births) per 1,000 of the population 14.4 The sex and legitimacy of the live births was :— M ale. Female. Total. Legitimate 303 294 597 Illegitimate 22 10 32 325 304 629 The number of still births registered was 27, of which 13 were male. Twenty-five were legitimate and 2 illegitimate. The still birth rate was 41 per thousand of the total births. The proportion of illegitimate births was 1 in every 19 of the total births registered. Deaths. Nett number of deaths 491 Increase compared with year, 1933 24 Death rate per 1,000 of the estimated population 11.5 Increase compared with 1933 0.3 The death rate was practically the same as that for the preceding year and was 0.5 per thousand less than that for England and Wales generally and the same as that for towns of comparable size. 4 CAUSES OF DEATH AT ALL AGES. Year 1934. Registrar General's figures. Causes of Death. Males. Females. Total. All causes 224 267 491 1. Typhoid and Paratyphoid Fevers - 1 1 2. Measles 2 6 8 3. Scarlet Fever 1 2 3 4. Whooping Cough — — — 5. Diphtheria 1 2 3 6. Influenza — 3 3 7. Encephalitis Lethargica — — — 8. Cerebro-spinal Fever — — — 9. Tuberculosis of respiratory system 11 5 16 10. Other tubercular diseases 1 1 2 11. Syphilis — — — 12. General paralysis of the insane, tabes dorsalis 1 1 2 13. Cancer, malignant disease 28 49 77 14. Diabetes 1 5 6 15. Cerebral hæmorrhage, etc. 12 10 22 16. Heart disease 53 69 122 17. Aneurysm 1 — 1 18. Other circulatory diseases 7 14 21 19. Bronchitis 2 5 7 20. Pneumonia (all forms) 20 6 26 21. Other respiratory diseases 2 6 8 22.. Peptic ulcer 5 — 5 23. Diarrhoea, etc. (under 2 years) 3 4 7 24. Appendicitis 3 — 3 25. Cirrhosis of liver 1 2 3 26. Other diseases 01 the liver, etc. 1 3 4 27. Other digestive diseases 11 8 19 28. Acute and chronic nephritis 5 7 12 29. Puerperal sepsis — 2 2 30. Other puerperal causes — — — 31. Congenital debility, premature birth, malformations, etc. 11 8 10 32. Senility — 7 7 33. Suicide 6 4 10 34. Other violence 14 14 28 35. Other defined diseases 21 23 44 36. Causes ill-defined or unknown — — - Compared with the preceding year there was a marked decline in deaths from Influenza Tuberculosis of the respiratory system and Bronchitis, while there was an increase in the number of deaths from Measles, Cancer and Diarrhoea in young children. The deaths from violence excluding suticide, numbered 2S, an increase of 8 over that for the year 1933 and an increase of 18 over the figure for the year 1932. Of the total deaths of Twickenham residents, 136 occurred in the Middlesex Count} Council Institutions principally at West Middlesex Hospital, 75 in hospitals in Twickenham Richmond, London and elsewhere and 3 in Sanatoria. It appears, therefore, that more than 43 per cent. of the deaths of Twickenham residents occurred in hospitals, excluding menta. hospitals. The number of deaths occurring in Nursing Homes cannot be given accurately and is excluded from this figure. Deaths from Infectious Diseases. Disease 1933 1934 Number Rate per 1000 of population. Number Rate per 1000 of population. Measles — — 8 0.18 Whooping cough 3 0.07 — — Scarlet fever 1 0.02 3 0.06 Diphtheria 1 0.02 3 0.06 Enteric fever — — 1 0.02 Influenza 20 0.48 3 0.06 Tuberculosis (pul.) 34 0.81 16 0.36 Puerperal Deaths. Two women died from sepsis in consequence of childbirth during the year. Of these births one occurred in an institution outside the area and one in the Borough, the patient being removed to hospital for treatment. The causes of maternal deaths during the past five years have been as follows :— 1930 1931 1932 1933 1934 From Sepsis — — 1 — 2 From other causes 1 1 3 — — The maternal death rate for the year was 3.0 per 1,000 births. 5 Infant Deaths. Nett deaths of infants under 1 year of age 41 Infant death rate per 1,000 live births 65.2 Infant death rate per 1,000 legitimate births 65 Infant death rate per 1,000 illegitimate births 62.5 Deaths from diarrhoea (under 1 year) per 1,000 live births 9.5 Table of death rates per thousand live births of infants in Twickenham during the Past 25 years. Year Rate Year Rate Year Rate 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 51.4 1917 82.2 1925 70.1 1933 52.0 1934 65.2 The number of infants who died before the end of the first month of life was 18, giving a neonatal death rate of 28.6 per thousand live births. The neonatal death rate for the past live years has been :— Year 1st Week 2nd week 3rd week 4th week Rate 1930 12 — 2 2 28.5 1931 8 1 — 3 19.6 1932 8 2 — 1 18.1 1933 15 1 2 1 32.1 1934 14 2 — — 28.6 The following table shows the deaths of infants under 5 years of age which occurred during 1934. Causes of death of children under 5 years of age, 1934. CAUSES OF DEATH. 1 week 1-2 weeks 2-3 weeks 3-1 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 3-1 years 4-5 years Total under five years Measles ... ... ... ... ... 1 ... ... ... 1 3 ... ... 1 5 Scarlet Fever ... ... ... ... ... ... ... ... 1 1 ... ... ... ... 1 Whooping Cough ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 Erysipelas ... ... ... ... ... ... ... 1 ... 1 ... ... ... ... 1 Tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pneumonia ... ... ... 1 1 ... ... ... 3 4 9 1 ... ... 7 Enteritis & Gastritis ... ... ... ... ... 3 1 1 1 6 ... ... 1 ... 7 Syphilis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Atelectasis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Accident or injury at birth 3 ... ... ... 3 ... ... ... ... 3 ... ... ... ... ... Congenital malformations 3 ... ... ... 3 1 1 ... ... 5 ... ... ... ... 5 Premature birth 5 ... ... 1 6 2 ... ... ... 8 ... ... ... ... 8 Debility ... ... ... ... ... ... ...... ... ... ... ... ... ... ... ... Atrophy and Marasmus ... 1 ... ... 1 1 ... ... ... 2 ... ... ... ... 2 Other diseases 1 1 ... ... 2 1 2 ... 9 7 ... ... l ... 8 Violence ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Inattention at birth 2 ... ... ... 2 ... ... ... ... 2 ... ... ... ... 2 Total 14 2 ... 2 18 9 4 9 7 40 5 1 3 1 50 6 The death rate of infants during the first year of life, per thousand live births, was 65.2. This was somewhat higher than that for the previous year, but was nevertheless a very favourable figure especially taking into consideration the prolonged dry character of the summer. Public Mortuary. During the year 57 bodies were brought into the Mortuary. Thirty-one post-mortem examinations were made and thirty-four inquests were held. 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. Aurist: R. Savage, M.B., F.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. 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. 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, 589 ; over 5 years, 431. Total visits paid, 1020. 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 was not necessary. 7 Midwives. The number of Midwives who declared their intention of practising in the district during the year was 12. The scheme for the provision of midwives for women in necessitous circumstances who desired to be confined at home, came into operation during the year. No application for assistance was received. Home Helps. A scheme for the provision of home helps to carry out the domestic duties of women who were unable to obtain help of this character during labour, the lying-in period or in consequence of some abnormality of pregnancy was considered and approved. 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 9. LEGISLATION IN FORCE. The adoptive Acts and Bye-Laws which are in force in the Borough, and which have been set out in detail in previous reports, remained unaltered. HOSPITALS. For Smallpox. The provision of hospital treatment for smallpox is made by the Middlesex County Council under the " Prevention and Treatment of Smallpox : Regulations, 1928." For Other Infectious Diseases. Other infectious diseases were treated at the Hospital, Nelson Road. In my reports for 1931, 1932 and 1933, reference was made to the consideration which was being given to the proposal to form a Joint Hospital district to comprise the Boroughs of Heston and Isleworth, Richmond (Surrey) and Twickenham, together with the Urban Districts of Hampton, Hampton Wick and Teddington. The deliberations resulted in a decision to apply for a Provisional order to form a united district of the County districts mentioned above, for the purpose of maintaining and managing hospitals for the reception of cases of infectious disease. The provisional order was made and duly confirmed by the Ministry of Health Provisional Order Confirmation (South Middlesex and Richmond Joint Hospital District) Act, 1934. The Joint Board so constituted consists of 19 members, of whom 4 are elected by the Council of the Borough of Twickenham. The day on which it was appointed that the Joint Board should take over the hospitals, was April 1st, 1935. Admissions. The total number of admissions to the hospital during the year was 283, the number admitted during the previous year being 147. Of the admissions, 136 were cases of Scarlet Fever ; 104 Diphtheria ; and 1 Erysipelas. Of the remainder, 22 sent in with a diagnosis of Diphtheria, 13 as Scarlet Fever and 1 as Enteric Fever, were not confirmed on observation. The greatest number of beds occupied on any one day by cases of Scarlet Fever was 26, and by cases of Diphtheria 25. The highest total number of occupied beds on any one day was 34. While, admittedly, the year was a somewhat exceptional one as far as the occurrence of infectious diseases in Twickenham was concerned, the figures set out above constitute an effective justification for the proposed increase in the number and the re-organisation of the provision of hospital beds for infectious disease in the area which will be provided by the new Joint Hospital Board. The degree of severity of the cases admitted to hospital is indicated in the following table :— Mild Moderate Severe Deaths Diphtheria 68 56 12 6 Scarlet Fever 43 60 1 2 The above numbers included cases admitted from Twickenham and other areas. The number of cases admitted from the Borough of Twickenham was:— Diphtheria, 110; Scarlet Fever, 81 ; Other, including cases in which the diagnosis was not confirmed on observation, 29; Total 220. 8 Other Hospitals. The only general hospital in the borough is St. John's Hospital, of which the management is by a voluntary Committee, and there is no resident medical staff. The number of beds is 34. The other hospitals largely used by Twickenham residents are the West Middlesex County Hospital, Isleworth, and the Royal Hospital, Richmond. Extensive use is also made of the general and special hospitals in London. Maternity Homes. There is no municipal maternity home in the borough. Maternity cases are received at almost all the private nursing homes, and admission to the maternity Wards at the West Middlesex County Hospital is much sought after. CLINICS AND WELFARE CENTRES. Following is a list of clinics and treatment centres within the borough :— Name. Address. Days of Attendance. By 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. Diphtheria Immunization Clinic York House Mondays, 2 p.m., Saturdays, 9.30 a.m. Twickenham 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. Following is a table of the use of the casualty ambulance during the year 1934. Total calls Casualty calls Patients carried Mileage Calls during 1933 1st quarter 115 52 116 644.7 99 2nd quarter 123 62 116 730.7 125 3rd quarter 125 70 125 713.0 106 4th quarter 127 63 127 626.8 105 490 247 484 2715.2 435 The casualty calls amounted to 50 per cent. of the total calls during the year. The reciprocal arrangements for the use of the ambulance made with adjoining local authorities have proved satisfactory, and no difficulty or undue delay in dealing with cases has been experienced during the year. 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 (including those taken at the hospital), was as follows :— For Diphtheria, 638; for Tuberculosis, 97 ; Other 4. MATERNITY. The total number of births which were notified as occurring in the borough during the year was 642, of which 27 were still births, 93 per cent. of the births being notified. Of the 642 births which were notified, 462 were notified by midwives and 180 by doctors or parents. Midwives were present in 71.9 per cent. of the births, but it is possible that a medical practitioner was also present in some of the cases notified by midwives. 9 Care of the expectant mother. The Ante-Natal Clinic was held every fortnight throughout the year. The total attendances of expectant mothers numbered 463, of which 129 were first attendances. Calculated on the births which occurred in Twickenham, 20.1 per cent. of the total number of women confined in Twickenham attended the Ante-Natal Centre. It is difficult to estimate the number of expectant mothers who received adequate ante-natal supervision. In most instances some advice was obtained, but in. at least four of the cases of still birth there was no history of any ante-natal supervision and in several the supervision appeared to have been decidedly inadequate. It must not, however, be assumed that this was necessarily due to neglect on the part of the midwife or medical practitioner who attended the confinement, as a certain number of women either fail to recognise the importance of ante-natal care or decline to obtain it for reasons best known to themselves. During the year 101 Twickenham mothers were confined in the West Middlesex Hospital, and 24 in special hospitals in London, and it may be assumed that all these received as complete ante-natal supervision as was possible. It was found that a certain number of expectant mothers who applied to West Middlesex Hospital for admission for confinement but who were subsequently unable to obtain admission, were being kept under supervision at that hospital for a considerable time before they were informed that admission was impossible, the decision frequently being delayed until the confinement was imminent. After consultation with the Medical Officer of Health of the Middlesex County Council, arrangements v/ere being made with a view to a decision as to admission being reached at an early a date as possible, and these arrangements have resulted satisfactorily. Under the scheme for dental treatment, certain expectant mothers received dental treatment and were supplied with sets of artificial teeth. As the County Council have not been able to make arrangements for the dental treatment of mothers attending the Ante-Natal Clinics of the West Middlesex Hospital, expectant mothers residing in Twickenham who are in attendance at the West Middlesex Hospital Ante-Natal Clinics now receive dental treatment at the Twickenham Ante-Natal Centre Dental Clinic. In accordance with requests from the Public Assistance Authority, enquiries were made into the home conditions of 20 expectant mothers living in Twickenham who had applied for admission to the maternity block at the West Middlesex Hospital, and reports furnished to the Committee of that Authority. Birth Control. While it has been permissible for Maternity and Child Welfare Authorities to provide facilities for advice, etc., as to birth control in cases of married women suffering from certain forms of illness, the circular (1408), issued by the Ministry of Health extended the conditions for which advice on this subject may be given to include various other diseases which might render pregnancy detrimental to health. To give effect to this, authority was given by the Council to the Medical Officer of the Ante-Natal Clinics to refer suitable cases to one of the birth control clinics in London. Care of mothers during Confinement. The Corporation have not established a Maternity Home nor have arrangements been made with any Institution for the reception of complicated or difficult cases of labour or of women whose home conditions are unsuitable. Although the services of a consultant are available for medical practitioners in cases of complicated or difficult labour, no request for these services was received during the year. Arrangements for the provision of midwives to attend necessitous women who desire to be confined at home and for the attendance of Home Helps in similar circumstances, were adopted" during the year. Subsequent to Confinement. The services of a consultant are available for cases of puerperal pyrexia when medical practitioners desire a special opinion and the patient is not in a position to afford an adequate fee. The arrangements under which Nursing Mothers were supplied with milk when necessary and whereby dental treatment and the provision of dentures are available, were continued during the year. Child Welfare. Home Visiting. The Health Visitors called at all the homes, when a birth occurred, in 540 cases out of the 619 live births notified. The visits paid to homes by the Health Visitors during the year included the following :— To expectant mothers 257 To children under one year of age 2903 To children between the ages of 1 and 5 years 4327 10 Winter School. One of the Health Visitors attended a revision course during the winter. These courses are attended each year by the Health Visitors in turn and are valuable in enabling them to keep in touch with developments in Maternity and Child Welfare work. 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 S,060, only those attending for consultation or weighing being included. New cases. Centre No. 1. York House. Centre No. 2. Whitton. Totals. Under 1 year 251 86 337 1 to 5 years 85 31 116 Mothers 16 12 28 Total Attendances:— Under 1 year 3460 1156 4616 1 to 5 years 2485 906 3301 Mothers 41 12 53 Total attendances at all the Centres 8000 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 117 children during the year and was obtained in 106 cases. Dental treatment for children under 5 years was given to 31 children. All the cases were extractions of carious teeth, which were carried out under " gas " anaesthesia. Prevention of Deafness. By arrangement with the Education Committee, infants who were found to be suffering from ear disease were allowed to attend at the School Clinic for treatment and if necessary for examination by the Consulting Aurist. Under this arrangement 10 infants attended for treatment during the year. 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 1934 were as follows :— Number of foster children on register at beginning of year 58 Number removed from register 52 Number registered for first time during year 56 Number on register at end of 1934 62 Deaths of foster children 1 SECTION C. SANITARY CIRCUMSTANCES OF THE AREA. The number of dwellings which derive their water supply from wells is negligible. All the new houses erected are connected with the main supply and even in the portion of the district (Heathfield Farm Estate) where most of the wells existed, the Council have guaranteed the cost of a supply from that of the Metropolitan Water Board which supplies the district generally. During the abnormally dry seasons during the years 1933 and 1934, the only restrictions placed on the use of water did not apply to that for drinking and domestic purposes, and any menace to health from this direction did not arise. Although a few cesspools still exist no difficulty has arisen, although the Council have ceased to arrange for the periodic emptying. The remainder of the district is sewered on the separate system and in spite of the erection of large numbers of new dwellings the disposal works have met the demand satisfactorily. The colossal West Middlesex sewerage scheme has not yet commenced to function, although evidence of the activity of those carrying out the works has been only too apparent to persons living in the neighbourhood. 11 The collection of house refuse is carried out under the direction of the Borough Engineer and Surveyor, and from his reports it is noted that 9,130 tons of refuse have been disposed of in the destructor. The removal of trade refuse has not been undertaken with equal success. Many complaints are still being received of nuisance arising from the burning of shop refuse in yards behind shops, with consequent annoyance of those living in the neighbourhood and especially those persons occupying flats over the shops. 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 7,194.' 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 331 Informal notices complied 298 Statutory notices served 9 Statutory notices complied S 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 done in this department of the Inspector's duties will be noted from the list which follows:— Visits to premises after complaint 439 Visits after the occurrence of infectious disease 294 Visits under Housing Regulations 75 Total visits and inspections 7,194 The following works were carried out in consequence of the above visits:— Drains tested 3 Drains unstopped and repaired 70 Waste pipes disconnected or repaired 15 Soil pipes provided or repaired 4 Inspection chambers inserted 2 Complete drainage reconstructions — Water supply cisterns repaired 5 Draw taps from main provided 30 Gutters repaired 43 Roofs repaired 100 W.c. apartments repaired or re-built 28 W.c's repaired 67 Dustbins provided 86 Damp walls remedied 115 Ventilation provided 20 Yards paved or repaired 30 Rooms stripped and cleansed 152 Offensive accumulations removed 9 Other works carried out 535 Schools. The sanitary conveniences, water supply and lavatories were inspected quarterly throughout the year and found to be satisfactory. 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 The number of visits paid by the sanitary inspectors to premises where offensive trades were carried on was 75. 1 12 Petroleum Acts. Fifty-two licences to keep petrol were issued to 49 persons, and 8 licenccs to 6 persons ;o keep carbide of calcium. The number of visits paid by the Inspectors in connection with these premises was 186. FACTORIES AND WORKSHOPS. Number of factories in the district 60 Number of workshops 103 Number of workplaces 1 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. Number of Premises. Inspections Written Notices Prosecutions (1) (2) (3) (4) Factories (including Factory Laundries) 125 5 - Workshops (including Workshop Laundries) 161 5 - Workplaces (other than Outworkers' premises) 1 - - Total 2S7 10 — DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H..M. Inspector. (1) (2) (3) (4) (5) *Nuisances under the Public Health Acts:— Want of cleanliness — — — — Want of ventilation — — — — Overcrowding — — — — Want of drainage of floors — — — — Other nuisances 1 1 — — Sanitary accommodation— insufficient — — — — unsuitable or defective 7 7 — — not separate for sexes — — — — Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (s. 101) — — — — Other offences 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) 6 6 — — Total 14 14 — — *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. 1 13 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. 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 an 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 ihc Year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 357 (b) Number of inspections made for the purpose (excluding re-inspections) 437 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 38 (b) Number of inspections made for the purpose (excluding re-inspections) 81 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 21 (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 336 2 Remedy of defects during the Year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in conscquence of informal action by the Local Authority or their officers 298 3. Action under Statutory Powers during the Year:— A.—Proceedings under sections 17, IS and 23 of the Housing Acts, 1930 : (1) Number of dwelling-houses in respect of which notices were served requiring repairs 2 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 1 (b) 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 served requiring defects to be remedied 7 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 7 (b) By local authority in default of owners Nil 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 7 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 16 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 3 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil 1 14 SECTION E. INSPECTION AND SUPERVISION OF FOOD. Milk. 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 (6 cows kept) Dairymen 17 Purveyors of milk 37 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 2 Meat. Although some registered slaughter-houses remain in the Borough, most of them have not been used for a very considerable period, and slaughtering locally may be said to have ceased. No seizure of unsound or diseased meat was made, but 74 lbs. of beef, 13 lbs. veal, 11½ lbs. cooked ham and 40 lambs' hearts were surrendered during the year. There are 41 butchers' shops in the Borough, which were kept under close supervision, 312 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, 230 visits; fish shops, 95 visits. The following unsound fish was surrendered during the year 84 lbs. skate, 235½ lbs. cod and 14 lbs. kippers. SECTION F. PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. The number of cases of notifiable infectious disease which occurred during 1934 is set out in the following table. Cases in which the diagnosis was not confirmed on observation subsequent to notification are not included. Month Diphtheria Scarlet Fever 1 Puerperal F ever Puerperal Pyrexia Pneumonia Primary Pneumonia Influenzal Ophthalmia Neonatorum Erysipelas Typhoid Fever Acute Poliomyelitis Malaria January 6 7 1 1 — 1 — 6 — — — February 2 11 — — 5 — — 2 — — — March 4 22 1 — 1 2 1 — — — — April 8 31 — — 1 3 — 3 — — — May 12 11 1 — 1 — — 3 — — — June 24 1 — — 1 — — 2 — — — July 11 3 — — 2 — — 4 — — — August 5 4 — — 1 — — — — — — September 24 3 — — — — — 1 — — — October 5 3 — — — — 1 1 — — — November 7 7 1 — — — 1 — — — — December 13 3 — — 2 2 — 1 — — 1 TOTALS 121 106 4 1 14 8 3 23 — — 1 1 1 15 Infectious Disease, 1934. 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 15-05 65, etc. Admitted to Hospital Deaths Diphtheria 121 1 1 3 11 3 56 28 7 9 5 3 1 — 110 3 Scarlet Fever 106 2 9 3 3 7 32 35 6 9 4 3 — — 81 2 Puerperal Fever 4 — — — — — — — — — 4 — — — 1 1 ] Puerperal Pyrexia 1 — — — — — — — — — 1 — — — — — Pneumonia:— — — — — — — — — — — — — — — — — Primary 14 — — 1 1 — 4 — 1 — 1 3 3 — — — Influenzal 8 — — — — — 1 — 1 — 1 9 3 — — — Ophthalmia Neonatorum 3 3 — — — — — — — — — — — — — — Erysipelas 23 — — — — — 2 2 1 1 4 3 8 2 — — Acute Polio-myelitis — — — — — — — — — — — — — — — — Malaria 1 — — — — — — — — — 1 — — — — Scarlet Fever. Of the 106 cases notified, 36 occurred in one residential institution, so that only 70 cases of this disease occurred among the general population of the town. The type of disease was not severe. After the occurrence of 3 cases of scarlet fever in a residential school for boys (Fortescue House School), it was decided to apply what is known as the Dick test to ascertain what number were liable to contract scarlet fever. The ages of the boys at this school ranged from 10—14 Following is a summary of the results:— Boys Staff Total Number tested 12S 6 134 Number of positives 31 2 33 Those found to be positive received 4 inoculations at intervals of one week, with Burroughs Wellcome and Co. Scarlet fever Prophylactic, in the following doses:— lst injection. 2nd injection. 3rd injection 4th injection. 0.2 cc., A. 0.4 cc., A. 0.25 c.c., C. 0.5 cc., C. In no case-was there any undue reaction and no further case of scarlet fever occurred. Diphtheria. The number of cases of diphtheria was considerably in excess of those for the past 3 years. Of the 121 notifications, 33 cases occurred in one institution. The fatality rate of the cases generally was 2.4 percent. of those attacked. After the occurrence of several cases of the disease in a large residential school (Police Orphanage) it was decided to apply the Schick Test to the remainder to ascertain what number were liable to contract diphtheria. The ages of the boys and girls tested varied from 7 to 15 years. Following is a summary of the results:— Number tested 198 Number found positive 106 Those found to be positive were inoculated with three injections of Toxoid-Anti-toxin mixture. This was carried out before the school broke up for the summer holidays. During the last two months of the year three cases of diphtheria occurred in the same school and it is of great interest and importance to note that of these three cases, two were members of the domestic staff who were not immunized, and one was a child who contracted diphtheria shortly after admission to the school and before immunization could be carried out. Other Diseases. An unusual number (23) of cases of Erysipelas were notified during the year. Although it might be expected that a high figure of notifications of this disease might coincide with a excessive prevalence of Scarlet Fever, such a coincidence cannot be traced by reference to the records of the occurrence of these diseases in Twickenham in the past. Measles, which was almost absent from the district during 1933, became prevalent during the first and second quarters of 1934. This disease is not notifiable, but particulars of 123 cases among children of school age were obtained and many cases occurring among children under school age were discovered by the nursing staff when visiting the school children. It is not possible to estimate closely the total number of cases which occurred, but 6 deaths were registered as being due to this disease, a number equal to that of deaths from Diphtheria and Scarlet Fever added together. 1 16 Immunization against Infectious Disease. As set out above, this was carried out in connection with Scarlet Fever at Fortescue House School and with Diphtheria at the Police Orphanage School. In September, 1934, after a report on the subject of immunization against Diphtheria had been submitted, the Council gave instructions for a special clinic to be established for the purpose of testing and if necessary immunization against Diphtheria of such persons who desired to avail themselves of the facilities offered. The Clinic was opened for the first time in December, 1934. At first it was intended to hold one session per week only, but almost immediately after the establishment of the Clinic the numbers applying to be immunized became so great that three sessions per week became necessary. The measures of publicity adopted were to issue notices to every child attending the public elementary schools, and to mothers at the Infant Welfare Centres, the display of postenat these places and the circulation of all parents known to have children between the ages of 1 and 5 years. No special publicity campaign was undertaken, but the response from the schools was immediate and overwhelming. That from parents of children between 1 and 5 years has been less enthusiastic, although it is between these ages that the greatest danger from Diphtheria arises. Table of notifications of Infectious Disease during the past ten years. 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 Anthrax — — 1 — — — — — — — Small-pox — — 1 — — — — — — — Scarlet Fever 36 25 49 71 124 173 102 96 91 106 Diphtheria 37 60 88 117 93 136 64 27 29 121 Dysentery — — — — 28 — — — — — Enteric Fever 3 4 3 3 3 2 1 1 — — Puerperal Fever 2 2 — 3 6 2 6 1 1 4 „ Pyrexia † 3 6 2 8 2 6 4 2 1 Ophthalmia Neonatorum 6 6 3 1 3 1 6 5 — 3 Pneumonia:— Primary 43 19 24 15 22 6 19 14 17 14 Influenzal 5 5 10 5 17 4 6 5 6 8 Erysipelas 13 13 10 17 9 11 7 12 8 23 Malaria — — 1 — — — — 2 1 1 Encephalitis Lethargica 4 1 — — 1 — — — — — Acute Polio Encephalitis — — — — — — — — Poliomyelitis 1 — — — — — — — 1 — Cerebro-spinal Fever — — — — — — — — — — Tuberculosis: — Pulmonary 45 36 42 40 44 49 44 51 27 45 Non-pulmonary 11 13 16 11 13 14 2 9 11 3 1 † Not notifiable Tuberculosis. Following is a table of the notifications of new cases of tuberculosa 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 age- at which death occurred. 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 NonPulmonary Pulmonary Pulmonary M. F. M. F. M. F. M. F. 0 - - - - - - - - 1 - - — - - — - - 5 - - — — — — 1 — 10 9 1 1 — — — — — 15 2 2 — — — - — — 20 2 5 — — — 1 — — 25 2 8 — 2 3 2 — — 35 7 1 — — 1 1 — — 45 5 2 — — 2 — — — 55 5 1 — — 4 — — 1 65 and upwards - - - - 1 1 - - Totals 25 20 1 2 11 5 1 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. 1