Twi 4 Borough of Twickenham ANNUAL REPORT OF THE Medical Officer of Health 1936 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. George H. Duport. Medical Officer of Health. Borough of Twickenham. Public Health Department, Municipal Offices, Twickenham. August, 1937. To the Mayor, Aldermen and Councillors of the Borough of Twickenham. Ladies and Gentlemen, The report on the health and sanitary conditions and on the measures taken to safeguard and improve the health of the inhabitants of the Borough during the year 1936, which I now submit, is the last report which will refer to the Borough of Twickenham as it existed before its extension by the inclusion of the Urban Districts of Hampton, Hampton Wick and Teddington. As the year also marks the completion of twenty-six years of my service as your Medical Officer of Health, it affords an opportunity of viewing in retrospfept some of the changes which have taken place during that period. In 1911, the population, according to the census which was taken that year, was 29,367. In 1936 the estimated population was 49,780, an increase of more than 20,000 persons. In Whitton at that time there were 373 separate families. To-day the number in that ward alone is nearly 4,600. It is significant to note that, although the population of the town has increased by 20,000 persons, the number of births which occurred in 1936 was only 114 more than the corresponding number in 1911. To put it in another way, in 1911 ten babies were born in every hundred houses, but in 1936 in every hundred houses only five babies arrived. In 1911, the Medical Officer of Health for the first time became a whole-time officer and devoted his entire time to the duties of Public Health administration and the School Medical Services. His staff consisted of one School Nurse and two Sanitary Inspectors (one unqualified). No clerks were employed and no office was provided for the Medical Officer. In 1936 the staff comprised 18 persons, including part-time and specialist officers. The Maternity and Child Welfare service had not arisen. The School Clinic was not organised, although limited arrangements were made for the treatment of defects of vision and of tonsils and adenoids among school children. In 1936 four Health Visitors were occupied in the Maternity and Child Welfare service and at two Centres specially designed for the purpose, Clinics had been established for the care of Expectant and Nursing Mothers, of children under 5 years of age and for the observation and treatment of school children. Prior to 1911, cases of Scarlet Fever were admitted to the Isolation Hospital, which contained 26 beds, but no provision was made for the hospital treatment of Diphtheria, although ten out of every hundred cases notified during the preceding nine years had proved fatal. To-day cases of all the infectious diseases are admitted to a hospital with a resident medical staff, and the deaths from Diphtheria during the past nine years have averaged less than three per hundred cases notified. In the same year, the death rate of infants per 1,000 births was 111, and 39 infants died in consequence of epidemic diarrhoea. In 1936, the infant death rate was 49, and the number of children who died from diarrhoea was 4. Without going into a more detailed examination of the circumstances leading to the improved conditions, it is evident that the expanding scope of Public Health administration during the last 25 years has been associated with an improvement in the health of the community which would have appeared almost incredible to sanitarians a generation ago. Much has been done, but still more remains to be accomplished, not only in preventing disease which affects the community, but in maintaining and improving the standard of health in the individual. It is in these directions that the extended facilities offered by the ever increasing powers which are conferred on Local Authorities, operating over a greatly extended area, will furnish opportunities for still greater progress in the years to come. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient servant. I 3 THE HEALTH COMMITTEE. (as on December 31st, 1936.) Councillor C. H. Oliver [Chairman). Councillor A. C. Boucher. „ Mrs. F. Walton (Vice-Chairman). ,, Captain D. D. Jones. Alderman V. G. Heptinstall „ F. J. Neighbour. „ J. R. Potterill. ,, C. V. B. Read. ,, T. Wheelhouse . ,, Captain A. E. Robertson. „ G. J. Simmons. With the Mayor, Alderman Edgar Ollis and the Deputy Mayor, Alderman J. H. Knaggs, ex-officio. THE MATERNITY AND CHILD WELFARE COMMITTEE. The members of the Health Committee with the following co-opted members :— Mrs. F. E. Bloye. Mrs. M. V. Farrer. 1 Mrs. R. M. Butcher. Mrs. G. Morgan. STAFF. Medical Officer of Health : George H. Dupont, M.D., C.M., D.P.H. Assistant Medical Officer of Health: Ethel Richmond Emslie, M.D., D.P.H. Consultant in obstetric emergencies and puerperal sepsis : J. W. Bell, L.R.C.P.I., L.R.C.S.I., L.M. (part-time). Ophthalmic Surgeon : C. J. Longworth Blair, M.R.C.S. (part-time). Aurist: R. Savege, M.B., F.R.C.S.E. (part-time). Dental Surgeon : G. Woolford, L.D.S., R.C.S. 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. i ' . ' ' 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. Health Visitor: Doris Bates, Srk.N., Cert., Central Midwives Board and Health Visitors' Certificate, R.S.I. Part time. School Nurse : Laura Manning, S.R.N. Whole time. Clerks : Walter Brearley, Cert., Sanitary Inspector, R.S.I. ; Violet Williams, Barbara Heslett ; George Goram and Evelyn Elston. I Mortuary Attendant: W. Parsons,, SUMMARY OF CONTENTS. Page Section A.—Statistics and Social Conditions 4 Section B.—General Provision of Health Services 7 Section C.—Sanitary Circumstances of the Area 10 Section D.—Housing 14 Section E.—Inspection and Supervision of Food 15 Section F.—Prevalence of and Control over Infectious Disease 15 4 SECTION A. STATISTICS AND SOCIAL CONDITIONS. Area of district in acres 2,435, Population at Census, 1931 39,980 Population estimated by Registrar General to mid 1936 49,780 Number of inhabited separate dwellings, December, 1936 15,240 Rateable value, December, 1936 £477,633 Gross product of penny rate. £2,016 Rainfall during 1936 21.97 inches The borough still retains its residential character. No new industry was commenced, and the increasing urbanisation is indicated by the fact that 1,370 new dwellings came into rating during the year. The amount of available building land has become comparatively small, but the erection of flats continues. Population. The population estimated by the Registrar General to the middle of the year 1936 was 49,780. This compares somewhat closely with the figure 50,000, at which I had previously estimated the population. The increase in the population during the year compared with the Registrar General's estimate for the preceding twelve months, was 3,070. As the natural increase in the population, i.e., the excess of live births over deaths during the year 1936 was 212, the balance 2,858 consisted of persons who had moved to Twickenham from other places. Births. Total births registered 814 Number of live births 789 Number of still births 25 Increase in total births compared with 1935 98 Birth rate (live births) per 1,000 of the population 15.8 The sex and legitimacy of the live births was:— Male Female Total Legitimate 393 361 754 Illegitimate 18 17 35 411 278 789 The live birth rate showed an increase,of 1.0 per thousand of the population over the corresponding figure for the previous year, and was 0.8 higher than that of 143 towns in England and Wales with populations of comparable size. The number of still births registered was 25, of which 22 were legitimate and 3 illegitimate. Assuming that the notifications in each case were complete, one of every 34 legitimate babies was still-born, whereas the corresponding figure for illegitimate babies was one in eleven. The proportion of illegitimate births was one in every 23 of the total births registered. Deaths. ) Nett number of deaths 577 Increase compared with year 1935 110 Death rate (crude) per 1,000 of estimated population 11.59 Increase compared with year 1935 1.6 Comparability factor 1.02 Corrected death rate 11.8 The death rate was slightly higher than that of the preceding year, which was almost the lowest on record. The causes of death which showed the more marked increase were those associated with middle and more advanced age. Thus cancer, heart disease, cerebral haemorrhage and other diseases of the circulatory system caused an increased number of deaths. This is a condition which must be expected in a population in which the average age of persons living tends to become higher owing to the diminished number of children. A more disappointing figure is an increase in the number of infants dying from prematurity of, or debility from birth, although against this must be noted an increase of nearly one hundred births. 5 The cancer death rate per 1,000 of the population was 1.74. CAUSES OF DEATH AT ALL AGES. Year 1936. Registrar General's figures. Causes of Death. Males. Females. Total. All causes 273 304 577 1. Typhoid and Paratyphoid Fevers - - - 2. Measles 1 — 1 3. Scarlet Fever — - - 4. Whooping Cough 1 — 1 5. Diphtheria — — — 6. Influenza 6 5 11 7. Encephalitis Lethargica — — — 8. Cerebro-spinal Fever — — — 9. Tuberculosis of fespiratory system 17 17 34 10. Other tubercular diseases 2 1 3 11. Syphilis 1 — 1 12. General paralysis of the insane, tabes dorsalis — 2 2 13. Cancer, malignant disease 42 45 87 14. Diabetes 4 5 9 15. Cerebral haemorrhage, etc. 10 17 27 16. Heart disease 62 106 168 17. Aneurysm 2 — 2 18. Other circulatory diseases 12 16 28 19. Bronchitis 9 3 12 20. Pneumonia (all forms) 15 17 32 21. Other respiratory diseases 3 2 5 22. Peptic ulcer 7 1 8 23. Diarrhcea, etc. (under 2 years) 2 3 5 24. Appendicitis 1 3 4 25. Cirrhosis of liver 2 2 26. Other diseases of the liver, etc. - 2 2 27. Other digestive diseases 10 4 14 28. Acute and chronic nephritis 5 5 10 29. Puerperal sepsis — — — 30. Other puerperal causes — 1 1 31. Congenital debility, premature birth, malformations, etc. 17 7 24 32. Senility 4 1 5 33. Suicide 4 3 7 34. Other violence 12 7 19 35. Other defined diseases 23 30 53 36. Causes ill-defined or unknown — - — Deaths from Infectious Diseases. Disease 1936 1935 Number Rate per 1000 of population. Number Rate per 1000 of population. Measles 1 0.02 — —- Whooping cough 1 002 — — Scarlet fever — — 1 0.02 Diphtheria — — 3 0.06 Typhoid fevers — — — — Influenza 11 0.22 8 0.17 Tuberculosis (pul.) 34 0.68 27 0.57 The death rates from infectious diseases generally were low, and it is particularly gratifying to note that no death occurred as the result of Diphtheria, this being the first year since 1918 during which no case of diphtheria terminated fatally. Puerperal Death. Only one woman died from a cause associated with pregnancy, and this death was not caused by puerperal sepsis. The maternal deaths during the past six years have resulted from the following causes :— 1931 1932 1933 1934 1935 1936 From sepsis — 1 — 2 2 — Other causes 1 3 — — 2 1 Infant Deaths. Nett deaths of infants under 1 year of age 39 Infant death rate per 1,000 live births 49.4 Infant death rate per 1,000 legitimate births 49.0 Infant death rate per 1,000 illegitimate births 57.1 No. of deaths from diarrhoea (under 2 years) 5.0 Death rate from diarrhoea (under 2 years) per 1,000 live births 6.3 6 , _ T1?e 'n^ant death rate for 143 towns with populations of comparable size was 55 That for Twickenham was 49.4. Table of death rates per thousand live births of infants in Twickenham during the rast 25 years:— Year Rate Year Rate Year Rate 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 1918 113.9 1926 49.0 1934 65.2 1919 66.3 1927 55.4 1935 1936 41.8 49.4 1 he number of infants who died before the end of the first month of life was 23 giving a neonatal death rate of 29.1 per thousand live births. The neonatal death rate for the past five years has been:— Year lst week 2nd week 3rd week 4th week Rate 1932 8 2 — 1 18.1 1933 15 1 2 1 32.1 1934 14 2 — 2 28.6 1935 14 1 2 - 24.5 1936 17 2 2 2 29.1 The following table shows the deaths of infants under 5 years of age which occurred during1936 Causes of death of children under 5 years of age, 1936. CAUSES OF DEATH. 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 fire years Measles ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculosis ... ... ... ... ... ... ... ... ... ... ... 1 1 ... 2 Bronchitis ... ... ... ... ... ... ... ... 1 1 ... ... ... ... 1 Pneumonia ... . . . ... 1 1 2 1 1 1 6 3 ... ... ... 9 Enteritis&, Gastritis ... ... ... ... ... 1 2 1 1 5 ... ... ... ... 5 Syphilis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Atelectasis 2 ... ... ... 2 ... ... ... ... 2 ... ... ... ... 2 Accident or injury at birth 1 ... ... ... 1 ... ... ... ... 1 ... ... ... ... 1 Congenital malformations ... 1 1 1 3 ... ... ... ... 3 ... ... ... ... 3 Premature birth 9 ... 1 ... 10 1 ... ... ... 11 ... ... ... ... 11 Debility 1 ... ... ... 1 ... ... ... ... 1 ... ... ... ... 1 Atrophy and Marasmus 1 ... ... ... 1 2 ... ... 3 1 ... ... ... 4 Other diseases 2 1 ... ... 3 1 ... ... ... 4 1 1 2 ... 8 Violence ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Inattention at birth 1 ... ... ... 1 ... ... ... ... 1 ... ... ... ... 1 Total 17 2 2 2 23 7 3 2 3 38 6 2 3 ... 49 The total number of deaths under one year of age in this table differs slightly from those in the table of the Registrar General, as the period to which they refer is not identical with that from which this figure was taken. i ■ 7 Public Mortuary. During the year 102 bodies were brought into the mortuary. Sixty-one post-mortem examinations were made, and 44 inquests were held. SECTION B. GENERAL PROVISION OF HEALTH SERVICES. Laboratory Facilities. The arrangement whereby the bacteriological examination of specimens has been carried out at the Pathological Department at Richmond Hospital has worked in an entirely satisfactory manner. Delay in receiving reports, consequent on retention of specimens in the post, has been eliminated. The majority of the specimens sent were from cases of suspected diphtheria, but the facilities for the diagnosis of tuberculosis and typhoid fever were also used to a considerable extent. Laboratory examinations of specimens of venereal diseases were carried out at the West London Hospital, Hammersmith, under the arrangement made by the Middlesex County Council. Ambulance Service. The two motor ambulance vehicles continued in use throughout the year. The ambulances are maintained and staffed by the fire brigade, and the service both in reference to the removal of patients and the maintenance of the vehicles has been entirely satisfactory. Following is a table of the use of the ambulances during the years 1935 and 1936:— Year Total Calls Casualty Calls Patients Carried Mileage 1935 1936 1935 1936 1935 1936 1935 1936 1st quarter 131 159 64 78 127 159 548.4 829.4 2nd „ 123 152 60 84 116 153 591.2 744.8 3rd „ 80 175 50 92 79 170 416.9 832.5 4th „ 127 162 63 76 137 155 914.7 844.3 461 648 237 330 459 637 2471.2 3251.0 The striking increase in the use of the ambulance both for the collection of casualties and the removal of patients is shown in the above table. The casualty calls again amounted to approximately fifty per cent, of the total calls. Nursing in the Home. General. The Nurses of the Twickenham Nursing Association continued the home itursing of persons who were suffering from those diseases for the nursing of which the Council is able to make provision. Three whole-time nurses are now employed. 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 schemed— Visits paid to patients under 5 years, 814 ; over 5 years, 331. Total visits paid, 1,145. Nursing of Infectious Cases. Cases of Pneumonia, Whooping Cough and Ophthalmia Neonatorum, were nursed in their own homes. Provision for home nursing of cases of puerperal fever was not required during the year. Midwives. The number of Midwives who declared their intention of practising in the district during the year was 17. Applications were received for assistance in providing the services of a midwife from 30 necessitous women who desired to be confined in their own homes, and 27 were granted. Home Helps. The services of a home help were granted in one case. The home helps assist in the domestic duties of the homes during the time that the mother is incapacitated on account of her confinement or some complication of pregnancy. No whole-time home help has been appointed, but the patient is allowed to select her own help, provided the person selected is not a relative, and the selection is approved by the Medical Officer. 8 The increasing tendency of women of all classes to enter hospitals or nursing homes for their confinement continues, and in consequence the provision of a satisfactory service of home helps calls for special attention. The large number of women confined in hospitals, especially the West Middlesex Hospital, and in smaller nursing homes is also a factor to be taken into consideration in estimating the number of salaried midwives who will be engaged under the Midwives Act, 1936. CLINICS AND WELFARE CENTRES. Following is a list of clinics and treatment centres within the borough:— Name Address Days of Attendance By whom provided Infant Welfare Clinic York house Tuesday and Wednesday, at 2 p.m; Twickenham Council Infant Welfare Clinic Hospital Bridge road, Whitton Monday and Thursday, 2.30 p.m. ditto Ante-natal Clinic York house Friday at 2 p.m, ditto School Clinic, including minor ailments, dental. and ophthalmic clinics York house Daily Twickenham Education Committee School clinic Hospital Bridge ✓ road Tuesday, 10 a.m. ditto Tuberculosis Dispensary 1 Staines road Wednesday, 10 a.m Middlesex County Council Diphtheria Immunization clinic York house Saturday, 9.30 a.m Twickenham Council 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. Certain cases of these diseases requiring treatment in Hospital are admitted to the Mogden Hospital of the South Middlesex Joint Hospital Board. The extensions to this hospital are not yet completed. The cases admitted from Twickenham during 1936 were Scarlet fever 45, Diphtheria 13, Paratyphoid B. 1, Erysipelas 3, Meales 4, Whooping Cough 3, Other diseases 4. Other Hospitals. The Corporation subscribes annually to The Royal Hospital, Richmond, and to the West London Hospital. Increasing use is being made by residents in Twickenham of the facilities for treatment now provided at the West Middlesex County Hospital. MATERNITY SERVICES. The number of births which were notified as 4tcurring in the borough was 809, of which 19 were still births. Of the notifications, 656 were made by midwives. In approximately 80 per cent, of confinements a midwife was present. Care of expectant mothers. The Ante-natal Clinic was held fortnightly during the year. The total attendances of expectant mothers was 353, of whom 136 attended for the first time. The number of mothers who attended for examination after their confinement was 33. The Twickenham women who were confined in the West Middlesex County Hospital Maternity Block attended that hospital for Ante-Natal supervision, as the proposed arrangement for supervision at the Twickenham Ante-natal Clinic of women who were to be admitted to West Middlesex Hospital for their confinement had not been brought into effect before the end of the year under review. 9 Under the scheme for providing dental treatment, 22 expectant mothers received treatment at the Dental Clinic, the total attendances being 50. At the request of the West Middlesex Hospital, investigation was made of the environmental conditions of 4 women who had applied for admission to the Maternity Block at that Hospital. Milk was supplied either free or at less than cost price to 16 expectant mothers. . An arrangement exists whereby expectant mothers, for whom special observation or treatment is required, can be admitted to Queen Charlotte's Hospital, London. ' Birth Control. Facilities are available which enable women, for whom pregnancy is inadvisable for mcdical reasons, to obtain the necessary advice at a Birth Control Clinic in London. Care of mothers during confinement. The Corporation have not established a Maternity Home, and in view of the proximity of the West Middlesex Hospital, no formal arrangement has been made with any hospital for the reception of Complicated or difficult cases. No request has been received during the year for the services of a consultant in cases of difficult labour. Subsequent to Confinement. No application was made during the year for the services of a consultant in cases of puerperal pyrexia, although these services are provided if necessary. The explanation of this is that Medical Practitioners usually send these cases into hospital for treatment at an early stage instead of waiting until the case is well established. During the year 4 cases of these diseases were admitted to West Middlesex Hospital and to the Isolation Block of Queen Charlotte's Hospital. This is a procedure which has been encouraged in every way, and the attention of Medical Practitioners has been called to the facilities for the treatment of these cases which are available. This appears to be one of the most valuable measures in preventing maternal mortality or diminishing morbidity. A special Clinic for the examination of mothers after confinement has not been established although several mothers attended at the Ante-Natal Clinic for this purpose. I understand that a considerable number of the mothers who have beeruconfined in West Middlesex Hospital, attended at that Hospital for examination after their confinement. Milk was supplied to three necessitous nursing mothers. Dental treatment was provided in approved cases for nursing mothers as follows:— Number of cases 9 Total attendances 29 Dentures supplied. 8 Health Visitors. The Health Visitors called at the homes of 718 out of the 790 live births notified. Visits of enquiry were also made in the case of six still births and eleven deaths of infants. The visits paid to homes by the Health Visitors during the year included the following :— To expectant mothers 225 To children under one year of age 3592 To children between the ages of 1 and 5 years 5201 Owing to the increase in the population, the appointment of an additional Health Visitor became necessary. Pending the opening of the new Clinic at Whitton, it was decided to engage the services of the fourth Health Visitor on a part-time basis and to appoint a whole-time officer on the completion of the Clinic. Winter School. One of the Health Visitors attended a study course during the winter. With the increase of the Health visiting staff it will be necessary to increase the number of nurses sent each year as it is of the utmost importance that they shall be kept conversant with developments in Maternity and Child Welfare work and refresh their knowledge of existing methods. 10 Infant Welfare Clinics. The Infant Consultations were held on four afternoons weekly throughout the year. The total attendances numbered 8,194. In this figure only those attending for consultation or weighing are counted. New cases. Centre No. 1. York House. Centre No. 2. Whitton. Totals. Under 1 year 258 138 390 1 to 5 years 55 27 82 Mothers 23 13 36 Total Attendances:— Under 1 year 3510 1822 5332 1 to 5 years . 1733 1092 2825 Mothers 23 14 37 Total attendances at all the Centres 8194 In addition to the usual advice given as to care and nutrition of the infants attending the centres, medical or surgical treatment was found to be necessary for 109 children, and'was obtained by 95 of these. Dental treatment was given to 20 children under five years of age and in a number of cases, treatment of minor ailments, especially that of discharging ears, was carried out at the School Clinic. One child, aged three years, who was a deaf mute, was admitted to a special institution for the reception of these cases. The new Clinic at Hospital Bridge Road, Whitton, which has been designed to serve the purposes of the Maternity and Child Welfare and School Medical services in the Whitton and western portions of the Borough, was in course of erection, but was not completed by the end of the period to which this report refers. Infant Life Protection. Each Health Visitor is appointed an Infant Life Protection Officer under the Children's Acts, 1908-32. The details as to registration during 1936 were ;— Number of foster children on register at beginning of year 57 Number removed from register 72 Number registered for first time during year 80 Number on register at end of 1936 65 Deaths of foster children Nil Massage, etc. Hitherto, no special arrangement existed whereby children could be sent to a suitable Clinic for massage and treatment by yltra violet rays. During the year, definite arrangements were made whereby infants requiring such treatment could be sent to St. John's Hospital, Twickenham, for this purpose, and under this scheme 11 children attended. In the case of 2 crippled children under five years, assistance was granted to the parents to enable them to obtain apparatus which was necessary for the child's treatment. SECTION C. SANITARY CIRCUMSTANCES OF THE AREA. Every house in the Borough derives its water supply from that of the Metropolitan Water Board. Water closet accommodation is general throughout the district, which is drained on the separate system. A few cesspools still exist on Eel Pie Island and the Heathfield Farm Estate. The Sewage Disposal Works of the Corporation at the Merew'ay ceased to function during the year, and the sewage of the Borough is now disposed of at the Mogden Works, which form part of the West Middlesex Sewerage Scheme. The collection of house refuse is carried out under the direction of the Borough Engineer and Surveyor, from whose reports it is found that 12,019 tons of refuse were disposed of in the destructor, a limited quantity being dealt with by tipping. House refuse was collected weekly except from certain large blocks of flats, where a daily collection was effected. The question of more frequent collection throughout the Borough was again considered, but no alteration of the present system was decided upon. ' 11 While the accumulation of house refuse during seven days, in a dustbin kept in the yard or garden of a self-contained house, or its daily removal from a well appointed block of flats inflicts but little inconvenience on the occupants, the position is not quite so simple in the case of families occupying a portion of one of the larger dwellings which have been converted into flats or which have been let without particular adaptation to several families under the euphemistic name of "maisonettes." Here the daily collection does not apply ; it is not possible to keep a dustbin in the dwelling, nor is it possible to dispose of any quantity by burning. House refuse has to be brought down flights of stairs to a common space which is occupied by a collection of receptacles in varying conditions of efficiency, while a considerable amount is spilled on the ground between. While the additional expense of more frequent collection is obvious, an extension to dwellings of this character would be advantageous to the occupants both physically and psychologically. Frequent complaints were received during the year from annoyance arising from the burning of papers, cardboard boxes, etc., in the yards of tradesmen's premises. The arrangement under which trade refuse is removed on payment of a charge and the limited removal of what may be described as partial domestic refuse from shops, are not sufficiently attractive to prevent the disposal on the premises of a certain amount by burning and consequent inconvenience being caused to persons living in flats over shop premises. If any more generous scale could be devised for the removal of combustible trade refuse,. much discomfort would be prevented. Sanitary Inspection. The details of this 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. The figures give some indication of the attention needed to secure effective supervision in this very important branch of public health work. The total number of inspections and re-inspections carried out during the year was 8,737. The visits paid in respect of each branch of the duties of the inspectors are set out under each heading. In consequence of these visits, notices were served on owners or occupiers as follows :— Informal notices (intimations) served 448 Informal notices complied 404 Statutory notices served 16 Statutory notices complied 11 Domestic Sanitation. The duties of visiting premises after complaint, of housing inspections, the investigation of alleged nuisances, the investigation of cases of infectious disease, and the necessary actions by way of disinfection of dwellings, together with the multifarious other tasks which confront the Sanitary Inspector in his daily round, have been carried out actively and effectively by the Inspectors. Following is a summary of the visits paid during the year :— Visits to premises after complaint 608 Visits after occurrence of infectious disease 140 Visits under Housing Regulations 110 Total visits and inspections 8737 The following works were carried out in consequence of the above visits :— Drains tested 33 Drains unstopped and repaired 100 Waste pipes disconnected or repaired 28 Soil pipes provided or repaired 8 Inspection chambers inserted 5 Complete drainage reconstructions 11 Water supply cisterns repaired 8 Draw taps from main provided 18 Gutters repaired 65 Roofs repaired 176 W.c. apartments repaired or re-built 21 W.c's repaired 83 Dustbins provided 114 Damp walls remedied 135 Ventilation provided 20 Yards paved or repaired 35 Rooms stripped and cleansed 137 Offensive accumulations removed 23 Other Works carried out 676 12 Offensive Trades. Two applications to establish the trade of fish fryer were received during the year. The applications were not granted. The following offensive trades which have been established were kept under frequent supervision :— Fish fryers 9 Fat melters 2 Rag and bone dealers 1 The number of visits paid by the Inspectors to these premises was 76. Keeping of Animals. Much time of the Inspectors was devoted to the inspection of piggeries especially during the summer and particularly in respect of one pig keeping and breeding establishment where the business was of a somewhat extensive character. Up to ten years ago, when a considerable portion of the district was rural or semi-rural in character, the existence of piggeries, although well known to the officers of the Health Department and under regular observation, was not a cause of complaint. Now that houses have been built in close proximity to the sties, the odours and noises associated with the keeping of large numbers of pigs have become the source of constant and bitter complaints, and although the persons complaining were aware that the Corporation have no power to cause the removal of estabished piggeries and although most of them were aware that the piggeries existed when they purchased their houses, the complaints were no less loud and embittered. After the collection of evidence from the officers of the Department and persons living in the neighbourhood of these piggeries, the Corporation decided to take proceedings under Sections 41 and 91 of the Public Health Act, 1875. The evidence brought forward failed to convince the Magistrates and the cases were dismissed. Since then the conditions have remained as before, and it may be added the complaints have continued. Smoke Abatement. In a district such as Twickenham, but little trouble is experienced from the emission of smoke from factories, while the increasing use of gas for cooking and heating and of coke-fired boilers has resulted in an improvement as to the production of smoke from domestic fires which is remarkable to those who remember the conditions when the town was little more than half its present size. In one or two instances in which smoke was emitted from factory premises in quantities which caused inconvenience to persons living in the neighbourhood, improvement was effected without statutory action. Swimming Bath. The Public Open-Air Swimming Bath at the Embankment, provided by the Corporation, at a cost of approximately £18,000, excluding furniture and fittings, was opened in May and remained open until the last week in September. During the season, the bath was used by 78,327 persons. Eradication of Bed Bugs. The bed bug has attracted considerable attention during the year. It does not appear that this harmful and unnecessary associate of uncleanly conditions is more prevalent than it has been in the past, but the increased interest is probably due to the improved standard of domestic surroundings set by the new dwellings erected by the Corporation, and as the level of personal hygiene rises, the presence of bugs is no longer tolerated as inevitable by those who still live in older houses. No special measures have been taken by the Corporation to secure that the property of entrants to new houses shall be disinfected before removal. It is estimated that 7 per cent. of the Council houses are infested. No precise record has been kept of the number of houses found to be infested by bugs. Where the existence of bugs has come to the notice of the Sanitary Inspectors, advice has been given to the occupiers of the infested dwellings and spraying apparatus and disinfesting solution have been lent free of charge. No large scale measures have been taken and no measures of disinfestation by cyanide gas have been employed. Schools. The sanitary conveniences, water supplies and lavatories of each school in the Borough were inspected quarterly throughout the year, and with the exception of minor defects were found to be satisfactory. 13 Petroleum Acts. The Sanitary Inspectors are appointed Inspectors under the Petroleum Acts, and supervise the stores where petroleum spirit and carbide of calcium are kept. Fifty-four licences to keep petroleum spirit were issued. Of these, nine were for the storage of petrol in cans, six for storage of petrol in tanks, and a small supply in cans, the remainder being for storage in underground tanks only. Five licences were granted for the keeping of carbide of calcium. The number of visits paid by the Inspectors in connection with these premises was 197. Factories and Workshops. Number of factories in the district 68 Number of workshops 120 Number of workplaces 2 In accordance with the requirements of the Factory and Workshops Act, 1901, a statement of inspection 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. Premises. Number of Inspections Written Notices Prosecutions (1) (2) (3) (4) Factories (including Factory Laundries) * 135 10 Workshops (including Workshop Laundries) 157 9 — Workplaces (other than Outworkers premises) 5 2 — Total 297 21 — DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulats. 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 4 3 — Want of ventilation — — — Overcrowding — — — — Want of drainage of floors — — — — Other nuisances 5 4 Sanitary accommodation— — — insufficient — 1 — — unsuitable or defective 6 3 — — not separate for sexes — — — — Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (s. 101) — — — — Other offences (Excluding offences relating to but-work and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factory and Workshops Transfer of Powers) Order, 1921) 5 5 — — Total 20 16 — — *including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Acts. Shops Acts. The Sanitary Inspectors are not authorised as Inspectors under the Shops Acts. 14 SECTION D. HOUSING. The survey under the Housing Act, 1935, which was commenced in December, 1935, was continued during the early months of the year. As a report on this survey was submitted in May, 1936, it is only necessary to give a summary in this report. The number of houses surveyed was 6,958, containing 8,113 separate families. The information was obtained by a visit of an officer to each house, and in every case measurements were obtained whether or not overcrowding was found. The value of this has been proved by subsequent experience, as it has been possible to furnish the necessary information as to the number of persons permitted to occupy any house inspected, not only without delay but with the knowledge that this information was based on actual measurements. At the survey, 143 houses were found to be overcrowded, the percentage of overcrowded dwellings to the total investigated being 1.76 per cent. Of these, 12 families were removed to council houses during the year, and 15 obtained other accommodation, leaving 116 to be dealt with. To these must be added 12 which were found to be overcrowded subsequent to the survey, so that at the end of the year 128 dwellings were known to be overcrowded. The inspection of the district for the purposes of discovering dwellings which were in part or completely unfit for human habitation was continued, and 44 were represented as being incapable of repair at a reasonable expense. Of these 12 were basements and 2 parts of houses other than basements. Closing orders were made in respect of 10 of these. In three cases undertakings not to use the basement for human habitation were accepted, and in one case a closing order was not made as the dwelling was to be demolished in the near future. During the year demolition orders were made in respect of 31 other unfit houses. Following is a summary of the housing work carried out during the year; 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) 786 (b) Number of inspections made for the purpose 896 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 110 (b) Number of inspections made for the purpose 220 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 44 (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 5 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 404 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 (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 13 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 11 (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 31 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 22 15 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 13 (2) Number of separate tenements or underground rooms in respect . of which Closing Orders were determined, the tenement or room having been rendered fit 1 4. Housing Act, 1935 :— (a) (i) Number of dwellings overcrowded at the end of the year 128 (ii) Number of families dwelling therein 128 (b) Number of new cases of overcrowding reported during the year 155 (c) (i) Number of cases of overcrowding relieved during the year 27 SECTION E. INSPECTION AND SUPERVISION OF FOOD. Milk Supply. The cessation of the practice of delivery of milk in cans was followed by the substitution of glass bottles and a further development, that of the sale of milk in cartons, has occurred and is being used to an increasing extent. There is also a definite tendency for the business of the smaller retail dairymen to be absorbed by the larger companies. In consequence of this change the number of dairymen in the borough who bottled milk received in bulk was reduced to one. Most of the milk sold has been pasteurised before being bottled, although this process is not compulsory unless the milk is sold under that special designation. In view of the extensive and dangerous outbreaks of disease that may arise from the neglect of this simple procedure it is difficult to understand the reason why compulsory pasteurisation of all milk sold for human consumption has not been made obligatory, at any rate as far as towns are concerned. At the end of the year the following were registered. Cowkeepers. 2 Dairymen. 15 Purveyors of milk. 51 Under " The Milk (Special Designations) Order, 1936," which came into force during the year, three grades only of specially designated milk are now permitted to be sold, " Tuberculin Tested," Accredited and " Pasteurised." Meat and Other Foods. There are 48 butcher's shops in the Borough which were kept under close supervision, 361 visits being paid for the purpose by the Inspectors. There are 6 registered and one licensed slaughter-house in the borough, and it is an interesting fact that on no occasion did slaughtering take place in the borough throughout the year, although slaughtering took place on an extensive scale in adjoining districts. No seizure of diseased or unsound meat was made, but 406 lbs. of unsound meat were surrendered voluntarily. Although there are a few butcher's shops in the town in which fixed windows have not yet been provided, these are in a minority, and the butchers have adhered loyally to the undertaking given at a conference with their representatives, that in no instance would meat be exposed in front of or on a level with the glass line. The unhygienic practice of displaying meat on tables or hooks in front of the shop has ceased as far as Twickenham is concerned. Other shops from which foodstuffs were sold were also kept under regular supervision, the following visits being paid for this purpose :—Restaurants and eating house kitchens and grocers shops, 358 visits; greengrocers' shops, 240 visits ; fish shops, 102 visits. SECTION F. ' PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. The number of notifiable infectious disease which occurred during 1936 is. set out in the flollowing table. Cases in which the diagnosis was not confirmed no observation subsequent to notification are not included. 16 Month Diphtheria Scarlet Fever Puerperal Fever Puerperal Pyrexia Pneumonia Primary Pneumonia Influenzal Ophthalmia Neonatorum Erysipelas Paratyphoid Encephalitis Lethargica Malaria Dysentery January 4 11 — — 2 — — — — — — — February 4 6 — — 3 — — — — — — — March — 7 — 2 1 1 1 2 — — — — April — 3 1 — 2 o — — — — — — May — 3 — — — — — — — — — — June 1 7 1 — 1 1 — 1 — 1 — — July 1 3 — — — — — 1 — — — — August — 1 — — — 1 — — — — — — September 1 2 — — — — — — — — — — October 1 7 1 1 1 — — — 1 — — — November 1 5 — 1 — 1 — — — — — — December 1 7 — — — 2 — 2 — — — — TOTALS 14 62 3 4 10 8 2 6 1 1 — — Infectious Disease, 1936. Ages at notification. Disease Under 1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-25 25-35 35 45 45-65 65, etc. Admitted to Hospital Total Deaths Diphtheria — — — 2 1 6 1 1 — 3 — — — 13 14 — Scarlet Fever — 1 1 4 3 26 13 2 3 3 4 1 1 45 62 — Puerperal Fever — — — — — — — — 1 1 1 — — 2 3 — Puerperal Pyrexia — — — — — — — — — 4 — — — 2 4 1 Pneumonia :— Primary 1 — — — — — 1 2 2 2 2 — — — 10 32 Influenzal — — — — — — — — — 2 — 5 1 — 8 Ophthalmia Neonatorum 2 — — — — — — — — — — — — — 2 Erysipelas — — — — — 1 — — — 2 — 2 1 3 6 Acute Polio-myelitis — — — — — — — — — — — — — — — — Encephalitis lethargica — — — — — — 1 — — — — — — — 1 Paratyphoid — — — — — — — — — — — — — 1 1 — Scarlet Fever. The general incidence of Scarlet Fever was low and the type of case mild. No death resulted from this disease. Cases occurred during each month, the highest number of cases (11) occurring during January. During the last week in December, six cases occurred at Fortescue House School, where approximately 135 boys between the ages of 9 and 14 are in residence. On January 8th, 1937, the Dick Test (of susceptibility to scarlet fever) was applied and immunization of susceptibles was commenced. Although this action was taken during 1937 it appears advisable for the sake of continuity to include it in this report. In all, 128 were Dick Tested, and of these 52 were found to be susceptible, and these received four inoculations at fortnightly intervals. In three of the positive cases, who had only had time to receive their first inoculation, signs of mild Scarlet Fever appeared, in one case one day, in one case three days, and in one case five days after the inoculation. In no other susceptible child who had been inoculated did the disease appear and the outbreak ceased. The result was so striking that it justified the adoption of the procedure in similar circumstances even when the outbreak has commenced. t 17 Diphtheria. Only 14 cases of Diphtheria occurred in the Borough during the year, and it is necessary to go back as far as 1905 to find an equal or smaller number of notifications, and it must be remembered that at that time the population of the town was only about one half of its present number. Eight of the cases occurred in the first two months of the year, and only single cases arose subsequently and no fatal case occurred. Detailed reference to the action taken to ascertain which children were liable to contract the disease and to protect those that were found susceptible were set out in detail in the report for the year 1935, during which year, it may be recalled, more than 1,500 children were immunized. The Immunization Clinic has been held on each Saturday, and although the numbers attending have not equalled those of the preceding year, the fact remains that a large number of parents who appreciate the value of the procedure are bringing their children to be treated. All children over seven years of age were Schick Tested before being inoculated. T.A.M. was used for inoculation and no severe reactions followed. The number of persons who attended the Clinic for testing or inoculation or both, with their ages at date of first attendances, follows Ages. 1 2 . 3 4 5 6 7 8 9 10 11 12 to 15 15 to 20 20 to 25 25 X Total 42 16 20 12 36 32 9 23 30 33 33 80 3 — — 369 The total attendances were 2,035 Following is a summary of the work done :— First Schick Test before inoculation— Number Susceptible Immune Failed to attend. 212 120 91 1 Number receiving first completed course of injections 288 Second Schick test of those who had completed first course of injections :— Number Protected Susceptible Failed to attend. 349 290 19 40 All those found to be incompletely protected after the second Schick Test were reinoculated. One did not appear for re-test. Other Infectious Diseases. One case of encephalitis lethargica of somewhat uncertain character was notified. In the case of paratyphoid fever (B) which was notified in October, careful enquiries failed to elicit any definite source of infection. No other case of this or similar disease arose. Although measles and whooping cough were prevalent in the early months of the year, the type of case did not appear to be severe, only one case of each disease proving fatal. During the year, the South Middlesex Joint Hospital Board decided to admit certain cases of erysipelas, measles and whooping cough to their hospital, and under this arrangement a few cases of these diseases were admitted. When the extensions to the hospital, which are at present in progress, are completed, it will no doubt be possible to admit a larger number of these cases who require hospital treatment to a much greater extent than most of the cases of Scarlet Fever which are sent in. The Joint Hospital Board also agreed to admit cases of the following diseases—anthrax, dysentery, encephalitis lethargica, ophthalmia neonatorum, typhus and cholera. The provision of hospital beds for cases of infectious disease seems therefore to be complete and satisfactory. 18 Table of notifications of Infectious Disease during the past ten years. 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 Anthrax 1 — — — — — — — — — Small-pox 1 — — — — — — — — — Scarlet Fever 49 71 124 173 102 96 91 100 44 62 Diphtheria 88 117 93 13(i 04 27 29 121 42 14 Dysentery — — 28 — — — — — 1 — Enteric Fever 3 3 3 2 1 1 — — 1 1 Puerperal Fever — 3 — 2 6 1 1 4 2 3 Pyrexia 15 2 8 2 6 4 2 1 — 4 Ophthalmia Neonatorum 3 1 3 1 6 5 — 3 3 2 Pneumonia :— Primary 24 15 22 6 19 14 17 14 14 10 Influenzal 10 5 17 4 6 5 6 8 7 8 Erysipelas 10 17 9 11 7 12 8 23 9 6 Malaria 1 — — — — 2 l 1 — — Encephalitis l.ethargica — — 1 — — — — — — 1 Acute Polio Encephalitis — — — — — — — — — — Poliomyelitis — — — — — — 1 — — — Cerebro-spinal Fever — — — — —. — — — — — Tuberculosis: — Pulmonary 42 40 44 49 44 51 27 45 43 50 Non-pulmonary 16 11 13 14 2 9 11 3 8 8 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 NonPulmonary Pulmonary NonPulmonary M. F. M. F. M. F. M. F. 0 — — — — — — — — 1 — — — — — — 1 1 5 — — 2 — — — — — 10 — — 2 — — — — — 15 9 4 1 — 1 2 — — 20 5 7 — — 1 5 — — 25 7 4 1 1 3 4 — — 35 7 — — 1 3 2 — 1 45 5 — — — 4 9 — — 55 4 2 — — 2 1 — — 65 and upwards 2 1 — — 3 1 — Totals 32 18 6 2 17 17 1 2 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.