TWI 6 Borough of Twickenham ANNUAL REPORT OF THE Medical Officer of Health 1938 JOHN MADDISON, M.D., D.P.H., Medical Officer of Health. Twickenham: Printed by Walker & Co. (Printers) Ltd., 6 Heath Road and 162 Colne Road, Borough of Twickenham. PUBLIC HEALTH COMMITTEE. Chairman: Councillor Mrs. N. K. Taylor, B.A. Vice-Chairman: Councillor Capt. D. D. Jones, M.C. The Mayor, Councillor Coun. C. H. Drake A. C. Boucher, J.P. „ A. H. Handel-Dale The Deputy Mayor, „ Capt. B. T. Harding Alderman E. Ollis, J.P. „ R. F. E. Howard-Hodges Alderman V. G. Heptinstall. „ the Rev. A. M. Johnson, M.A. „ J. H. Knaggs, J.P. „ J. M. Johnson Coun. Mrs. M. F. Bligh, B.Sc. „ G. J. Simmons „ Mrs. H. M. Butlin „ E. G. Ure-Whyte „ W. A. Cooke MATERNITY AND CHILD WELFARE COMMITTEE. Chairman: Councillor Mrs. M. F. Bligh, B.Sc. Vice-Chairman: Mrs. F. Walton. The Mayor, Councillor Coun. A. H. Handel-Dale A. C: Boucher, J.P. „ Capt. B. T. Harding The Deputy Mayor, „ R. F. E. Howard-Hodges Alderman E. Ollis, J.P. „ the Rev. A. M. Johnson, M.A Alderman V. G. Heptinstall „ J. M. Johnson „ J. H. Knaggs, J.P. „ Capt. D. D. Jones, M.C. Coun. Mrs. H. M. Butlin „ G. J. Simmons „ W. A. Cooke. „ Mrs. N. K. Taylor, B.A. „ (p. H. Drake „ E. G. Ure-Whyte Co-opted members:—Mesdames F. E. Bloye, R. M. Butcher, D. I. Jones and N. M. Pearce. Town Clerk: EDWIN G. STRAY, Esq. 2 Borough of Twickenham. STAFF OF THE PUBLIC HEALTH DEPARTMENT. Medical. Medical Officer of Health: John Maddison, M.D., D.P.H. (commenced Sept., 1938); George H. Dupont, M.D., C.M., D.P.H. (retired Sept., 1938). Deputy Medical Officer of Health : John Young, M.B., Ch.B., D.P.H. Senior Assistant Medical Officer of Health: Dora F. Rose, M.A., M.B., Ch.B., D.P.H. Assistant Medical Officer of Health: Sarah Harris, M.B., Ch.B., B.A.O., D.P.H. (commenced Feb., 1938). Obstetric Consultant: J.W. Bell, L.R.C.P.I., L.R.C.S.I, (part-time). Ophthalmic Surgeon: C. J. Loxgworth Blair, M.R.C.S. (part-time). Dental Surgeons. J V. Bingay, L.D.S., R.C.S. (Senior); George Woolford, L.D.S., R.C.S. (retired March, 1938); M. Cohn, L.D.S., R.C.S. (commenced March, 1938). Sanitary Inspectors. L. Marsden (a) (b) (Senior), M. V. Sutcliffe (a) (b), C. J. Rabbits (a) (b) (resigned June, 1938), W. F. Newport, (a) (b) (resigned Nov., 1938), W. K. Pickup, (a) (b), S. W. S. Scott (a) (b) (resigned April, 1938), R. R. Creasey (a) (b) (commenced June, 1938), C. W. Baxter (a) (b) (commenced Aug., 1938), H. G. Easter (a) (b) (commenced Dec., 1938). Nursing Staff. Health Visitors: A. B. Pilkington (c) (d) (e) (Principal), E. Dunkley (c) (d) (e), M. G. Heath (c) (d) (c), E. M. Clarke (a) (c) (d), S. G. Briggs (c) (d) (e) (resigned March, 1938), B. Garrett (c) (d) (e), A. M. S. Mathews (c) (d) (e), M. Blatchley (c) (d) (e), D. M. White (c) (d) (e) (commenced June, 1938). School Nurse: Laura Manning (e) Dental Nurse: Mrs. Weller (c). Municipal Midwives: E. M. Clark (c) (e), E. Jenkins (c) (c), A. E. MacNama.viara (c), B. Nash (c), D. A. Ponting (c), L. A. Ward (c). Clerical Staff. H. J. Puch, W. Breari.ey (a), Violet Williams, Victoria R. Chaplin, Evelyn F. Elston, G. E. Goram (a), Margaret Williams, Eva Williams, E. Lucas, Jeanne Martindeli , C. F. Davis, Violet Chiles. (a) Certificate as Sanitary Inspector. (b) Certificate R.S.I. as Inspector of Meat and Other Food (c) S.C.M. (d) Health Visitor's Certificate. (e) Trained Nurse. 3 Borough of Twickenham. Public Health Department, Elmfield House, High Street, Teddington. To the Mayor, Aldermen and Councillors of the Borough of Twickenham. Ladies and Gentlemen, I have the honour to submit my Annual Report on the health and sanitary condition of the borough during the year ended December 31st, 1938. The report is drawn up in accordance with the directions contained in Circular 1728, issued by the Minister of Health in October, 1938, and is compiled as an ordinary report. I very much regret the delay which has occurred in the preparation of this report; the work on it has had to be set aside from time to time on account of pressing and urgent problems in connection with the preparation and carrying into effect of the Council's Air Raid Precautions Scheme. My association with the work of the Department dates only from September, 1938, and the greater part of the administrative work during the year was carried out by my predecessor, Dr. G. H. Dupont. Points of interest in the report are the low death rate in the borough as compared with the country as a whole, the principal causes of death being heart disease, cancer, and tuberculosis; the infant mortality rate, which is also below the rate for the country as a whole; the ready acceptance byparents of immunization against diphtheria for their children; the satisfactory working of the municipal midwifery service. The incidence of scarlet fever rose from 118 cases notified during 1937 to 271 during 1938, but notifications of diphtheria fell from 116 in 1937 to 70 during 1938. I desire to acknowledge with grateful thanks the consideration and courtesv which the Council have shown to me during the period of my introduction as your new Medical Officer of Health; also, the friendly co-operation and help which I have received from my colleagues in other departments ; and not least to the staff of the Health Department, who have been most w illing and loyal. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, JOHN MADDISON, Medical Officer of Health. 4 Statistics Social Conditions General Provision of Health Services for Area 5 STATISTICAL SUMMARY for the Year 1938 Area in acres 7,007 Population (as extended—census, 1931) 79,376 Resident population—estimated to mid-year, 1938 (as supplied by the Registrar General) 96,550 Number of inhabited houses (1938) 28,210 Rateable value (31st December, 1938) £1,011,085 Sum represented by a penny rate £3,965 1s. 8d. Total M. F. Live births: Legitimate 1,336 717 619 1,395 Illegitimate 59 26 33 Birth rate per 1,000 of estimated resident population 14.4 Total M. F. Still births : Legitimate 50 32 18 Illegitimate 2 2 - Still birth rate per 1,000 total (live and still) births 35.9 M. F. Deaths: 487 470 957 Crude death rale per 1,000 of estimated resident population 9.91 Adjusted death rate 9.81 Deaths from puerperal causes: Puerperal sepsis, nil Other puerperal causes, 4 Rate per 1,000 total (live and still) births 2.7 Death rate of infants under one year of age— All infants per 1,000 live births 45.8 Legitimate infants per 1,000 legitimate live births 47.1 Illegitimate infants per 1,000 illegitimate live births 16.9 Deaths from : Cancer (all ages) 179 Measles (all ages) 2 Whooping cough (all ages) 1 Diarrhoea (under 2 years of age) 12 6 Population. The population as estimated by the Registrar General for the middle of the year 1938 was 96,550, representing an increase of 2,320 compared with last year. As will be seen from the preceding statistical summary, the natural increase in the population during the year—i.e., excess of live births over deaths, was 4-38. Immigration exceeded emigration therefore to the extent of 1,882 persons. Births. The births registered in the borough in 1938 numbered 1,395, made up as follows:— Males Females Total Legitimate 717 619 1336 Illegitimate 26 33 59 Total 743 652 1395 This gives a birth rate of 14.4 per 1,000 of the population as compared with 15.1 for England and Wales. Deaths. The nett deaths registered in the borough during 1938 numbered 957, and were made up as follows : males, 487; females, 470. The crude death rate per 1,000 of the population for the year was 9.91. By the use of the Registrar General's comparability factor, an adjusted death rate of 9.81 is obtained. This shows a decrease compared with last year, and is well below the comparable death rate (11.6) for England and Wales. Main Causes of Death. An analysis of the death returns reveals that the main causes of death were (i) diseases of the heart and circulatory system and cerebral haemorrhage (35 percent.); (ii) cancer (18 per cenl.). 7 Causes of Death, 1938. Registrar General's official returns. Causes of Death. Males Females Total All causes 487 470 957 1. Typhoid and paratyphoid fevers - - - 2. Measles — 2 2 3. Scarlet fever - 1 1 4. Whooping cough — 1 1 5. Diphtheria 3 2 5 6. Influenza 4 4 8 7. Encephalitis lethargica — 1 1 8. Cerebro-spinal fever — — - 9. Tuberculosis of respiratory system 32 10 42 10. Other tubercular diseases 2 5 7 11. Syphilis 2 — 2 12. General paralysis of the insane, tabes dorsalis 4 2 6 13. Cancer, malignant disease 92 87 179 14. Diabetes 4 10 14 15. Cerebral haemorrhage, etc. 9 27 36 16. Heart disease 111 138 249 17. Aneurysm 1 2 3 18. Other circulatory diseases 26 21 47 19. Bronchitis 10 8 18 20. Pneumonia (all forms) 29 24 53 21. Other respiratory diseases 5 3 8 22. Peptic ulcer 9 3 12 23. Diarrhoea, etc. (under 2 years) 10 2 12 24. Appendicitis 5 3 8 25. Cirrhosis of liver 4 3 7 26. Other diseases of the liver, etc. 1 3 4 27. Other digestive diseases. 12 10 22 28. Acute and chronic nephritis 9 13 22 29. Puerperal sepsis — — — 30. Other puerperal causes — 4 4 31. Congenital debility, premature birth, malformations, etc. 27 8 35 32. Senility 5 17 22 33. Suicide 6 7 13 34. Other violence 18 15 33 35. Other defined diseases 46 34 80 36. Causes'ill-defined or unknown ... 1 — 1 37. Diarrhoea, 2 years and over — — — Maternal Mortality. During the year 1938, four women died from conditions associated with pregnancy or childbirth. The maternal mortality rate per 1,000 total (live and still) births was 2.7, compared with 2.97 for England and Wales. Infantile Mortality. The deaths of infants under one year of age during 1938 numbered G4, producing an infantile mortality rale of 45.8 per 1,000 live births. The rate for England and Wales was 53. 8 As will be seen from the following table, congenital debility, premature birth, malformations, etc., caused 35 (or 54 per cent.) of the total infant deaths. The death of. infants under one month is bound up very closely with the question of ante-natal supervision, and it is by the 'added care of the expectant mothers' health, together with adequate nutrition, that a reduction in the mortality will be achieved. Infantile Mortality, 1938. Compiled from the official registrations. Und'r 1 week 1—2 wks. 2—3 wks. 3—4 wks. Total under 1 month 1—3 mth. 3—6 mths. 6—9 mths. 9—12 mths. Total deaths under 1 year Smallpox - - - - - - - - - - Chickenpox — — — — — - — — — — Measles — — — — — - — — — — Scarlet fever - - - - - - - - - - Diphtheria and croup - - - - - - - - - - Whooping cough - - - - - - - - - - Diarrhoea - - - - - - 1 1 — 2 Enteritis - - - - - 2 7 1 — 10 Tuberculous meningitis - - - - - - - - - - Abdominal tuberculosis - - - - - - - - - - Other tuberculous diseases - - - - - - - - - - Congenital malformations 6 — — — 6 2 1 — — 9 Premature forth 20 — — — 20 — — — — 20 Atrophy, debility and marasmus - - - - - 3 2 1 - 6 Atelectasis 1 — — — 1 — — — — 1 Injury at birth 3 — — — 3 — — — — 3 Erysipelas - - - - - - - - - - Syphilis - - - - - - - - - - Rickets - - - - - - - - - - Meningitis (not tuberculous) - - - - - - 1 - - 1 Convulsions — 1 — — 1 — — 2 — 3 Gastritis - - - - - - - - - - Laryngitis - - - - - - - - - - Bronchitis - - - - - - - - - - Pneumonia (all forms) - - - - - 2 2 — — 4 Suffocation, overlying — — — — — — — — — — Other causes 1 — — — 1 2 - 2 - 5 Total 31 1 — — 32 11 14 7 - 64 9 10 Birth Rate, Death Rate and Analysis of Mortality during 1938. Provisional figures. Birth Rate per 1,000 total population. Annual Death Rate per 1.000 population Rate per 1,000 live births. Live births Still births All causes Typhoid and Paratyphoid Fevers Smallpox Measles Scarlet fever Whooping Cough Diphtheria Influenza Diarrhoea and Enteritis (under 2 years) Total deaths under 1 year. England and Wales 15.1 0.60 11.6 0.00 0.00 0.04 0.01 0.03 0.07 0.11 5.5 53 126 County Boroughs and great towns, including London 15.0 0.65 11.7 0.00 - 0,05 0.01 0.03 0.07 0.10 7.8 57 148 smaller towns (resident populations 25,000 to 50,000 at 1931 census 15.4 0.60 11.0 0.00 0.00 0.03 0.01 0.02 0.06 0.11 3.6 51 London 13.4 0.48 11.4 0.00 - 0.06 0.01 0.03 0.05 0.06 13.1 57 Twickenham 14.4 0.53 9.81 0.00 0.00 0.02 0.01 0.01 0.05 0.08 8.6 45.8 ' GENERAL. Laboratory Work. Specimens for bacteriological examination, as hitherto, were sent to th Pathological department, Royal hospital, Richmond. The arrangement work smoothly and are quite satisfactory. The following table shows the number of specimens examined during the year:— Nature of Specimens. No Result Throat and nasal swabs for diphtheria 609 37 positive Sputum, etc., for tubercle bacilli 265 49 „ Miscellaneous 28 Total specimens examined 902 Ambulance Facilities. Infectious diseases. A motor ambulance is provided by the South Middlesex and Richmond Joint Hospital Board. Non-infectious and accident cases. Four motor ambulances are provided by the Council. Three of these are stationed at Twickenham fire station, and the other at Teddington fire station. The facilities are adequate for the needs of the borough. The following table shows the work done in connection with the borough ambulances during the year 1938:— Year 1938. Total calls. Patients carried. Mileage. 1st quarter 297 290 1603.4 2nd ,, 315 305 2141.9 3rd ,, 297 288 1866.4 4th „ 419 40G 2311.1 1,328 1,289 7922.8 Nursing in the Home. There are five home-nursing associations in the borough employing nurses—viz., Twickenham Nursing Association, Teddington and District Nursing Association, Hampton Nursing Association, Hampton Hill Nursing Association, and the Hampton Wick Nurse and Dispensary Fund. The Council contributed the total sum of .£194 to the associations during the year. 11 Clinics and Welfare Centres. The following is a list of the clinics within the borough. Clinics. Address. Days. By whom provided. Infant Welfare Centre York house, Twickenham Tuesday and Wednesday, 2 p.m. Twickenham Council ditto Hospital Bridge road, Twickenham Monday and Thursday, 2 p.m.; Friday, 10 a.m. ditto ditto Adult school, Teddington. Tuesday and Thursday, 2 p.m. ditto ditto Station road, Hampton Wednesday and Friday, 2 p.m. ditto ditto The Baptist hall, Hampton Wick Friday, 2 p.m. ditto Ante-natal clinic York house, Twickenenham. Friday, 2 p.m. ditto ditto Hospital Bridge road, Twickenham Wednesday, 10 a.m. ditto ditto Elmfield house, Teddington Monday, 2 p.m. ditto ditto Station road, Hampton Thursday (1st and 3rd), 10.30 a.m. ditto School clinic ... York house, Twickenham Monday and Friday, 10 a.m. Middlesex County Council ditto Stanley road, Teddington Tuesday, Wednesday, and Thursday, 10 a.m. ditto ditto Hospital Bridge road, Twickenham Tuesday, 10 a.m. ditto Dental clinic York house, Twickenham Daily Twickenham Council and Middlesex County Council ditto Stanley road, Teddington ditto ditto Ophthalmic Clinic York house, Twickenham Thursday, 2 p.m. Middlesex County Council ditto Stanley road, Teddington Monday, 2 p.m. ditto Diphtheria immunization York house, Twickenham Saturday, 10 a.m. Twickenham Council ditto Stanley road, Teddington Wednesday, 10 a.m. ditto Tuberculosis dispensary 1 Staines road, Twickenham Wednesday, 10 a.m. Middlesex County Council 12 Hospitals. Smallpox. Arrangements for the provision of hospital accommodation are made by the Middlesex County Council. Tuberculosis. Residential institutional treatment is provided by the Middlesex County Council. Puerperal Pyrexia. Cases requiring hospital treatment are sent to the Queen Charlotte's hospital, Hammersmith. Infectious diseases. Other cases of infectious diseases are admitted to the hospital of the South Middlesex and Richmond Joint Hospital Board. Other Hospitals. The following voluntary hospitals are situated within the borough:—St. John's hospital, Twickenham, St. Mary's hospital, Hampton, and the Teddington, Hampton Wick and District Memorial hospital, Teddington. A total sum of £115 was contributed to these hospitals by the Council during the year. 13 Maternity and Child Welfare. MATERNITY AND CHILD WELFARE. Midwifery and Maternity Services. The total number of births which were notified as occurring in the borough was 855. This figure does not include births which occurred elsewhere, but which were subsequently transferred to Twickenham. Of the births which occurred in the borough, 464—i.e., 54.3 per cent., were attended by midwives in their, capacity as midwives, and 391—i.e., 45.7 per cent., were attended by doctors. Midwives Acts. On account of the increased size and importance of the borough consequent upon amalgamation, an order was received from the Minister of Health at the end of September, 1937, whereby the Corporation became the Local Supervising Authority under the Midwives Acts in place of the Middlesex County Council. This order became operative on October 1st, 1937. The responsibility thus placed upon the Corporation constitutes the most important and extensive addition which has been made to the public health services of the town for many years past. Not only did the Corporation become responsible for exercising supervision over all midwives practising in the area—a duty formerly carried out by the Middlesex County Council—but also for establishing and maintaining a service of Municipal Midwives. This duty was imposed upon Local Supervising Authorities by the Midwives Act, 1936. The proposals for the establishment of this service which were submitted to the Minister of Health and subsequently approved, included the appointment of seven whole-time midwives, arrangements in connection with applications for their services, duties, control, supervision, salaries, superannuation, uniform, residence and other conditions of employment, together with the fees chargeable for their services and the contributions payable by patients. The above proposals became effective on May 16th, 1938, when six midwives commenced duty as whole-time Municipal Midwives. While these important additions were being made, the established branches of the Maternity and Child Welfare service were being carried out with increased activity. Care of Expectant Mothers. The number of sessions devoted to this important work were as follows:— York House centre One weekly session. Whitton centre ,, ,, Teddington centre ,, ,, Hampton centre One session first and third week of each month. At the end of the year, the Teddington clinic was transferred to the same premises as the Infant Welfare centre, which was held at the Art school, Church road. 16 Attendances of expectant mothers at the ante-natal clinics show an appreciable increase, as will be seen from the following figures:— Attendances Total Year for first time. attendances. 1937 607 1,987 1938 638 2,406 A considerable proportion of this increase is due to the exertions of the Council's Municipal Midwives. The arrangements for providing dental treatment for expectant and nursing mothers in the borough were continued during the year. Milk or other foods were supplied free of charge to all necessitousapplicants. On account of the adequate facilities which now exist at the West Middlesex County Hospital, expectant mothers for whom special observation or treatment is required are referred to that hospital. Birth Control. Women for whom pregnancy is inadvisable for medical reasons are referred to one of the birth control clinics at Hounslow or Richmond for the necessary advice, etc. Care of Mothers during Confinement. The Corporation have not established a Maternity Home, and in view of the proximity of the West Middlesex County Hospital, no formal agreement has been made with any hospital for the reception of complicated or difficult cases. One request has been received during the year for the services of a consultant in a case of difficult labour. Medical Practitioners called in by Midwives. Steps have been taken in accordance with the suggestions issued by the Minister in Circular 1705 to draw up a list of practitioners who notify themselves as willing to be called in by midwives in an emergency, and also to set up an advisory committee for this area consisting of the Medical Officer of Health (as chairman), two general practitioners, and two obstetric consultants. We have been successful in obtaining the services of two practitioners and one consultant, and are hoping to enlist the services of a second consultant at an early date. The committee will meet from time to time for. the purpose of scrutinising the list, and for" making such recommendations to the Authority as appear to them desirable. Subsequent to Confinement. Medical practitioners have again been encouraged to send cases of puerperal pyrexia into hospital at an early stage, and the reluctance on the part of women to go to hospital for these conditions is disappearing. Fifteen cases of puerperal pyrexia weve admitted to hospital during the year, five to the isolation block at Queen Charlotte's Mateunity Hospital eight to West Middlesex County Hospital, one occurred in a Nursing Home, and the other was treated at home. All the cases recov ered. 17 No application was received for the services of a consultant in cases of puerperal pyrexia. A special clinic for the examination of mothers after confinement has not been established, but mothers are urged to attend at the Ante-Natal Clinic for subsequent examination. It is still a matter of great difficulty to obtain satisfactory attendances and only 21 mothers attended during the year. Two maternal deaths occurred in the borough during the year, both of which were unavoidable. One of these cases was a non-resident in the borough. Three deaths in consequence of childbirth took place amongst Twickenham residents whose confinements took place outside the borough, making a total of four deaths due to childbirth. With the exception of one case who was not under a private medical practitioner's supervision and who did not attend at any ante-natal clinic prior to confinement, these deaths were nonpreventable. Dental Treatment. Dental treatment carried out during the year was as follows:- Expectant mothers 48 Nursing mothers 30 Patients supplied with dentures 25 Dentures supplied 43 Institutional Provision for Mothers and Children. No formal arrangements have been made to provide institutional treatment for mothers and children. Health Visitors. No change took place in the number (8) of Health Visitors employed by the Council. They carry out the duties of School Nurses on behalf of the Middlesex County Council. The visits paid to the homes by the Health Visitors during the year included the following:— To expectant mothers 471 To children under 1 year of age 5,046 To children between the ages of 1 and 5 years 8,002 In addition, many visits were paid to children of school age for suspected infectious disease and for following up those recommended for medical treatment or observation. The Health Visitors also attended when required at the minor ailment and dental clinics. Winter School. To of the Health visuors attended a study course during the winter. 18 Infant Welfare Clinics. There are now five centres for infant welfare, ten sessions for infant consultation being held weekly. The total attendances of children under 5 years of age at the various sessions numbered 20,006 during the year. The figures for each centre are set out below: — 1938 New cases. York house centre Whitton centre Teddington centre Hampton centre Hampton Wick centre Totals Under 1 year 243 407 168 110 47 975 1-5 years 44 138 65 44 25 316 Mothers 3 3 1 — - 7 Total attendances Under 1 year 2814 5194 2359 1910 653 12930 1-5 years 1154 2225 1544 1828 385 7136 Mothers 3 3 1 — — 7 Total attendances 3971 7422 3904 3738 1038 20073 Dental Treatment of Children under 5 years. During the year, 82 children under 5 years of age received completed dental treatment. Milk and Other Foods, etc. During the year, 1,157 applications for assisted supplies of milk and other foods were granted in necessitous cases and supplied free of charge. The total quantity of milk supplied was as follows:— Liquid milk 3,423⅛ galls. (Supplied to applicants free of charge) Dried milk 11,480 lbs. Infant Life Protection. There are no large and unsatisfactory homes where numbers of fosterchildren are received. There have been frequent instances where foster-mothers have failed to give prior notice of intention to take a child. No proceedings were authorised during the year for contravention of the law, but in every instance warning letters were sent. Special cards and report forms are kept for foster-children, and the Health Visitors keep in touch with all foster-mothers at least once a month. All the Health Visitors are appointed Infant Life Protection Officers, and the visits of supervision of foster-children are carried out by them. The details as to registration during 1938 were:— Number of persons who were receiving children for reward at the end of the year 69 Number of children on register at the end of the year 96 Number of children who died during the year 7 19 Orthopaedic Treatment. No formal arrangement has been made in the borough for the treatment of children requiring massage, orthopaedic treatment or remedial exercises. The facilities provided by the Middlesex County Council at the West Middlesex County Hospital, Isleworth, include the services of an orthopaedic surgeon, and cases can be treated as out-patients or admitted for operative treatment if necessary. While there are also facilities for massage and remedial exercises, for which frequent attendance is required, the distance to be travelled by patients is considerable and the time which is occupied in taking children to the hospital cannot be easily spared by working-class mothers. Two children, under five years of age, were sent to convalescent homes during the year at the expense of the Committee. Nursing Homes. There were 12 private nursing homes in the borough, all of which are registered. A request from one for removal from the register was received before the end of the year. The three voluntary hospitals which receive private patients are exempted from registration. A children's convalescent home was opened in the borough during the year. Exemption from registration was granted after application. The homes were kept under periodic supervision throughout the year. 20 Sanitary Administration. 21 Water Supply. The Metropolitan Water Board maintained a constant and satisfactory water supply throughout the borough. There are very few wells, practically every house deriving its water supply from that of the Board. Drainage and Sewerage. Arrangements have been made to disconnect the sewage from Kingstonon-Thames, where it has been conveyed and treated for many years, and connect it to the Mogden Scheme of the Middlesex County Council, and so bring it into line with that of the Teddington and Twickenham areas. Similarly, negotiations have been in progress for the Hampton sewage to be connected to the Mogden system. It is expected that this work will also shortly be put in hand. The surface water main outfall in Wharf lane has been relaid and an area, central in Twickenham, liable to flooding in heavy rain, thereby relieved. Rivers and Streams. No complaints regarding the pollution of the river Thames or streams were received by the Department during the year. Public Cleansing. A scheme is being submitted to the Ministry of Health providing for a greatly enlarged destructor, centrally situated on the site of the existing inadequate Twickenham plant, designed to dispose of the whole of the refuse from the borough. This scheme also embraces the operation of a modern combined horse and mechanical system of collection over the whole of the borough, covering a population of over 100,000 persons. It is hoped that this will be approved by the Ministry of Health at an early date. Sanitary Inspection of District. Despite the difficulties experienced by three changes in the personnel of the Sanitary Inspectorate during the year, the work under this heading has nroreeded stearlilv and has been nrosecuted with thoroughness. The visits paid in respect of each branch of the work are set out under the appropriate headings. Notices served. Informal notices served 695 * Informal notices complied 639 Statutory notices served 41 Statutory notices complied 33 Summary of visits and inspections. Visits to premises after complaint 1,031 Visits after occurrence of infectious disease 515 Visits under Housing Acts 166 Total v isits and inspections 18,366 22 Summitry of works executed in consequence of above visits. Drains unstopped and repaired 95 Waste pipes disconnected or repaired 27 Soil pipes provided or repaired 7 Complete drainage reconstructions 22 Water supply cisterns repaired 4 Draw taps from main provided 64 Gutters repaired 9G Roofs repaired 22G W.c. apartments repaired or rebuilt 68 W.c's repaired 96 Dustbins provided 228 Damp walls remedied 234 Ventilation provided 75 Yards paved or repaired 60 Rooms stripped and cleansed 304 Offensive accumulations removed 17 Other works carried out 1,339 Smoke Abatement. Occasional complaints regarding smoke nuisances were received during the year, every one of which was thoroughly investigated by a Sanitary Inspector. It was not found necessary to take statutory action under the Public Health Act with regard to any of these cases. Swimming Baths and Pools. There Arc three open-air swimming baths within the borough, all of which are owned by the Corporation. The water in the baths is frequently tested to determine the amount of treatment necessary and the maintenance of a high standard from the bacteriological aspect. Eradication of Bed Bugs. (1) Number of Council houses. (a) Found to be infested 8 (b) Disinfestcd 8 (2) Number of other houses. (a) Found to be infested 20 (b) Disinfested 20 The methods of disinfestation employed were set out in the report for last vcar. During the year under review the insecticide solutions used were "Keritox" and "Zaldecide." No application was received from the Housing Department with regard to the disinfestation of the belongings of persons before their removal to Council houses. An employee of the Corporation undertakes the work of disinfestation under the direct supervision of the Sanitary Inspectors. The latter give advice to the tenants as to the measures necessary for preventing infestation or re-infection 23 Offensive Trades. During the year, four applications were received to establish the trade of fish fryer. In each case the application was not granted. The following premises under this heading were kept under frequent supervision:— Fish fryers 26 Fat melters 2 Rag and bone dealers 4 Number of visits paid by Sanitary Inspectors, 142. Schools. There are in the borough 26 elementary schools, three secondary schools, and a technical college. The Sanitary Inspectors visited the schools quarterly during the year to ensure that the sanitary condition and water supply were satisfactory. It was not necessary to take any action in respect of the closure of any of the schools on account of infectious disease among the children. Petroleum (Regulation) Acts, 1928 and 1936. The supervision of stores where petroleum spirit and carbide of calcium are kept is undertaken by the Sanitary Inspectors. Licences were issued in respect of 116 premises during the year. Of these, 13 were for the storage of petrol in cans, 13 for the storage of petrol in tanks and a small supply in cans, the remainder being for storage in underground tanks.- Number of visits paid by inspectors, 387. Shops Act, 1934. The general duties under the Shops Acts are carried out by the Shops Inspector, who is a member of the Town Clerk's Department staff. The relevant provisions of the above Act with regard to sanitary conveniences, etc., are subsequently carried out by the Health Department. Inspection of offices, as a matter of routine, was not carried out during the year. Rats and Mice (Destruction) Act, 1919. The Middlesex County Council are responsible for the administration of the above Act in the borough. All complaints and enquiries regarding rat infestation received by the Department are sent to the County Council. Factories and Workshops. The Factories Act, 1937, came into force on the 1st July, 1938. The new Act supersedes the Factories and Workshops Act, 1901, and not only effects important changes regarding matters previously dealt with, but introduces a number of new requirements. Included among the new provisions and matters now dealt with in more detail affecting the Department are: temperature, drainage of floors, examination of basement bakehouses within one year of the commencement of the Act and thereafter everv five vears. Inspections for Purposes of Provisions as to Health. Including inspections made by Sanitary Inspectors. Premises. (1) Number of Inspections (2) Written Notices (3) Occupiers Prosecuted (4) Factories with mechanical power 247 12 - Factories without mechanical power 218 2 - *Other premises under the Act (including works of building and engineering construction. but not including outworkers' premises) 63 - - Total 528 14 - *Electrical stations should be reckoned as factories. Defects Found. Particulars. Number of Defects. Number of defects in respect of which prosecutions were instituted. Found. Remedied Referred to H.M. Inspector (1) (2) (3) (4) (5) Want of cleanliness (S.l) 8 8 — — Overcrowding (S.2) - - - - Unreasonable temperature (S.3) — — - - Inadequate ventilation (S.4) 3 - - Ineffective drainage of floors (S.6) 1 1 - - -Sanitary Conveniences (s.7) Insufficient - 1 - - Unsuitable or defective 7 8 - - Not separate for sexes - 1 - - Other offences (Not including offences relating to home work or offences under the sections mentioned in the schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921, and re-enacted in the Third Schedule to the Factories Act, 1937). 6 14 Total 22 36 - - 25 Establishments for Massage or Special Treatment. During the year 1938 the Corporation adopted Part VII. of the Middlesex County Council Act, 1034. Part VII. provides, inter alia, for the licensing of establishments for massage or special treatment. Byelaws for the regulation of such licensed establishments were also made. One application—to carry on the business of chiropody—was received during the year, and this was granted. Hairdressers' and Barbers' Premises. The Council made byelaws during the year under section 78 (1) of the Middlesex County Council Act, 1934, for the purpose of securing the cleanliness of any premises in the borough used for the purpose of carrying on the business of a hairdresser or barber, and of the instruments, towels, equipment and materials used in such premises. Housing. During the year under review, housing inspection proceeded steadily, and the following statistics show the useful work carried out under this heading. In pursuance of the policy of clearing insanitary and unhealthy areas, considerable attention was given during the latter part of the year to this matter. As a result it is probable that representations will be made to the Council in respect of some six areas. This subject will be dealt with fully in my next report. Housing Statistics, 1938. 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) 870 (b) Number of inspections made for the purpose 1,033 (2) (a) Number of dwelling houses (included under head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 and 1932 1G6 (b) Number of inspections made for the purpose 271 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 10 (1) Number of dwelling houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit lor human habitation 695 2. Remedy of defects during the year without service of formal notices. Number of defective dwelling house rendered fit in sequence of information by the local authority or their officers 639 20 3. Action under statutory powers during the year. A.—Proceedings under sections 9, 10 and 16 of the Housing' Acts, 1936 (1) Number of dwelling houses in respect of which notices were served requiring repairs 7 (2) Number of dwelling houses which were rendered fit after service of formal notices: — (a) By owners 4 (£>) 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 34 (2) Number of dwelling houses in which defects were remedied after service of formal notices:— (a) By owners 29 (b) By local authority in default of owners Nil C.—Proceedings under sections 11 and 13 of the Housing Act, 1936 (1) Number of dwelling houses in respect of which Demolition Orders were made 8 (2) Number of dwelling houses demolished in pursuance of Demolition Orders 14 D.—P roceedings under section 12 of the Housing Act, 1936:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 2 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit 2 4. Housing Act, 193G. Part 5—Overcrowding. (a)( i) Number of dwellings overcrowded at the end of the year 192 (ii) Number of families dwelling therein 195 (iii) Number of persons dwelling therein 1,193½ (b) N umber of new cases of overcrowding reported during the year 9 (c) (i) Number of cases of overcrowding relieved during the year 11 (ii) Number of persons concerned in such cases 55½ Inspection and Supervision of Food. Milk Supply. There arc on the registers of the Department three cowkeepcrs and 101 dairymen and purveyors of milk. The inspection of all premises comes within the routine work of the Sanitary Inspectors. During the year, 410 visits were made. Milk (Special Designations) Order, 1936. The following licences for the sale, of designaved milk were in force during the year:- " Tubercutin tested'' milk 9 " Pasteurised " milk 24 27 Meat and Other Foods. At the beginning of the year there were 13 registered and seven licensed slaughterhouses within the borough. A number of the registered slaughterhouses have not been used for a number of years and as a result of representations being made to the occupiers five premises were removed from the slaughterhouse register during the year. During the year, 10,624 animals were slaughtered for human consumption within the borough and, with the exception of 10 pigs, every one was inspected by the Sanitary Inspectors. This work is of vital importance, and although it entails a tremendous amount of time on Sundays, public holidays and often late at night on week-days, no effort is spared to ensure to the public a wholesome food supply. The following table shows the number of animals examined and action taken:— 1938. Cows Other Beasts Calves Pigs Sheep and Lambs Number killed 5 73 1398 6134 3014 Number inspected 5 73 1398 6124 3014 All diseases cxcept Tuberculosis. Whole carcases condemned - - - 2 - Carcases of which some ,part or organ was condemned - 2 3 214 68 Percentage of number inspected affected with disease other than tuberculosis 2.74 0.21 3.53 2.25 Tuberculosis only. Whole carcases condemned - 1 2 6 - Carcases of which some part or organ was condemned 3 5 12 230 - Percentage of the number inspected affected with tuberculosis 60.00 8.22 1.00 3.85 - Other food condemned. 275 soup powders. 3 stones of herrings. 8 tins.of pineapple. 1 cooked gammon. 4 stones beef. Proceedings were instituted by the Corporation against a local firm in respect of the soup powders referred to above. The case was heard at the Brentford Police Court, and although no conviction was recorded, costs amounting to £20 were awarded against the firm. There are 90 butchers' shops on our records. These arc kept under supervision by the Sanitary Inspectors, who paid 559 visits during the year. 28 The following visits were also made to premises upon which food is prepared or sold:— Restaurants and eating-house kitchens; grocers' shops 64G Greengrocers' shops 343 Fish shops 208 Food and Drugs (Adulteration) Act, 1928. Artificial Cream Act, 1929. Public Health (Condensed Milk) Regulations, 1923 and 1927. Public Health (Dried Milk) Regulations, 1923 and 1927. Public Health (Preservatives, Etc., in Food) Regulations, 1925 and 1927. The administration of the whole of the above is carricd out by the Middlesex County Council. 29 ' - Infectious Diseases. 31 INFECTIOUS DISEASES. (a) Notifiable Infectious Diseases. Diphtheria. There were 70 cases of diphtheria notified as compared with 116 for the previous year. 60 cases were admitted to hospital. The number of deaths recorded was five, giving a death rate of 0.05 per 1,000 of the population. The figure for England and Wales was 0.07. Supply of anti-toxin. All medical practitioners practising ift the borough may at any time obtain a supply of diphtheria anti-toxin from the fire stations at Twickenham or Teddington, free of charg?. Diphtheria immunisation. The following is a record of the work carried out at the clinics during the year NewCases Ages. 1 2 3 4 5 6 7 8 9 10 11 12 to 15 15 to 20 20 to 25 over 25 656 130 48 51 44 71 70 46 36 39 34 30 48 2 - 7 1st Schick Test before inoculation:— Number 18 Susceptible 14 Immune 3 Failed to attend 1 Number receiving first completed course of injections during year 838 2nd Schick Test of those who had completed first course of injections:— Number 260 Protected 1,122 Susceptible 24 Failed to attend 114 All those found to be incompletely protected after the second Post Schick were re-inoculated. The diphtheria prophylactics used were T.A.M., T.A.F., and A.P.T. Scarlet Fever. There were 274 cases of scarlet fever notified during the year as compared with 148 for 1937. There was a sharp rise in the number of cases notified in March. During the following quarter the notifications continued to be higher than usual, but thereafter fell. This is rather curious, for the study of epidemiology has shown that, in so far as the seasonal incidence of diseases is concerned, scarlet fever increases in this country through the summer to a maximum in October and November. There is then a fall in incidence to a minimum in March or April. The cases were, however, of a mild character, and several were not recognised as scarlet fever until other cases occurred among contacts. One death was recorded from this disease. This gives a death rate of 0.01 per 1,1)00 of the population—the same as that for England and Wales. 32 Smallpox. No case of smallpox was notified during the year. Pneumonia, Malaria and Dysentry. Pneumonia. There were 68 cases of pneumonia notified as compared with 75 for the previous year. The number of deaths recorded from this disease was 53. Malaria. No case of malaria was notified during the year. Dysentery. Six cases of dysentery were notified during the year. Four cases occurred in the same road, three being members of the same family. There was no apparent connection between the cases, however, and no specific mode of infection could be established. There were no deaths. Acute Poliomyelitis, Acute Polio-encephalitis. Three cases of acute poliomyelitis and one of acute polio-encephalitis were notified during the year. There was one death from the former disease. Ophthalmia Neonatorum. The following table shows the number of cases notified and result of treatment:— Year. Cases notified. Cases Treated Vision unimpaircc Vision impaired Total blindness Deaths. At home. In hospital 1938 12 11 1 12 - - - Puerperal Pyrexia. 15 cases of puerperal pyrexia were notified during the year. Eight were treated in the West Middlesex County Hospital and five in Queen Charlotte's Maternity Hospital. There were no deaths. Enteric Fever. No case of enteric fever was notified and no deaths from this disease were recorded during the year. (b) Non-notifiable Infectious Diseases. Diseases under this heading include chicken-pox, measles, mumps and whooping-cough. It is not possible to arrive at any definite figures with regard to the incidence of these diseases during any year, but some indication is given by the number of notifications sent in by the head teachers of the schools in the borough. Every case brought to our notice in this way is visited by one of the Health Visitors. The figures for 1938 are as follows:— Chicken-pox 30 Measles 120 Mumps Whooping-cough 60 33 34 CASES OF INFECTIOUS DISEASES NOTIFIED DURING THE YEAR 1938 Disease. Cases notified at various ages (years). Total cases notified No. of cases admitted to hosp. Total deaths Under 1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-25 25-35 35-45 45-65 Over 65 Scarlet Fever - 6 9 14 19 149 40 11 3 18 4 - 1 274 233 1 Diphtheria - - 2 3 5 31 16 5 3 2 2 1 - 70 69 5 Pnuemonia— Primary Influenzal 2 2 4 4 2 14 3 1 2 6 6 9 4 59 53 - - - - - 1 2 - - 1 3 - 2 9 Acute Poliomyelitis - - 1 - - 1 - - - 1 — — — 3 2 1 Acute Polio-Encephalitis. - - - - - - 1 - - - - - - 1 1 — Dysentery - — — - 1 3 2 - — — — — — 6 1 — Ophthalmia Neonatorum. 12 - - - - - - - - - - - - 12 1 - Puerperal Pyrexia - - - - - - - - - 10 5 — — 15 13 Erysipelas — — — 1 — — 3 2 - 6 6 15 6 39 6 - 35 MONTHLY INCIDENCE OF INFECTIOUS DISEASES DURING THE YEAR 1938. Disease. Number of cases. Total Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Scarlet Fever 14 20 48 39 30 28 18 12 18 15 18. 14 274 Diphtheria 17 9 7 6 2 6 3 6 2 4 4 4 70 Pneumonia— Primary 13 4 7 4 6 6 3 3 2 1 4 6 59 Influenzal 2 1 3 1 — 1 1 — — — - - 9 Acute Poliomyelitis — — — — — - 1 - 1 - - 1 3 Acute Polio-Encephalitis — — — — — - — 1 — — - — 1 Dysentery 4 1 1 - - - — — — — — — 6 Ophthalmia Neonatorum 2 — 1 3 — 2 2 — 1 — — 1 1 2 Puerperal Pyrexia 3 1 - 1 1 3 — 1 1 1 1 2 15 6 3 6 5 4 4 — 4 — 2 3 2 39 Tuberculosis. During the year 1938 there were 130 new cases of tuberculosis notified. Of these, 100 were pulmonary and 30 non-pulmonary. This shows an increase compared with the previous year. On the other hand, the number of deaths recorded from the disease was lower. 14 per cent, of the total tuberculosis deaths had not been notified as cases of tuberculosis during life. New Cases and Mortality', 1938. Age Periods. New Cases. Deaths. Pulmonary NonPulmonary Pulmonary NonPuI mo nary M. F, M. F. M. F. M. F. Under 1 - - - - - - - 1 -5 1 2 — 1 1 - - - 5—10 1 1 3 3 - - - - 10—15 1 2 2 1 - 1 - 1 15—20 3 7 3 1 - 1 1 - 20—25 9 6 3 1 3 - 1 - 25—35 13 16 3 5 10 6 - - 35—45 10 5 1 - 6 - - - 45—55 10 1 1 - 5 1 - - 55—65 7 3 - 1 4 1 - 1 65 and upwards 2 - - 1 3 - - 2 Totals 57 43 16 14 32 10 2 4 Public Health (Prevention ok Tuberculosis) Regulations, 1925. During the year under review it was not found necessary to take action under the above Regulations with reference to persons suffering from tuberculosis and employed in the milk trade. Public Health Act, 1936 (Section 172). This section of the Public Health Act is concerned with the compulsory removal to hospital of persons suffering from tuberculosis. It was not found necessary to exercise our powers thereunder during the year. Prevention of Blindness. No action was taken during the year under section 176 of the Public Health Act, 1936, for the prevention of blindness or for the treatment of persons suffering from any disease or injury to the eyes. 36 INDEX Page Ambulance Facilities 11 Ante-Natal Clinics 12, 16, 17 Anti-toxin, Supply of 32 Artificial Cream Act, 1929 29 Births 7, 16 Birth Control 17 Blindness, Prevention of 36 Care of Mothers during Confinement 17 Care of Mothers subsequent to Confinement 17 Deaths 7, 8 Dental Clinics 12 Dental Treatment 18, 19 Diphtheria 32 Diphtheria, Immunisation 12, 32 Disinfestation 23 Drainage and Sewerage 22 Dysentery 33 Enteric. Fever 33 Factories and Workshops 24, 25 Food, Inspection and Supervision of 27, 28, 29 Food and Drugs (Adulteration) Act 29 Hairdressers' and Barbers' Premises 26 Health Visiting 18 Hospitals 13 Hospitals Housing 26, 27 Infant Life Protection 19 Infantile Mortality 9 Infant Welfare Clinics 12, 19 Infectious Diseases 13, 32, 33,33,35, Institutional Provision for Mothers and Children 18 Isolation Hospital Accommodation 13 Laboratory Work Malaria Message or Special Treatment Establisments 26 Maternty and child welfare committee 2 IN D E X—continued. Page Maternal Mortality 8 Medical Practitioners called in by Midwives 17 Midwives Acts, Administration of 10, 17 Milk and Other Foods, etc., Provision of 19 Milk Supply 27 Nursing Associations 11 Nursing Homes 20 Offensive Trades 24 Ophthalmia Neonatorum 33 Ophthalmic Clinics 12 Orthopœdic Treatment 20 Petroleum (Regulation) Acts 24 Pneumonia 33 Poliomyelitis 33 Polio-encephalitis 33 Population 7 Public Cleansing 22 Public Health Committee 2 Public Health (Condensed Milk) Regulations 29 Public Health (Dried Milk) Regulations 29 Public Health (Preservatives, etc., in Food) Regulations 29 Puerperal Pyrexia 13, 33 Rats and Mice (Destruction) Act 24 Rivers and Streams 22 Sanitary Inspection of District 22 32 Scarlet Fever Schools 24 School Clinics 12 Shops Acts 28 Slaughter-house 13,33 Smallpox 23 Smoke Abatement Staff 6,10 Statistics, General and Vital 23 Swimming Baths and Pools Tuberculosis 12, 13, 36 Unsound Food 22 Water Supply Winter School for Health Visitors 18