Public Health Hck. 14/1/55 Bgp AC 439(1) TWICKENHAM NOVEMBER, 1952 Twi 19 GOOD HEALTH IN TWICKENHAM The Annual Report of the Medical Officer of Health. JOHN MADDISON, M.D., B.S., D.P.H. Pc. ack. 18/.2/52 CONTENTS Page Introduction 2 Health Committee and Staff 3 Research in Health and Education 4 The Survival of the Fittest 10 Tracing Contacts 14 Pest Destruction 15 Keeping the Borough Clean 15 Water Supply 16 Industrial Health 17 General Matters 17 Statistical Summary 21 1 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 current Annual Report on the health and sanitary conditions of the Borough. The report contains as a supplement the statistical tables for the year 1951 as required by the Ministry of Health. A glance at the tables in the appendix will show the vast and important field covered in environmental health and the volume of work done. The figures show that on the whole the health of the population of the Borough is good and the sanitary circumstances, with a few exceptions, are satisfactory. The outstanding problem is, of course, the heavy overcrowding in many of the houses. The Medical Officer of Health cannot limit his interest to the field of environmental health alone. As Area Medical Officer I am concerned with a great many other public health functions now administered by the County Council, and as the health of the population is in a sense indivisible, my various duties are really different ways of looking at the same objective, which is to have the healthiest population possible. The Annual Report affords an opportunity for the Medical Officer to give some account of what he is thinking about. For a long time I have thought how necessary it is to try to determine the causes of the variation in health among school children and to try to institute measures for preventing subnormal health amongst them. In the body of the report I have given an account of some of the problems inherent in such an investigation. I beg to acknowledge my indebtedness to the Chairman and members of the Public Health Committee for their helpfulness and support, which is always of the greatest encouragement. I desire also to acknowledge with thanks the friendly co-operation and help which I have always received from my colleagues in the other departments of the Corporation and the other members of the Council. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, JOHN MADDISON, Medical Officer of Health. 2 MEMBERS OF THE HEALTH COMMITTEE Ex officio members: His Worship The Mayor, Alderman G. Jamieson, J.P. The Deputy Mayor, Alderman J. W. Nicholls, J.P. Chairman: Alderman J. Allinson Vice-Chairman: Councillor Mrs. J. L. Gill Alderman V. G. Heptinstall Councillor A. T. Kremers Alderman J. H. Knaggs, J.P. Councillor J. H. W. Mears Councillor L. Clements Councillor N. T. Poulter, B.A. Councillor Mrs. M. B. Davies Councillor Mrs. O. M. Renier Councillor R. F. E. Howard Hodges Councillor N. Sheldon Councillor J. W. M. Hurles STAFF OF THE PUBLIC HEALTH DEPARTMENT Medical Officer of Health ... Dr. J. Maddison, M.D., B.S., D.P.H. (Also Area Medical Officer, Twickenham, Feltham, Staines and Sunbury.) Deputy Medical Officer of Health Dr. W. Cormack, M.B., Ch.B., D.P.H. (Also Deputy Area Medical Officer, Twickenham, Feltham, Staines and Sunbury.) Chief Sanitary Inspector Mr. T. Williams Deputy Chief Sanitary Inspector Mr. H. G. Easter Sanitary Inspectors Messrs. L. Burrows, K. E. Evans, J. A. K. Garratt, J. W. Paine, J. Hacker All the Inspectors hold the Certificate of the Royal Sanitary Institute and Sanitary Inspectors' Examination Joint Board, and the Meat Inspectors' Certificate. Chief Clerk Mr. H. J. Pugh (Also Area Chief Clerk, Twickenham, Feltham, Staines and Sunbury.) Senior Clerk Mr. W. J. Larwood Clerical Staff Miss G. Payne, Mrs. W. E. George, Miss K. Dopson Senior Rodent Operative Mr. H. T. Jackman Rodent Operatives Messrs. C. H. Deacon, M. P. Robinson Disinfector/Drain Tester Mr. E. G. Cooper 3 RESEARCH IN HEALTH AND EDUCATION Differences in People. As an officer of the Education Committee I am deeply interested in education. During this year I was asked to help in an investigation conducted by the National Foundation for Educational Research on why it is that some boys and girls who pass the examination at 11 plus for entrance to a grammar school fail to progress, or sometimes even deteriorate; or conversely, some children who fail to pass, and go to modern schools, are found at the top of their classes and so presumably would have done well had they been sent to a grammar school. This question is part of a wider one; why do some children, who show great promise in the infant and junior schools, deteriorate as they reach adolescence and adult life? And still wider: why are we all different, and what are the basic differences? We are different in shape and size, in features and colour, in character and intelligence, in sociability and determination. We vary too in our health, in our ability to withstand infection, in the readiness with which we get heart disease or cancer and other ailments, and in the onset of the degeneration of old age. Year after year my department collects information in the school health service showing that out of about 7,000 children examined in the periodic inspections in schools some 200 have poor physique, 250 have skin diseases, 450 have eye defects, 100 suffer from diseases of the ears, 200 have tonsils and adenoids, about 100 have diseases of the heart and lungs, 250 have deformities of various sorts, and another 200 a miscellaneous assortment of ailments. Not all of these are serious; most of those with eye defects can be corrected with glasses, and remedial treatment can be provided for nearly all the others. These figures refer only to those children with defects found at the medical examinations in schools; in addition, about 3,500 attend the clinics mostly of their own accord, and another 3,000 by appointment in the specialist clinics. The Influence of Home. In 1951 we began to look for causes as to why a proportion of all children are always found with defects of various sorts. It has long been known that the influence of a child's home is of enormous importance. Therefore, as each child was examined in school at the periodic medical inspections, we made a note, based on information obtained from the health visitors, about the child's home. We used a very rough classification of three grades, good, average, and bad. We recorded also the height and weight of each child, and his position in the family—first child, second or third, etc. To record the ailments and defects more accurately we used the International Classification of Diseases where each disease is listed and given a code number. There were about 7,000 children examined altogether; the particulars about each one were arranged in code form and the results punched on cards for use in the Powers Samas machines in the County Treasurer's department. Various tables have been made which classify the children in a number of ways. The final analysis is not yet complete, but a preliminary examination of the figures has shown conclusively that the children from poor homes have more defects, suffer more from ill health, are less in stature than the children from better homes. This leads at once to the question—what do we mean by a good home, an average home and a bad home? A bad home is not one caused by mere lack of money and possessions, although this can be an important cause. 4 I would describe a bad home as one having some of the following characteristics. Low family income resulting in insufficient food, clothing, footwear and material needs; the house generally untidy, dirty or squalid; restricted living space with gross overcrowding due to a large family or the presence of relatives, lodgers or another family. It might be a broken home with one parent dead, or parents divorced, separated, or abandoned, deserted or imprisoned; an unmarried mother; or a parent suffering from a long physical or mental illness, especially in hospital. There may be a bad marital relationship with frequent and severe quarrelling; or drunkenness; and one or both parents not carrying their fair share of responsibility. There may be a poor attitude of one or both parents to the child from lack of interest, no time for the child, no discipline, too much severity, harshness, neglect, cruelty, frequent corporal punishment; or mental torment by derogatory and insulting expressions to the child, a hostile attitude, rejection, absence of love and security, jealousy; or alternatively, over-indulgence, pampering, inconsistent treatment as from violent oscillations of love and hate. The child may be subject to bad influence in addition to these as with bad companions, unhappy relationships with brothers and sisters, a poor relationship with other adults or a teacher; long absences from home or school; changes of school; or the child's inability to obtain help with some problem which he believes important. As our investigation proceeded it became clear that in order to determine the relative importance of these deleterious influences on the health, welfare and education of children, we must have a much finer classification of homes and some sort of a measure. Now this is a matter of great difficulty. The list of untoward influences shows that many are due to the goodness or otherwise of the character and personality of the parents. We can observe such things as overcrowding and poor sanitary environment, but it is not so easy to assess personality. Nevertheless, most of us, every day of our lives, are making observations on our friends and acquaintances and in doing so we mentally classify them however roughly it may be. For research purposes we must be much more accurate which leads me now to consider the assessment of personality. Assessing Personality. From time immemorial men and women have made judgments about each other using the noun, adjectives, and phrases of ordinary language to describe the numerous factors of personality and character. Novelists, dramatists and historians have described the personality of their characters; school teachers have assessed the potentialities of their pupils. An ordinary dictionary contains over 4,000 words whose meanings have to do with the numerous facets of personality, such as abhor—(feel horror, disgust, or hate for), ability—(power to perform or accomplish), abject— (feeling wretched or miserable), abnegate—(deny oneself), above-board— (honest, without tricks or concealment), abrupt—(short spoken, blunt). As large numbers of these words are synonyms or near synonyms, it was possible for Professor R. B. Cattell1 to reduce the 4,000 words to 171 groups which describe the various aspects of human behaviour; these he calls trait elements, as in the group—thoughtful, reflective, studious, meditative, or the opposite group thoughtless, unreflective, hasty, incogitant. A trait is a collection of reactions or responses bound together by some sort of unity which permits them 1 Cattell, R. B. (1946). Description and Measurement of Personality. McGraw Hill. 5 to be gathered under one term or heading; the word thoughtful, for instance, combines the reactions of a person who is intelligent, conscientious, emotionally stable and possibly other things. Cattell's groups of trait elements can be reduced still further to 35 clusters of general description of personality as used in everyday speech. He calls these clusters the surface traits. They describe the features, qualities or characteristics of persons as observed in everyday life by their companions, workmates, playmates and fellow citizens. Such a cluster might be, for instance—surly, hard, thankless, hardhearted, embittered, shorttempered. If we think about a number of people we know well, we may note the great variation there is amongst them in their ability to do things, their interests, their conscientiousness and reliability, whether they are steady or emotional, or whether they are likeable or not. The Source Traits of Personality. For nearly half a century psychologists have searched for the basic or source traits of personality and character. What are the real root differences in personality make-up ? There have been dozens of classifications; we have the fat jolly type, the thin mean type, or the assertive type, or acquisitive type or amorous type, etc. In the field of mental illness patterns have been established with considerably more certainty such as in the clinical conditions of schizophrenia or split mind, mania, melancholia, delusional insanity and neurasthenia. Some of these seem to fit in with the idea of being the extreme form of a mental pattern often met with in normal people. The split mind type of personality is one in which the person is able to think clearly and accurately and to make sound judgments and yet seems curiously deficient in emotional feeling, resulting in a withdrawal from social contacts, and conduct which is moody, rigid and unadaptable. Mania is the extreme form of eagerness and joyous excitement. Melancholia is the opposite—a feeling of depression, worthlessness and anxiety. Statisticians describe the distribution of these types of personality as forming a normal curve; thus, for instance, in intelligence, most people are of average level, fewer and fewer people are found as we ascend the scale, and similarly fewer and fewer as we descend the scale. How to Find the Source Traits. The method of finding the source traits used by psychologists is the technique of factor analysis. In an experiment, a group of persons are classified in numerous ways by others who know them well. The classification or rating means making an assessment of their behaviour from a large list of descriptions of pieces of behaviour or surface traits. Now there is no scale such as a scale of inches by which we can measure, let us say, honesty; but we can compare people in our minds and we can say that some person is scrupulously honest, or substantially honest, fairly honest, neither particularly honest or dishonest, slightly dishonest, often dishonest, or completely dishonest and untrustworthy. Here we have a scale of honesty in which we can award seven marks for scrupulous honesty, six marks for being substantially honest, five marks for fairly honest, and so on down to one mark for the lowest category. Now we can take some other trait such as assertiveness with its opposite extreme submissiveness, and we can divide this one into seven grades as before. It is now possible to classify person A on two traits, honesty and assertiveness, by giving him marks. We can go on doing the same for as many other traits as we please up to say 50 or 100. We do the same with person B, then with person C and so on until we have a list of persons numbering say 250. 6 The psychologist now does a sum to see if there is any relationship and how much between trait 1 and trait 2—in our case between honesty and assertiveness. He does another sum for trait 1 and trait 3, another for trait 1 and trait 4, and so on for the whole table. Then he repeats the process for the relationship between trait 2 and trait 3, then trait 2 with trait 4 and so on until every possible relationship in the whole table has been ascertained. He has now obtained a table of correlations. From such a table it is possible to find what common factors there are in the various pieces of behaviour which have been assessed. Cattell has found 16 of these factors which he regards as the root or basic traits of personality. The factors are, so to speak, the foundation stones on which the superstructure of personality is built. An abbreviated list is as follows:— Personality Factors Factor number With a great deal of the With very little of the and letter factor a person is factor a person is 1. A. Good-natured, co-operative. Hard-hearted, obstructive. 2. B. Intelligent, clear thinking. Mentally slow, stupid. 3. C. Emotionally calm. Very emotional, intolerant. 4. E. Dominating, assertive. Submissive, dependent. 5. F. Cheerful, frank. Depressed, silent. 6. G. Persevering, conscientious. Gives up easily, unreliable. 7. H. Adventurous, sociable. Cautious, shy. 8. I. Very sensitive, fastidious. Hard, set and smug. 9. L. Suspicious, jealous. Composed, not jealous. 10. M. Unconventional, eccentric. Conventional, narrowly correct. 11. N. Polished, sophisticated. Clumsy, awkward. 12. O. Worrying, anxious, brooding. Placid, trustful. 13. Ql. Deep thinking, experimenter. Conservative, accepts explanation. 14. Q2. Independent, self-sufficient. Lacks resolution. 15. Q3. Strong control of behaviour. Weak control of behaviour. 16. Q4. Much nervous tension, restless. Little nervous tension, steady. The person who is high in factor 1 (A), is good-natured, easy-going, ready to co-operate, attentive to people, soft-hearted, kindly, trustful and adaptable; at the opposite end of the scale is the person who is spiteful, grasping, critical, obstructive, cool, aloof, hard, suspicious, rigid and cold. We can all recognise in our minds persons who fit these extremes. Factor 2 (B), is the one best known in schools. It is the factor of intelligence or general mental capacity as opposed to dullness or mental defect. The intelligent person is clear thinking, systematic, precise, thoughtful and has wide interests; he usually has other special abilities such as literary, mathematical, mechanical or musical. The opposite is the person who is mentally slow, simple or stupid and unimaginative; he has very few abilities and interests. In this factor of intelligence there is also a certain amount of goodness of character in persons of good intelligence and the opposite—weakness of character—in the mentally dull. It is not surprising that the greatest amount of delinquency occurs amongst both children and adults who are mentally below average. As a further example we may take factor 6 (G) which is sound character as opposed to immature dependent character. A person high in the factor is 7 persevering, determined, responsible and consistently ordered; he is reliable, can be trusted to pursue a task without supervision and is generally extremely conscientious. The opposite person is fickle and frivolous, impatient and demanding, slack and idle; he cannot be trusted with anything and may be even obstructive. On its positive side this factor is what we know as self-esteem—the urge and willingness to drive oneself even to the limits of fatigue and self-denial, in order to achieve a desirable goal, to produce good work or bring a project to a successful conclusion. Its reward is the pride of satisfaction in achievement and the esteem of others. We have to imagine that each of these source traits has the normal curve type of distribution in the population. Thus, if we picked out 1,000 people at random and considered them with respect to trait 1, it should happen that 500 would be good-natured and co-operative; of these about 300 would be just above average, about 150 well above average, and about 50 very much above average. On the down side of the curve there would be similarly 500 who were hard-hearted and obstructive, about 300 would be a little below average, 150 well below average, and 50 very much below average. Now this same 1,000 people can be classified for factor 2, i.e., intelligence; when this has been done we should find that they have been entirely reshuffled; it may thus happen that a person high in good nature might be average in intelligence or even mentally slow and vice versa. Each of the six grades in the good-natured/ hard-hearted scale can be spread over the six grades in the intelligence scale so that there are 6x6=36 ways of classifying on the two factors. When we come to three factors the number of ways is 6x6x6=216 or 63. With 16 factors each classifiable in six ways we would have 616 combinations. This works out to be 2,821,109,907,456. There are just under 50,000,000 people in this country so that the odds are more than 1,000 to one against finding even one person who is very high in all the factors. Shaping Character. It is believed that all of us are born with a certain amount of each of the 16 factors or source traits which may thus be called the hereditary or constitutional portions; these constitute the basic framework on which personality is built. But as each person goes through life, he has to learn that in order to attain whatever immediate or remote objective in life he desires, he must adapt himself to circumstances and modify his conduct as he deems best in his own light. As he goes through infancy, the toddler stage, school, adolescence, manhood and onwards to old age he has constantly to adapt himself to his environment, to the pleasures and displeasures of his parents, brothers and sisters, companions, teachers, workmates, wife, and all his associates; he must conform to the social code and the pattern of society. His hereditary or constitutional source traits, whether they be high, average or low and in whatever way they be mixed, become conditioned or modified into the more subtle attitudes and sentiments. Just as in the case of insects, birds and animals, we are all born with the instinctive urges to find food, to find companionship, to flee from danger, to overpower an aggressor, to find a sex mate and so on. The methods we use to satisfy any of these desires depend partly on the amount of each source trait we possess, how the source traits have been modified by experience in life, and by the way in which these modified traits are combined in order to attain any particular goal. 8 Any piece of observable behaviour is composed of a complex mixture of varying amounts of the basic source traits as modified by experience. The contributions of the factors in each of two individuals who exhibit the same apparent piece of behaviour will almost certainly be differently compounded. One person will take care to make good preparation, another will rely on intelligence and ability, a third will be governed by cupidity and falsehood, and a fourth maybe, by domineering assertiveness. It all depends on how they are made. However, because the environment in which we live is common in many respects to all of us, e.g., the same country, town, manners and customs of society ; the same subjects taught in school, and the influence of the churches, it comes about that the hereditary source traits, in being modified by the experience of the environment, become moulded to a basic common pattern. In the language of the psychologists all our habits have been rewarded or punished together. Thus a person is likely to be honest according to the degree in which his family and school have been successful in producing on his mind the impress of that particular social objective. But as the emphasis of the environmental pattern falls this way or that, we distinguish superficial types of personality which we label patriotic, domestic, conservative or sporting. But for a real understanding of the personality of anyone we must examine his endowment of each of the personality factors or source traits. Measurement. How can these factors be measured? The most outstanding progress has been made in intelligence testing (factor 2 B), which is now used a great deal in the selection of pupils for the various types of schools. For a number of years now the selection of pupils for grammar schools has rested almost wholly on the results of intelligence tests and attainment tests in language and arithmetic. In so far as it went, this system has worked fairly well because success in academic subjects is closely associated with intelligence; the shortcomings of the method, and the anomalies frequently encountered have emphasised the necessity for tests covering a much wider field of the whole personality than is found in factor 2 (B) alone. Recently, as the outcome of his researches, Cattell2 has published a personality test for adults and another is soon to be published for senior boys and girls. It is possible that the personality tests for senior boys and girls may prove to be a much more reliable means of assessing the capabilities in its wider sense and predicting the probable progress of any boy or girl, and even in judging his fitness for some future career than anything which has been possible hitherto. To return to our assessment of the influence of the home on the health and educational progress of the child we have been compelled hitherto to depend on assessments or ratings made by one or more observers. With the new tests and with a sample of co-operative parents it might prove possible, with further research, to determine the real relative importance of a child's home background, and perhaps to suggest measures for improvement where the conditions are deleterious. 2 Cattell, R.B. 16 Personality Factor Test. Institute for Personality and Ability Testing, Champaign, Illinois. 9 THE SURVIVAL OF THE FITTEST Oecology. When a person becomes ill with an infectious disease the immediate aim of the patient's private doctor or the fever hospital physician is to give the patient such treatment as is appropriate to hasten recovery. The medical officer of health, although, of course, concerned with this immediate aim, has a further interest which is to prevent the spread of the infection to other persons. In this he is concerned with the nature of the infecting micro-organism, its mode of multiplication and the channels through which it is conveyed to susceptible human beings. This leads in turn to a study of the harmful micro-organisms as one group of many living things, and to the still wider study of the impact of all living things on each other and the effects of all the different environments in which they exist. This study of the rise and fall of all living species and their relationships to environments is the study of oecology. In the case of any living organism, oecology is concerned with the supply of food and materials necessary for survival; the rate at which offspring are produced ; the other living organisms which can act harmfully ; and the effects of environments, especially adverse ones. Starvation. For example, in India and Pakistan the size of the population is determined by the quantity of food produced by primitive methods, the number of persons who die of starvation, and the number of persons who die from disease. Thus, 500,000 die each year from tuberculosis, 50,000 from smallpox ; in Bengal alone in 1941 there were nearly 400,000 deaths from malaria, over 100,000 from cholera and dysentery, and in Bengal in 1943, 700,000 persons died of starvation. A problem in applied oecology is given by Professor F. M. Burnet1; it is to determine the number of whales which can be killed each season in the Antarctic without risk of extinction of the commercially important species. To determine the number a great deal must be known about the migrations of whales, their rate of reproduction and growth, the amount of food available, and the enemies which attack them. The food supply is itself a complex problem; whales feed mostly on sea crabs; these crabs feed on smaller organisms and so on downwards in size until the smallest of all which feed on the tiny single-celled plants which grow in the upper layers of the sea. Every species of insect has its own special requirements for the growth of its larvae such as the amount of salt in the water, the range of temperature, the movement of the water, and the amount of sunlight. Every species of living organism from bacteria to man has in some way or other found means to obtain sufficient food and to resist the attacks of enemies adequately enough to survive. When the environment changes, as it does constantly, the organisms also change at a rate near enough to maintain a reasonable equilibrium. They do so by mutation, that is by slight changes in some of the newborn which enable them to withstand adverse circumstances. As the number of individuals born always exceeds the number which can survive, those who have undergone mutation become the ones most fit to survive whilst the unfit perish. This process can be watched in any bacteriological laboratory. When food supply is adequate and other conditions favourable, a colony of bacteria will 1 Burnet, F. M. (1951). Modern Practice in Infectious Fevers, edited by H. Stanley Banks. Butterworth. 10 multiply enormously; when conditions become unfavourable such as exhaustion of food supply, or change of temperature, or the presence of some harmful chemical or virus, there is equally enormous destruction in the colony. But new bacteria are constantly being produced slightly different from their parents and these in turn give rise to whole new strains which can withstand the changed circumstances and continue to survive. We can thus produce strains of organisms which are resistant to penicillin and the other new antibiotic drugs which have been produced in recent years. In some diseases the infecting agent is transmitted direct from person to person. Thus, in measles, the virus is transmitted in droplets from an infectious person, generally a child, to another; the virus appears to breed true, and once the infective stage is over the virus is entirely eliminated from the body. On the other hand, many diseases which were at one time thought to be due to a single organism are now known to be caused by many varying strains in a single species. Thus scarlet fever is caused by many different strains of streptococci; in food poisoning there have been recognised over 150 different strains of salmonellae; recently it has been found that poliomyelitis is caused by at least three and probably four strains of virus. The problem becomes more complicated when the relationship between the infecting parasite and the human patient is an indirect one. Thus we have diseases like yellow fever and plague in which the organism has its natural existence in some wild animal, is then transferred to an insect such as a flea or louse, and then in turn to man; or as in malaria where the organism is transferred from person to person by a mosquito carrier. But whatever the nature of the strain of the species of infective organism, or the particular species and strain of intermediate animal or insect carrier, or the uncertainties encountered in transmission to a host, the organism will most surely have adapted itself to a role which has enabled it to survive throughout the countless ages since the dawn of evolution. Food Sources. It is important from the point of view of the organism that the host should live and be capable of passing on the infection; for if all infected hosts were to die, the species of organism would be extinguished. The meningococcus, the organism which causes meningitis, lives as a parasite on the mucus membrane of the nose and throat. Under normal circumstances it goes on feeding on the debris, mucus and food particles it finds there, reproducing itself quite happily. When some change takes place either in the virulence of the organism, or in the resistance of the patient, the organism can invade the lining membrane of the brain and cause the disease meningitis. If the patient dies it is a tragedy for the organism (as well as for the patient's relatives) because the chain of survival of the organism ceases. Even if the patient recovers the germs reproduced inside the skull will never give rise to a continuing line of descent. The quantity and quality of the food supply of all living creatures is of paramount importance. Micro-organisms are composed of the same constituents as the cells of the body of any animal, that is of proteins, carbo-hydrates and various salts. Some organisms can manufacture these constituents for themselves out of very simple substances; however, when the organisms are grown on a medium which contains the constituents ready made, the new generations of organisms gradually lose the power of synthesising the complicated constituents in their own bodies, and come to rely on finding them ready made in 11 their environment. So long as they can find an environment in which the constituents are ready made, they find the loss of ability to manufacture them no disadvantage whatever. They are then able to reduce the size of their bodies until finally they appear as the smallest of viruses, left only with the function of reproduction. There is thus a sort of descending scale of sizes and abilities amongst organisms. The Battle of the Species. Most of them are able to live and to reproduce themselves in the tissues and on the mucus and skin surfaces of other living creatures. These other creatures have developed mechanisms for defence against the attacks of the parasitic organisms such as the production of antibodies against germ poisons, special cells able to devour invading organisms, and mechanical devices such as blinking, sneezing and coughing. But although we do not know what is the exact nature of the intrinsic resistance of a cell to an organism, it is clear it is only a relative resistance. The symptoms of an infectious disease can be regarded as due to the damage done to cells when organisms feed on their constituents and multiply within them. In poliomyelitis, for instance, the nerve cell is disorganised whilst the virus is breeding inside it, with consequent damage to the nerve fibre and resulting paralysis. Thus the virulence of an organism is really the readiness with which it can obtain its food for growth and multiplication from the cells of the host. As time goes on, the virulence of an organism changes; it may increase, as in the influenza epidemic of 1918, or it may decrease as scarlet fever has done this century. These variations in virulence are due to mutations occuring at random in the offspring of microorganisms; if the new strain has an increased virulence, the attack rate on the hosts will be temporarily increased. It can never be permanently increased to such an extent as to cause the deaths of all hosts, for then that species of organism would perish. The test of fitness of an organism is thus long-term survival. The ideal conditions for the survival and propagation of an organism are that it should be readily transmissible from one person to another, that almost everyone should become infected, and that whilst infected there should not be any very great disability—indeed, preferably the patient should be able to walk about. The common cold is a good example. Changing Virulence. The cause of the diminution of the virulence of pathogenic organisms varies with different diseases. With tuberculosis, in the absence of treatment or improved social conditions, the diminution may have to wait for genetic mutants to arise in the human population who can withstand more ably the attacks; this process may take five or six or more generations. Over the last hundred years diphtheria has shown increases and decreases in severity with a periodicity of about 30 years. The reason for the change is the ability of human beings to develop immunity. Repeated small infections by the diphtheria bacillus can produce an acquired immunity sufficient to withstand the evil effects of a large and severe infection. We might ask why it is that if this mechanism is possible in diphtheria, why is it not so in all diseases, and why are some of us liable to be severely smitten. Defensive Weapons. The answer is that human beings have had to develop protective mechanisms of a general kind and designed to deal with as many as possible of the huge variety of harmful invaders always ready to attack. These mechanisms 12 have also had to be developed over the whole period of evolution and parallel with the evolution of the organisms; and also within the limitations of the framework, structure, organs and functions of the human species. The mechanism of acquired immunity has thus been built up over countless generations by the only method known to nature, that is the production of slightly varying mutants amongst children who have had genetically favourable constitutions, able to develop an immunity of a general character and able to deal with the ordinary attacks of the majority of organisms. This process has served nature's purpose best, since it is of little moment if a few individuals die so long as the race survives. Thus we find that children in the age range of about 4 to 16 years, although subject to a great many infectious diseases, manage to get over them with comparatively little trouble, and that the death rate of these children is very small indeed. It would seem that over these ages nature has managed to contrive a nicely balanced response to general infection. Most of these infections are transmitted directly from one child to another; after the illness the child has acquired an absolute or substantial immunity. This is typical in measles, chicken-pox, rubella (german measles), whooping-cough, diphtheria, scarlet fever and poliomyelitis. But in diphtheria, scarlet fever and poliomyelitis we encounter different strains amongst the species of organisms which can vary widely in virulence. In young babies the main infections are those due to organisms which normally live without causing harm in the throats of adults such as staphylococcal skin infection (pemphigus), diarrhoea and vomiting due to salmonellae, dysentery and other food poisoning organisms, mouth infections from the blisters of shingles, meningitis and infantile paralysis. Although out of the vast majority of babies who must become infected only a few contract severe illness, it seems that infection is more readily initiated, and is more likely to spread throughout the whole body of the infant especially to the brain and nervous system. The defensive mechanisms, so evident in later childhood, are much less developed in babies, a factor which accounts for the higher death rate. Severe Reactions. When an infectious disease which is comparatively "new" falls on a population it mostly causes the severest re-action among young adults. This seems to be because the population has not had a chance of becoming immunised to the particular invading strain. Thus in the influenza epidemic of 1918, although all ages were affected, the severe complications and deaths fell most heavily in the age group 20-35 years. The probable explanation is that the severity of infection in non-immune young adults is not due to any deficiency in the mechanism of resistance, but to a more enhanced reaction to the products of cell damage. It is thought that the main requirement from the evolutionary point of view for this group of the population would be a rapid response by a defensive mechanism to attacks of organisms acquired through the skin from injury as from scratches, cuts or fighting. These young adults also seem to become peculiarly over-sensitized to the products formed within the body by infection, so that they seem even less able to make a good recovery than might be expected. The effect of the increased reactivity is seen in the severity of an attack of pneumonia in a young adult, and of the over-sensitization in the poor response in tuberculosis. 13 In later life there are a few rarer diseases which attack people after the age of about 40, such as psittacosis (parrot disease) and encephalitis. At still more advanced ages the human body loses the power of resisting attacks of all micro-organisms, so that in old age the terminal event is often caused by a comparatively minor infection which at a younger age would have caused little or no inconvenience. Antibiotics. Over the last 20 years or so there have been discovered a number of drugs and chemical compounds which have astonishing efficiency in curing many human microbial infections and in controlling numerous pest diseases in humans, animals and plants. Examples are the sulpha drugs, penicillin, aureomycin, DDT, and the organic phosphorus compounds. It is supposed that in human infections, the chemotherapeutic agent strikes at one or more of the enzymes present in the body of the organism and necessary for its survival and propagation. Most of the common organisms can, by gene mutation, enable succeeding generations to acquire resistance to the healing drug. This is of little importance in the case of one individual patient; but a danger would arise if a large proportion of individuals at risk were partially protected, or where most of the reservoirs or sources of the infection were being treated. There might thus arise new species of organisms with greatly enhanced virulence which would not respond to any of the known drugs in current use. Suppose, for instance, a drug was discovered which affected one small part of the vital processes of the tuberculosis bacillus, and suppose the drug were given to all known cases of tuberculosis, it might happen that the descendants of the bacillus would acquire a resistance to the drug and a greatly increased power of attack, not only against those people already infected, but also against those—the rest of the population—who have already acquired a comparative immunity against the non-virulent strain. It is important therefore that research be continued to discover drugs which have a deleterious effect on the vital processes of the bacteria in a number of ways, so that if one remedy proves ineffective another can be used; the danger of spread of drug-resistant variants would thus be minimised and there would be no argument for withholding treatment from any individual for fear of creating resistance strains of organisms. The thought here is that the warfare amongst species—from bacteria to human beings—is constantly being waged; it is the fittest who survive ; and we must be constantly on guard. TRACING CONTACTS The control of infectious diseases sometimes calls for exhaustive enquiries and often occasions visits at week-ends and in the evenings to persons who have been in contact with major infections such as smallpox and typhoid. A large number of these contacts are persons who have recently returned from abroad. The tracing of such contacts is vital. It must be carried out unobtrusively and with painstaking care, and moreover must be done speedily as in these days of travel, a person can move from a tropical country to residence in Twickenham in a matter of two days. If such a person is an infected contact he may show no 14 apparent symptoms until the disease has been incubated for a further day or so. Therein lies the danger. These contacts are all visited daily by my inspectors or myself, until the risk of disease occurring has passed. A little while ago an elderly man returned from abroad and stayed at an hotel in the Borough; we were notified he had travelled on a steamship which had carried a single case of typhoid. In such cases the contacts are visited by the inspectors; this particular man was found to have a "cold" and had consulted a practitioner. I was able to assist the practitioner by suggesting the advisability of further investigation in hospital. It was subsequently confirmed that the man actually was suffering from typhoid. In the meantime, due precautions had been taken to deal with the room and articles at the hotel. Further contacts were investigated and no other case developed. Frequently all this preventive work has little to show for it, but a single case, if missed, and later confirmed as positive could lead to an epidemic in the Borough. PEST DESTRUCTION The service provided by the Health Department not only includes the carrying out of rodent destruction, but nowadays has extended to a wider field. Requests are frequently received from residents for advice on identification and methods of eradication of household insect pests, the two most serious causes for complaint during the past year being wasps and carpet beetles. There are probably many householders in the Borough who are concerned to find carpets damaged by moths. We have found that in some cases the damage has, in fact, been caused by carpet beetles, which have given rise to an increasing number of complaints in the Borough. KEEPING THE BOROUGH CLEAN I am obliged to Mr. A. S. Knolles, the Borough Surveyor, for the following report about drainage, sewerage and public cleansing:— Drainage and Sewerage. The continued restriction of capital expenditure has again meant that no works of major improvement have been possible in the Borough. No serious flooding by storms of the surface water sewers has occurred. The new sewer to Eel Pie Island is proving a success and there have been a number of applications to connect W.C.s and drainage from premises to this sewer. The investigation of the possibility of polluting matter entering the surface water system has progressed, and in some instances trade waste has been found to be wrongly connected to the sewer, and the drainage of factories is being reorganised so as to separate the foul from the surface water drains and an improvement is confidently anticipated. 15 Public Cleansing. (a) Streets. Difficulties continue in relation to the engagement of adequate labour for street orderly work, and conditions continue much the same as in the past year. (b) Refuse Collection. The new Dennis "Paxit" vehicles are now fully in operation and arrangements are proving satisfactory and much more hygienic than the previous methods of collection. Salvage and refuse are collected weekly, apart from special requirements, and the sale of salvage materials has continued to give a profitable return to the rate-payers. As an experiment, four pedestrianoperated electrically-propelled vehicles for collecting pig food have been purchased, and an issue of approximately 4,000 household collecting bins or buckets have been made in an area of approximately quarter of the Borough. These household bins or buckets, are provided with lids, are attractive in design and easy to handle, and householders are requested to place their kitchen waste in the bin and to bring it to their front entrances twice weekly. The kitchen waste is then collected in the electrically-operated vehicle, so that there is no need for pig food bins of the type previously supplied and sited in the highway. Active co-operation from the public has resulted in as much kitchen waste being collected from a quarter of the Borough by the new method as by street bins in three-quarters of the Borough in the past, and the new system is felt to be more hygienic and in all ways more desirable. Consideration will, in due course, be given to the extension of this system to the whole of the Borough. (c) Refuse Disposal. The present disposal of refuse is by controlled tipping on various low-lying sites. The destructors at Teddington and Twickenham have not been in use. Permission to proceed with the Charlton Plant is eagerly awaited, as it is felt that the completion of this scheme will solve many of the difficulties which are likely to arise in the Twickenham area in the near future, when low lying land for tipping purposes will no longer be available. WATER SUPPLY I am indebted to Lt.-Col. E. F. W. Mackenzie, Director of Water Examination, Metropolitan Water Board, for the following report:— The water supply to the Twickenham area is abstracted from the River Thames at Wraysbury, Laleham and Walton, purified in the storage reservoirs at Staines, Littleton and Walton and at the filtration works at Hampton. After filtration the water receives a small dose of chlorine and adequate contact is provided to ensure complete action of the chlorine before the water is pumped into supply. It is therefore possible to provide a water of consistently high bacterial quality and yet having none or so little chlorine remaining in the water in the distribution system that there is no likelihood of chlorinous tastes being detected by consumers. Samples of water are collected at all stages of purification at least five times each week and are analysed by experts at the laboratories of the 16 politan Water Board. Any falling off in the quality of the water is immediately reported to the Chief Engineer's department and remedial measures are put into operation forthwith. The average results of chemical and bacteriological analyses of the water are shown in Table No. 9. Number of houses supplied by the Board:— (a) Direct 29,994 (106,289 persons) (b) By means of standpipes 5 (11 persons) Water Supplies from Wells. During 1951 samples of water from wells in the Borough were sent for bacteriological examination and chemical analysis. Many of the water supplies are used for allotment purposes, but informal action was necessary where contaminated water from wells was in use at a sports ground and at certain dwelling-houses. A summary of the action taken with regard to wells and underground water supplies known to exist in the Borough shows that samples of water were taken from 12 pumps on allotments and from wells at four houses. As a result of the bacteriological reports, the owner in each case was requested to affix a permanent notice to the pump stating the water was unfit for human consumption. INDUSTRIAL HEALTH Factories. It is surprising that in a Borough like Twickenham there are as many as 378 factories. Most of them are engaged in light industries such as the manufacture of electrical components, piston rings, aircraft parts, nameplates, and bakery furniture. The number of persons employed in these factories ranges from 500 in the largest to one or two in the smallest. All factories are visited to see that proper sanitary accommodation is provided; those factories which do not use mechanical power are inspected for cleanliness, avoidance of overcrowding, for adequate warmth and ventilation, and proper drainage of floors. During 1951 the inspectors paid 372 visits to factories; in 68 factories the attention of the management had to be drawn to contraventions of the regulations. The inspectors also paid 33 visits to out-workers' premises. GENERAL MATTERS. Shops. The Shops Act, 1934, was repealed and replaced by the Shops Act, 1950, as from the 1st October, 1950. Section 38 of the new Act which deals with the provisions for the health and comfort of the staff, is substantially the same as the section of the old Act which it replaces. Shops are required to be properly ventilated, adequately warmed, and sufficiently lighted; they have to have toilet and washing facilities; if the staff take meals on the premises there must be suitable arrangements. Occasionally it happens, as in the case of a small lock-up shop, it is impossible to provide a separate toilet on the premises. In 17 these cases the occupier may make an alternative arrangement to share a nearby toilet and a certificate of exemption is granted from the requirement in the Act. During 1951 no exemption certificates were granted which makes a total of 17 in the Borough. Mortuary. The mortuary at Hampton, though small, is a good building. It provides an important public service. During any year there occurs a series of cases in which owing to either accident, sudden death, drowning in the river or other untoward happening, a post-mortem examination is required by the coroner to ascertain the cause of death. The number of bodies admitted to the mortuary for this purpose during 1951 was 156. The mortuary has been supplied with a new refrigerator and has been redecorated throughout. We hope shortly to effect further improvements in the arrangements for viewing bodies. Swimming Baths and Pools. Excellent facilities for swimming are provided at the Corporation's three open-air baths. Water is supplied by the Metropolitan Water Board's main, and samples for bacteriological examination are taken throughout the season. Health Education. Continued use is made of various health education methods, including propaganda by posters, leaflets and lectures illustrated by films or lantern slides. Laboratory Work. The usual arrangements were continued during the year and worked satisfactorily. Establishments for Massage, Chiropody, Electrical and Special Treatment. Fifteen licences in respect of establishments for these purposes were issued during the year 1951. The premises are all inspected regularly and are well run. Registration of Hawkers of Food and their Premises. A strict watch is kept on street food traders. Both the persons and the premises where they store their food have to be registered. Registration can be refused if the conditions are unsatisfactory. During the year 1951, ten persons and seven premises were registered. The inspectors paid 67 visits. Petrol Filling Stations. During the year 1951, 216 visits were paid by the sanitary inspectors to premises where petroleum or carbide of calcium is stored, and 109 licences were issued. 18 Rent Restriction Certificates. One certificate was granted for premises which were in bad repair. Four cancellation certificates were issued. Tents, Vans and Sheds. During 1951, two renewals of consents were issued for temporary sites for caravans. Smoke Abatement. It was not necessary to take any formal action during 1951 regarding excessive emissions of smoke. Schools. Inspections of the sanitary arrangements and canteens at the schools within the jurisdiction of the Divisional Executive were carried out by the sanitary inspectors during the year 1951. It was not necessary to close any schools on account of infectious disease among children. Ambulance Facilities. The Middlesex County Council is the responsible authority for the provision of the ambulance service under the National Health Service Act, 1946. Rag Flock and Other Filling Materials Act, 1951. The Rag Flock and Other Filling Materials Act, 1951, was operative as from the 1st November, 1951, and four premises have so far been registered. There are no premises requiring to be licensed as there is no manufacture or storage of rag flock in the Borough. One of the difficulties apparent in this Act is the exemption from registration of premises where re-making and re-conditioning of any article is carried out. It is known that at least eleven establishments dealing in secondhand articles are thus exempt from registration. Therefore, there would appear to be no barrier to the continued sale of articles which may contain contaminated filling materials. National Assistance Act, 1948, Section 47. It was not necessary, during 1951, to remove to suitable premises any persons in need of care and attention. 19 TABLES FOR STATISTICAL YEAR 1951 21 STATISTICAL SUMMARY for the Year 1951 Area in acres 7,078 Population (preliminary census return figure, 1951) 105,645 Civilian population—estimated to mid-year (as supplied by the Registrar-General) 106,300 Number of inhabited houses 29,999 Rateable value £l,092,750 Sum represented by a penny rate £4,440 14s. 2d. Total M. F. Live Births: Legitimate 1,306 682 624 Illegitimate 57 34 23 Total 1,363 716 647 Birth rate per 1,000 of estimated civilian population 12.82 Total M. F. Still Births: Legitimate 34 17 17 Illegitimate 4 2 2 Total 38 19 19 Still birth rate per 1,000 total (live and still) births 27.12 M. F. Deaths 622 650 1,272 Crude death rate per 1,000 of estimated civilian population 11.97 Adjusted death rate 11.61 Maternal deaths Nil Rate per 1,000 total (live and still) births Nil Death rate of infants under one year of age:— All infants per 1,000 live births 24.98 Legitimate infants per 1,000 legitimate live births 24.50 Illegitimate infants per 1,000 illegitimate live births 52.63 Deaths from: Cancer (all ages) 209 Measles (all ages) — Whooping cough (all ages) 1 Diarrhoea (under 2 years of age) — 22 Table 1. population 1938-1951. Year Population Population trend Migration excess Total increase or decrease Percentage proportion Natural increase or decrease Inward Outward 1938 96,550 +2,320 +2.46% +363 1,957 — 1939 97,440 +890 +0.92% +383 507 — 1940 94,070 -3,370 -3.46% -15 — 3,355 1941 91,820 -2.250 -2.39% +38 — 2,288 1942 92,460 +640 +0.70% +450 190 — 1943 92,780 +320 +0.35% +502 — 182 1944 88,660 -4,120 -4.44% +507 — 4,627 1945 91,920 +3,260 +3.68% +424 2,836 — 1946 102,850 +0,930 +11.89% +835 10,095 — 1947 105,930 +3,080 +2.99% +918 2,162 — 1948 106,700 +770 +0.73% +621 149 — 1949 106,900 +200 +0.19% +399 — 199 1950 107,600 +700 +0.65% +246 454 — 1951 106,300 -1,300 -1.28% +91 — 1,391 Table 2. Causes of Death. Registrar-General's Official Returns. Causes of Death Males Females Total All causes 622 650 1,272 1. Tuberculosis, respiratory 11 10 21 2. Tuberculosis, other 2 1 3 3. Syphilitic disease 3 2 5 4. Diphtheria — — — 5. Whooping cough 1 — 1 6. Meningo-coccal infections — 1 1 7. Acute poliomyelitis — — — 8. Measles — — — 9. Other infective and parasitic diseases 2 — 2 10. Malignant neoplasm, stomach 10 15 25 11. Malignant neoplasm, lung, bronchus 31 8 39 12. Malignant neoplasm, breast — 17 17 13. Malignant neoplasm, uterus — 15 15 14. Other malignant and lymphatic neoplasms 64 49 113 15. Leukaemia, aleukaemia 4 2 6 16. Diabetes 3 2 5 17. Vascular lesions of nervous system 69 103 172 18. Coronary disease, angina 86 71 157 19. Hypertension with heart disease 27 26 53 20. Other heart disease 89 120 209 21. Other circulatory disease 19 31 50 22. Influenza 13 21 34 23. Pneumonia 31 26 57 24. Bronchitis 53 38 91 25. Other diseases of respiratory system 4 4 8 26. Ulcer of stomach and duodenum 8 2 10 27. Gastritis, enteritis and diarrhoea 3 2 5 28. Nephritis and nephrosis 6 5 11 29. Hyperplasia of prostate 10 — 10 30. Pregnancy, Childbirth, abortion — — — 31. Congenital malformations 2 5 7 32. Other defined and ill-defined diseases 45 52 97 33. Motor vehicle accidents 10 4 14 34. All other accidents 10 15 25 35. Suicide 6 3 9 36. Homicide and operations of war — — — 23 Table 3. Zymotic Diseases Mortality. The mortality rates for this group of diseases, which includes enteric fever, smallpox, scarlet fever, diphtheria, measles, whooping cough and diarrhoea under two years of age, were:— Disease No. of Deaths Death rate per 1,000 of the population Male Female Total Enteric Fever — — — — Smallpox — — — — Scarlet Fever — — — — Diphtheria — — — — Measles — — — Whooping Cough 1 — 1 .009 Diarrhoea — — — — Table 4. Main Causes of Death. An analysis of the death returns reveals the following main causes of death:— Disease Percentage of total deaths Death rate per 1,000 of the population Diseases of heart and circulatory system 36.87 4.41 Intra-cranial vascular lesions 13.52 1.61 Bronchitis, Pneumonia, and other respiratory diseases 13.04 1.46 Cancer 16.43 1.96 Violence 3.77 0.45 Tuberculosis 1.88 0.22 24 Table 5. Infantile Mortality. (a) The following table, compiled from official registrations, gives details of the causes of death at various ages under one year of age:— Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 4 weeks 4 weeks and under 3 months 3 months and under 6 months 6 months and under 9 months 9 months and under 12 months Total deaths under 1 year All Causes:—Certified 19 4 - 2 25 6 2 - 2 35 Uncertified — — — — — — — — — — Smallpox - - - - - - - - - - Chicken-pox - - - - - - - - - - Measles - - - - - - - - - - Scarlet Fever - - - - - - - - - - Diphtheria and Croup - - - - - - - - - - Whooping Cough - - - - - - - - - - Influenza - - - - - - - - - - Enteritis - - - - - - - - - - Tuberculous Meningitis - - - - - - - - - - Abdominal Tuberculosis - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - Congenital Malformations 1 — — — 1 — — — 1 2 Premature Birth 11 1 — 1 13 — — — — 13 Atrophy, Debility and Marasmus - - - - - - - - - - Atelectasis 3 1 — — 4 — — — — 4 Injury at Birth — — — — — — — — — — Erysipelas - - - - - - - - - - Syphilis — — — — — — — — — — Rickets — — — — — — — — — — Meningitis (not Tuberculous) - - - - - - - - - - Convulsions — — — — — — — — — — Gastritis — — — — — — — — — — Laryngitis — — — — — — — — — — Bronchitis — — — — — — — — — — Pneumonia (all forms) 1 1 — 1 3 4 1 — 1 9 Suffocation (overlying) — — — — — — — — — — Other causes 3 1 — — 4 2 1 — — 7 Totals 19 4 - 2 25 6 2 — 2 35 (b) An analysis of the mortality reveals that neo-natal deaths were responsible for 71.43 per cent. of the total deaths, viz.:— Under 24 hours l to7 days 1 to 4 weeks Total under 4 weeks Percentage total infant deaths 12 7 6 25 71.43 25 Table 6. Birth Rate, Death Rate and Analysis of Mortality. Provisional Figures. 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 Whooping Cough Diphtheria Tuberculosis Influenza Smallpox A cute Poliomyelitis and Polioencephalitis Pneumonia Diarrhoea and Enteritis (under two years) Total Deaths under 1 year England and Wales 15.5 0.36 12.5 0.00 0.01 0.00 0.31 0.38 0.00 0.00 0.61 1.4 29.6 126 County Boroughs and great towns, including London 17.3 0.45 13.4 0.00 0.01 0.00 0.37 0.36 0.00 0.01 0.65 1.6 33.9 148 smaller towns, resident populations 25,000 to 50,000 at 1931 census 16.7 0.38 12.5 0.00 0.01 0.00 0.31 0.38 0.00 0.01 0.63 1.0 27.6 London Admin. County 17.8 0.37 13.1 — 0.01 0.00 0.38 0.23 — 0.00 0.61 0.7 26.4 Twickenham 12.82 0.36 (a) 11.97 - 0.01 - 0.22 0.32 - - 0.54 - 24.98 (b) 11.61 A dash (— ) signifies that there were no deaths (a) crude (b) adjusted 26 Table 7. Review of the Comparative Vital and Mortality Statistics for the Borough of Twickenham, together with those for England and Wales for years 1938.1951 inclusive. Year Birth Rate Death Rate Infantile Mortality Rate Twickenham England and Wales Twickenham England and Wales Twickenham England and Wales 1938 14.4 15.1 (a) 9.91 11.6 45.8 53 (b) 9.81 1939 14.2 15.0 (a) 10.46 12.1 26.4 50 (6) 10.35 1940 14.67 14.6 (a) 14.8 14.3 45.8 55 (b) 14.9 1941 13.4 14.2 13.0 12.9 70.95 59 1942 16.49 15.8 11.6 11.6 53.1 49 1943 17.7 16.5 12.3 12.1 47.99 49 1944 18.5 17.6 12.8 11.6 37.1 46 1945 16.76 16.1 12.15 11.4 48.02 46 1946 19.01 19.1 10.89 11.5 26.09 43 1947 19.72 20.5 11.05 12.0 40.21 41 1948 15.86 17.9 10.04 10.8 20.69 34 1949 14.99 17.09 (a) 11.26 11.7 21.21 32 (b) 11.03 1950 13.63 16.17 (a) 11.05 11.6 20.10 29.8 (b) 10.72 1951 13.18 15.86 (a) 11.97 12.5 24.98 29.6 (b) 11.61 (а) Crude (b) Adjusted 27 Table 8. Results of the Chemical and Bacteriological Examination of the Water Supply to the Borough of Twickenham for 1951. Parts per million (unless otherwise stated). (a) Chemical. Description of the Sample Number of Samples Ammoniacal Nitrogen Albuminoid Nitrogen Oxidised Nitrogen (Nitrate) Chlorides as Cl Oxygen abs. from Permanganate 3 hrs. at 80° F. Turbidity, in terms of Silica Colour, m.m. brown, 2 ft. tube. Burgess's Tintometer Hardness (total) Hardness (Non-carb.) pH. Value Phosphate as P.O. 111/4 Silica as SlO2 Conductivity River Thames water filtered at Hampton Works 250 0.019 0.085 4.1 22.0 1.21 0.3 15 268 63 7.9 0.32 11.0 450 (b) Bacteriological. Description of the Sample Number of Samples Plate count (average per millilitre) Colonies counted on agar after 20-24 hrs. at 37°C. Bact. coli test Percentage of samples negative in 100 ml. Average number of Bact. coli per 100 ml. River Thames water filtered at Hampton Works 766 19.0 100.0 Nil 28 Table 9. Analysis of Complaints Received. Nature of Complaint Number Received Housing defects 553 Choked and defective drains 138 Accumulations of offensive matter 41 Unsound food 312 Verminous premises:— (a) Bugs 31 (b) Rats and mice 405 (c) Other 65 Keeping of animals 23 Unsatisfactory milk supplies 3 Miscellaneous 228 Total 1,799 29 Table 10. Summary of Visits, Inspections, etc. Number Dwelling-houses for housing defects under Public Health Act:— (a) After complaint 1,174 (b) Subsequent visits 4,360 Dwelling-houses under Housing Act:— (a) After complaint 358 (b) Subsequent visits 6 Dwelling-houses:— Housing applications, specially investigated 111 Infected dwelling-houses:— (a) After notified infectious disease (other than tuberculosis) 663 (b) Contacts 245 (c) Fumigations after infectious disease 7 (d) Phthisis enquiries and fumigations 10 School and church halls 23 Swimming baths 1 Water sampling:— (a) Swimming baths 9 (b) Dwelling-houses 19 Business premises 2 Cinemas, dance halls, billiard halls 56 Offensive trade premises 18 Stables, piggeries, keeping of animals 207 Houses let in lodgings Nil Factories Acts, 1937 and 1948:— Factories with mechanical power 333 Factories without mechanical power 39 Outworkers' premises 33 Common lodging houses 2 Underground rooms 33 Hairdressing premises 16 Tents, vans and sheds 36 Smoke nuisances 72 Fairgrounds 25 Drainage: Testing by:— (a) Smoke 54 (b) Coloured water 74 (c) Water 50 (d) Breaking down 181 Re public sewers 791 Watercourses and ditches 7 Land and tips 67 Septic tanks and cesspools 7 Sanitary conveniences—including public-houses 13 Miscellaneous visits 1,131 Visits not inspections 1,942 Verminous premises:— (a) Rats and mice: (i) After complaint or from survey 18 (ii) Subsequent visits 318 (b) Bug infestations: Number of premises visited 134 Number of premises where definite infestation existed 38 (c) Cockroaches 17 (d) Other vermin 380 30 Table 10—continued. Inspections for supervision of food:— Unfit foodstuffs other than meat 469 Slaughterhouses 6 Butchers' shops (Public Health (Meat) Regulations, 1924) 500 Food and Drugs Act, 1938, Section 13:— Bakehouses 313 Fish shops, grocers and greengrocers 1,222 Factory canteens 15 Restaurant kitchens, etc. 816 Hotel and beerhouse bars and cellars: (a) Day inspections 166 (b) Night inspections 8 Food and Drugs Act, 1938, Section 14:— Ice-cream premises (Heat Treatment) Regulations, 1947 to 1951 208 Sausage manufacturers 19 Preserved meat preparation premises 6 Preserved fish preparation premises 37 Milk and Dairies Regulations, 1949:— Milk sampling for bacteriological examination 7 Contraventions of Milk and Dairies Regulations 3 Dairies 42 Shops Act, 1950, Section 38 26 Middlesex County Council Act, 1950:— Hawkers' vehicles 28 Hawkers' premises 39 Noise nuisances 76 Massage and/or special treatment establishments 24 Petroleum (Regulation) Acts, 1928 and 1936; Petroleum Spirit Regulations, 1929-1950 216 National Assistance Act, 1948, Section 47 17 Total number of visits and inspections 17,343 31 Table 11. Sanitary Improvements Effected. Number Offensive accumulations removed 9 Nuisance from keeping of animals remedied 2 Chimney flues repaired 1 Chimney stacks repaired 4 Roofs repaired 443 Eavesgutters repaired 162 Downspouts repaired 45 Pointing renewed 62 Drains repaired 23 Drains unstopped 16 Dustbins provided 56 Fireplaces repaired 58 Filthy condition of premises remedied 2 Floors repaired 109 Gullies repaired 9 Plaster to walls and ceilings repaired 382 Window frames and sashcords repaired 68 Public sewers repaired 16 Sinks provided — Sink waste pipes repaired 45 Soil pipes repaired 17 Stairs repaired 16 External walls repaired 4 W.C.s repaired 17 W.C. cisterns and fittings provided 99 W.C. accommodation provided 12 Yard paving repaired 17 Other works carried out 580 32 Table 12. Housing Statistics. I. Inspection of dwelling-houses during the year Number 1. (a) Dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1,532 (b) Inspections made for the purpose 5,898 2. (a) Dwelling-houses (included under sub-head (1) above) which were inspected under the Housing Consolidated Regulations, 1925 Nil (b) Inspections made for the purpose Nil 3. Dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 4. Dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 929 II. Remedy of defects during the year without service of formal notices Defective dwelling-houses rendered fit in consequence of informal action by the local authority or their officers 859 III. Action under statutory powers during the year A.—Proceedings under sections 9, 10 and 16 of the Housing Acts, 1936:— (1) Dwelling-houses in respect of which notices were served requiring repairs Nil (2) 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) Dwelling-houses in respect of which notices were served requiring defects to be remedied 81 (2) Dwelling-houses in which defects were remedied after service of formal notices: (a) By owners 104 (b) By local authority in default of owners Nil C.—Proceedings under sections 11 and 13 of the Housing Act, 1936:— (1) Dwelling-houses in respect of which Demolition Orders were made Nil (2) Dwelling-houses in respect of which an undertaking was accepted under sub-section (3) of section 11 of Housing Act, 1936 1 (3) Dwelling-houses demolished in pursuance of Demolition Orders Nil D.—Proceedings under section 12 of Housing Act, 1936:— (1) Separate tenements or underground rooms in respect of which Closing Orders were made Nil (2) Separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit 3 33 Table 13. Notices Served. Administrative action was taken during the year to secure abatement of nuisances and to enforce the appropriate statutory enactments, as follows:— Subject of Notice Public Health Act Food & Drugs Act, Sections 13 & 14 Number of Informal Notices served 929 293 Number of Informal Notices complied with 859 236 Number of Statutory Notices served 81 — Number of Statutory Notices complied with 104 — Number of cautionary letters sent by Town Clerk — 4 Table 14. Offences under Food and Drugs Act, 1938. Case No. Section contravened Offence Action taken 1 10 Nail in Battenberg cake. Cautionary letter sent by the Corporation. 2 10 Slug in chocolate eclair. Ditto 3 13 Dirty condition of premises. Ditto 4 10 Nail in bun Ditto 5 38 Sale of horseflesh without proper notice. Legal proceedings instituted. Fine of £5 and £2 2s. costs imposed. 6 13 Dirty condition of premises. Legal proceedings instituted. Fine of £18 and £3 3s. costs imposed. 34 Table 15. Prevention of Damage by Pests Act, 1949 VISITS Initial Visits following upon Complaints or Resulting from Surveys Re-inspections for Laying Baits, Poisoning and Trapping Total Visits 4,745 7,156 11,901 NUMBER OF INFESTATIONS Food Premises Non-food Premises Private Dwellings Factories Rats only Mice only Rats and mice 44 44 416 18 418 95 9 DEGREE OF INFESTATION rats mice Reservoir Major Primary 50-100 Minor Secondary 1-50 Reservoir Major Primary 50-100 Minor Secondary 1-50 Nil 9 409 Nil 3 101 Prevention of Damage by Pests Act, 1949 Notices served Notices outstanding Preliminary Notices Statutory Notices Final (Default) Notices Preliminary Notices Statutory Notices Final (Default) Notices 74 4 Nil 3 1 Nil RAT DESTRUCTION WORK UNDERTAKEN BY:— Corporation Occupiers Rats Mice Rats Mice 387 93 40 2 NUMBER OF PREMISES UNDER CONTRACT WITH CORPORATION TOTAL 480 12 months 6 months 3 months 1 month Others Total Receipts 29 256 184 11 Nil £573 5s. 11d. Prevention of Damage by Pests (Application to Shipping) Order, 1951 There were 84 vessels inspected and no evidence of rat infestation was found. 35 Table 16. Eradication of Insect Pests. D.D.T. and Other Special Treatments. Number of Infestations Treated Type of Premises Ants Beetles Bugs Cockroaches Fleas Flies Lice Moths Silver Fish Wasps Miscellaneous Wood Beetles Totals Dwelling-Houses 4 - 38 - 6 27 1 3 - 31 9 - 119 Workplaces — — — — — 2 - - - - - 2 Food Shops — — — 6 — 44 - - - - - 50 Miscellaneous — - 1 - - 1 - — — 3 — — 5 Totals 4 — 39 6 6 74 1 3 — 34 9 — 176 Total income for D.D.T. and other special treatments, £101 12s. 7d. Corporation premises treated (re-housed families only), 0.7 per cent. 36 Table 17. Disinfections, etc. Number Premises disinfected after infectious diseases 22 Premises disinfected after other diseases 3 Articles disinfected after infectious disease 109 Persons (children and adults) treated for scabies at cleansing station — Table 18. Housing Act, 1936. Overcrowding. The known cases of overcrowding on the register of the department at the end of the year were as follows:— Number (a) (1) Dwellings overcrowded at the end of the year 128 (2) Families dwelling therein 152 (3) Persons dwelling therein 582 (b) New cases of overcrowding reported during the year 25 (c) (1) Cases of overcrowding relieved during the year 19 (2) Persons concerned in such cases 97 Table 19. Milk and Dairies Regulations, 1949. Milk (Special Designation) (Raw Milk) Regulations, 1949. Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations, 1949. The necessary registration of persons and premises, and the issue of appropriate licences, has been effected in accordance with the following table:— Milk and Dairies Regulations, 1949. Persons registered as distributors 14 Premises registered as dairies (not being dairy farms) 15 Special Designation Dealers' Licences Supplementary Licences Milk (Special Designation) (Raw Milk) Regulations, 1949. Tuberculin tested 19 10 Accredited Nil Nil Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations, 1949. Pasteurised 21 11 Sterilised 18 10 37 Table 20. Food and Drugs Act, 1938. Public Health Act, 1936, Section 89. Insanitary Conditions in Food Premises. Number of premises found with insanitary conditions 293 Number of premises remedied 236 Insanitary conditions found in premises above Number of defects Number of defects remedied Accumulation of refuse 14 15 Ceilings—defective 24 40 Ceilings—dirty 71 60 Cleanliness (personal) unsatisfactory 2 1 Dampness — — Floors—defective 28 38 Floors—dirty 15 15 Lighting inadequate 2 2 Sink—absence of — — Sink-waste pipe inadequate 1 — Storage facilities unsatisfactory 6 3 Ventilation insufficient 7 11 Walls—dirty 95 79 Wall-plaster—defective 22 18 Insufficient or absence of hot and cold water for cleansing utensils 4 7 Absence of hot water for ablution purposes 24 37 W.C. accommodation—insufficient or unsuitable 2 3 Other defects. 311 310 Totals 628 639 Byelaws under Section 15 of the Food and Drugs Act, 1938. Byelaws with respect to Handling, Wrapping and Delivery of Food and Sale of Food in the open air were made by the Corporation in 1950. The requirements of this legislation have been enforced, particularly on Fairgrounds on holiday occasions. No formal action has been necessary. Public Abattoirs. There is no public abattoir within the Borough. Slaughterhouses. Three licences were renewed during the year. The licencing of two slaughterhouses was again deferred pending the execution of essential repairs. There is no horse-slaughtering establishment within the Borough. Slaughter of Animals Act, 1933. Nine slaughter-men were on the register of the department at the end of the year. Table 21. Meat—Carcases Inspected and Findings at Private Slaughterhouses in the Borough. Cattle, excl. Cows Cows Calves Sheep and Lambs Pigs Number known killed — — — - 2 Number inspected — — — — 2 All diseases except tuberculosis: Whole carcases condemned - - - - - Carcases of which some part of organ was condemned - - - - - Percentage of the number inspected affected with disease other than tuberculosis - - - - - Tuberculosis only: Whole carcases condemned - - - - - Carcases of which some part or organ was condemned - - - - - Percentage of the number inspected affected with tuberculosis — — — — — 38 Table 22. (a) Meat. Diseased and unsound conditions found in meat caused the detention and surrender for destruction of:— lbs. Beef 539 Mutton and lamb 144 Pork 43 Other meats 1,133 Total 1,859 (b) Other Foodstuffs. The following foodstuffs, other than meat, being unfit for human consumption, were voluntarily surrendered for destruction:— Eggs 145 Fowls — lbs. Bacon 68 Butter — Cheese 70 Cooked meat — Fish 456 Flour and cereals 225 Preserves 6,312 Chocolate — Cake mixture — Biscuits — Sugar — Swedes — Potatoes — Tea — Fruit — Bottles Pickles 34 Canned foodstufls:— Tins Fish 280 Fruit 2,467 Meat 1,000 Milk 585 Vegetables 3,686 Other 2,696 39 Table 23. Sampling. The Middlesex County Council is the food and drugs authority for the Borough. The Chief Officer, Public Control Department, has kindly supplied the following information relating to samples taken in the Borough during the year ended 31st December, 1951:— A rticle Taken Unsatisfactory Milk (various) 137 1 Bread 2 2 Cakes (various) 36 1 Cake decorations 1 - Cooked meat 7 - Creamed rice 1 - Desiccated fondant 1 - Drugs 7 1 Fish 26 1 Fish cakes 1 - Fish paste 1 - Gin 4 - Honey 1 - Ice-cream mix 1 - Jam 1 - Jelly 4 - Lobster soup 1 - Marmalade 1 - Malt cod liver oil 1 - Meat paste 2 - Meat pie 8 - Mint rock 1 - Rum 5 - Sausages (various) 42 - Sausage meat 7 1 Sherry 2 - Sherbert Fruit 1 - Tomato ketchup 4 - Vinegar, malt 3 - Whisky 22 - Tizer 1 - White pepper 1 - Total 333 7 40 Table 24. Factories Acts, 1937 and 1948. Part I of the Act. 1. INSPECTIONS for Purposes of Provisions as to Health: Premises Number on Register Number of Inspections Written Notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 56 39 29 - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 322 333 16 - (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) - - - — Total 378 372 45 - 2. Cases in which DEFECTS were Found: Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness (S.l) 12 17 - - - Overcrowding (S.2) — — - — — Unreasonable temperature (S.3) — — - — — Inadequate ventilation (S.4) - — - — — Ineffective drainage of floors (S.6) - 1 - - - Sanitary Conveniences (S.7):— (a) Insufficient 5 10 - — — (b) Unsuitable or defective 9 10 1 — — (c) Not separate for sexes 2 — - — — Other offences against the Act (not including offences relating to outwork) 40 41 - — — Total 68 79 1 — — Part VIII of the Act. Outwork. Nature of the work Lampshades Wearing apparel Section 110: Number of outworkers in August list required by Section 110 (1) (c) 5 1 Number of cases of default in sending lists to Council — — Number of prosecutions for failure to supply lists — — Section 111: Number of instances of work in unwholesome premises — — Notices served — — Prosecutions 41 Table 25. Infectious Diseases. Incidence and Mortality. Diphtheria, Scarlet Fever and Enteric Fever. 1938-1951. Diphtheria Scarlet Fever Enteric Fever Year No. of Cases Case Rate per 1,000 pop. No. of Deaths Death Rate per 1,000 pop. No. of Cases Case Rate per 1,000 pop. No. of Deaths Death Rate per 1,000 pop. No. of Cases Case Rate per 1,000 pop. No. of Deaths Death Rate per l,ooo pop. 1938 70 0.72 5 0.05 274 2.83 1 0.01 — — — — 1939 25 0.25 3 0.03 93 0.95 — — 2 0.02 — - 1940 18 0.19 3 0.03 38 0.41 — — 2 0.02 — — 1941 25 0.27 3 0.03 78 0.85 — — 7 0.07 — — 1942 7 0.08 1 0.01 125 1.35 — — — — 1 0.01 1943 4 0.04 1 0.01 238 2.56 — — — — — — 1944 5 0.06 3 0.03 121 1.37 — — — — — — 1945 4 0.04 1 0.01 97 1.06 - - - - - - 1946 4 0.04 — — 60 0.58 — — — — — — 1947 4 0.04 1 0.01 60 0.58 — — — — — — 1948 1 0.01 — — 99 0.93 — — — — — — 1949 — - — — 128 1.20 — — — — — — 1950 — — — — 115 1.07 — — — — — — 1951 — — — — 64 0.60 — — — — — — 42 Table 26. Ophthalmia Neonatorum, years 1938-1951. The following table shows the number of cases notified and result of treatment:— Year Cases notified Cases Treated Vision unimpaired Vision impaired Total blindness Deaths At home In hosp. 1938 12 11 1 12 — — — 1939 7 7 — 7 — — — 1940 4 3 1 4 — — — 1941 5 2 3 5 — — — 1942 4 4 — 4 — — — 1943 6 6 — 6 — — — 1944 8 8 — 8 — — — 1945 2 2 — 2 — — — 1946 3 2 1 3 — — — 1947 5 5 — 5 — — — 1948 4 4 — 4 — — — 1949 — — — — — — — 1950 2 2 — — — — — 1951 8 6 2 8 — — 43 Table 27. Cases of Infectious Diseases Notified during the Year 1951. CASES NOTIFIED AT VARIOUS AGES (YEARS) DISEASE Under 1 year 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-25 25-35 35-45 45-65 Over 65 Age not known Total cases notified Cases admitted Hospital Deaths Dysentery 4 1 7 4 2 13 1 — — 2 2 4 4 3 47 5 - Erysipelas — — — 1 — - 1 — 1 — 3 10 6 1 23 3 — Food Poisoning 1 2 2 1 2 — — — 3 6 4 2 — — 23 2 — Measles 37 119 162 203 208 681 22 10 7 20 3 1 — 8 1,481 32 — Para-typhoid — — — — — — — 1 — — — — — — 1 1 — Acute Poliomyelitis - - - - - 2 1 - - - - - - - 3 3 — Pneumonia 2 1 — — 6 5 2 3 4 3 10 22 17 8 83 4 — Puerperal Pyrexia - - - - - - - 2 7 3 2 — — — 14 14 — Scarlet Fever 1 1 1 6 8 36 6 1 1 1 1 — — 1 64 32 — Typhoid Fever — — — — — — — — — — — — — — — — — Whooping Cough 27 16 37 51 47 143 5 1 2 3 2 4 1 3 342 15 - Totals 72 140 209 266 273 880 38 18 25 38 27 43 28 24 2,081 111 — 44 Table 28 Monthly Incidence of Infectious Diseases during the Year 1951. DISEASE NUMBER OF CASES TOTAL January February March April May June July A ugust Sept. October Nov. Dec. Dysentery — 8 7 5 4 8 6 — 4 1 3 1 47 Erysipelas 2 3 2 2 3 1 1 1 1 3 — 4 23 Food Poisoning — 1 — — 3 1 1 5 7 3 — 2 23 Measles 300 384 366 210 78 25 16 17 1 19 26 39 1,481 Para-typhoid — — - — — — — — — 1 — — 1 Acute Poliomyelitis 1 — - — — — — 1 1 — — — 3 Pneumonia 9 21 14 6 2 4 4 3 2 9 4 5 83 Puerperal Pyrexia 3 1 1 — 1 2 1 2 1 1 — 1 14 Scarlet Fever 5 4 5 7 3 7 7 3 2 3 11 7 64 Typhoid Fever — — — — — — — — — — — — — Whooping Cough 25 65 64 81 37 26 18 11 3 6 2 4 342 Totals 345 487 459 311 131 74 54 43 22 46 46 63 2,081 45 Table 29. Ward Distribution of Infectious Diseases Notified during the Year 1951. Disease T wickenham Whitton Hampton Hampton Hill Teddington Hampton Wick Heath- field Total East Central South West Upper Lower Dysentery 2 — 1 16 2 6 3 3 — 1 13 47 Erysipelas 2 2 2 3 3 — — 5 4 2 — 23 Food Poisoning 1 — 1 2 — 1 12 2 2 1 1 23 Measles 111 119 65 133 262 238 160 102 141 81 69 1,481 Para-typhoid — - — 1 — — — — — — — 1 Acute Poliomyelitis 1 1 — 1 — — — — — — — 3 Pneumonia 5 1 2 2 1 17 23 10 7 14 1 83 Puerperal Pyrexia 1 — — — — 13 — — — — — 14 Scarlet Fever 4 4 — 5 4 18 5 6 4 7 7 64 Typhoid Fever — — — — — — — — — — — — Whooping Cough 31 33 10 33 33 79 46 23 23 22 9 342 Totals 158 160 81 196 305 372 249 151 181 128 100 2,081 46 Table 30. Tuberculosis. The following tables have been compiled from the notifications received:— New Cases and Mortality. Age Periods New Cases Deaths Pulmonary Non-pulmonary Pulmonary Non-pulmonary Male Female Male Female Male Female Male e Under 1 — — — — — — — — 1-4 1 3 1 — — — — — 5-9 - - 1 — — — — — 10-14 — 1 1 — — — — — 15-19 8 10 — 2 — — — — 20-24 9 5 1 2 — — — — 25-34 10 10 — 4 1 4 — — 35-44 12 14 — — 3 1 — — 45-54 13 1 1 — 5 — — 1 55-64 5 2 — — 3 1 — — 65 and over 3 — — 1 — 1 - 2 Totals 61 46 5 9 12 7 — 3 Public Health (Prevention of Tuberculosis) Regulations, 1925. It was not necessary to take any action under the above regulations concerning persons suffering from tuberculosis and employed in the milk trade. Public Health Act, 1936 (Section 172). No action was taken under this section for the compulsory removal to hospital of persons suffering from tuberculosis. Table 31. Primary Notifications of Tuberculosis, 1938-1951 inclusive. 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 Pulmonary 100 106 114 127 112 119 133 118 120 132 117 115 96 107 Non-Pulmonary 30 19 12 14 18 18 18 18 19 11 17 5 15 14 Totals 130 125 126 141 130 137 151 136 139 143 134 120 111 121 47 Table 32. Food Poisoning. Food Poisoning Notifications: 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL 1 4 5 1 11 Outbreaks Due to Identified Agents: Number of outbreaks Nil Number of cases Nil Outbreaks due to: Salmonella organisms Nil Staphylococci (including toxin) Nil Outbreaks due to Undiscovered Cause: Number of outbreaks Nil Number of cases Nil Single Cases: Cases due to identified agents: Staphylococci 4 Salmonella 1 Other bacteria 2 Number of cases 7 Cases due to undiscovered cause:- Number of cases 4 Total all cases 11 48 Table 33 Clinics and Welfare Centres. The following clinics are being held within the Borough:— Clinic Address By whom provided Infant Welfare Centres York House, Twickenham; Hospital Bridge Road, Twickenham; Church Road, Teddington; 24, Station Road, Hampton; 20, Seymour Road, Hampton Wick. Middlesex County Council. Ante-Natal Clinics York House, Twickenham; Hospital Bridge Road, Twickenham; Church Road, Teddington; 24, Station Road, Hampton; 20, Seymour Road, Hampton Wick. Middlesex County Council. School Clinics York House, Twickenham; Hospital Bridge Road, Twickenham; Stanley Road, Teddington; 24, Station Road, Hampton; 20, Seymour Road, Hampton Wick. Middlesex County Council. Dental Clinics 20, Seymour Road, Hampton Wick; York House, Twickenham; Hospital Bridge Road, Twickenham; Stanley Road, Teddington; Church Road, Teddington (Orthodontic). Middlesex County Council. Ophthalmic Clinics York House, Twickenham; Stanley Road, Teddington. Middlesex County Council. Diphtheria Immunisation York House, Twickenham; Hospital Bridge Road, Twickenham; Church Road, Teddington; Stanley Road, Teddington; 24, Station Road, Hampton; 20, Seymour Road, Hampton Wick. Middlesex County Council. Child Guidance Clinic 58, Hampton Road, Twickenham. Middlesex County Council. Orthopaedic Clinic Church Road, Teddington. Middlesex County Council. 49 Walker & Co. (Printers) LTD. 84 Health Road. Twickenham,