AC 439 (1) TW 125 1 An Que. for 503 2 Library DECEMBER, 1958 GOOD HEALTH IN TWICKENHAM The Annual Report of the Medical Officer of Health JOHN MADDISON, M.D., B.S., D.P.H. CONTENTS Page Introduction 2 Health Committee and Sta 4 The Preventive Medical Service at the Teddington Geriatric Clinic 5 The Cure of Catarrh and the Prevention of Colds 18 Pest Destruction 21 Keeping the Borough Clean 21 Water Supply 21 Industrial Health 22 General Matters 22 Statistical Tables 29 1 PUBLIC HEALTH DEPARTMENT, ELMPIELD HOUSE, HIGH STREET, TiEDDINGTON. To the Mayor, Aldermen and Councillors of the Borough of Twickenham. LADIES AND GENTLEMEN, I have the honour to submit my Annual Report for 1958 on the health and sanitary conditions of the Borough together with the supplement containing the statistical tables for 1957 as required by the Ministry of Health. I trust you will not be disappointed that my report this year is a little shorter than usual; indeed you may think that is a great advantage. Much of my time this year has been occupied in trying to get started on the correct lines the clinic for the old people in Teddington. In the pages which follow I have tried to give a short account of what has been happening. Some of you are already aware of the details in this report and I hope you won't mind it being said again I am sure the clinic is one of the best things the health service has provided for our town in many a long year; in fact since the maternity and child welfare and school health services were established years ago," That it will thrive I have no doubt, and I dare say I could predict that in five or ten years time these clinics will have been established all over the country This first clinic does not pretend to set the pattern or determine the experience or qualifications of the doctor, or the number of assistant staff or anything like that. It is an experiment to try out all sorts of ideas as they occur, as for example why the functions of the body deteriorate as we grow older, how to prevent cataract or coronary thrombosis, But I do wish I could have the equipment to do it with it is so difficult working with home made apparatus constructed out of tins and wire, Dr. Bloom of Teddington has contributed an article this year about catarrh This is the first time I have had such a contribution in the 20 years I have been here His thesis is that you can reduce inflammation in the nose and throat by washing away the inflammatory exudates It is certainly true in community epidemiology that if you can reduce the number of people carrying germs to a small proportion you can wipe out an epidemic For example if say 70% of the population carry germs in their throats an epidemic will spread, but if you can reduce it to say 30% the epidemic dies out of its own accord Raising the number of immune people has the same effect, as in diphtheria immunisation As individuals each of us can tolerate and deal with a few infectious organisms, but we succumb to heavy infections Dr Bloom advocates also clearing the nose. In doing so we open up the tiny canals and openings which drain the sinuses in the bones of the face and the internal canal into the ear. Opening up these orifices allows noxious material to 2 flow away. We do it too in the position of the head common to lower mammals, that is with the mouth and nose downwards. Anatomically this is the most efficient position for clearing exudates. Catarrh might be one of the tribulations of man from having adopted the upright position. It is not the only one. I would like to mention specially for commendation Miss Francis, the Superintendent Health Visitor who has been helping me with the clinic and on whom I have placed an enormous load of work; she has often worked extra time and at extra speed to get it done; also my Secretary, Miss Reeves, who has had more than her share of the additional burden. Dr. Cormack has had to carry an extra part part of my duties and also some of Dr. Whitfield's since she left us at the end of October. Mr.Pugh has looked after the office side of things with his usual conscientiousness and efficiency. Mr. Easter and the Inspectors have worked at full speed and also have done a good job in tackling the clean air problem. We hope we shall provide evidence for you one way or another in the near future. We are making steady progress with the clearance of the unfit houses, we have now cleared off 73 out of 180 houses scheduled for action under the Housing Act in the current programme. I would like also to mention the other 400 odd members of the staff whose work you hardly ever hear of. The services go on automatically with rarely a complaint, which speaks well for the zeal and enthusiasm so commonly evinced. There are clerks, health visitors, midwives, nurses, matrons, doctors, psychologists, psychiatrist, social workers, speech therapists physiotherepist home helps, rat catchers, odd job people, caretakers and dozens of voluntary workers; and also some voluntary societies, who will derive benefit and feel better for a word of praise from me. 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 Council. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, JOHN MADDISON, Medical Officer of Health 3 MEMBERS OF THE PUBLIC HEALTH COMMITTEE Ex-officio members: THE MAYOR, COUNCILLOR E. P. G.LEWIS, J. P. THE DEPUTY MAYOR, COUNCILLOR MRS. M. B.DAVIES Chairman: COUNCILLOR MRS. M. B. DAVIES Vice-Chairman: COUNCILLOR A. R. MELVIN, P. R. I. C. S. Alderman P.J.Edwards, J.P. Councillor G.H.Loman Alderman J. H.Knaggs, J. P. Councillor G. E. Morris Councillor Mrs.C.C.Cunningham- Councillor G.J.Samuel Howie Councillor C. W. Sewell Councillor L.Defries-Porter, Councillor N.Sheldon LL. B., A. M. I. A. A. A. R. C. S. , F. R. I. C. Councillor R. P. E. Howard-Hodges, Councillor S. C.Tanner M. B. E. M. R. C. V. S. 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, Peltham, Staines and Sunbury) Deputy Medical Officer of Health Dr. W. Cormack, M. B., Ch. B., D. P.H. (Also Deputy Area Medical Officer, Twickenham, Peltham, Staines and Sunbury) Chief Public Health Inspector Mr. H. G. Easter Deputy Chief Public Health Inspector Mr. H. D. Smith Specialist Housing Inspector Mr.K.E.Evans Public Health Inspectors Messrs. J.W. paine (Resigned 6/7/58) A.E.G. Walker, B.E. W. Gabb 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, Peltham, Staines and Sunbury) Senior Clerk Mr. R. N. Himson Clerical Staff Miss K.Dopson,(Resigned 30/8/58) Mrs. J. Hodgson Miss M. Baylis(Resigned 3/7/58) Miss J. Lovett (Commenced 11/8/58) Senior Rodent operative Mr. H. T. Jackman \ Rodent Operative Mr. s. Jackman Disinfector/Drain Tester Mr.E.G.Cooper 4 THE PREVENTIVE MEDICAL SERVICE AT THE TEDDINGTON GERIATRIC CLINIC. Disabilities of the Elderly,, For three years up to 1955 I took part in a survey of elderly people.- An account of it appeared in the British Journal of Social Medicine in July 1955. We showed that the majority of elderly people have something wrong; men suffer from anaemia and bronchitis; women suffer from multiple disabilities and get frailer; both men and women suffer very heavily from atherosclerosis, high blood pressure, coronary thrombosis and strokes. The remarkable thing is they often do not know there is anything wrong. They have not been to doctors. We said there was a great need for clinics for the elderly to try to prevent this great mass of disability. Other workers • Dr.' Sheldon, Lord Amulree, Dr. Hobson and Dr. Pemberton, and many others have said the same. In September, 1955, I wrote a report for the Area Health Committee about these matters and asked them to approve the setting up of a preventive health clinic for the elderly The Area Committee gave it their unanimous blessing and sent it forward. By March,1956, the views of the Middlesex Executive Committee had beenobtained; they were non-committal. They approved the principle; they were all for preventive medicine; but they thought this could be done by lectures to the old people's clubs and by health visitors in the homes; they did not want any clinics. Getting Approval It so happened that in 1956 there was set up a Liaison Committee in South-West Middlesex consisting of practitioners, consultants and medical officers of health to discuss problems of mutual interest. In November, 1956, this committee met. I was asked and willingly seized this opportunity to present a report about the need for a preventive health clinic for the elderly. After a long discussion and many explanations, the meeting - with one exception was fully in favour of the proposal and prepared to advise the Executive Council that it was a worthwhile project. I was overjoyed. In January, 1957, the County Council agreed to the setting up of the clinic and asked the Executive Council to approve. In June, 1957, it went to the Ministry informally. In September the Minister indicated that he would have no objection. In October formal application was made to the Minister for consent to modify the Proposals under section 28 of the National Health Service Act. On the 7th February, 1958, the Minister's formal consent was received as follows: "Special Clinics for the Elderly The County Council will provide for one year, as an experiment in preventive medicine, a special clinic for the elderly at which they can be medically examined and given general health education, particularly in regard to diet and, if proved satisfactory, and subject to the Minister's agreement, will provide such clinics where considered necessary." This was the first official consent for such a clinic to any local authority in the country and I regarded it as a triumph. It 5 had taken six years, but all the effort was worth-while. I was anxious to begin, but I needed a certain amount of equipment at the clinic to start me off. I knew there was nothing the in County estimates because we could not anticipate when the consent would come, or even if it would have come at all, and I was anxious to exercise the greatest economy and keep the initial expenditure to the absolute minimum. Disappointment. I asked the County Medical Officer to obtain consent for expenditure of about £200 for the instruments which I could not improvise. He refused. He said this clinic should be an advisory clinic aimed at helping old people to understand the proper measures to adopt to safeguard the maintenance of their health, and that any departure from normal would be referred either to the patient's own doctor or to the hospital for further investigation. It was thought that in the course of an ordinary interview with the old person, by some magical means it would be revealed to me whether or not there was anything wrong; and that this would form a firm basis for advice about the maintenance of health or the need to go to another doctor or hospital. The clinic would thus be run on "conventional" lines. As no examinations were to be carried out, no equipment for medical examination would be necessary. I was supposed to rely upon insight or flair. The local practitioners thought little of this idea. They said in effect "do not send us rubbish". I was thus in a dilemma. If I pretended to examine my visitors, and then pronounce them either fit or else in need of medical attention because of some particular disability, the hollowness of such a method would at once be apparent. But if I were to set about dicovering the diseases and disabilities which were found in cur earlier survey and which I knew quite well existed in the so called healthy population, then I would have to do examinations and I would have to have the equipment to do them with.No other course seemed to me to be possible. I felt it to be unethical and inhuman to try to do the work anything but professionally and properly. A "conventional" clinic for babies is presumably one where advice is given about the health of the baby. But the baby is examined to see if there is anything wrong and nobody objects to that. A "conventional" school clinic is again one where children are examined and advice given. I should have thought that a conventional geriatric health clinic would be one where also the elderly are examined and advised. It is impossible to give advice without examination. The difference between clinics for babies and children, and clinics for older persons is that diseases and disabilities are present in the older people which never appear in the children. The detection of these disabilities requires much more complicated equipment than it does for children; our children's clinics have never been equipped for this work. The refusal of consent for expenditure on the instruments was disheartening and I was bitterly disappointed. For the fundamental reason for the clinic had evidently been quite forgotten that there exist in the population people with disabilities who do not know they have them, and that it is good business to get these people back to health and to keep them healthy. Progress. I had been going to the local hospitals for years, and very 6 frequently during the past year to try to keep abreast of clinical methods and techniques in all departments. This last ten years or so have seen enormous improvements in clinical methods; new instruments have been introduced; new and better ways of examining the functions of the body and mind have been found out. The things needed for a good examination of an elderly adult are much more complicated and expensive than those needed for a child. So I approached the charity associations in my own Borough. Their response was magnificent. The Teddington Old People's Welfare Committee bought me an ear microscope which cost £47.13S.0d. The Paint Research Station gave £10.10s.0d. towards the cost of a retinoscope which cost £14.14s.0d. The Teddington Nursing Association contributed £102; the Twickenham Old People's Welfare Association £20; the Teddington Women's Conservative Association £5. This money was paid into the Treasurer's fund and he paid the bills for the things I needed I spent some time around the instrument shops in London looking for bargains. I managed to gather together some useful instruments in almost new condition at bargain prices. The instruments for examining eyes and ears are the most expensive and all these together with an instrument for examining blood came to about £190.I began to improvise on other equipment by making things at home, by lending tools, by using my own workshop, by supplying equipment such as transformers, microscope camera and other items. I worked at nights and weekends making things for the clinic. I made a slit lamp microscope for examining eyes which will do as a makeshift substitute for a new one which might have cost over £200. The health visitors at the clinic worked hard moving cupboards, tables, filing cabinets and re-arranging things to get the clinic suitable for the geriatric work. The caretaker made the curtains for the dark room. By a lucky stroke it happened that an old clinic at Willesden was being given up, and the old equipment being disposed of. Out of the rubbish I managed to obtain a small glass instrument cabinet which after painting and cleaning was quite presentable. It was mounted on a bracket and fixed on to the wall in the clinic. Another small wooden cupboard was treated similarly and proved very useful. There was an old case of eye test lenses with many missing. I cleaned it up and tried to use it for the time being. Years ago at the end of the war I picked up for about £3 a fairly good set of test lenses from the war surplus disposal depot. These have been used continuously at Hanworth clinic until recently. The ophthalmologist there said they were not good enough for her; so a new set has recently been bought for £66. I have had the old ones Cleaned up,replaced where necessary out of the old willesden set and am making it do. At Willesden there was also an old wall lamp bracket for eye work which they threw out. I took it home, cleaned off the rust, oiled it, renewed the wiring inside and the lampholder, brought it back to the clinic and screwed it up on the wall. I had thought the best place would be to begin at Church Road Clinic in Teddington as I know most of the practitioners personally; there are lots of streets where the people are not well off near the clinic and within easy walking distance; and there were some vacant sessions. There was the clinic building but apart from a stethoscope, a blood pressure instrument, some old furniture, and a few trivial odds and ends there was no equipment worth talking about. 7 The Examination Prom our previous survey, and from surveys in other parts of the country and from my frequent visits to the hospital I felt I was fairly familiar with the type of diseases I should expect to come across. There was need to get the procedure of examination into systematic order. I begin with a chat with my visitor and we get to know each other. I explain the purpose of the clinic is to provide a medical check-up to see if there is anything needing attention and to see if the clinic can help in any and every way possible to prevent deterioration in health and to keep the visitor as fit as we can. I explain I can write to the private practitioner; to the optician about glasses and about applying for assistance in paying for them; to the National Assistance Officer in certain cases for assistance with extra money for food and special items; and by seeking to smooth out difficulties through relatives, the charity associations, and any other agencies necessary. I ask about the home and the family, about past illnesses, accidents and operations; and by this time the ice is broken. In every case my visitor has then been most willing to be examined. I do a complete examination from hair to toes. In the dark room I do a full eye examination, test the vision and check the glasses. I examine the eats and do hearing tests. I examine the nose, teeth and dentures, mouth and throat. In the examination room I examine the thyroid gland, arm, hands and grip, heart, lungs, abdomen, legs and feet. Later I take the blood pressure, a drop of blood for haemoglobin examination, and a blood slide for examination under the microscope. I take a photograph for record purposes. The height and weight are recorded and a specimen of urine tested. In every case, whether the person needs treatment or not I have sent a full report to the practitioner of every person who has attended the clinic; it gives the medical details of everything found; The practitioners seem very satisfied with this arrangement. They know what is going on; there can be no question of misinterpretation as to what I have said or found. I feel I must give a special word of praise for the general practitioners. Prom the start they have co-operated in every possible way and have shown the most enlightened approach which augnrs well for the future. Smoothing out the Troubles Every person I have examined has had something wrong. I wish I could claim that it was always possible to put it right; some day we may be able to prevent it from ever hapening. In the meantime something can usually be done even it it is only relief from the anxiety of worrying about it,for a trouble shared is a trouble halved. Good Equipment Needed However, I do need proper equipment. In addition to a case of eye test lenses, I need properly illuminated test charts of a special kind for old people; I need some sort of a slit lamp microscope to examine for early cataract and other conditions; I need a perimeter for testing restriction of the visial fields which is an early sign of glaucoma. 8 Old people don't like a lot of lights shining in their eyes at a medical examination and you have to be quick. Therefore it is best to use every piece of apparatus you can so as to reduce the inconvenience to the patient, and to save the time of the doctor. A refractometer for measuring refraction and a refraction unit for ease of subjective testing are very desirable. These machines are expensive but they are worth it in the long run. I have had people come into the clinic with most of the common eye disabilities of the elderly, beginning often before the age of 60, and some have been nearly blind. I have had people come in who imagine their vision to be perfect and said they could see quite well; and yet they were walking about the streets with vision not better than 6/36, and obviously gravely defective. No wonder they are knocked down in the traffic - they cannot see vehicles coming. And yet I have been able with the correct glasses to restore their vision to 6/6. It is no use saying these people have plenty of opticians to go to. In a sense that is true, but they do not know that they ought to go. They do not know that these disabilities slowly creep on them, and because they have no means of comparing themselves with others are quite unaware that things can be righted. That is why I need first class equipment to test them properly. After the eye test comes the examination of the ears. Mr. & Mrs. F. could knock up 160 years between them. Mr. p. was pretty fit but his wife was thin and deaf. They said they would not wish to come to the clinic separately but would come if they could be examined together. Mr. p. did all the talking and answered all my questions, both for himself and Mrs. P. Every now and again he spoke to her in a loud voice and she was obviously deaf. The briefest glance in her ears showed they were completely stopped up with hard, solid wax. She had been like this for years and had never thought of seeking medical advice She just accepted it as one of these things which you get as you get older and resigned herself to her disability with fortitude. Mrs. P. was frail and could not walk very far and it had taken some effort to get her to the clinic at all. After her ears were syringed the result was amazing. Her drums were perfectly normal and her hearing quite good. Her husband was astonished, he said "Doctor, here have I been yelling at her all these years when I needn't have done. I will tell her a few extra things when I get home." When I was examining the heart of one woman she said to me "Doctor, aren't you going to do an electrocardiograph?" I had to confess that I hadn't got the instrument. I have had a number of people with diseases of the heart and I do wish I had the electrocardiograph to provide further evidence for this part of the examination. You might say that it needs a cardiologist to interpret the findings. If this is conceded you might argue it needs an eye specialist to examine the eyes, an ear specialist to examine the ears, an endocrinologist to check up on the glands, a chest physician to examine the chest and so on. This sort of argument leads us nowhere. Its not too difficult to detect the abnormal; the finer points can be checked up later. No Duplication There are doctors, hospital consultants, opticians and medical auxiliaries everywhere. Why then start a clinic when people can have all these things through the National Health Service? Are we not duplicating these services? Is this not a waste of public money? The answer is that these doctors, consultants and auxiliaries 9 are all dealing with sick people who know they are sick and who approach them for advice and treatment on account of some physical or mental disability. I am dealing with those who believe themselves to be healthy and as a rule have not been to consult a practitioner for a long time. I have to be on the watch for possible developments at an early stage. So in the clinic I am not dealing with the very sick and I am not duplicating any of the practitioner or hospital services, because I am dealing with so called healthy people who are not aware that they are suffering from anything. In the surgery a general practitioner, sick people will get advice on some specific complaint. In the hospital it may well be they will be referred to a number of departments for advice by independent consultants in various specialities, such as geriatric, cardiology,, metabolism, ophthalmology, endocrinology, surgery, nose, throat and ear, dermatology. Those patients who have had to do this in the past tell me they get weary of going round various departments; of having to wait for an appointment on a certain day; and then to go and.wait their turn to see the consultant. In my clinic it is already clfear that an old person will brace herself up for one examination provided that examination is to be a complete one done at the same time and place. In the hospitals consultants are employed to deal with sick people. In the social and preventive services of a local authority the medical officer of health is the consultant physician in preventive medicine. The geriatric clinic requires the services of only one consultant in preventive medicine whose function is to determine early signs of departure from normal and to suggest measures where possible for the prevention of further deterioration. I hope this makes clear the difference between the two types of,work. Providing the Service. Certainly in the hospital the consultants and specialists would not devote their services to the examination and investigation of the so-called healthy people for preventive purposes. They would say that it is not their function. It is the function of the health authorities. The same argument applies to the general practitioners. A practitioner will say he is not there to examine fully an apparently healthy person. The function of providing the preventive medical service lies with the local authorities. Delay in Seeking Advice. The primary function of the clinic is the detection of deterioration - in other words real preventive medicine - yet in this short time certain facts have become amazingly clear. The average old person delays and delays in seeking medical advice, sometimes from fear of something being found; sometimes from "not wishing to tempt providence; "but most often from unwillingness to sit waiting in a doctor's surgery or unwillingness to undertake the journey to hospital and to hang about various departments, for lengthy periods. One great attraction of the clinic has been the desire to be "checked up for everying in one place" and if possible at one particular time and by appointment promptly kept. Where serious and urgent conditions have been discovered, the fact that the examination has been conducted as described has been a positive;adjunct in persuading the patient that treatment by the private practitioner or hospital was urgently needed. Because of the thoroughness of the examination and the experience that the examination was almost a complete one, it is not surprising that they were willing to accept advice more readily. 10 It is quite apparent that whereas at the start of life we may order this or that routine guidance or treatment in an infant welfare centre, at the opposite end of the scale, with a lifetime's experience behind him, the patient will only seek medical advice in so far as it can disturb his daily routine as little as possible. It seems to me that if at our clinic we can forestall incapacity by the early detection of deterioration or even merely give the patient reassurance and comfort about the limitation of his activities according to his individual physique, then the knowledge gained thereby is of immeasurable benefit to each patient, it also lessens the burden on busy middle aged relatives. Everyone is most impressed and appreciative. Some who come rather apprehensively and obviously a little nervous go away feeling completely confident, and often comment what a good idea it is, and say how terribly grateful they are. I have no difficulty whatever in my supply of clients. The trouble is to give them all appointments. Up to now we have not even contacted the old people's clubs. Miss Francis, the superintendent health visitor, says in her subsequent visits to the people in their homes it is very evident that they greatly appreciate the enormous amount of time and attention given in the clinic. An elderly woman said that these clinics were the most wonderful thing that had happened, and already she and some of her friends had begun to feel a sense of comfort from having somewhere to come where they could be examined leisurely and fully. I have had one or two come to the clinic uninvited seeking attention and treatment, but I have had to explain that they must go to their private practitioners for this. They have been invited to come again for a full check-up if they wished. Almost every one who has come has said how pleased they have been and even although I have not been able to do much, they seem to have been reassured and comforted. Extending the Existing Services. In years gone by we have tackled a number of special groups of the population the mother and her young child, the schoolchild, the tuberculous, those with venereal disease, those needing immunisation, the blind, the handicapped, the deprived, the factory worker, and now the aged. I feel sure the day will come when we shall be examining the whole population at all ages. One of the duties of the medical officer of health is to inform himself as far as practicable respecting all matters affecting or likely to affect the public health in the district and be prepared to advise the local authority on any such matter. Examining the various groups of the population is an effective way of doing this. As in the case of the infant welfare and school health services, the people come to the geriatric clinic for a check-up. Almost without exception everyone I have examined in the clinic has needed help of some sort. This fact is the justification for the provision of geriatric health clinics. Only a minority need urgent medical treatment by a practitioner. The commonest conditions are malnutrition, defects of vision and incorrect glasses, deafness, nasal and sinus infection, ill-fitting dentures, atherosclerosis, endocrine disorders, bunions and corns needing chiropody. I have to write to the national assistance officer for supplementary grants for food, glasses and dentures; to the area welfare officer; to 11 opticians and other agenpies. Very little of this falls within the province of a family doctor, in every case I send a full report to the family doctor saying what has been done and found. If the practitioners are to have confidence in these reports they must be accurate and reliable. The patients are given advice on diet, food preparation, dietary supplements and other matters, especially comfort and reassurance when I can tell them they are not suffering from something they imagined they had. If the work was skimped and slipshod, then the information about all the disabilities would be incomplete, and important things would be missed. It takes time and patience to listen to the patient's story, to gain his confidence, and to give the full advice, comfort and interest which he needs. The Purpose of the Clinic, As I have already said, in the geriatric clinic I am testing the fitness or otherwise of so-called healthy persons. In so far as these people have not recently attended a practitioner for some specific complaint they believe themselves to be well. Often they say to me "You won't find anything wrong with me doctor." I have to investigate the functional efficiency of these people without any specific medical complaints and to see if they are healthy. For this purpose I need the appropriate instruments and apparatus. I have to answer the question in every case "Am I all right, doctor." It so happens that the instruments needed for testing the functional efficiency of the various systems of the body and for detecting early departures from normal are almost exactly the same instruments as are used for the investigation of established disease. This is not surprising, but it has lead to much misunderstanding. To detect an early cataract before even the patient knows it is there requires a slit lamp microscope; to detect restriction of the fields of vision - an early sign of glaucoma and threatened blindness - requires a perimeter; to test the breathing capacity requires a spirometer; to test the function of the heart requires an electrocardiograph. It is ridiculous to rely on guess work when accurate readings are possible with the correct instruments. It is like asking a scientist to do modern experiments without instruments. If the medical instruments reveal that all is well the patient is so much better pleased. But if the instruments show abnormality, it is far better to send accurate information to the practitioner than rely on guess work. Poor Equipment. In The Lancet for 29th November, 1958, the leader is talking about doctors emigrating and states that one reason is "dissatisfaction with the circumstances of practice or the opportunities for research in Britain. Too often the British clinician of the mid-20th century has to work with 19th-century tools; the general practitioner may lack proper ancillaries and may not even have access to hospital diagnostic departments; while the specialist may have to divide his time wastefully between three or four different hospitals, and be denied such needs as routine virology service or a biochemistry department equipped for modern tests. Compared with the United States, research here is being starved; and a keen worker with an idea, who in North America could be sure of a warm welcome and unstinted support, may have a battle to extract even from a well-stocked hospital endowment fund a few hundred pounds for essential equipment. The potential emigrant, gazing across the Atlantic, sees practice pursued with vigour and vitality (although, 12 admittedly, not always with.perspicacity), and he sees research most lavishly supported. Nor are these the only attractions. The example of many who have gone tells us that full scope and full honour are accorded at once to those with merit, regardless of their age. in this country, on the other hand, underlying the sense of frustration among younger doctors is a conviction that we are not making nearly full use of our profession's resources; and this discontent crystallises round the seniority of our leaders." The instruments 1 need, in rough order of importance, are:- Approximate cost £ 1 Electrocardiograph 400 1 Spirometer 100 1 Perimeter 125 1 Optometer 360 1 Refracting Unit 450 1 Slit Lamp Microscope 285 1 Dioptrescope 85 1 Pantoscope 35 1 Microscope 85 1 Tonometer 15 2 Swivel Chairs etc. 35 2 Transformers 15 Miscellaneous items 10 £2000 If anyone in Twickenham or elsewhere feels like making a gift, small or large, or leaving a legacy for the benefit of the old people's clinic we shall be delighted, it will be put to excellent purpose. The money will be used entirely for the purchase of essential equipment. Everyone who makes a gift can be assured of the eternal blessing and thankfulness of the old people of this Borough. Experience & Research The Teddington clinic is providing the very experience we need. It is flexible; I am always thinking of how to improve the methods; of how we can give a better service to the people; of how we can save them trouble and inspire their confidence. Research on the aged is constantly going on. In The Triangle for November, 1958, Professor versar of the University of Basle, speaking about experimental research into ageing says "Research into the biological problems of ageing aims not at extending the span of life, but rather at avoiding premature ageing and at ensuring that advanced age shall not be accompanied by chronic disease. The elderly should not be allowed to become a burden to themselves and others; they should be given such assistance as they need to enable them to spend their time usefully and contentedly, in good health." And later speaking of tests he says "The experimental study of ageing seeks measurable functional phenomena which can be used to characterise age. Only when such biological tests of age are available will it be possible to prove whether given influences acting on the individual can halt or even reverse the process of ageing. Clearly it is desirable that such investigations should be carried out principally on human subjects. 13 A study group at the University of Basle began a 'longitudinal research programme' on aging three years ago. One hundred volunteers participate in the programme and every two years a number of functions or physiological criteria are examined in each subject: visual adaptation, vital capacity, ECG, blood pressure and pulsewave velocity, the skin, and" so on. It is hoped, in this way, to find criteria for ascertaining how various organ systems age, and whether the course of aging can be predicted." My clinic can take and record measurements on the physiological normals in old age. There is practically nothing known on this subject, and information is urgently needed. The clinic should be in the nature of a physiological laboratory. We need much more information about the biological processes of aging; the progressive ' stages of physiological deterioration, both physical and mental, and how to measure these; how to deal best with the clinical problems of old age; and study on the social and economic aspects. These studies will require observations on samples of the population for both long term and short term ranges. The attendance at a clinic is one of the ways of obtaining information. There people can be tested if we have the instruments and means of testing them, which at present I have not. We need to know why it is the various organs deteriorate at different periods of life's span and how to prevent this; and we need to know also how performance in various aspects, such as manual dexterity,muscular activity, breathing capacity, mental functions and so on deteriorate. Some of these observations and measurements can be carried out in a local clinic such as mine, but some special clinical tests will need the more elaborate and extensive facilities of special laboratories, and X-ray departments. It must therefore be possible to work in close co-operation with hospital departments and one good way of ensuring this is for the medical officer of health to be appointed to the staff of the hospital in an honorary capacity as a physician in community medicine and concerned with the study of the social and preventive medical problems of various groups of the community. There would be enormous advantages in having direct contact with the other consultants in the hospital service; one great asset would be the smoothing away of various ethical difficulties when patients require the services of more than one doctor. It would give us the right to use the hopsital technical services for special work without having to ask several people. Some have said that the preventive services for old people should be part of the geriatric out-patient department of the hospitals. I think it would be better if it were part of a department of social and preventive medicine, both inside and outside the hospitals. If we medical officers of health had a focal point inside each hospital and were regarded as physicians in charge of the department of social and preventive medicine, then our clinics and services outside would fall into place as extensions of that hospital service. A Special Institute for Research. If, as may well be the case, the hospital resources are already strained to the full and cannot accept any more commitments for research in community medicine, then I think we should consider setting up a department specially equipped to carry out this sort of work. It could be organised as part of the preventive work of a number of district authorities or perhaps done by the County 14 Council, or perhaps by the Government through the Medical Research Council. I believe such an institute, properly equipped and staffed and maintained even at some considerable expense would be well worth while, and might eventually save huge sums of money in medical and social services in the long run. Health Education We need to extend our health education. First to medical students in the universities, for it is generally admitted that there is very little preventive medicine in the present day curriculum. Second we must try to educate our medical colleagues who may have had little opportunity of studying the problems of preventive medicine in the aged. Finally we need to teach the general public the principles of correct medical, social and economic welfare for the elderly, so that many mistaken practices may be avoided and better attitudes engendered. Employment. Many times have the men and women attending my clinic said they wished they could continue their employment instead of having to retire. Most of these people are perfectly capable of doing work within their strength and ability. This is not the same as saying that they should continue their previous work at the former speed, pressure and wage; but it is possible to find work at a slower rate, with less demand on brain and muscle, and yet having some value, which will keep these people occupied and happy and provide a certain amount of income. In Finsbury there is an experiment in which elderly men and women are employed for two hours each day at 1s 6d. an hour on light industrial tasks in a workshop given over specially to the needs of the elderly. This experiment has shown one way of how to do it. I would like to see something similar started in this Borough. Case Finding In the infant welfare and school health services we know where to find our cases because we receive notifications of every birth by law and we know what children are in the schools. But we cannot say this of the elderly because for some reason unknown to me we cannot get notifications from the Ministry of Pensions and National Insurance. Our aim is the prevention of deterioration. The causes are noti-necessarily only medical: there are difficulties over income, housing, relatives, social relationships, habits and often ignorance. This last maybe ignorance of the principles of healthy living, but also of where to obtain the information of services available. If we try to immitate the infant welfare services by sending round health visitors to call on the elderly we must know who and where they are and we need some sort of register system as we have for children. At present there is no organised system for determining the progress of the deterioration in an elderly person. After each illness trivial or severe, there is a residue of disability slowly increasing. The burden of attention and nursing falls mainly on the relatives. In time the stress can become very severe and almost intolerable. This produces unhappiness in the home. Alternatively old people living alone without supervision and attention get to the stage where they cannot manage and break down. A system of geriatric clinics could cater for the assessment of deterioration. Each clinic could become the centre for receiving information 15 about old people and for arranging for the necessary supporting services, e.g. health visitors, nurses, home helps, practitioners, meals clubs, chiropody, libraries, and if need be more frequent transfer in and out of hospital to relieve the strain on relatives; or arranging accommodation in one room flats where meals and domestic service are laid on for whole blocks. Malnutrition. I have already had several elderly people come showing signs of malnutrition. If a person is allowed to choose freely anything he wishes to satisfy appetite he will probably get every essential foodstuff. Many cannot do this because they have not the money. As the money gets less, they cut out fruit and vegetables, protein and then fat. They are left with bulky starchy foods as the cheapest food available. It is true you can buy protein in the cheaper cuts of meat. You can cook effectively and appetisingly, but if you have rheumatoid arthritis and are feeble it is often impossible and malnutrition is the result. In a number of cases I have applied to the National Assistance Officer for extra allowances and these have always been granted. These cases have been brought to light because the clinic has been there for them to come to. The prevention of Atheroma I find that a great many people coming to the clinic are showing signs of atheroma or arteriosclerosis. Atheroma of the coronary artery which supplies the heart muscle is the commonest cause of failure of blood supply to the heart muscle with injury to the heart or even death. It also causes injury to the conducting tissues of the heart which maintain the heart rhythmn. Atheroma can affect the heart valves and also the arteries in other parts of the body, causing for example cramps in the calves. The Role of Fat Pat in the body is in two forms (l) saturated, e.g. stearic acid, and palmitic acid and (2) unsaturated, e. g. linoleic,. linolenic,and arachidonic acids; and oleic and palmitoleic acids. LinoleicjLinolenic and arachidonic acids are essential for health and are known as essential fatty acids, (E. P. A.) In the body linoleic is converted to arachidonic in the presence of vitamin B6pyridoxine. The linoleic acid must be in a certain chemical shape called the cis-trans-cis form and not in its mirror image form which may be even antagonistic. Arachidonic acid is needed in the body; it is very unstable because it has four double bonds and is very rarely found naturally. Linoleic acid is abundant in maize oil, soya oil. safflower oil and sunflower oil, which may contain 50% or more. They also contain vitamin E or tocopherol which protects the linoleic acid from going rancid. In the body vitamin E prevents the break-down of arachidonic acid; this protection is still further supported by vitamin C, ascorbic acid which acts as a synergist or chemical accelerator. In the body the protected arachidonic acid combines with cholesterol to form a cholesterol ester, cholesterol is manufactured in the body probably in the liver, the exact method being in doubt; it is a steroid. The ester is very soluble and can be carried easily in the blood stream. It enters into combination with glycerol to form a triglyceride which contains a stearic radicle, an arachidonic radicle and a phosphocholine. This product is a phospholipid or lecethin and is needed to form brain and nerve tissue and the 16 membranes of cells. After the cholesterol has carried its quota or arachidonic acid in the phospholipid to the tissues which need it, it is freed again to pick up another molecule and repeat the process, and so on over and over again. It thus acts as the transport vehicle for fats. It is thought that when linoleic acid is in short supply in the diet, and hence arachidonic is in short supply for making phospholipids, the body keeps calling out for more and more arachidoniccholesterol ester to keep up the supply of arachidonic to the phospholipid. The mechanism goes awry; more and more cholesterol is manufactured but has no arachidonic to attach itself to. There is evidence to show that the cholesterol attaches itself to other acids, mainly the unsaturated ones like oleic acid found in olive oil. These are non-essential fatty acids. The combinations with cholesterol are insoluble. It is thought that these insoluble products get deposited in those tissues which are lacking in blood capillaries and lymphatics such as the skin, the inside of blood vessels, the cornea, and the lens of the eye, giving the conditionsdiabetic xanthoma (yellow cholesterol tumours in the skin), atheroma, arcus senilis, and cataract. These conditions can be imitated in rabbits by feeding with diets deficient in essential fatty acids. It is known that in animals the essential fatty acids can protect the body against coronary thrombosis, and it may be they have the same effect in humans. The Registrar General's figure for deaths from coronary thrombosis keeps rising. The deaths from coronary thrombosis follow the curve for consumption of fats in rich countries. Men suffer more heavily from the deficiency than do women because they need 7 to 10 times more E. P. A. than women. We should try to ensure that we get some E. F. A., vitamin E. and vitamin B6 every day. A Remedy After much searching and experimenting I have found a source of supply of maize oil and soya oil with a good linoleic acid content tested for me by the kindness of Dr.Bell and his staff at the paint Research Station. Thus elderly people who come to the clinic and show sign of atheroma are being told about this; are given samples and can purchase it in the clinic. The instruction is for the patient to take l fluid ounce of maize oil or soya oil in a measure. This is emulsified with two heaped teaspoonfuls of Complan which supplies a small amount of vitamins and minerals. This mixture is quite palatable either alone, or flavoured with orange, lemon, lime, blackcurrent or Horlicks. The vitamins can be supplemented by juvel tablets which increase the vitamin B6 and E. I cannot do a controlled trial, but in some cases the blood pressure has been reduced quite considerably and patients have felt much better. The method can do no harm and may do considerable good. 17 THE CURE OF CATARRH AND THE PREVENTION OF COLDS By DR.H.BLOOM, Medical Practitioner, Teddington. Most of us have catarrh, and most of us suffer from colds of varying duration and severity. Nany of our colds extend and go down to the chest. When this happens the illness is serious, not only for us but also for our families because colds and chest illnesses quickly spread round the family. Catarrh is now disregarded and has become part of our way of life. The word 'catarrh' has come to describe not only the symptoms, such as the morning cough and phlegm, but also the nasty lumps of discharge which we either expectorate or politely swallow. The cold is accepted as part of the national heritage like the weather. It is the most prevalent of all family illnesses and everybody knows that 'catarrh' is the sequel to frequent colds. Yet, in spite of the universal prevalence of colds and catarrh no method of prevention or cure has hitherto been found. Now let us look round our homes and find out what happens to us as individuals and families. Catarrh is a family illness and is infectious to others: it begins as snuffles soon after birth, and once established progresses in severity, but with intermissions, as the years go by. Prom the moment of birth we are attacked by countless millions of germs, in battalions of so many varieties that science is finding new ones every month. These germs come to us, impregnating the air we breathe,from coughs, sneezes, wheezes, phlegm,hawking and 'clearing the throat' - in fact from all the symptoms of catarrh which perpetually surround us. We breathe these germs into our sinuses and lungs, the linings of which continually try to smother them.As a result of this warfare, catarrhal exudates are produced in large quantities in us, and we have catarrh, which is the result of the continuous fight put up by our breathing tract in combating the damage inflicted by the germs. 18 Our breathing tract is one continuous sheet of membrane, stretching from the topmost sinus in the skull to the smallest tube in the bottom of the lungs, it is lined by millions of tiny hairs, just like velvet. These hairs work day and night wafting the catarrh down from the sinuses and up from the lungs to the back of the nose and throat where it collects, and where in time it gradually obstructs and paralyses the action of the hairs. In addition, virulent germs simply love these juicy collections of catarrh, in which they quickly multiply and soon spread around extending the damage and inflammation. The volume of the sinuses in the face and skull alone would measure a cupful. That of the bronchial tree is much greater. So you see that when this enormous area gets inflammed as the result of attacks of germs the pouring out of secretions is considerable; in other words the catarrh is bad. As you all know having this catarrh is a constant state of affairs - it is always there. When there is a heavy attack of germs, as we get from others coughing in trains or cinemas or schools, there is a flare-up of our defence mechanism and a fight occurs. The cold, and its complications - bronchitis, pneumonia and ear infections - are therefore the flaring up of the inflammation which is constantly with us. Now let us see what happens when, instead of trying to kill germs with high-powered drugs, we simply wash them away. If we gargle with plain warm water, we find that with each gargle masses of catarrh are brought away from the throat. The more we gargle the more we wash away, and the more room we leave for the enormous amounts of catarrh imprisoned in our sinuses and lungs to escape and leave the spaces free for life-giving air. This gradually occurs over a period of time depending partly on the severity of the catarrh. The catarrh is thus gradually cured. At the same time, the millions of germs which thrive on the catarrh are washed away before they can establish a foothold. The chances of a flare-up of illness are thus considerably reduced. In addition to simple gargling, you will find that spraying the throat with warm water from a shower while in the bath, augments the effect of the gargling in washing away the catarrh. A third way of getting rid of germs and catarrh is to blow them away. But we all know that blowing into a handkerchief makes our noses more stuffy and sore. We know too that the handkerchief is a dangerous germ carrier. Then let us abolish the handkerchief. You will be surprised and gratified at the freedom of breathing and feeling of well being this 'blowing the nose like a navvy'. into the bathroom basin will bring you. Finally, we must, as far as possible, prevent germs getting into us. One of the most dangerous spots is the tooth-brush rack exposed in the bathroom. The brushes collect millions of virulent germs from the air-borne spray every time somebody coughs or spits into the basin. These germs are transferred straight to our mouths and are a source of serious but preventable illness. Let us then abolish tooth-brush racks. So clear out the accumulation of useless medicines and antiseptics from the bathroom cabinet and keep the the tooth-brushes and glasses in it. Here then are four very simple measures to cure our catarrh and at the same time keep us free from colds. 19 1. Gargle night and morning with a glassful of warm water. 2. Shower the throat for a minute or two with warm water while in the bath. 3. Abolish the handkerchief and blow the nose 'like a navvy into the bathroom basin every morning and evening. 4. Abolish tooth-brush racks and keep tooth-brushes and glasses in the bathroom cabinet. You will find that if a cold does come, its course will be considerably shortened if you gargle and blow your nose 'like a navvy' as frequently as possible. These measures are entirely without risk or cost, and they work, Won't you try them? 20 PEST DESTRUCTION The service provided by the Health Department enables residents in the Borough to obtain advice as to the identification and method of eradication of a wide variety of insect pests. The British Museum (Natural History Section) are always willing to assist in the identification of unusual specimens, and I am most grateful to them for their assistance. The normal work of the department connected with rodent destruction continued during the year and the sewers were again treated during the months of March and September. Ten premises were treated against bugs, in all cases complete clearance was effected. KEEPING THE BOROUGH CLEAN I am obliged to A. S. Knolles Esq., B. Sc., M. Inst, C. E. , M. I. Mun. E., Chartered C.E., the Borough Engineer and Surveyor, for the following report on Drainage, Sewerage, Public Cleansing and Refuse Disposal: Drainage and Sewerage The tender has now been let for the first section of the East Twickenham Sewer Scheme and trial holes having been made, the Contractor should be on the site in the near future. It is probable that this work will take some 18 months to complete. At the same time contract documents are being prepared in connection with the diversion of the foul and surface water sewers in the vicinity of the London Road Railway Bridge and Twickenham Station so as to permit of the construction of the Bridge for widening London Road. This work, which will entail crossing under the River Crane, tunnelling under London Road and crossing the main railway line by thrust boring, should be completed in 1958. The work has been rendered necessary by the fact that it is desirable that the sewers should be clear of the foundations for the new railway bridge. Public Cleansing, No special points have arisen during the year. Refuse Disposal, The operation of the Charlton Plant is continuing as in the past, and although, due to a recession in the price of paper,there has been a reduced income from salvage, the plant is working satisfactorily and the tipping and screening into the lagoon is continuing as heretofore. WATER SUPPLY I am indebted to E. Windle Taylor, Esq. , M. A., M. D., D. P. H., M. R. C.S., L. R.C. P., Barrister-at-Law, Director of Water 21 Examination, Metropolitan Water Board for the following report: The source of water is the River Thames abstracted at the Wraysbury, Walton and Laleham intakes and stored in the Thames Valley reservoirs at Staines, Littleton and Walton. After storage the water is treated at the filtration works at Hampton. The water is filtered by means of primary or rapid filtration followed by secondary or slow sand filtration. All water is finally chlorinated before it leaves the works. In order to provide adequate contact to ensure complete action by the chlorine a contact tank is provided at the works. The water is treated by a method of controlled superchlorination by maintaining a fixed residual of free chlorine after a given period of contact. The chlorination process is entirely automatic both in regard to changes in quality as well as changes in quantity of the filtered water. Samples of water are collected at all stages of the purification process at least five times each week and analysed at the laboratories of the Metropolitan Water Board. The supply is not plumbo-solvent. All new and repaired mains are disinfected with chlorine before being restored to supply and samples of water from them are tested to establish that its quality is up to that normally supplied. INDUSTRIAL HEALTH Factories Most of the 375 factories in the Borough are engaged in light industries such as the manufacture of electrical components, piston rings, aircraft parts, name plates, 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 1957 the inspectors paid 227 visits to factories. GENERAL MATTERS Housing Further progress was made during the year in dealing with unfit houses. The Minister of Housing and Local Government has held a local inquiry with regard to a third clearance area (a group of seven houses in Hampton Wick) and his decision is awaited. In addition, demolition or closing orderswere made on eleven individual unfit houses and an undertaking was given by an owner not to use four premises for human habitation. Rent Act, 1957 The Rent Act, 1957, came into operation in July and up to the 22 end of December, 1957, 134 applications were received for certificates of disrepair, and the table below shows how these applications were dealt with: Period covered by return 6th July to 31st December, 1957 PART I - Applications for Certificates of Disrepair. (1) Number of applications for certificates 134 (2) Number of decisions not, to issue certificates 5 (3) Number of decisions to issue certificates 129 (a) in respect of some but not all defects 122 (b) in respect of all defects 7 (4) Number of undertakings given by landlords under paragraph 5 of the First Schedule 83 (5) Number of undertakings refused by Local Authority under proviso to paragraph 5 of the First Schedule Nil (6) Number of Certificates issued 42 PART II - Applications for Cancellation of Certificates (7) Applications by landlords to Local Authority for cancellation of certificates 7 (8) Objections by tenants to cancellation of certificates 1 (9) Decisions by Local Authority to cancel in spite of tenant's objection Nil (10) Certificates cancelled by Local Authority 6 The machinery of the Act is mainly worked by the owner and tenant with the local authority acting as referee. The tenant, if he fails to reach agreement with the owner, applies to the Corporation for a certificate of disrepair. In granting a certificate, regard must be had to the age, character and locality of the premises, and only items of disrepair can be included. In addition only those items specified on the tenants application for a certificate of disrepair can be considered. It can readily be seen that many tenants find it almost impossible to draw up an application form in an explicit manner. Another difficulty is caused by the numerous prescribed forms which both the landlord and tenant must use at each stage of the proceedings. This complex legislation made a considerable amount of work for the inspectors and clerical staff and called for a high degree of liaison between the Town Clerk's department and my own staff. So far very few complaints have been received either from the owners or tenants about the items specified or omitted on a certificate of disrepair and no owner or tenant has availed himself of his right of appeal to County Court. The defects specified on a certificate of disrepair are not necessarily enforceable under the Public Health or Housing Acts. Notices are, however, served on the owner for such items as can 23 be dealt with under the Public Health Acts. Clean Air Act, 1956 The major part of the Clean Air Act was brought : into operation with effect from the 31st December, 1956. The more important provisions required that new furnaces should be as far as practicable smokeless, regulated the height of chimneys and enabled local authorities to set up smoke control areas. Section 24 provided that building byelaws may require the provision in new buildings of such arrangements for heating and cooking to prevent as far as practicable the emission of smoke. This byelaw was adopted by the Twickenham Corporation in February, 1957. The remainder of the Clean Air Act came into operation on the 1st June, 1958. These provisions prohibited, with certain exceptions, the emission of dark smoke from chimneys; regulated the discharge of grit and dust from furnaces and provided new powers for dealing with smoke nuisances. At the same time the Dark Smoke (Permitted Periods) Regulations, 1958, became operative and superseded the byelaws made under Section 104 of the Public Health Act, 1936, which made it an offence to emit black smoke for more than two minutes in any period of 30 minutes. The effect of these regulations is that the local authority can now control the emission of dark smoke, as well as black smoke from chimneys. In June, 1958, a sub-committee was appointed by the Corporation to consider setting up a smoke control area in the Borough. Complaints During 1957 the number of complaints received by the department was 819. Shops Section 38 of the Shops Act 1950 deals with provisions for the health and comfort of the staff. Shops must be properly ventilated, adequately warmed and sufficiently lighted; they must 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 these cases, the occupier may make an alternative arrangement to use a nearby toilet, and a certificate of exemption is granted from the requirement of the Act. There are at present 20 exemption certificates in force. Schools Further improvements were carried out under the Pood Hygiene Regulations, 1955, and the table on page 45 gives details of this work. The general standard of the canteens remains good. It was not necessary to close any schools on account of infectious disease among the children. 24 Food and Drugs Act, 1955 Food Hygiene Regulations, 1955 During the year 2,939 visits were made to food premises under these regulations and' at 243 premises contraventions were found. As a result of action taken, 246 contraventions were remedied, and the table on page gives details of this work. It was found necessary to take legal proceedings for contraventions of the regulations in two cases. A grocer was fined £2. in respect of each of six summonses together with £5. 5s. 0d. costs, and a stall keeper selling fish was fined £7. 10s. 0d. By reason of special circumstances, two certificates of exemption were granted under the regulations. One was in respect of premises without a wash-hand basin and an adequate supply of hot and cold water or of hot water at a suitably controlled temperature; the other was where a room communicating directly with a sleeping place was being used for handling open food. Twenty-seven complaints were received about unsound food bought from retailers in the Borough. Details of the complaints are given below: 1. Foreign body in bread 14. Mouldy pork pie 2. Bad tin of pineapple 15. Bad pigs head 3. Beetle in loaf 16. Foreign body in milk 4. Moths in packet of Vitamin B 17. Foreign body in milk Invalid food 18. Bad tin of ham 5. Paraffin-smelling cheese 19. Jubbly drink not fit for 6. Bad turkey human consumption 7. Dirty loaf 20. Black object in milk 8. Bread unfit to eat 21. Piece of wire in loaf 9. Unsound milk 22. Bad sausages 10. Bad bacon 23. Button in bun 11. Watch in sausage 24. Bad luncheon meat 12. Bad tinned goods 25. Unsound meat 13. Mouldy loaf 26. Rank bacon 27. Bad tin of pineapple 6 cases were reported to the Public Health Committee, and in each case a warning letter was sent to the offender. It was not found necessary to institute legal proceedings. Petroleum Installations In March, 1958, the Corporation approved new conditions of licence and principles of construction for premises where petroleum is stored. These were based on recommendations issued by the Home Office. The change involved a considerable amount of work by the inspectors on their districts and by the office staff, but we now have a set of up-to-date regulations and of a type likely to be found throughout the country. I would like to acknowledge the assistance which was received from the Town Clerk and his staff 25 in the drafting of the conditions of licence and principles of construction. During the year 1957. 146 visits were paid by the public health inspectors to premises where petroleum or carbide of calcium is stored, and 101 licences were issued. Establishments for Massage, chiropody, Electrical and Special Treatment Eleven licences in respect of establishments for these purposes were issued during the year 1957. 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. Registrations can be refused if the conditions are unsatisfactory. During the year one person was registered. The inspectors paid 14 visits. Rag Flock and Other Filling Materials Act, 1951 Three premises have so far been registered under the Rag Flock and Other Filling Materials Act, 1951. There are no premises requiring to be licensed as there is no manufacture or storage of rag flock in the Borough. Pet Animals Act, 1951 No person is allowed to keep a pet shop except under the authority of a licence granted in accordance with the provisions of this Act. These conditions have regard to the need for securing; (a) that animals will at all times be kept in accommodation suitable as respects size, temperature, lighting ventilation and cleanliness; (b) that animals will be adequately supplied with suitable food and drink and (so far as necessary) visited at suitable intervals; (c) that animals, being mammals, will not be sold at too early an age (d) that all reasonable precautions will be taken to prevent the spread among animals of infectious diseases; (e) That appropriate steps will be taken in case of fire or other emergency. There are 10 licences in force in the Borough and 25 visits were made for the purpose of securing compliance with the conditions of licence. In January I received a letter from the Royal Society for the Prevention of Cruelty to Animals asking if the Council would 26 consider appointing their inspector for the Richmond and District branch to be an honorary inspector under the Act. The public health inspectors are, of course, appointed as authorised officers; whenever it has been necessary they have always had co-operation from the Society's inspectors. The Society agreed that if appointed, their inspector would only make use of his power of entry when accompanied by a public health inspector. Over 30 authorities have appointed the Society's inspectors in this capacity and I wrote to six authorities asking for details of appointment and enquired whether the scheme worked well in practice. The replies I received confirmed that the Society's inspectors were appointed in an honorary capacity and all replies said that the arrangement worked well. The matter was considered by the Public Health committee. It was agreed that the Society's inspector for the Richmond and District branch should be appointed as an honorary officer to assist the Chief Public Health Inspector on the understanding that the Society's inspector would not have power of entry under the Act except when asked to accompany a public health inspector when the latter is carrying out his duties. So far the public health inspectors have not had occasion to ask for assistance, but I am happy to know that this is always available if required. Hairdressing Establishments The Corporation have made Byelaws under the Middlesex County Council Act for "the purpose of securing the cleanliness of any premises 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". During the year 12 inspections were made of these premises. It was not found necessary to take any action for contraventions. Swimming Baths 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 14 samples for bacteriological examination were taken throughout the season, all of which were satisfactory. Laboratory Work The usual arrangements were continued during the year and worked satisfactorily. Type of Sample or Specimen No. Taken Result Ice Cream 130 119 Grade l Satisfactory 7 Grade 2 3 Grade 3 Unsatisfactory 1 Grade 4 Water 39 31 Satisfactory 8 Unsatisfactory Faeces etc. 264 Bone Meal 7 27 Ambulance Facilities The Middlesex County Council is the responsible authority for the provision of the ambulance service under the National Health Service Act, 1946. National Assistance Act, 1948, Section 47 National Assistance (Amendment) Act, 1951 It was necessary during 1957, to remove to suitable premises two persons who were in need of care and attention. Health Education Continued use is made of various health education methods, including propaganda by posters, leaflets and lectures illustrated by films or lantern slides. Mortuary Extensive additions to the mortuary building have now been completed, and there are now separate offices for the coroner's officers and attendant and for the doctor in charge of post-mortem examination. There is also a waiting room for friends and relatives with a separate viewing room. The w,c. accommodation has been improved and there is more cupboard space for storage of clothes and equipment. The doctor's office is entered from the post mortem room, the ventilation system has been greatly improved, and the general arrangement and appearance of the building is more in keeping with the importance of the service. The number of bodies admitted to the mortuary in 1957 was 506. 28 TABLES FOR STATISTICAL YEAR 19 5 7 29 STATISTICAL TABLES for the Year 1957 Table 1 Summary 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) 103,600 Number of inhabited houses 30,735 Rateable value £1,825,806 Sum represented by a penny rate £7,656. 10. 7. Total M. F. Live Births: Legitimate 1269 697 572 Illegitimate 63 35 28 Total 1332 732 600 Birth rate per 1,000 of estimated civilian population 12,86 Adjusted birth rate 13,25 Total M. F. Still Births: Legitimate 19 8 11 Illegitimate 1 1 - Total 20 9 11 Still birth rate per 1,000 total (live and still) births 14,79 M. F. Deaths 515 600 1,115 Crude death rate per 1,000 of estimated civilian population 10.76 Adjusted death rate 10.33 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 16.52 Legitimate infants per 1,000 legitimate live births 17.34 Illegitimate infants per 1,000 illegitimate live births Nil 30 Population 1940-1957 Table 2. Year Population Population trend Migration excess Total increase or decrease Percentage proportion Natural increase or decrease Inward Outward 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 i944 88,660 -4,120 -4.44% +507 - 4,627 1945 91,920 + 3,260 +3.68% +424 2,836 - 1946 102,850 +10,930 +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 1952 106,500 +200 +0.19% +144 56 - 1953 105,300 -1,200 -1.13% +250 - 1,450 1954 104,700 -600 -0.57% +167 - 767 1955 104,300 -400 -0.38% +105 - 505 1956 104,000 -300 -0.29% +146 - 446 1957 103,600 -400 -0.39% +217 - 617 Table 3. Causes of Death. Registrar-General's Official Returns Causes of Death Males Females Total AH causes 515 600 1115 1. Tuberculosis, respiratory 5 3 8 2. Tuberaulosis, other - 1 1 3. Syphilitic disease 2 1 3 4. Diphtheria - - - 5. Whooping cough - - - 6. Meningo-coccal infections - - - 7. Acute poliomyelitis - - - 8. Measles - - - 9. Other infective and parasitic diseases - 2 2 10. Malignant neoplasm, stomach 11 16 27 11. Malignant neoplasm, lung, bronchus 49 9 58 12. Malignant neoplasm, breast 1 23 24 13. Malignant neoplasm, uterus - 7 7 14. Other malignant and lymphatic neoplasms 49 63 112 15. Leukaemia, aleukaemia 2 1 3 16. Diabetes 3 6 9 17. Vascular lesions of nervous system 50 104 154 18. Coronary disease, angina 119 63 182 19. Hypertension with heart disease 17 22 39 20. Other heart disease 53 105 158 21. Other circulatory disease 25 25 50 22. Influenza 3 7 10 23. Pneumonia 33 41 74 24. Bronchitis 30 7 37 25. Other diseases off respiratory system 1 8 9 26. Ulcer of stomach and duodenum 6 3 9 27. Gastritis enteritis and diarrhoea 1 4 5 28. Nephritis and nephrosis 5 5 10 29. Hyperplasia of prostate 6 - 6 30. Pregnancy, childbirth, abortion - - - 31. Congenital malformations 1 4 5 32. Other defined and ill-defined diseases 26 50 76 33. Motor vehicle accidents 4 1 5 34. All other accidents 12 14 26 35. Suicide 1 5 6 36. Homicide and operations of war - - - 31 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 38.48 4.14 Intra-cranial vascular lesions 13.81 1.49 Bronchitis, Pneumonia, and other respiratory diseases 11.66 1.25 Cancer 20.45 2.20 Violence 3.32 0.36 Tuberculosis 0.81 0.09 32 Table 5. Infant 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 mths. 3 months anc under 6mths. 6 months and under 9mths. 9 months and under 12 mths Total deaths under 1 year All Causes: certified 13 3 - - 16 1 4 1 - 22 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 1 - - - 1 - - - - 1 Atrophy, Debility and Marasmus - - - - - - - - - - Atelectasis 8 - - - 8 - 1 - - 9 Injury at Birth - - - - - - - - - - Erysipelas - - - - - - - - - - Syphilis - - - - - - - - - - Rickets - - - - - - - - - - Meningitis,(not Tuberculous) - - - - - - - - - - Convulsions - - - - - - - - - - Gastritis - - - - - - - - - - Laryngitis - - - - - - - - - - Bronchitis - - - - - - - - - - Pneumonia,(all forms) 1 2 - - 3 1 2 1 - 7 Suffocation (overlying) 1 - - 1 - - - - 1 Other causes 1 1 - - 2 - - - - 2 Totals 13 3 - - 16 1 4 1 - 22 (b) An analysis of the mortality reveals that neo-natal deaths were responsible for 72.73 per cent. of the total infants deaths, viz.:— an increase of 8.44 from the previous year. Under 24 hours 1 to 7 days 1 to 4 weeks Total under 4 weeks Percentage total infant deaths 7 6 3 16 72.73 33 Table 6. Review of the Comparative Vital and Mortality Statistics for the Borough of Twickenham, together with those for England and Wales for years 1940-1957 inclusive Year Birth Rate DeathRate Infantile Mortality Rate Twickenham England and Wales Twickenham England and Wales Twickenham England and Wales 1940 14.67 14.6 (a) 14.8 (b) 14.9 14.3 45.8 55 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 16.7 (a) 11.26 11.7 21.21 32 (b) 11.03 1950 (a) 13.34 15.8 (a) 11.05 11.6 20.10 29.8 (b) 12.54 (b) 10.72 1951 (a) 12.82 15.5 (a) 11.97 12.5 24.98 29.6 (b) 12.05 (b) 11.61 1952 (a) 12.54 15.3 (a) 11.18 11.3 20.22 27.6 (b) 11.79 (b) 10.84 1953 (a) 13.26 15.5 (a) 10.88 11.4 20.06 26.8 (b) 13.53 (b) 10.01 1954 (a) 12.73 15.2 (a) 11.14 11.3 14.25 25.5 (b) 12.98 (b) 10.25 1955 (a) 12.13 15.0 (a) 11.12 11.7 22.92 24.9 (b) 12.37 (b) 10.23 1956 (a) 12.77 15.7 (a) 11.37 11.7 10.54 23.8 (b) 13.15 (b) 10.92 1957 (a) 12.86 16.1 (a) 10.76 11.5 16 .52 23.0 (b) 13.25 (b) 10.33 (a) Crude (b) Adjusted 34 35 AVERAGE RESULTS OF THE CHEMICAL AND BACTERIOLOGICAL EXAMINATION OF THE WATER SUPPLY TO THE BOROUGH OF TWICKENHAM FOR 1957 Milligrammes per litre (unless otherwise stated) (a) Chemical Description of the Sample Number of Samples Ammoniacal Nitrogen Albuminoid Nitrogen Oxidised Nitrogen (Nitrate ) Chlorides as C1 Oxygen abs. from Permanganate 4 hrs. at 27°C. Turbidity in terms of Silica Colour, mm. brown 2 ft. tube Burgess's Tintometer Hardness (total) Hardness (Non carb.) pH. Value Phosphate as P.O 4 111 Silica as SiO2 Sulphate as SO4 Electrical Conductivity (gemmhos.) Hampton 236 0.020 0. 076 3.9 29 1.20 0.4 12 260 58 7.9 0.95 10 58 550 Table 7 (b) Bacteriological, after chlorination (water passing into supply) Description of the Sample Number of Samples Plate count (average per millilitre) Colonies counted on agar. Coliform Test Percentage Samples Negative in 100 ml. 3° C. 20-24 hrs. 22°C. 3 days Coliform E.Coli Hampton 801 3.7 - 99.50 99. 75 Table 8. Analysis of Complaints Received Nature of Complaint Number Received Housing defects 226 Choked and defective drains 127 Accumulations of offensive matter - Unsound food 90 Verminous premises: (a) Bugs 7 (b) Rats and mice 375 (C) Other 16 Keeping of animals - Unsatisfactory milk supplies - Miscellaneous 353 Total 1,194 36 Table 9 Summary of Visits, Inspections, etc. Dwelling-houses for housing defects under Public Health Act: Number (a) After complaint 939 (b> Subsequent visits 2555 Dwelling-houses under Housing Act: 549 Dwelling-houses under Rent Act 405 Dwelling-houses: Housing applications, specially investigated 51 Infected dwelling-houses: (a) After notified infectious disease (other than tuberculosis) 221 (b) Contacts 274 (c) Fumigations after infectious disease 12 (d) Tuberculosis enquiries and fumigations 1 School and church halls 21 Swimming baths - Water sampling: (a) Swimming baths 6 (b) Dwelling-houses 9 Business premises - Cinemas, dance halls, billiard halls 23 Offensive trade premises - Stables, piggeries, keeping of animals 69 Houses let in lodgings - Factories Acts, 1937 and 1948: Factories with mechanical power 221 Factories without mechanical power 6 Outworkers' premises 1 Common lodging houses - Underground rooms - Hairdressing premises 12 Tents, vans and sheds 1 Smoke nuisances 304 Fairgrounds 8 Drainage: Testing by: (a) Smoke 31 (b) Coloured water 48 (C) Water 30 (d) Breaking down 281 Public sewers 668 Watercourses and ditches - Means of escape in case of fire - Land and t ips 164 Septic tanks and cesspools 1 Sanitary conveniences—including public-houses 9 Miscellaneous visits 1839 Visits not inspections 1851 Rodent control 3 Verminous premises: (a) Rats and mice: After complaints or from survey 78 (b) Bug infestations: Number of premises visited 20 (c) Beetles 12 (d) Other vermin 261 (e) Scabies - Inspections for supervision of food: Unfit foodstuffs other than meat 188 Slaughterhouses - 37 Table 9—continued Food and Drugs Act, 1955, Food Hygiene Regulations:- Bakehouses 176 Butchers' shops 492 Fish shops, grocers and greengrocers 1534 Factory and school canteens 149 Restaurant kitchens, etc. 502 Hotel and beerhouse bars and cellars: (a) Day inspections 85 (b) Night inspections 1 Food and Drugs Act, 1955. Section 16: Ice-cream premises (Heat Treatment) Regulations, 1947 to 1951 80 Sausage manufacturers - Preserved meat preparation premises 3 Preserved fish preparation premises 16 Milk and Dairies Regulations, 1949: Milk sampling for bacteriological examination 1 Contravention of Milk and Dairies Regulations 18 Dairies 1 Shops Act, 1950. Section 38 2 Game Licences 1 Middlesex county council Act, 1950: Hawkers' vehicles 13 Hawkers' premises 1 Noise nuisances 21 Massage and/or special treatment establishments - Petroleum (Regulation) Acts, 1928 and 1936; Petroleum Spirit Regulations, 1929-1950 146 National Assistance Act, 1948, Section 47 2 Rag Flock and other Filling Materials Act, 1951 2 Dealers in Old Metal and Marine stores - Pet Animals Act, 1951 25 Agriculture (Safety, Health &Welfare) Provisions Act, 1956 56 Total number of visits and inspections 14,499 38 Table 10. Sanitary Improvements Effected Number Offensive accumulations removed 1 Nuisance from keeping of animals remedied - Chimney flues repaired - Chimney stacks repaired 1 Roofs repaired 127 Eavesgutters repaired 46 Downspouts repaired 17 Pointing renewed 11 Ditches requiring cleansing - Drains repaired 2 Drains unstopped 10 Dustbins provided 13 Fireplaces repaired 6 Filthy condition of premises remedied - Floors repaired 19 Gullies repaired 2 Pail closets renewed - Plaster to walls and ceilings repaired 74 Window frames and sashcords repaired 15 Public sewers repaired - Sinks provided - Sink waste pipes repaired 1 Soil pipes repaired 1 Stairs repaired 1 External walls repaired 1 Wash boilers defective - W C.s repaired 14 W.C. cisterns and fittings provided 18 W.C. accommodation provided 2 Yard paving repaired 1 Unpaved Yards and Passages - Other works carried out 202 39 Table 11. Housing Statistics HOUSES IN CLEARANCE AREAS AND UNFIT HOUSES ELSEWHERE Return for the Year ended 31st December, 1957 A. HOUSES DEMOLISHED In Clearance Areas; (Housing Act, 1936.and Housing Repairs, and Rents Act, 1954) Houses Demo Ii shed Displaced during Year Dersons Families (1) Houses unfit for human habitation 6 5 2 (2) Houses included by reason of bad arrangements, etc. - - - (3) Houses on land acquired under Section 27, Housing Act, 1936 - - - Not in Clearance Areas: (4) As a result of formal or informal procedure under Section 11, Housing Act, 1936 5 7 2 B. UNFIT HOUSES CLOSED Number (5) Under Section 11,Housing Act,1936, and Sections 10(1 )andn(2) Local Govt. (Misc. Prov.) Act.1953 9 35 13 (6) Under Sections 3(l)and3(2)Housing Act, 1949 (7) Parts of buildings closed under Section 12. Housing Act, 1936 1 13 3 C. UNFIT HOUSES MADE FIT AND HOUSES IN WHICH DEFECTS WERE REMEDIED By Owner By Local Authority (8) After informal action by local authority 294 _ (9) After formal notice under: (a) Public Health Acts 37 (b) Housing Act, 1936 - - (10) Under Section 5 Housing Repairs and Rents Act 1954 - _ D. UNFIT HOUSES IN TEMPORARY USE (Housing Repairs and Rents Act, 1954) Position at the end of year: Number °f houses (1) Number of separate dwe11ings containea in column (1) (2) (11) Retained for temporary accommodation: (a) under Section 2 - (b) under Section 3 - - (c) under Section 4 - - (12) Licensed for temporary occupation under Section 6 - - E. PURCHASE OF HOUSES BY AGREEMENT Number , °f nouses (1) Number of occupants of houses in column (1) (2) (13) Houses in Clearance Areas other than those included in confirmed Clearance Orders or Compulsory Purchase Orders purchased in the year - - 40 Table 12. 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 Ac t Food andDrugs Act Number of Informal Notices served 329 243 Number of Informal Notices complied with 272 246 Number of Statutory Notices served 42 - Number of Statutory Notices complied with 42 - 41 Table 13. Prevention of Damage by Pests Act, 1949 TYPE OF PROPERTY Non-Agricultural Agriculturai Local Authority Dwe11ing Houses (inci CounciI Houses) All other (incl. Business Premises) Total °f Cols. 1,2&3 Number of properties in Local Authority's District 111 30,007 4587 34,705 38 Number of properties inspected as a result of (a) Notification 18 298 68 384 Nil (b) Survey under the Act 16 3, 130 512 3, 658 Nil (c) Otherwise (e.g., when visited primarily for some other purpose) Nil 16 3 19 Nil Total inspections carried out including re-inspections 279 6,762 1,762 8, 803 Nil Number of properties inspected which were found to be infested by (a) Rats 21 284 55 360 Nil (b) Mice 6 86 20 112 Nil Number of infested properties treated by L.A. 27 359 65 451 Nil Total treatments carrieo out includingere-treatments 38 328 67 433 Nil Number of notices served under Section 4 of the Act (a) Treatment Nil 11 10 21 Nil (b) Structural work Nil Nil Nil Nil Nil Number of cases in which default action was taken following the issue of a notice under Section 4 of the Act Nil Nil Nil Nil Nil Legal proceedings Nil Nil Nil Nil Nil Number of Block control Schemes carried out 5 42 43 Eradication of Insect Pests. D.D.T and Other Special Treatments Number of Infestations Treated Type of Premises Beetles Bugs Cockroaches Fleas Flies Lice Wasps Woodworm Totals Dwelling-houses - 10 1 6 2 1 56 2 78 Workplaces 1 - - - 1 - - - 2 Food Shops - - - - - - 1 - 1 Miscellaneous - - - - - - 1 - 1 Totals 1 10 1 6 3 1 58 2 82 Total income for D.D.T. and other special treatments, £53. 9. 6d. Table 14. Table 15. Disinfections, etc. Number Premises disinfected after infectious diseases 9 Premises disinfected after other diseases - Articles disinfected after infectious disease 209 Persons (children and adults) treated for scabies at cleansing station - Table 16. Housing Act, 1936, Overcrowding Number New cases of overcrowding reported during the year 15 (1) cases of overcrowding relieved during the year 4 (2) Persons concerned in such cases 13 Table 17. 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, 1919 Persons registered as distributors 33 Premises registered as dairies (not being dairy farms) 16 Special Designation Dealers' Licences Supplementary Licences Milk (Special Designation) (Raw Milk) Regulations 1949. Tuberculin tested 19 10 Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations, 1949. Pasteurised 22 10 Sterilised 32 9 44 Table 18. Food and Drugs Act, 1955 Public Health Act, 1936, Section 89 INSANITARY CONDITIONS IN FOOD PREMISES Number of premises found with insanitary conditions 243 Number of premises remedied 246 Insanitary conditions found in premises above Number of defects Number of defects remedied Equipment not kept in good order 101 114 Food so placed as to involve risk of contamination 50 53 Food placed within eighteen inches of the ground and not adequately protected 3 3 Absence of personal cleanliness 2 1 Insufficient ventilation to w C. 72 48 Absence of "Wash your Hands-' notices to W C s 52 78 Absence of suitable and sufficient wash-hand-basins 80 80 Absence of hot water at a suitably controlled temperature over wash hand basins 88 102 Absence of soap nail brushes, clean towels etc near wash-hand basins 39 49 Absence of first aid materials 96 104 Absence of accommodation for clothing not worn during working hours 47 57 Absence of suitable and sufficient sinks for the washing of food and equipment 23 41 Absence of hot water at a suitably controlled temperature over sinks 18 38 Absence of soap, clean cloths etc. at sinks 3 3 Absence of suitable and sufficient lighting in food room 18 8 Absence of suitable and sufficient ventilation in food room 1 2 Walls, etc. not kept clean 286 218 Walls, etc. not kept in good order 64 90 Accumulation of refuse, etc 4 5 Miscellaneous 111 95 Total 1158 1189 SCHOOLS Number of defects Equipment not kept in good order 7 Insufficient ventilation to W.C. 4 Absence of suitable and sufficient wash-hand basins 2 Absence of hot water at a suitably controlled temperature over wash-hand-basins 3 Absence of accommodation for clothing not worn during working hours 1 Absence of suitable and sufficient sinks for the washing of food and equipment 4 Absence of suitable and sufficient lighting in food room 1 Absence bf suitable and sufficient ventilation in food room 3 Walls, etc. , not kept clean 6 Walls, etc., not kept in good order 9 Accumulation of refuse, etc. - Miscellaneous 6 Total 46 45 Table 19. (a) Meat-Carcases inspected and Findings at private Slaughterhouses in the Borough Cattle excl. Cows Cows Calves Sheep and Lambs Pigs Horses Number killed (if known) - - - - - - Number inspected - - - - - - All diseases except Tuberculosis and Cysticerci: - - - - - - Whole carcases condemned - - - - - - Carcases of which some part or organ was condemned - - - - - - Percentage of the number inspected affected with disease other than tuberculosis and cysticerci - - - - - - Tuberculosis only; Whole carcases condemned - - - - - - Carcases of which some part or organ was condemned - - - - - - Percentage of the number inspected affected with tuberculosis - - - - - - Cysticercosis: Carcases of which some part or organ was condemned - - - - - - Carcases submitted to treatment by refrigeration - - - - - - Generalised and totally condemned - - - - - - (b) Other Carcases Inspected NIL 46 Table 20. (a) Meat Diseased and unsound conditions found in meat caused the detention and surrender for destruction of: lbs. Beef 625 Mutton and lamb 315 Pork 75 Other meats 226 Total 1241 (b) Other Foodstuffs The following foodstuffs, other than meat, being unfit for human consumption, were voluntarily surrendered for destruction: lbs. Bacon 20 Butter 12 Cheese 173 Fish 210 Fresh Fruit 16 Margarine 8 Offal 242 Poultry 134 Sausages 68 Sweets 17 jars Paste 17 Pickles, sauce, etc. 37 Preserves 52 tins Cream 19 Fish 67 Fruit & Fruit Juices 405 Meat 285 Milk 143 Puddings 34 Soup 52 Vegetables 714 Other 10 47 Table 21. 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, 1957. Article Total Samples procured Unsatisfactory Milk (Various) 109 - Arrowroot 5 - Butter 12 - Cakes 10 2 Cooked Meat 7 - Cream 12 - Fish and Fish Products 23 - Fruit (Canned) 44 8 Fruit (Fresh) 11 - Fruit Squash, Etc. 7 - Garden Peas 19 - Ice-Cream 5 - Iodine 7 - Liver 9 - Meat and Meat Products 15 - Non-Brewed Condiment 6 - Pickles and Sauces 8 - Preserves 7 - Sausages, Etc. 10 1 Sweets 9 1 Vinegar 31 1 Miscellaneous 25 1 Totals 391 14 48 With regard to the samples noted on that list as being unsatisfactory I add the following comments - Cakes. A sample of "Coconut Fancy" cakes was found to contain a nail, pull enquiries were made including a detailed examination of the plant and methods used by the manufacturer concerned; all possible precautions against such an occurrence appeared to have been taken and part of the manufacturer's precautions included the use of an electronic device to detect the presence of metal in their products. No explanation for the presence of this nail in this sample could be found. An official caution was addressed to the manufacturers concerned A sample of "Macaroon Tarts" was found to contain no almond, coconut having been used instead. An official caution was sent to the bakers concerned. Canned Fruit. 8 tins of fruit labelled as containing "Victoria Plums" were each found to contain "Giant Prune" plums. These 8 tins, although obtained from two separate shops in the District, were found to have been packed by the same canners. Enquiries were instituted throughout the whole of the County and subsequently by 23 other large food and drugs authorities in the country, and in consequence a number of other similar offences were disclosed it was found that offences had been committed by the packers in respect of this particular brand of plums at their cannery in Essex and by arrangements with the food and drugs authorities concerned the Essex county Council instituted proceedings against the canners in respect of 9 offences. The canners pleaded guilty and were fined £25 on each summons with £10.10S-0d legal costs and £345, 16s.l0d in respect of special costs of the five County Councils concerned, a total of £581.6,10d. A fuller report of these investigations and proceedings will be found in the Minutes of the meeting of the County Council of Middlesex held on 26th February, 1958-Report of the General Purposes Committee, item 9. Sausages A sample of pork chipolatas were found to contain an undeclared preservative in an amount which would have been permissible had its presence been disclosed. A subsequent sample was found to be genuine and no further action was called for. Sweets A sample of Butter Macaroons" was found to contain no almond and a letter of caution was addressed to the manufacturers. Vinegar. A sample sold as vinegar was found on analysis to be non-brewed condiment. A letter of caution was sent to the retailer concerned. Brandy Butter Spread A sample labelled as Brandy Butter Spread bore the following statement of ingredients 'Sugar, butter and Lemon Hart rum". The attention of the manufacturers was drawn to this inconsistency Merchandise Marks Acts, 1887-1953 229 inspections of shops were undertaken to ensure that the Marking Orders relating to certain imported foodstuffs made under the Merchandise Marks Act. 1926 were complied with 2126 separate displays of meat apples tomatoes, poultry dried fruit fresh salmon and bacon were examined A butcher was selling and exposing for sale imported meat and imported offal not marked with the required indication of origin 5 summonses were issued against him and he was convicted and fined a total of £10 and ordered to pay £2 2s 0d costs The Labelling of Food Order, 1953 At 192 premises 732 articles of pre packed food were examined to see that they bore a label which gave a clear statement of the designation of the food and in the case of compound foods, the ingredients, and also the name and address of the packer or labeller. No infringement of this Order was detected 49 False or Misleading Descriptions. As in previous years a considerable amount of work has been done in the detailed scrutiny of advertisements and the labels on pre-packed foods, and taking suitable action in those cases where a label or advertisement contains a false or misleading description of the food to which it relates. This work is of benefit to the whole county irrespective of where within the County offences may be detected. During the year under review corrective action has been secured in respect of salmon with potato salad, crystallized jelly pineapple slices, pure egg mundelech, cherry juice, lime juice, imitation cream, cream filled biscuits, cream filled Easter eggs and cheese. In every case the person responsible agreed to make necessary suitable amendments to labels as a result of my representations. In no case was it necessary to institute proceedings. Special Designated Milks. No licences were issued by my Council in respect of the use of a special designation for milk processed within your area. 4 samples of pasteurised milk were taken from roundsmen in your district during the year and submitted to examination. They proved satisfactory. 50 Table 22 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 1Vritten Notices Occupiers prosecuted (i) factories in which Section 1,2, 3,4 and 6 are to be enforced by Local Authorities 33 6 1 - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 312 221 8 - (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) - - - - Total 345 327 9 - 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. 1 ) 1 - - - - Overcrowding (S.2) - - - - - Unreasonable temperature (S.3) - - - - - Inadequate ventilation (S-4) 1 - - - - Ineffective drainage of floors (S. 6) - - - - - Sanitary Conveniences (S 7) - - - - - (a) Insufficient 1 - - - - (b) Unsuitable or defective 6 4 - - - (c) Not separate for sexes 1 1 - - - Other offences against the Act (not including offences relating to outwork) 1 - - - - Total 11 5 - - - Part VIII of the Act Outwork Nature of the Work Lamp shades Wearing apparel Electric Fuse Makers Umbrellas Cardboard boxes Section 110: Number of outworkers in August list required by Section no (1)C) 6 34 65 1 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 - - - - - 51 Table 23. Infectious Diseases. Incidence and Mortality DIPHTHERIA, SCARLET FEVER AND ENTERIC FEVER 1940- 1957 Year Diphtheria Scarlet Fever Enteric Fever 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 1,000 pop. 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 - - - - - - 1952 - - - - 135 1.28 - - - - - - 1953 - - - - 100 0.95 - - - - - - 1954 - - - - 64 0.61 - - - - - - 1955 - - - - 97 0.93 - - - - - - 1956 - - - - 51 0.49 - - - - - - 1957 - - - - 17 0.16 - - - - - - 52 Table 24 Ophthalmia Neonatorum, years 1940-1957 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. 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 - 2 - - - 1951 8 6 2 8 - - - 1952 4 3 1 4 - - - 1953 4 4 - 4 - - - 1954 2 2 - 2 - - - 1955 5 2 3 5 - - - 1956 4 - 4 4 - - - 1957 5 5 - 5 — — — 53 54 Cases of Infectious Diseases Notified during the Year 1957 DISEASE CASES NOTIFIED AT VARIOUS AGES (YEARS) Total cases notified Deaths 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 Dysentery 1 - 1 2 - 3 3 - - 2 1 3 1 - 17 - Encephalitis - - - - - - - - - - - - - - - - Erysipelas - - - - - - - - - - 6 4 - - 10 - Food Poisoning - 2 1 2 3 3 1 - 7 7 3 8 - 6 43 - Measles 10 52 80 106 106 431 20 3 1 1 2 - - 12 824 - Meningococcal Infections - - - - - - - - - - - - — - - - Ophthalmia Neonatorum 5 - - - - - - - - - - - - - 5 - Acute Poliomyelitis - - - - - - - - 1 - - - - - 1 - Pneumonia 1 1 1 - 1 8 4 4 1 3 6 22 20 3 75 74 Puerperal Pyrexia - - - - - - - - 2 5 1 - - 1 9 - Scarlet Fever - - 1 - 2 10 1 2 1 - - - - - 17 - Typhoid & ParaTyphoid - - - - - - - - - - - - - - - - Whooping Cough 2 5 8 8 10 33 5 - - 1 - - 1 5 78 - Totals 19 60 92 118 122 488 34 9 13 19 19 37 22 27 1079 74 Table 25 55 Monthly Incidence of Infectious Diseases during the Year 1957 DISEASE NUMBER OF CASES TOTAL January Feb. March April May June July August Sept. October Nov. Dec. Dysentery - 1 3 - 2 1 4 2 - 1 - - 17 Encephalitis - - - - - - - - - - - - - Erysipelas 3 3 - - 1 - - 1 1 - 1 - 10 Food Poisoning 2 5 5 6 5 4 4 6 4 - 2 - 43 Measles 2 16 40 86 102 289 147 120 18 1 1 2 824 Meningococcal Infections - - - - - - - - - - - - - Ophthalmia Neonatorum - 2 - - - - - 1 - 1 1 - 5 Acute Poliomyelitis - - - - - - - - 1 - - - 1 para-Typhoid - - - - - - - - - - - - - Pneumonia 3 7 4 2 5 3 5 4 3 28 3 8 75 Puerperal Pyrexia 1 - - - 1 4 1 1 - - - 1 9 Scarlet Fever 2 2 2 3 - - 2 1 3 1 1 - 17 Whooping Cough 1 2 3 5 5 17 21 13 5 4 - 2 78 Totals 14 41 57 102 121 318 184 149 35 36 9 13 1079 Table 26 56 Ward Distribution of Infectious Diseases Notified during the Year 1957 Disease Twickenham Heathfield Whitton Hampton Hampton Hill Teddington Hampton Wick Total East Central South West Upper Lower Dysentery 1 1 2 2 - 1 2 1 3 3 1 17 Encephalitis - - - - - - - - - - - - Erysipelas 1 - - 1 1 - 1 - 1 4 1 10 Food Poisoning 8 4 - 2 1 2 10 4 1 1 10 43 Measles 53 62 23 42 68 10 135 169 77 95 90 824 Meningococcal Infections - - - - - - - - - - - - Ophthalmia Neonatorum - - - 2 - - - — 1 - 2 5 Acute Poliomyelitis - - - - - - 1 - - - - 1 para-Typhoid - - - - - - - - - - - - Pneumonia 2 2 4 5 3 - 7 16 10 7 19 75 Puerperal Pyrexia - - - - - - 8 - - 1 - 9 Scarlet Fever 2 1 1 2 1 1 1 3 4 1 - 17 Whooping Cough 9 3 4 3 5 2 6 7 7 7 25 78 Totals 76 73 34 59 79 16 171 200 104 119 148 1079 Total 27 Table 28 Tuberculosis The following tables have been compiled from the notifications receive NEW CASES AND MORTALITY Age Periods New Cases Deaths Pulmonary Non-pulmonary Pulmonary Non-pulmonary Male Female Male Female Male Female Male Female Under l - - - - - - - - 1-4 - - - 1 - - - - 5-9 - 2 - - - - - - 10-14 - 1 - - - - - - 15-19 4 3 - - - - - - 20-24 1 2 - - - - - - 25-34 5 4 2 - 1 - - - 35-44 7 4 - - - - - - 45-54 7 4 1 - 2 1 - 1 55-64 8 - 1 - - - - - 65 and over 3 1 - 1 2 2 - - age unknown 1 - 1 - - - - - Totals 36 21 5 2 5 3 - 1 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 29 PRIMARY NOTIFICATIONS OF TUBERCULOSIS, 1940-1957 INCLUSIVE 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 Pulmonary 114 127 112 119 133 118 120 132 117 115 96 107 79 105 88 70 58 57 Non- Pulmonary 12 14 18 18 18 18 19 11 17 5 15 14 20 14 12 11 3 7 Totals 126 141 130 137 151 136 139 143 134 120 111 121 99 119 100 81 61 64 57 Table 30 Food Poisoning Food Poisoning Notifications: 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL 12 15 13 3 43 OUTBREAKS DUE TO IDENTIFIED AGENTS: Nil Number of cases Nil. Outbreaks due to: Chemical Poisons - Salmonella organisms - Staphylococci (inc.toxin) - Cl.Welchii - OUTBREAKS DUE TO UNDISCOVERED CAUSE Nil Number of cases Nil SINGLE CASES: Due to identified agents: Number of cases 6 Chemical poisons Nil Salmonella organisms 2 Staphylococci 4 P.Morgani Nil Due to undiscovered cause 37 Number of cases 37 Total all cases 43 58 59 Premises concerned with Health Services in Area 10 A Ante-natal and post-natal care of mothers. D Dental H Headquarters Personal Health P Family Planning (provided by Voluntary Organisation). B Baby Welfare E Eye testing I Vaccination and Immunisation. C Chiropody (Old people-provided by Voluntary Organisation). P Distribution of Welfare Foods, J Geriatric S School Health M Mental Health T Talking and Speech Therapy G Child Guidance O Orthopaedic. V Environmental Health Enquiries should be made at the appropriate address for particulars as to persons eligible, special conditions as to services and the time the premises are open. Elmfield House, High Street, Teddington H V Council Offices, Bridge Street, Staines. V Grove Crescent, Hanworth A B D E F I S T Church Road, Teddington A B C D F Stanwell Road, Ashford. A B C D Imperial Road, Bedfont. A B D F I I 0 E F I 0 S S T Hospital Bridge Road, Whitton. A B C D F The Grange, A B D E F Council Offices, Green Street, Sunbury. V I S Gresham Road, Staines, G I M 0 P S T 20 Seymour Road, Hampton Wick A B D F I Duddingston House, Green street, Sunbury A B C D F P S Village Hall, Stanwell. A B F I I S Stanley Road, Teddington. C D E I S Village Hall, Laleham. B F I Chertsey Road, Ashford Common A B C D F I S T 24 Station Road, Hampton. A B C D F St. Anne's School, Ashford S Laleham Road, Shepperton. A B D F I I S S T York House, Richmond Road, Twickenham, A B C D E St. Mary s Church Hall, Bridge street, Staines F F I S New Hall, Upper Halliford. A B F I 58 Hampton Road, Twickenham. G T Council Offices, Hanworth Road, Feltham. V Hawke House Green Street, sunbury. F Baptist church Hall, Hounslow Road, Whitton. F Cardinal Road, Feltham. A B D E F I S P Table 31