ACT 23 1920 URBAN DISTRICT OF ACTON. ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1920. ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH FOR THE YEAR 1920. Council Offices, Acton, W.3. April, 1921. To the Chairman and. Members of the Urban District Council of Acton. Ladies and Gentlemen, I beg to submit the Annual Report on the work carried out by the Public Health Department, together with the Vital Statistics for the year 1920. The Report has been arranged as to contents and arrangements in accordance with the Memorandum of the Ministry of Health. Some of the sections which were dealt with fully in last year's Report are only lightly dealt with this year, unless the conditions have materially changed. Vital Statistics. The most marked feature of the Vital Statistics has been the increase in the birth-rate. The birth-rate for the year was 24 per 1,000 compared with 17.1 in 1919, and 14.5 per 1,000 in 1918. The birth-rate for England and Wales was 25.4 per 1,000 and for the 96 Great Towns 26.2 per 1,000. The death-rate—10.4 per 1,000—was exactly the same as that of 1919. In 1919 it was stated that the death-rate was the lowest on record for the district. The death-rate for England and Wales was 12.4 per 1,000 and for the 96 Great Towns 12.5 per 1,000. The Infantile Mortality was 64 per 1,000 births, which is the lowest Infantile Mortality on record for the district. The Infantile Mortality for England and Wales was 80 per 1,000 births and for the 96 Great Towns 85. 4 There was a great increase in the number of deaths from Diphtheria. The virulent outbreak of this disease which occurred in the autumn is dealt with in another paragraph. For the fifth year in succession there has been no death from Scarlet Fever ; there has been no death from this disease since 1915. There was an increase in the number of cases notified. There was no death also from Enteric Fever. This disease is becoming more and more rare, and with increasing knowledge, it is not too much to hope for its complete extermination. There was an outbreak of Measles in the Spring and Summer, which is dealt with in a separate paragraph. Nine deaths occurred from this disease. General Character of the District, Social Conditions, Including Occupations, etc. A full description of the district was given in last year's Report, and it is unnecessary to repeat fully the information then given. The district is divided municipally into four Wards:— North East, North West, South East, and South West. The most important industries are Laundry and Engineering, and the most important change that has occurred has been the depression and slackness of business in the engineering works in the district. It was stated last year that the three engineering works in the Vale employed between 5,000 and 6,000 persons. It is probable that in the whole district there are about 5,000 people out of employment. Unemployment made its appearance in the summer, and it became very acute in the autumn and winter. Unemployment affected the number of persons supplied with free milk under the Council's Maternity and Child Welfare Scheme, and this matter will be referred to under Infant Mortality. Extent to which Hospital and other Forms of Gratuitous Medical Relief are Utilised. The only voluntary Hospital in the district is the Acton Hospital, which was opened in 1898. The Hospital has 35 beds, and it is for the treatment of Acton residents and of any persons injured in the district. Only a very small proportion of those who died in public institutions received treatment in the Acton Hospital. 5 215 deaths of residents occurred in Hospitals and Public Institutions, and of these only 10 deaths occurred in the Acton Hospital. 15 deaths of residents occurred in the Fever Hospital. The Infirmary of the Union is situated in Isleworth, and 90 deaths of residents occurred there. These Institutions do not represent the extent to which hospital treatment is utilised. Our proximity to London enables the residents to resort to the large General Hospitals for treatment. It is impossible to estimate the number of persons who are treated in the large General Hospitals. Table 11 gives the number of deaths which occurred in hospitals outside the district. The total number of deaths which occurred in hospitals and public institutions was 215; in addition, six deaths occurred in Nursing Homes. Amount of Poor Relief. The amount of poor relief increased considerably during the year. No unemployment relief was granted in 1920, and the following figures simply show the ordinary outdoor relief given in the district:— Quarter ending Money Kind £ s. d. £ s. d. March 31st 417 2 0 129 0 7 June 30th 429 0 9 118 7 5 Sept. 30th 447 13 2 137 17 1 Dec. 31st 517 10 0 107 11 6 £1,811 5 11£492 16 7 To wives of interned aliens for March quarter only 26 19 6 Nil. £1,838 5 5£492 16 7 (These figures do not include the Acton Green area.) Food and Drugs Act. The following table has been kindly supplied by Mr. R. Robinson, Chief Officer of the Control Department, County Council of Middlesex, showing the number of samples taken and the number adulterated:— Article Taken Adulterated Milk 208 17 Separated Milk 1 — Cream 2 2 Preserved Cream 3 — 6 Butter 11 — Lard 2 — Coffee 2 Fish Paste 2 1 Egg Powde 1 — Egg Substitute Powder 1 — Lime Juice Cordial 1 1 Saccharin Tablets 1 — 235 21 Number of Prosecutions 4 Number of Convictions 3 Fines imposed £17 The figures given for adulterated samples include some adulterated informal samples in respect of which no proceedings could be taken. Population. In the Annual Reports for the five years 1915—1919 inclusive, two estimates were made of the population, one for deathrate purposes and the other for the birth-rate. The former was an estimate of the civil population only, whilst the latter included the men on military service. In 1920 demobilisation had reached a stage at which it is felt that the distinction between "Birth-rate populations" and "Death-rate populations," made during a period when a large part of the male population was under arms, might in general be discontinued. A single estimate of the population has therefore been made, and this is applicable to both births and deaths. The Registrar-General has estimated the population in June, 1920, at 64,192. This estimate is based upon the number of ration-cards issued in November, 1919. In last year's Report I gave certain facts from which it could be reasonably assumed that the Registrar-General's figures were an under-estimate of the population of the district. For the year 1919, the RegistrarGeneral estimated the population at 64.306; and he therefore assumes that there was a decrease of 114 in the year. I believe that the Registrar-General's estimate is too low by nearly 3,000 inhabitants, but in view of the interesting figures given by the Registrar-General in his recently published Annual Report for 1919, I have deemed it expedient to accept his figures. The following paragraphs may be quoted, as they bear, not only upon the estimate of the population, but also as to the housing needs as affected by the growth of the population. 7 The difficulty of framing reasonably accurate estimates of population towards the close of an intercensal period has always been found very great—so great, in fact, that each new census, when taken, has revealed serious errors in the Registrar-General's estimates of local populations. The difficulty is greatly increased at the present time by the disturbing effects of the war ; and until the results of the 1921 census are available, all that can be claimed for the estimates is that they are the best which the means at his disposal has enabled the Registrar-General to prepare. At the same time, while the war has rendered the methods relied upon for estimating local populations in normal times quite useless for this purpose now, it has fortunately brought in its train new sources of information in the shape of the National Register and Rationing Statistics, which have greatly mitigated the difficulty. The mid-1919 estimates (also mid-1920) of local populations have been mainly based upon the returns of the distribution of rationing cards in November, 1919. It may be mentioned that the general tendency is for local estimates to rule higher than those prepared in the General Register Office. In fact, the impression is left that if the sum of local estimates could be ascertained, it would be found much in excess of any reasonable estimate of the population of the country as a whole. The local estimates are very largely based upon comparison of the numbers of occupied houses in 1919 and 1911, and upon the fact that the margin of unoccupied houses then existing has since disappeared. This method of estimation generally assumes that the number of persons per house has remained at least as large as at the last census. But the acuteness of the housing problem, and the frequency of cases in which two families now occupy one house because of the failure to obtain a second, invites the assumption that an increase has taken place in the average number of persons per house. Were this the case, the method of estimation would understate the increase of the population. But in a comparison between conditions in 1911 and 1920, other factors must be set off against the more recent effects of the housing shortage, which are so much under public notice. Many households in 1920 were without one or more members, killed in the war; many were without young children, who would have been added to their number under peace conditions. Lastly, the fall in the birth-rate, even apart from the war, has to be taken into consideration. Probably this was a main factor in causing the decrease in average numbers recorded up to 1911; and the decrease in the birth-rate has continued since. There is no doubt that the size of the average family has been on the decline for many years; 8 and so far - the rule of one family one house prevails—as it still must largely do—the fall in the birth-rate would, other things being equal, have reduced the average number of persons per house. As the estimated population for 1919 was 700,000 in excess of that of the last census, it would only require (apart for replacement of defective houses) a net addition of 140,000 houses for the whole period 1911-1919 to maintain the standard of 1911 —that is, if the new census shows the present population estimate to be fairly correct. If we reverse the process, and accept the estimated population for Acton of the Registrar-General as correct, we may endeavour to calculate the deficiency in the number of houses in the district. At the 1911 census there were 9,445 inhabited and occupied houses in the district and 490 unoccupied houses. Between April 1st, 1911, and July, 1914, 442 new dwelling houses were erected and occupied. Most of the 490 houses empty in 1911 are now occupied; so that roughly accommodation for an additional 5,500 persons has been provided. This would leave 1,200 persons unaccommodated, or a shortage of about 200 houses. The houses that are being erected under the Council's Housing Scheme are not comparable to the older houses in the district. As far as accommodation is concerned, they are more comparable to tenements. At the census in 1911, there were 12,965 tenements, with an average number of 4.5 persons, compared with 6 per house. In last year's Report it was stated the Surveyor estimated that 1,700 new houses were required to meet the immediate needs of the district. The discrepancy between this latter figure and the Registrar-General's estimate of the population is not so great as it appears on the surface. Conditions have changed since the Surveyor's estimate was made. The depression in the engineering trade has had an effect upon the demands for housing in the district. In the Surveyor's estimate, provision was made for the developments which were about to take place within the area. In view of all these circumstances, it is fortunate that a census is due, but the preliminary figures of the census will not be published in time to be utilised in this Report. In the Memorandum of the Ministry of Health it is urged that the preparation of the Annual Report should be undertaken immediately after the conclusion of the year to which it relates. Births. The birth-rate is higher than that of the previous year, and is the highest birth-rate recorded since 1914. As far as the 9 actual number of births is concerned, the number is the highest recorded since 1908. The number appears lower than that of 1913, but that is accounted for by the fact that births of nonresidents are now deducted and credited to other districts. Throughout the kingdom since the Armistice and the return home of the men from the Forces, there has been a substantial recover}- in the birth-rate. In England and Wales the birth-rate was 25:4 per 1,000 inhabitants in 1920, as compared with 18.5 in 1919 and 17.7 in 1918. It is probably only a temporary phenomenon, and as far as Acton is concerned, the birth-rate is again declining. The births registered in the district in the four quarters were as follows :— First quarter 423 Second quarter 399 Third quarter 337 Fourth quarter 283 The sharp rise in the first half of 1920 is not likely to affect permanently the general tendency towards a reduced birth-rate, which has been such an outstanding feature of our Vital Statistics during the past 40 years. No question has been the subject of more discussion in recent years than the birth-rate, and the views held as to the declining birth-rate are as divergent as the poles. On the one hand we have persons who assert that those who seek to restore the birth-rate of half a century ago are engaged in a task which would be criminal if it were not based on ignorance, and which is in any case fatuous. On the other hand, there are people who regard the falling birth-rate as nothing less than race suicide. On one point, though, all are agreed. All admit that the reduction in the birth-rate is deplorable in its differential distribution. From the eugenic point of view, the reduced birth-rate operates chiefly amongst those classes which, humanly speaking, are the best fitted to be parents; whilst it operates little, if at all, amongst those classes which are least fitted. Although the question of the birth-rate is discussed quite freely nowadays, candidly, one must admit that the question of over-pouplation is not faced fairly and squarely. The following extract from a review in the Medical Officer of the Registrar-General's Annual Report for 1919, places the matter fairly, if somewhat strongly:— "Has anyone, since the days of Malthus, ever faced, fairly and squarely, the consequences of all the facts that are summarised in these reports which come from the Registrar-General every year? These islands are not distensible: already they are in parts stretched almost to the limit of their capacity. How long can they continue to accommodate and support a population 10 which has already in these few short months, not only made good the losses of war and epidemic disease, but is threatened at the same time with an overflowing increase in numbers, based on the principle of ' To him that hath shall be given,' and is merely a question of elementary arithmetic ? "Look at a not too distant future, when the death-rate, particularly the infant death-rate, will be negligible, when venereal disease will only be remembered for the horrid pictures that were wont to embellish the text-books; when tuberculosis is dead or dying ! What is going to happen then? "Perchance an occasional outburst of influenza or measles or some ridiculously inadequate epidemic to relieve the everaccumulating pressure. "Something is bound to burst—but what ? We can only hope that the law which holds sway in so many biological processes —that after a period of acceleration, there shall follow a period of deceleration, due to exhaustion of the substrate or to the inhibitory effect of re-action—products— may not fail us ere it be too late. It is a wonderful stride that medicine has taken along the path of prevention and mastery of disease, but by its side there stalks a shadow—is it of pestilence or is it of war ? *- There is a slight discrepancy between the numbers given on Table 3 and the figures published by the Registrar-General. The numbers of births included in the Registrar-General's figures are those registered during the calendar year, and are corrected, for inward and outward transfers. Table 3 includes the births notified during the year and those registered in the district, but not notified, together with the births belonging to the district, but registered outside. The Registrar-General's figures are those of births belonging to the district that were registered during the year. The figures in Table 3 are based mainly upon the notifications received during the year. The number of births registered in the district was 1,442— 740 males and 702 females. In addition 99 births belonging to the district occurred outside the area. The total number of registered births belonging to the district was 1,541—792 males and 749 females. Of these 34 males and 26 females were born out of wedlock. 11 There was a great reduction in the illegitimate birth-rate —39 per 1,000 births, compared with 58 in 1919 and 57 in 1918. The total number of illegitimate births was higher than that of 1918, and only 4 lower than that of 1919. During the year 1,356 live births were notified and 35 still births. 112 births were registered in the district, but not notified. 58 live births and 1 still birth belonging to the district were notified by outside authorities. The Ward distribution is given on Table No. 3. Cinemas. There are two Cinema Houses in the district, and a third is in course of erection. During the year a circular was received from the Ministry of Health dealing with the lavatory and closet accommodation in picture theatres. In both cinemas the closet accommodation was considered insufficient, and as a result of the inspection and report, additional accommodation is being provided. The sanitary accommodation in cinemas is only a minor part of the question compared with the want of means of ventilation and lack of arrangements to prevent harm to the eyesight of children. In view of the undoubted fact that cinema hcvses play an important part in the spread of infectious diseases, regulations should be adopted with respect to the ventilation of and sanitary accommodation. The subject is complicated in Acton by the fact that the Council is not the licensing authority, and the only power it possesses is in respect of any new buildings which may be erected or adapted. The inlets for fresh air are usually insufficient, and where outlets for foul air are provided, they are insufficient and not always in working order. The unsatisfactory state of the atmosphere in some cinemas is indicated by the analyses which have been made in some towns, where as much as 40 to 50 volumes per 10,000 of carbon acid gas are found, compared with 4 in the outside air. Many authorities have also drawn attention to the increasing prevalence of defective vision amongst children. In Eastbourne, regulations are made whereby the seats for children are placed in a line with the centre of the screen at a distance of thrice its full height. Sanitary Inspection of the District. At the end of the Report will be found a Table giving a classified statement of the premises visisted, the number and nature of the inspections, etc. 12 I am obliged to Mr. M. W. Kinch, the Chief Sanitary Inspector, for the following report upon this section:— Houses Let in Lodgings. The present bye-laws dealing with these premises are made under Section 90 of the Public Health Act, 1875, and contain the following exemption clauses:— (a) Where the rent or charge payable by each lodger, and exclusive of any charge for the use by the lodger of any furniture is at the rate of not less than 10s. per week : (b) Where the rent or charge payable by each lodger, and inclusive of any charge for the use by the lodger of any furniture is at the rate of not less than 15s. per week. We find the amounts stated in such clauses sufficiently high to enable us to deal with the class of houses for which these bye-laws were intended, although further extensions of these byelaws would be beneficial. Under Section 26 of the Housing and Town Planning Act, 1919, further power is given to the Local Authority to extend the provisions of these bye-laws, but only in such cases where such houses are intended or used for occupation by the working classes. In the case of the bye-laws made under the Public Health Act, it is left to the discretion of the Council whether a house shall be registered or not, and in the case of the bye-laws made under the extended powers given by the Housing Acts, there is the difficulty of deciding whether or not a house is intended for occupation of the working classes. In my opinion, the provisions contained in both these sets of bye-laws would be of far more service if they applied to all houses let in lodgings within the rentals named, without the formality of registration. The Council has already considered a draft of these later bye-laws, and is waiting until the bye-laws submitted to the Ministry of Health by the London County Council have been approved before deciding on the adoption of the series under consideration. Underground Rooms. There are no underground rooms in the district which come within the provisions of Section 17 (7) of the Housing and Town Planning Act, etc., 1909. The Council has, however, made regulations as empowered by the said Section on the lines of the model series of the Ministry of Health. Seizures of Meat and Particulars re Same. There were no seizures under the Unsound Food Sections of the Public Health Act, but during the year 495 lbs. of meat (including bacon) were voluntarily surrendered, but none was affected with tuberculosis. In all cases it was unsound, due to decomposition—principally, bone-taint. 13 Slaughterhouses. No. in 1914 No. in June, 1920 No. in Dec., 1920 Registered 1 1 1 Licensed 2 2 2 Bye-laws for the regulation of these premises were adopted by the Council on the 19th June, 1899. Tents, Vans, Sheds, etc. The district is not much frequented by gipsies, and there are no persons occupying tents and sheds. There is a more or less permanent encampment of van dwellers (showmen) opposite Acton Green, and the average number of such vans during the year is 9. Bye-laws were made by the Council on the 29th October, 1906, and are found to be quite adequate for the purpose of dealing with this class of dwelling. Bakehouses. Of these, there are 7 underground and 18 aboveground. In 18 cases slight sanitary defects were found to exist, which were remedied by request. These defects were principally:— Want of lime-washing. Defective plastering. Defective floors. Defective drainage (in one case only). Unsound Foods. The following amounts of unsound foods (other than meat and bacon) were surrendered:— 450 lbs. rabbits. 201 lbs. fish. 192 lbs. fruit and vegetables. 129 lbs. other articles, such as tinned milk, butter, etc. No unsound foods were seized under Section 116 of the Public Health Act, 1875. The following is a list of the number of premises where foods are prepared, manufactured or sold:— 29 butchers' shops. 22 fishmongers. 47 greengrocers. 16 provision shops. 32 restaurants, food shops, and sausage makers. 83 dairies and milk purveyors' premises. 14 Section 28 of the Housing Acts, 1919. The Public Health Committee, at its Meeting held on January 27th, 1920, approved the proposal to serve all Notices in future under Section 28 of the Housing and Town Flanning Act, 1919. where such Section was applicable. As it was considered probable that such a course would entail a considerable amount of work in the Surveyor's Department (the Council being empowered in default of compliance with the Notices to have the work carried out), the Works Committee was informed of the matter and asked to prepare itself to carry out the works as expeditiously as possible. The first Notices under this Section were served in February, and to the 31st December totalled 621. In 528 cases the owners carried out the necessary work, but in 93 cases the Council did so in default, the total cost of which amounted to £4,820. The procedure in serving the Notices is as follows:— After the inspection of the premises has been made, the details are recorded on a specially prepared form. These forms are submitted to the Committee at each meeting, and authority obtained for the service of the Notice. The Notices are then typed out, specifying in detail what is required to remedy the defects, and four carbon copies are made. The Notices, after being signed by the Clerk, are served by hand upon the premises, addressed to "The Owner, c/o the Occupier," and at the same time a letter is sent to the person believed to be the owner, informing him of such service, together with one of the carbon copies above mentioned. A carbon copy is also attached to the office record form, and the other two are kept in reserve to send to the Surveyor in the event of the Owner failing to carry out the work. One of these copies the Surveyor retains for office use, and the other is handed to the Works' Foreman for the purpose of carrying out the work. This saves the Surveyor a considerable amount of typing in his department. In no instance has the Council received notice of appeal. The proviso in the Section refers only to cases where, in the opinion of the landlord, the works required to be carried out by the Council involve the reconstruction of the house. In many of the houses the number of defects found were very numerous and extensive, such, for instance, as the absence of efficient damp-proof courses and the defective and insanitary floors, due to the absence of concrete over the site and the inefficiently ventilated space under the wooden floors. In one or two. cases of defective roofs, it was found impossible to satisfactorily remedy the defects other than by completely stripping the roofs and reslating, and in the case of flats zinc roofs where the zinc had perished, it was necessary to cover the roofs with one of the approved preparations, such as "Ruberoid." 15 Towards the end of the year the number of Notices receiving attention by the Surveyor showed a marked drop, which, in my opinion, was due to the fact that owners realised that the Council were determined to have all insanitary conditions remedied, and they found it would be much cheaper to get the work done themselves than through the Surveyor's Department. During the war there was very little work done in the way of repairs and re-decorations to houses, and upon a house-to-house inspection the defects found were usually fairly extensive, as will be seen from the following list, which enumerates the principal defects:— Defective and insufficient yard paving. Insanitary conditions of forecourt. Defective drains. Defective soil pipe and ventilating shaft. Defective W.C. pan and trap, flushing apparatus and seat. Insanitary sink, or want of sink and water supply to same. Defective or untrapped sink waste pipe. Want of a sufficient food cupboard. Defective, or want of, cover to drinking water cistern. Insanitary condition of ground beneath floors. Insufficient ventilation under ground floors. Dampness, caused by defective roofs, rain water pipes and guttering, and want of damp-proof courses. Defective plastering. Dirty walls and ceilings. Defective flooring. Defective kitchen range or fire grate. Defective washing copper. Under this Section, which requires any house suitable for occupation by persons of the working classes to be in all respects reasonably fit for human habitation, the Council decided to adhere to the standard of fitness, as laid down in the Manual of Unfit Houses, Volume 1, issued by the Ministry of Health, and in all cases of houses or tenements which were not provided with sinks and food cupboards, such were required, and in addition, suitable coal storage cupboards were asked for. In one or two instances, owners have objected to the provision of these, but after talking the matter over with them, they have agreed to the Council's demands. 16 Classified Statement of the Number of Premises Visited during the Year. Number. Premises. 2,237 Dwelling houses. 259 Workshops. 3 Slaughterhouses. 37 Public House Urinals. 1 Common Lodging House. 97 Houses Let in Lodgings. 29 Butchers. 22 Fishshops. 37 Premises where food is manufactured. 89 Milk Purveyors. 2 Cowsheds. 9 Piggeries. 1 Offensive Trade. 4 Rag and Bone. 22 Mews and Stables. 11 Schools. 2 Show Grounds. 2,862 Number and Nature of Inspections Made. 405 House to House Inspections. .317 After infectious disease. 976 On Complaint. 539 Not on Complaint. 615 Premises under periodical inspection. 7,708 Re-inspections of premises. Number of Notices Served. 1,582 Statutory. 323 Preliminary, etc. Houses Let in Lodgings. Number registered 97 Tabular Statement of Inspections and Detail of Work Carried Out under the Public Health Department. 323 Preliminary Notices served. 1,582 Statutory Notices served. 12 Notices received from H.M. Inspector of Factories. 17 154 Notifications of waste of water sent to Metropolitan Water Board. 976 Complaints received. 976 Inspection of Premises on Complaint. 539 „ without complaint. 317 ,, after Infectious Disease. 405 „ House to House. 615 Premises under Periodical Inspection 7,708 Re-inspections of Premises. 621 Houses dealt with under Section 28. 97 Houses let in Lodgings registered under Bye-laws. 34 Contravention of Bye-laws. 17 Overcrowding nuisances abated. 86 Drains examined, tested, exposed, etc. 22 Smoke observations taken. 6 Smoke nuisances abated. 11 Nuisances abated from foul pigs and other animals. 63 Visits to Common Lodging Houses (1 registered) 483 „ Houses let in lodgings. 64 „ Van dwellings. 4 „ Cowsheds. 96 „ Piggeries. 12 „ Offensive Trades (1 tered) 26 „ Rag and Bone Dealers. 42 „ Mews and Stables. 148 „ Public House Urinals. 7 „ Schools. 12 „ Showgrounds. 863 Sanitary dustbins provided. 254 Yards paved or existing yard paving repaired. 56 Insanitary Forecourts remedied. 83 Defective drains repaired or reconstructed. 62 Defective soil pipes and ventilating shafts repaired or new fixed. 48 Defective fresh air inlets repaired, or new fixed. 132 Defective gullies removed and replaced by new. 10 Rain water down.pipes disconnected from drain. 211 Dishing and curb to gullies repaired, and new gratings fixed. 18 156 Defective W.C. pans and traps removed and replaced by new. 223 Defective W.C. flushing apparatus or new fixed. 65 Defective W.C. seats repaired or new fixed. 51 Defective flush-pipe connections paired. 22 Insanitary sinks removed or new sinks fixed. 322 Sink waste pipes repaired or trapped. 64 Insanitary wall surfaces over sinks remedied. 35 Ventilated food cupboards provided. 53 Drinking water cisterns cleansed. 65 Defective covers to drinking water cisterns repaired, or new fixed. 17 Insanitary sites beneath floors concreted. 183 Spaces beneath floors ventilated. 265 Dampness in walls from defective damp-proof courses remedied. 655 Dampness from defective roofs, rain water guttering, etc., remedied. 409 Defective plastering repaired (number of rooms). 1,861 Rooms where dirty walls and ceilings have been cleansed and repapered or distempered. 137 Defective floors repaired. 15 Defective or dangerous stairs repaired 39 Defective door and window fastenings renewed. 57 Defective window frames, sashes, or sills repaired. 123 Broken glass to windows renewed. 19 Defective hearths repaired. 64 Defective kitchen ranges and fire grates repaired. 57 Defective washing coppers repaired. 15 Coal cupboards provided. 6 New W.C. apartments provided. 56 Dirty yards cleansed. 48 Dirty W.C. pans cleansed. 47 Accumulations of offensive matter removed. 219 Drains unstopped and cleansed. 5 Manure receptacles provided. 19 ANNUAL REPORT ON THE ADMINISTRATION OF THE FACTORY AND WORKSHOP ACT, 1901, IN CONNECTION WITH FACTORIES, WORKSHOPS, WORKPLACES AND HOMEWORK. 1.—Inspection of Factories, Workshops, and Workplaces, including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. (1) Number of Inspections (2) Written Notices (3) Prosecutions. (4) Factories (including Factory Laundries) 12 5 - Workshops (including Workshop Laundries) 321 64 - Workplaces (other than Outworkers' premises included in Part III. of this Report) 16 3 — Total 349 72 — 2.—Defects found in Factories, Workshops and Workplaces. Particulars. (1) Number of Defects. Number of Prosecutions. (5) Found. (2) Remedied. (3) Referred to H.M. Inspector. (4) Nuisances under the Public Health Acts:— Want of cleanliness 26 26 - - Want of ventilation — - - - Overcrowding — — - - Want of drainage of floors 6 6 - - Other nuisances 39 39 - - Sanitary accommodation— Insufficient 1 1 - - Unsuitable or defective 37 37 - - Not separate for sexes — - - - Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (s. 101) - - - - Breach of special sanitary requirements for bakehouses (ss. 97 to 100) Other offences (excluding offences relating to outwork which are included in Part 3 of this Report) 18 18 - — Total 127 127 — 20 3.—HOME WORK. Nature or Work. Outworkers' Lists, Section 107. Outwork in Unwholesome Premises, Section 108. Outwork in Infected Premises, Sections 109, 110. Lists received from Employers. Notices served on Occupiers as to keeping or sending lists. Prosecutions. Instan ces Notices served. Prosecu tions. Instan ces Orders made (s. 110) Prosecutions (Sections 109, 110) Sending twice in y'r Sending once in y'r Failing to keep or permit inspection of lists. Failing to send lists. Lists. Outworkers Outworkers Contrac tors. Workmen. Lists Contrac tors. Workmen. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Wearing Apparel— Making, etc. ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cleaning & Washing ... ... ... 2 ... 14 ... ... ... ... ... ... ... ... ... Household linen ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Lace, lace curtains and nets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Curtains and furniture hangings ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Furniture and upholstery ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Electro-plate ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... File-making ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Brass & brass articles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Fur pulling ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 21 Cables and chains ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Anchors and grapnels ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cart gear ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Locks, latches & keys ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Umbrellas, etc. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Artificial flowers ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Nets, other than wire nets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tents ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Sacks ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Racquets and tennis balls ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Paper, etc., boxes, paper bags ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Brush making 2 ... 18 ... ... ... ... ... ... ... ... ... ... ... ... Pea picking ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Feather sorting ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Carding, etc., of buttons, etc. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Stuffed toys ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Basket making ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chocolates and sweetmeats ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cosaques, Christmas crackers, Christmas stockings, etc. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Textile weaving ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Total 2 ... 18 2 ... 14 ... ... ... ... ... ... ... ... ... 22 1920 4.—Registered Workshops. Workshops on the Register (s. 131) at the end of the year Number. (1) (2) Important classes of workshops such as workshop bakehouses may be enumerated here. Laundries 105 Dressmakers 32 Millinery 5 Tailoring 9 Bakehouses 25 Bootmakers 26 Others 57 Total Number of Workshops on Register 259 5.—Other Matters. Class. Number. (1) (2) Matters Notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factors and Workshop Acts (s. 133, 1901) Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Acts (s. 5, 1901):— Notified by H.M. Inspector 12 Reports (of action taken) sent to H.M. Inspector 12 Other — Underground Bakehouses (s. 101) in use at the end of the year 7 Refuse Removed, etc. Amount of house refuse collected 12,098 tons Amount of slop, etc., removed 5,599 loads Watering of roads 10,262 loads Shingle, etc. 70 loads Number of Houses Completed. Containing Living Room, Parlour, Scullery and three Bedrooms 84 Bungalows at North Acton, containing Living Room, Parlour, Scullery, and three Bedrooms 76 Built by a Private Builder 8 Huts converted into D w ellings ellin 9 Houses in Course of Construction 124 The position with regard to the construction of the Northern Relief Sewer is that the whole of the works have been commenced, and approximately two-thirds of the entire length of the Sewer has been completed. The work is still proceeding satisfactorily. 23 1920 Appendix No. 1. 1. Estimated population 64,192 2. General Death-rate 10.4 3. Death-rate from Tuberculosis 1.2 4. Infantile mortality 65 5. Number of Dwelling Houses of all Classes 9,935 6. Number of Working Class Dwelling Houses 6,428 7. Number of New Working Class Houses erected 162 Unfit Dwelling Houses. Appendix No. 2. 1.—Inspection. 1. Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 2,337 2. Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 621 3. Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil 4. Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 621 2.—Remedy of Defects without Services of Formal Notices. Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their officers 17 3.—Action under Statutory Powers. (a) Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919. 1. Number of dwelling houses in respect of which Notices were served requiring repairs 621 2. Number of dwelling houses which were rendered fit:— (a) By Owners 528 (b) By Local Authority in default of Owners 93 3. Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil. 24 1920 (b) Proceedings under the Public Health Acts. 1. Number of dwelling houses in respect of which Notices were served requiring defects to be remedied 961 2. Number of dwelling houses in which defects were remedied:— (a) By Owners 666 (b) By Local Authority in default of Owners 295 (c) Proceedings under Section 17 and 18 of the Housing, Town Planning, etc., Act, 1909. 1. Number of representations made with a view to the making of Closing Orders Nil. 2. Number of dwelling houses in respect of which Closing Orders were made Nil. 3. Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit 3 4. Number of dwelling houses in respect of which molition Orders were made Nil. 5. Number of dwelling houses demolished in suance of Demolition Orders Nil. Measles. Few questions confront Medical Officers of Health more regularly or more persistently than the control of Measles; and, I might add, that on no other subject is there such a lack of uniformity displayed in the measures adopted to deal with it. There is a seasonal periodicity of measles, and in large centres of population epidemics of measles occur with almost mathematical regularity every second year. It might be assumed that the seasonal and biennial periodicities of measles would be of value in that they enable a sanitary authority to be prepared for an epidemic outbreak of measles, but there is no situation which appears so hopeless to the Medical Officer of Health of an Urban Area as that in which he is face to face with an epidemic of measles on a large scale. Some authorities assert that the control of measles is non-existent. Until a vaccine has been discovered it would seem that measles must play its time-honoured role and visit in continually recurring epidemics the successive generations of men, who in this natural but sacrificial manner, acquire the protective immunity which enables the greater mass of the population to withstand the otherwise ever present presage of a pandemic disease. As a natural corollary of this fatalistic non-possumus attitude, we have some authorities who doubt, not only the pos- 25 1920 sibility of controlling the spread of measles, but even the desirability of doing so, were it possible. These persons regard all efforts at control to result at best only in a short postponement of the epidemic, and this postponement means a future bigger epidemic. It may be mentioned that these are the views of Medical Officers of Schools (not School Medical Officers). Very few Medical Officers of Health will admit that some amount of control is not possible, and they certainly will not admit that very little is gained by attempting to control the spread of measles. Even if the Medical Officer of Health fails with one method, he must devise another, and not fold his hands because he has failed. The different views held by Medical Officers of Schools and Medical Officers of Health may be partially explained by the fact that the subject is viewed from a different angle, and sometimes it is an advantage for the same person to hold the dual post of School Medical Officer and Medical Officer of Health. The School Medical Officer is concerned chiefly with the spread of the disease in schools, and he is apt to measure his success or his failure by the number of cases which occur. The Medical Officer of Health is apt to base his view of success or failure on the number of deaths which may result, and it is possible that under certain conditions the number of cases which occur may be high, but the number of deaths may be comparatively low, though as a general rule the bigger the epidemic the higher the fatality. It is well known that the main stress of measles falls upon the child population, and in particular upon children between the ages of 1 and 3 years. Ninety per cent. of the total deaths from measles occur among children under 5 years, and nearly one-half of the total deaths from the disease occur in the second year. In a report to the Local Government Board the importance of postponing an epidemic, even for a short time, was emphasised. It was pointed out that a short postponement would carry a certain number of children over the most susceptible period, and thus a certain number of lives would be saved. The case mortality at the age period 5-10 years has been found to be only one-ninth of that in the third year of life. In the fourth year of life the case mortality is less than one half that in the third year of life. In a discussion which took place at a meeting of the Medical Officers of Schools Association, it was argued that a postponement of the attack for more than six months could not be obtained, and such a postponement was not worth while. Against the slight postponement of attack is to be placed the fact that when 1920 26 closure occurs all knowledge of secondary cases is lost, and it is not until the school re-opens that the extent to which measles has spread in the interval can be ascertained. While in those schools which remain open absentees can be visited, and skilled help given, in cases where the school is closed the only knowledge that comes to hand in the interval is in the death returns. It is admitted that all children over 6 months of age, with a few rare exceptions, are exceedingly susceptible to measles. Although no complete explanation has been furnished, the low proportion of deaths among infants under 6 months of age is an interesting feature in measles. Whether the exemption is due to a natural immunity or to the comparative isolation of "cradle life," the evidence is not conclusive. In an enquiry into the medical history of 14,000 children in one district, 47 per cent. of those between 5 and 6 years of age had suffered from measles, whereas of those from 10 to 15 years of age 90 per cent. had had the disease. Similar inquiries have been made in other districts, and the figures bear out the contention that the disease is so universal in this country, few children escape it. On the face of it, it seems that very little benefit can accrue from the postponement of an epidemic. But there are other factors which govern, not so much the extent of an epidemic as its fatality. It is a general experience that an epidemic is not so fatal in the warm months of the year as it is in the colder months. When we consider the cause of deaths from measles, this phenomenon is easily explainable. In the Registrar-General's Annual Report for 1911, the causes of death in measles are given of the 13,128 deaths from measles in that year. 1,066 were stated to have died from measles (unqualified), 6,449 from broncho-pneumonia complicatory measles, 1,670 from pneumonia, and 1,109 from bronchitis. Over 90 per cent. of the deaths from measles were due to complications, and the most serious complications were due to respiratory diseases. The prevention of these respiratory complications is far more difficult in the winter months than it is in the summer months. If an outbreak makes its appearance in the early part of the year, it is undoubtedly an advantage to postpone, if possible, its epidemic appearance until the summer months. If, on the other hand, measles makes its appearance in the early summer, it is doubtful if any advantage can accrue from its postponement. Under present 27 920 conditions it is probably better to let the outbreak run its course in the summer months rather than postpone its appearance until the late autumn. The percentage mortality of those attacked is difficult to ascertain. Of course, it varies according to the age of the patient, and under present conditions the action of sanitary authorities, and more especially school authorities, will not alter much the age incidence. The case mortality is probably in the neighbourhood of 4 per cent. The point I wish to emphasise is that this case mortality is much higher in a winter epidemic than in a summer one, and every effort should be made to postpone, if possible, a winter epidemic into a summer one. The figures for Acton are too small to be of much use, but they are significant, and probably an index of those throughout the kingdom. The last occasion on which, we experienced a winter epidemic was in 1917. At that time compulsory notification was in force, and 1,485 cases were notified and 39 deaths occurred. In 1920, 950 cases were reported and 9 deaths occurred. The most notable difference between the two epidemics was, that the 1917 epidemic occurred in the winter and the 1920 occurred in the late spring and summer. Opinions differ as to the term of the postponement of an epidemic. Most authorities now admit that a certain amount of postponement of attacks can be brought about by a class closure in a school, or by the closure of a department, provided that closure took place before any secondary cases occurred or, as it was expressed, before the occurrence of the first crop. In some instances, it is possible to postpone an epidemic after the occurrence of the first crop. One of the objections to the postponement of an epidemic is that a postponement means a bigger epidemic at a later period, and it is a common experience that under ordinary conditions the bigger the epidemic the higher the case fatality. It is claimed that the symptoms are more severe if the infection is massive. There is very little ground for this obection. The postponement cannot be sufficiently delaved to modify the dimensions of the epidemic. Moreover, when the postponement of an epidemic can be successfully achieved, it is found that this takes place around the school holidays, and the infection is rendered less massive. If we take the 1920 epidemic as an example, we find that the disease made its appearance in two of the schools before the Easter holidays. These two departments were closed for a fortnight before the Easter holidays and re-opened after the Easter vacation. 28 1920 These departments were not closed sufficiently early to postpone the epidemic to any considerable extent, but measles did not affect the other schools to any appreciable extent until the beginning of May. Probably the closure of the departments and the intervention of the Easter holidays resulted in a slight postponement of the epidemic, and I am of opinion that this slight postponement, together with the splitting up of the epidemic, as it were, was instrumental in contributing towards a milder epidemic than if it had occurred as an explosion during the colder months. The history of the outbreak presented nothing of outstand ing interest; the outbreak followed the usual course observed in a mild epidemic of measles. A doubtful case was notified from Beaumont Park School in the early part of March, but in this instance it was probably a case of mistaken diagnosis. Undoubted cases were reported in March from the Southfield Road Infants' and Acton Infants'. The dates of the onset of symptoms in these cases were between March 8th and March 11th. These departments were closed on March 22nd and March 24th respectively, and re-opened after the Easter holidays, on April 12th. The Montessori Class at Southfield Road was again closed from April 13th to May 3rd. A case occurred in the Priory Infants' Department before the Easter holidays. The initial symptoms occurred on March 23rd, and the first crop fell during the Easter holidays. Cases occurred amongst the children attending Rothschild Road, South Acton, and Acton Wells Infants' Departments during the Easter Holidays, but there was no spread of the disease until the earl}7 part of May. Towards the end of April cases occurred in other schools, and the following Table gives approximately the dates on which the first and last cases occurred in these schools. School. First Case. Last Case. Beaumont Park 5/3/20 6/7/20 Acton 8/3/20 12'5/20 Southfield Road 11/3/20 16/5 20 Priory 23/3/20 27/5 20 Rothschild Road 29/3 20 27/5/20 Acton Wells 31/3/20 21/5/20 South Acton 31/3/20 11/7/20 Central 12/4/20 26/7/20 East Acton 15/4/20 23/7/20 Roman Catholic 12/5/20 11/6/20 29 1920 The following were the Infants Departments closed, together with the date's:— Southfield Road From March 3rd to April 12th Montessori Class only ,, April 13th „ May 3rd Acton „ March 24th„ April 12th Priory ,, May 3rd „ May 31st Acton Wells ,, May 10th ,, May31st Beaumont Park ,, May 10th „ May 31st East Acton „ May 10th „ May 31st The closure of the schools probably had very little effect upon the course of the epidemic, and certainly none upon the number of cases which occurred in the district. It will be noticed that the closure of all the departments occurred around the Easter and Whitsun vacations. In every instance it was simply an extension ot the ordinary school holidays, and very little dislocation of the school work thereby resulted. The average attendance had fallen so low that it was felt that some advantage accrued from closure. It is probable that the school closure would not have been resorted to if such procedure had been adpoted in the middle of the school term, and especially if that term happened to be the summer one. The following table gives the number of cases reported from each school together with the ages:— All ages 3 4 5 6 7 8 9 10 11 12 13 Acton Infants' 65 2 12 25 23 3 Acton Boys' 13 1 4 3 3 1 1 Acton Wells Infants' 52 2 6 19 19 5 1 Acton Wells Mixed 3 1 2 Beaumont Park Boys' 2 2 Beaumont Park Girls' 4 1 1 2 Beaumont Park Infants' 90 15 52 20 2 1 Central Senior 2 2 Central Junior 4 2 2 Central Infants' 40 2 5 20 10 2 1 East Acton 12 2 6 I 2 1 Priory Road Boys' 2 1 1 Priory Girls' 14 3 5 1 2 3 Priory Infants' 68 4 30 25 9 Rothschild Road Junior 5 3 2 Rothschild Road Infants' 110 14 49 30 15 2 South Acton B6ys' 4 4 South Acton Girls' 4 2 1 I South Acton Infants' 93 1 13 51 20 6 1 1 Southfield Road Infants' 48 2 5 21 14 6 Southfield Road J unior 3 3 Roman Catholic Infants' 7 1 2 3 1 Roman Catholic J unior 2 1 1 Ackmar Road Deaf 1 1 648 12 82 272 167 67 18 11 10 4 3 2 1920 30 No School. Under 1 1 2 3 4 5 6 11 14 Total 14 26 50 43 57 9 1 1 1 202 In 1915 the Local Government Board made an Order, providing under certain conditions for the compulsory notification of Measles and German Measles. Prior to that date a few of the large towns had exercised their powers and placed measles amongst the compulsorily notifiable diseases. Some of these towns had discontinued notification, and in none of them could the results obtained be considered a triumph for notification. Neither did the compulsory notification of cases of measles throughout the country during the four years 1916-1919 produce the results anticipated by its most enthusiastic advocates. In 1919, an Order was made which rescinded the Order of 1915, and from the end of 1919, the compulsory notification of Measles and German Measles was discontinued. The Ministry of Health, though, in its Memorandum, state that no difficulties will be placed in the way of those poLocal Authorities who desire to adopt compulsory notification and who are willing and able to take suitable action with respect to those cases brought to their notice. The lack of notification was always a reasonable excuse for inaction, and the attempt to deal with such an elusive disease may be useful, although the results seemed to prove that the universal notification of measles is not yet justified. Apart from the expense, one of the objections to the continuance of the Order was the fact that notification was seldom complete. A large number of children suffering from measles are not attended by a doctor, and though the parent or guardian is liable to a penalty for non-notification, the duty is seldom performed by any person other than the doctor in attendance Where there was no doctor in attendance, very seldom was the case notified under the Order. The following Table gives the number of children who were attended by a doctor, together with the schools:— 31 1920 School. Attended by a Doctor. Acton Infants' 28 Acton Boys' 4 Acton Weils Infants' 35 Beaumont Park Infants' 42 Beaumont Park Boys' 2 Central Infants' 35 Central Junior 2 Central Senior 1 East Acton 6 Priory Infants' 24 Priory Girls' 3 Priory Boys' 2 Southfield Road Infants' 42 Southfield Road Junior 3 Rothschild Road Infants' 68 South Acton Infants' 49 Roman Catholic Infants' 2 Excluding those schools in which less than 10 cases had occurred, the percentages where a doctor was in attendance were as follows:— School. Attended by a Doctor. Priory Infants' 35 Acton Infants' 41 Beaumont Park Infants' 46 South Acton Infants' 52 Rothschild Road Infants' 61 Acton Wells Infants' 67 Southfield Road Infants' 87 Central Infants' 87 It may be assumed that these figures represent fairly accurately the proportion of children suffering from measles attended by a doctor in the district in which the school is situated. Unfortunately, the percentage of cases where a doctor is not in attendance is highest in the districts where advice is most needed, and least care is paid to the illness. Where care and skill are exercised in the nursing of the patients, measles is seldom a fatal illness. But in spite of some improvement, measles is still regarded by many more as an inconvenience than as a serious illness, and a doctor is not called to see the child. In addition to medical attendance, the provision of adequate nursing is of the first importance in preventing mortality and 1920 32 ablement from measles. It is a truism that the better the conditions the less skilled the nursing need be. Under good sanitary conditions, the services of a sensible mother, under medical advice, are usually sufficient. Where the sanitary conditions are unfavourable, frequently a doctor is not in attendance until complications set in, and the mother does not appreciate the seriousness of the disease if neglected. In many instances the mother is not able to devote sufficient attention to the care of the patient. It was for such cases that the Council intended the services of the nurse appointed in 1919. The services of the nurse were not perpetually required for this purpose, and a joint appointment was made of Health Visitor and School Nurse. In the Annual Report of 1919 it was pointed out that the services of the nurse were not utilised for the purposes intended, and there were various reasons for this lack of appreciation. Neither was the accommodation at the Fever Hospital used to any appreciable extent. The Council has passed a Resolution that cases of measles may be nursed in the Fever Hospital when accommodation is available and when circumstances render it desirable that the patient should be nursed in an institution. Only 3 cases were removed to the hospital. Measles and its complications may be followed by ailments which cause prolonged or permanent disablement, where they do not cause death, and deafness and eye affections are complications which may seriously handicap a child in his educational career. Mr. McLeod Yearsley, in papers entitled "The Causes Leading to Educational Deafness in Children," with special reference to prevention, found that measles was responsible for nearly 12 per cent. of the cases of educational deafness. Conjunctivitis with lachrymation forms a part of the symptoms displayed by measles, which ordinarily subsides with the end of the illness. Persisting eye affections may reduce acuity of vision, or cause partial or even total blindness. Some authorities place measles as the responsible factor in 2 per cent. of the cases of total blindness. In order to ascertain what complications had occurred, all the cases were visited about three months after the end of the epidemic, and the following were the complications disclosed by this inquiry:— Ear discharge 12 Inflammation of the eyelids 11 Deafness 1 Nasal discharge 1 An attempt was made to obtain consent for the treatment of all those suffering from ear or eye disease at the School Clinic. Most of them obtained treatment either from their own doctor, 33 192 0 at a general hospital, or at the School Clinic. An inquiry was made of the condition of these cases at the end of 1920, and the result was as follows:— Cured. Better. No improvement Ear discharge 8 2 2 Inflammation of Eyelids 8 2 1 Deafness — — 1 Nasal Discharge 1 — — Scarlet Fever. There was a considerable increase in the number of notifications of scarlet fever, but no deaths occurred from the disease. The ages and the Ward distribution are given on Table 9. In the autumn a wave of excessive prevalence passed over London and the extra-metropolitan districts, and it seems that a record number of cases were under treatment in the hopsitals of the Metropolitan Asylums Board. We did not experience the same strain upon our accommodation as they did in London, and at no time was the hospital full. The disease was in many respects similar in type to that observed in interepidemic years. Usually when an epidemic occurs the type of the disease is also of a more severe character. But last year the type was a very mild one, and from the experience gained of the patients admitted into the hospital, there is no doubt of the frequent occurrence of mild or abortive cases which escaped diagnosis. In many instances the early symptoms were so evanescent and subsequent desquamation so indistinct that it was almost impossible to say definitely whether the process had taken place or not. Many cases came under my observation where the parents were positive that a rash had not appeared ; at any rate, the rash had not been observed. The following case may be taken as typical. W;B. was seen on December 2nd prior to his return to school as a contact. His twin sister had been removed to hospital on November 23rd. The boy had had a sore throat on or about November 21st, and was also sick at the same time. He was seen by a doctor, and the parents were positive that there had been no rash. On December 3rd his tongue had the appearance of the tongue of Scarlet Fever patients in the second week—slightly red with the papillae showing—the submaxillary glands were enlarged, and the orifice of the nose was inflamed and slightly excoriated. Personally I have no doubt that he had a mild attack of scarlet fever, though the subsequent peeling was very indistinct. 1920 34 It is generally conceded that these mild cases constitute a greater danger from the public health point of view than the severer and more pronounced forms, for they are more likely to escape detection and hence are mainly instrumental in keeping alive an outbreak. It is too frequently assumed that in every instance someone is to blame for the failure to recognise the mild cases. Even if it be granted that the virus of the disease, whatever it may be, is certainly present in the blood, and that this presence is always manifested by a characteristic rash, it is certain that the rash is frequently present for a very short period. I have examined many patients almost immediately on their admission to the hospital, and there has been no sign of a rash at the time of my examination. The other symptoms of scarlet fever are present, and I have subsequently seen the doctor in attendance, who informed me that there was a typical rash when he examined the case a few hours previously. In some of the milder cases, I can easily believe that the rash has made its appearance and disappearance within less than 24 hours. Possibly a larger percentage of these mild cases are detected in Acton than in some other districts, as a careful examination is made of each contact before he resumes school attendance. When a case of scarlet fever occurs, all the other children of school age in the house are examined at the end of the quarantine period, before they resume attendance at school. If the contact gives a history of sore throat since the occurrence of scarlet fever in the house, or exhibits any suspicious symptoms, he is excluded from school and kept under observation. It is unfortunate that we have as yet no definite means of determining where the infection of scarlet fever resides, how long it persists, and in what circumstances it can live apart from the human body. There are good clinical grounds for believing that the throat is the primary site of infection, and hence it is reasonable to suppose that all exudate from that part of the body, whether discharged through the mouth, nose, or by way of the eustachian tube from a running ear, is virulent and capable of conveying the disease to a susceptible-person. It is also probable that the occurrence of "return" cases is dependent upon some abnormal condition of the mucous membrane of the upper respiratory passages. The condition of the skin is not now regarded as an important index of the infection or non-infection of the patient. If we regard the rash as evidence of blood infection, and that the skin is performing its function as an excretory organ in common with the kidneys, there is nothing inherently absurd in the 35 1920 position that the desquamated skin is, or can be, infectious. As a matter of experience the period of six to eight weeks which elapses before desquamation is complete usually covers the time in which most of the complications of scarlet fever occur, and it is also well beyond the average time taken to clear the throat of diphthiritic infection. Unfortunately, though, the period of infection cannot be said to coincide with the period of desquamation. Probably the most infectious period is in the earl stage of the disease before desquamation has commenced; frequently the patient can, without risk, be discharged as free from infection, although he has not finished peeling on the soles of his feet and palms of his hands. More unfortunate still is the fact that in a small percentage of cases the infection persists long after desquamation has finished, and these are the ones which give rise to "return cases." The controversy concerning" return cases "which took place some years ago did much good in focussing attention on some of the conditions which were likely to give rise to "return cases." It is now known that patients suffering from enlarged tonsils and adenoids are likely to give rise to "return cases," and removal of the tonsils and adenoids are attempted before the patients are discharged from hospital, or at any rate before the resumption of school attendance. A sore in or around the orifice of the nose is another condition in which the affection is likely to persist, and as much attention is paid to this condition as was formerly paid to a discharge from the ears. Sometimes a post-nasal catarrh, or an ulceration of the nose or a discharging ear starts after the patient has been discharged from the hospital, and these are the patients which usually give rise to "return cases." Occasionally a "return case" occurs, and no abnormal condition whatsoever exists in the supposed infecting case. Whether these cases are dependent upon the persistence of the infection in the patient discharged from isolation cannot be ascertained until the germ of scarlet fever has been isolated. At present we reckon every case that occurs within two months of the discharge of a patient from hospital as a " return case," and last year we had 9 " return cases." Encephalitis Lethargica. There were two cases of Encephalitis Lethargica notified, and in one instance the patient died and the other patient recovered. In one of the cases the circumstances were peculiar, as it was the second case that occurred in the same house. Probably there was no connection between the first and the second case. The first case in the house occurred in May, 1919, and the patient died of the disease. Generally, the degree of infectivity from person to person is of a low order, and cases of the disease usually appear to be isolated or sporadic. Multiple cases of the disease 1920 36 in the same household, as well as multiple cases in institutions, have been observed in this country and elsewhere. It may also be noted as interesting that although the street in which these two cases in 1919 and 1920 occurred is a small one, a fatal case occurred in the same street in 1918. Cerebro-Spinal Meningitis. Two cases of cerebro-spinal meningitis were notified, and both were fatal. In one case, though, on the death certificate it was stated that the death was due to tubercular meningitis. Ophthalmia Neonatorium. Fifteen cases of ophthalmia neonatorium were notified. In every instance the recovery was complete and no loss of sight resulted. In four of the cases an unqualified midwife was present at the birth. Diphtheria. There is a great increase in the incidence of diphtheria, both in the number of cases and in the number of deaths. 141 cases were notified and 18 deaths occurred, compared with 54 notifications and 2 deaths in 1919. The Ward distribution of the disease is given on Table 9 but of more importance is the School distribution. The influence of school attendance upon the incidence of diphtheria has given rise to many discussions, and the subject is still a debatable one. The subject has too many ramifications for discussion in this Report, but the spread in schools is probably intimately connected with the carrier and undetected case. It was only in Southfield Road Infants' Department that systematical swabbing of the throat was undertaken, and a part of the Department was closed on two occasions in the Autumn. The following Table gives a list of the cases which occurred amongst children attending the elementary schools in the district:— School. Infants. Boys. Girls. Junior Mixed Junior Boys. Acton — 1 — — —— Acton Wells 8 — 1 — — Beaumont Park 5 — — — — Central 2 3 1 — — Priory 2 3 2 — 1 Rothschild Road 1 2 3 — — Southfield Road 15 1 3 8 — South Acton 5 1 8 — 1 37 1920 The earliest school to be affected was Acton Wells Infants'. Sporadic cases occurred in this Department throughout the early part of the year, and continued to September, but at no time did the disease assume serious proportions. One case each was notified in the four months May, June, August, and September, but no cases occurred in July and October. It was in the Autumn that the outbreak assumed serious proportions; the outbreak was characterised by the severity of the type of the disease. Most districts in London and the extrametropolitan area, suffered in a similar manner. From enquiries made, the disease in neighbouring areas was very similar in type to that which occurred in this district. The increase in the number of cases was not much greater than the usual autumnal rise might have led us to expect. In the first week after the re-opening of the schools after the summer holidays, 3 cases were reported amongst the children attending the Infants' Department of the Beaumont Park Schools, but the outbreak subsided here suddenly, and only one case was notified in September and one in October. It is possible, and even probable, that the 3 cases were infected in school. The school re-opened on Tuesday, and the initial symptoms appeared on Friday or Saturday. There was no history of a previous illness in the families of the children affected. On August 30th, one case was reported amongst the children attending the Infants' Department of the Southfield Road Schools, but nearly a month elapsed before further cases occurred. The following Table shows the Number of cases notified each week:— Week ending September 25th 2 Week ending October 2nd 2 Week ending October 9th 2 Week ending October 16th 4 Week ending October 23rd 2 Week ending October 30th 2 As the Council is aware, all the home contacts attending school are bacteriologically examined before they resume school attendance. Of the 30 contacts examined in October, 9 were found to have the germs of diphtheria in their throats. In none of these children clinical symptoms of diphtheria had appeared. These children were diphtheria carriers, and their treatment is always a source of interest and anxiety. 1920 38 The risk of these carriers varies enormously, and it is impossible to decide clinically or bacteriologieally what danger is attached to them. Even injections into guinea-pigs does not seem to clear up all the difficulties. The natural answer to the question of what constitutes a dangerous carrier is, that a person harbouring virulent bacilli, as tested by a guinea-pig inoculation is a dangerous carrier. But even here we are on uncertain ground, for it is an acknowledged fact that the virulence of the organism may wax and wane, and in time it may become non-virulent. It is also possible that a strain found non-virulent may later assume virulent characters. Again, it appears possible for even a strain virulent to the guinea-pig to have a very low virulence towards human beings. The procedure adopted here has been to exclude from school those contacts in which the Klebs Loeffler Bacillus is found in the throat. The children found harbouring the Klebs Loeffler Bacillus in the school belong usually to two categories. In one category are the children where a positive swab is obtained, but no clinical symptoms have appeared; usually, though, a history of slight sore throat is given when children are found to be harbouring the diphtheria bacillus and attending school. In the Southfield Infants' Department 11 swabs were taken of children attending school who had suffered recently from a sore throat, and 3 of these were found to be cases of diphtheria. In view of these circumstances it was deemed advisable to swab all the children in certain classes. In the first instance 13 swabs were taken and 3 were positive. This particular class was closed for a fortnight; when it was re-opened the whole class was again examined. Altogether 76 swabs were taken, and 13 were positive. On enquiry it was elicited that most of these children had suffered from a slight sore throat, so that these children really came under the category of missed or mild cases, and not carrier cases. But the same difficulty confronts us in the treatment of these cases. The parents do not welcome the suggestion that these children should be isolated in the fever hospital, and it is certain that sufficient precautions are not taken to isolate them at home. Some of the cases are undoubtedly virulent. One instance may be given. A child was found in school harbouring the germs of diphtheria. A history of slight sore throat was obtainable, but the parents did not believe that the child had suffered from diphtheria. He was allowed to sleep with an elder brother. In about a week's time this brother was notified as suffering from diphtheria, and he exhibited undoubted clinical symptoms of the disease. Shortly after, a smaller child, too young to attend school, 39 1920 was notified, and unfortunately, in the case of the latter, the disease proved fatal. It would probably be less risky to isolate the cases in the fever hospital if permission were obtained. Infantile Mortality. One hundred deaths occurred in children under 1 year of age. This number corresponds to an Infantile Mortality of 64 per 1,000 births. The Infantile Mortality in the whole of England and Wales was 80 per 1,000 births; in London 75, and in the 96 Great Towns it was 85 per 1,000 births. The deaths were distributed as follows:— North-East Ward 18 North-West Ward 19 South-East Ward 24 South-West Ward 34 It has been previously explained that it is not possible, under present conditions, to give the Ward distribution of the registered births, but based upon the distribution of the births notified and registered, but not notified during the year, the Infantile Mortality in each Ward was:— North-East Ward 46 North-West Ward 85 South-East Ward 74 South-WestWard 58 Twelve illegitimate children died under the age of 12 months. This corresponds to an Infantile Mortality of 307 per 1,000 births. Ante-Natal Clinic. During the year the Ante-Natal Clinic was removed from the Acton Hospital to the School Clinic premises. The Clinic was held on 24 occasions, and 75 expectant mothers attended. Three cases were admitted to the Acton Hos pital, and the operation of Caesarean section, was performed on each. The Council has continued its agreement with the Acton Hosptial for the provision of beds for the complicated cases of pregnancy. The terms of the agreement were varied, and up to Mav 1st. 1921, the following are the terms of the agreement with the Acton Hospital:— 40 1920 £ s. d. Caesarean Section Cases 26 5 0 Doctors' Fees 6 6 0 Total £32 11 0 £ s. d. Major operation cases 17 17 0 Doctors' Fees 6 6 0 Total £24 3 0 £ s. d. Minor operation cases 12 12 0 Doctors' Fees 3 3 0 Total £15 15 0 149 expectant mothers were visited by the Health Visitors. Post-Natal Work. On Table 14 will be found a record of the attendances made by the Health Visitors at the Child Welfare Centres, held at the Priory Schools and the Palmerston Road Mission. It will be seen that over 10,000 attendances by children were made at these Centres during the year. In addition to these, 1,135 births were visited in their homes by the Health Visitors. In many instances separate visits were paid to the homes where births occurred. Milk and Children's Order, 1919. It may be adviseable to review the powers under which the Council distributes milk free, and under cost price. Section 1 of the Maternity and Child Welfare Act, 1918, enacts that any local authority within the meaning of the Notification of Births Act, may make such arrangements as may be sanctioned by the Local Government Board for attending to the health of expectant mothers and nursing mothers, and children who have not attained the age of 5 years, and are not being educated in schools provided by the Local Education Authority. Two Orders were made in 1919, both dated December 22nd. One was made by the Ministry of Food and the other by the Ministry of Health. Both had for their object the supply of milk to 41 1920 pectant mothers. nursing mothers, and for children under 5 years of age. Under the Milk (Mothers and Children) Order, 1919, made by the Ministry of Food, it was enacted, amongst others, that until further notice the following conditions shall be observed:— Where, by reason of the retail price of milk in any area it appears to the Local Authority necessary or desirable that milk should be supplied free or at less than cost price, the Local Authority may, in cases in which a person authorised by them in that behalf certifies that such provision of milk is necessary, supply milk to expectant and nursing, mothers and children under 5 years of age, free or at less than cost price in accordance with the following subclause:— The quantity of milk to be supplied shall not exceed the amounts specified in the following scale:— For children under 18 months—pints daily. For children between 18 months and 5 years—1 pint daily. For nursing and expectant mothers—The quantity prescribed by the person certifying. A Local Authority may combine with another Local Authority or with any Food Control Committee in the exercise of the powers hereby given to the Local Authority, or may, with the approval of the Ministry of Health, delegate all or any of such powers to the Committee. Under the Order made by the Ministry of Health the powers contained in the preceding Order were conferred upon the Local Authority, and upon such officers as the Local Authority might designate or appoint. A circular of the Ministry of Health accompanied these Orders, and the circular strongly urged that adequate steps should be taken by means of handbills or otherwise, to bring to the notice of all expectant and nursing mothers who are likely to be unable to provide sufficient milk for themselves and their children, the facilities provided by the Local Authority and by other agencies in the district for obtaining a proper supply of milk. The Health Visitors, the Doctors and Midwives practising in the district were also asked to report any person who, in their opinion required an additional supply of milk. The Ministry stated that it hoped Local Authorities would take all possible steps to secure that expectant and nursing mothers and young children in the district should not suffer from a shortage 42 1920 of milk, owing to inability to obtain a sufficient supply at the price which they could afford to pay. The procedure adopted by the Health Committee in this district was on the whole a fair and considerate one. A scale of wages was adopted by the Council in 1918 and 1919. In 1918 the following scale was adopted:— Under 30s. A pint a day free (1 packet). Under 35s. Over 3 in family, a pint a day free. Under 35s. Under 3 in family a pint a day for 1d. 35s. to 40s. Over 3 in family, a pint a day for 2d. 35s. to 40s. Under 3 in family, a pint a day for 3d. 40s. to 45s. Over 3 in family, a pint a day for 4d. The matter was reconsidered by the Maternity and Child WelfareCommittee in 1919, and the rates of charges were amended as follows:— Where the weekly earning power of the family is:— Under 35s. A pint a day or its equivalent in dried milk free. Under 40s. Over 3 in family, a pint a day or its equivalent in dried milk free. Under 40s. Under 3 in family, a pint a day or its equivalent in dried milk for 1d. 40s. to 45s. Over 3 in family, a pint a day or its equivalent in dried milk for 2d. 40s. to 45s. Under 3 in family, a pint a day or its equivalent in dried milk for 3d. 45s. to 50s. Over 3 in family, a pint a day or its equivalent in dried milk for 4d. Exceptional cases to be dealt with as they arise. The income scale was again considered at the April meeting in 1920, but no change was made in the scale. The inquiry is made in the first instance by the Health Visitors and the inquiry form includes the names and ages of all the members of the family, the total income and the outgoings, such as rent, etc. Towards the end of the year the numbers increased to such an extent it was felt that it was impossible to keep the information up to date with the present staff. The matter was brought before the Health Committee, and the Chairman was instrumental in obtaining the voluntary services of Mrs. Knight to revise the information as to the conditions, etc., which obtained in the familyevery week. Mrs. Knight attends at the office on Thursday and Friday afternoons, and the father or mother has to attend every week 43 to vouch for the accuracy of the information which the Health Visitors had obtained. Any alterations in the conditions was noted, so that practically every case was reviewed weekly. In addition, a Sub-Committee was appointed to deal with exceptional cases, and this Committee met as often as the number of applications rendered their meeting desirable. In spite of these precautions, it was not, of course, possible to prevent all abuses, but in time these attempts were detected. For instance, a child would be sent up to the office on Thursday or Friday instead of a more responsible person. When the child was asked why some more responsible person had not been sent up to sign for the milk, the answer given was unsatisfactory; the milk was given oh that occasion, but the child was told that either the mother or the father would have to come the following week. Probably no one would come on the following week, and upon enquiries being made, it was found that father had again started work. From enquiries which I have made, the care which we exercise here was not observed in many other districts, and it is not surprising that by an Order dated the 14th March, 1921, the Ministry of Health, in conjunction with the Ministry of Food, have rescinded their Orders of 1919. The circular accompanying the rescission Order explains that this step has been rendered necessary by the lavish way in which many Local Authorities have incurred expenditure far greatly exceeding what is either necessary or desirable for the purpose in view. It will be seen from the following summary of the circular that in the past, in this distrct, we have kept very closely to the conditions which the Ministry now insists. The following are the conditions:— 1.—Milk may be supplied at less than cost price in necessitous cases only to :— (а) Nursing mothers. (b) Expectant mothers in the last 3 months of nancy. (c) Children up to 3 years of age, and exceptionally to children 1,3, and 5 years of age. 2.—The quantity must not exceed one pint per day per person. Exceptionally, 1½ pints per day may be supplied to infants between 3 and 18 months. 44 3.—Milk should be given only where the Medical Officer of Health, or in certain cases the Medical Officer of a Centre, is satisfied that a supply is essential. Where more than one pint is supplied, or where children between 3 and 5 years are supplied, a special medical certificate should be required. 4.—Milk should be given to nursing mothers only where they are actually suckling their children. 5.—A special Committee should be appointed to lay down a definite procedure for dealing with applications for milk, and to review all authorisations for supply. Each application should be considered by a small Sub-Committee. 6.—A scale of income should be adopted suitable to the circumstances of the locality. 7.—Every application for milk should be made on a printed form, which should show clearly the income of the family from all sources, and which should be signed as correct where practicable by both parents. 8.—Reasonable steps must be taken by the Local Authorities to satisfy themselves that the particulars of income given by applicants are correct. The following table will show the average number of women •each week who made application for free or cheap milk, together with the average number of packets distributed. Month. Average No. of Women. Average No. of Packets Free. Aver age No.of Packets at 1s. Average No.of Packets at 6d. January 115 106 4 7 February 130 124 4 9 March 132 122 8 10 April 122 114 8 8 May 120 * 109 10 9 June 160 119 12 12 July 106 123 9 9 August 134 125 11 10 September 144 134 12 12 October 145 133 14 12 November 161 150 13 16 December 190 185 11 17 The total cost of the milk distributed free and under cost price was £975 for the year ending March 31st, 1921. 45 Day Nursery. The Day Nursery in Bollo Bridge Road was taken over by the Council in 1919, and the ladies on the Maternity and Child Welfare Committee were constituted into a House Committee. The Nursery opened during the year on 215 days, and the average attendance was about 29. The majority of the children attend regularly. One child made 215 attendances, and several others attended on over 200 occasions. During the year, from 23 houses, there were two children from each house, and in one instance three children were attending from the same house. The average cost per child per day varies, according to the number of attendances. For instance, last year it varied from 2s. 3½d. in the month of February to 7s. 7d. in August; but during most of August the Nursery was closed, and only 136 attendances were made during the month. The highest number of attendances were made in the month of October, with 627 attendances. Your obedient servant, D. J. THOMAS. 46 TABLE 1. BIRTH-RATE, DEATH-RATE AND ANALYSIS OP MORTALITY DURING THE YEAR 1920. (Provisional Figures. Provisional populations estimated to the middle of 1920 have been used for the purposes of this Table. The mortality rates refer to the whole population as regards England and Wales, but only to civilians as regards London and the groups of towns). (Birthrate per 1,000 Total Population). Annual Death-rate per 1,000 population. Rate per 1,000 Births Percentage of Total Deaths. All Causes. Enteric Fever. Small-pox. Measles. Scarlet Fever. Whooping cough. Diphtheria. Influenza. Violence. Diarrhoea and Enteritis (under 2 years) Total Deaths under 1 year. Deaths in Public Institutions. Certified Causes of Death. Inquest Cases. Uncertified causes of Death. England and Wales 25.4 12.4 0.01 0.00 0.19 0.04 0.11 0.15 0.28 0.48 8.3 80 24.3 92.2 6.6 1.2 96 Great Towns, including London (Census Populations exceeding 50,000) 26.2 12.5 0.01 0.00 0.22 0 04 0.14 0.16 0.31 0.43 10.4 85 31.3 92.2 7.1 0.7 148 Smaller Towns (Census Populations 20,000—50,000) 24.9 11.3 0.02 0.00 0.19 0.03 0.10 0.14 0.27 0.38 7.8 80 16.5 93.2 5.3 1.5 London 26.5 12.4 0.01 0.00 0.22 0.05 0.17 0.22 0.30 0.47 9.5 75 46.8 91.2 8.6 0.2 Acton 23.7 10.4 0.00 0.00 0.14 0.00 0.11 0.28 0.11 0.18 9.7 65 32.0 99.8 5.4 0.15 47 TABLE 2. VITAL STATISTICS FOR WHOLE DISTRICT DURING 1920 AND PREVIOUS YEARS. Year Population estimated to Middle of each Year. Births. Total Deaths Registered in the District. Transferable Deaths. Nett Deaths belonging to the District. Under 1 year of Age. At all Ages. Uncorrected Number. Nett Number. Rate. of Non-Residents Registered in the District. of Residents Registered outside District. Number. Rate per 1,000 Births. Number. Rate per 1000 Inhabitants. Number. Rate. 1915 62,000 for B'th rate. 1390 1414 22.8 587 9.6 11 204 148 140 780 13.3 58,238 for D'th rate. 1916 63,010 for B'th rate. 1288 1324 21.0 504 8.7 21 204 102 77 687 11.8 57,913 for D'th rate. 1917 65,219 fo B'th rate. 936 972 14.9 480 8.2 18 225 94 96 687 11.7 58,507 for D'th rate. 1918 66,000 for B'th rate. 923 954 14.5 611 10.3 16 277 76 78 872 14.7 59,000 for D'th rate. 1919 64,306 for B'th rate. 950 1096 17.1 436 7. 12 222 72 65 646 10.4 61,732 for D'th rate. 1920 64,192 1442 1541 24 560 8.7 16 217 100 64 671 10.4 48 TABLE 3. BIRTHS NOTIFIED DURING 1920. Total—1,356 Males—684. Females—672. WARDS. North-East North-West South-East South-West Total. 334 198 280 544 1,356 Still Births—35. WARDS. North-East North-West South-East South-West Total 9 8 6 12 35 Births Registered but not notified— Total 112. Males—55 Females—57. WARDS. North-East North-West South-East South-West Total. 45 16 39 12 112 Outside—58. Illegitimate—10. Still Births—1. Notifications were received from— Doctors 725 Nurses 29 Midwives 588 Parents 49 Number of Births visited 1,135 Number of visits paid to houses of Infants 4,625 TABLE 4. REGISTERED BIRTHS. Total number Registered belonging to the District, according to the Registrar-General's return :— Total Registered. Males Females 792 749 Legitimate 758 723 Illegitimate 34 26 Registered within District. Males Females Illegitimate 740 702 35 49 TABLE 5. CAUSES OF, AND AGES AT DEATH DURING YEAR 1920. Causes of Death. Ages at Death, 1920 Public Institutions in District Resident and NonResident All Ages. Under 1 year 1 and under 2 2 and under 5 5 and under 15 15 and under 25 25 and under 45 45 and under 65 65 and upwards Measles 9 1 1 4 3 ... ... ... ... ... Whooping Cough 7 7 ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... Diphtheria 18 ... ... 6 12 ... ... ... ... 18 Enteric Fever ... ... ... ... ... ... ... ... ... ... Influenza 7 ... ... 1 1 1 2 2 ... ... Phthisis (Pulmonary Tuberculosis) 61 ... ... ... 1 14 24 20 2 ... Tuberculosis Meningitis 8 ... 3 1 2 1 ... ... ... ... Other Tuberculous Diseases 8 ... ... ... 3 1 3 1 ... ... Cancer (Malignant Disease) 57 ... ... ... ... ... 4 30 23 2 Rheumatic Fever 2 ... ... ... ... 1 1 ... ... ... Meningitis 3 ... ... ... ... ... ... 1 ... ... Organic Heart Disease 71 ... ... ... ... 3 16 21 30 2 Bronchitis 60 10 2 l ... ... 3 11 33 ... Pneumonia (all forms) 52 12 4 3 ... 2 10 10 11 1 Other Respiratory Diseases 9 ... ... ... 2 2 1 4 ... ... Diarrhoea and Enteritis 15 15 ... ... ... ... ... ... ... Appendicitis and Typhlitis 4 ... ... ... 2 1 ... 1 ... 1 Cirrhosis of Liver 1 ... ... ... ... ... ... 1 ... ... Nephritis and Bright's Disease 13 ... ... ... ... 1 1 7 4 ... Syphilis 4 4 ... ... ... ... ... ... ... ... Puerperal Fever 4 ... ... ... ... ... 4 ... ... ... Other Aiccdents and Diseases of Pregnancy and and Parturition 5 ... ... ... ... 2 3 ... ... ... Congenital Debility and Malformation, including Premature Birth 38 38 ... ... ... ... ... ... ... ... Violent Deaths (excluding Suicide) 12 1 1 2 ... ... ... 1 6 5 Suicide 4 ... ... ... ... 1 1 2 ... Other Defined Diseases 199 10 ... 2 6 3 20 40 118 4 Totals 671 100 11 21 34 33 93 152 227 33 50 TABLE 6. TOTAL DEATHS—WARD DISTRIBUTION. 1920. Causes of Death. North East. North West. South East. South West. Total. Measles 2 ... 3 4 9 Whooping Cough 1 1 3 2 7 Diphtheria 6 ... 4 8 18 Influenza 1 4 1 1 7 Phthisis (Pulmonary Tuberculosis) 13 8 20 20 61 Tuberculous Meningitis 2 ... 4 2 8 Other Tuberculous Diseases ... 3 1 4 8 Cancer (Malignant Disease) 22 13 12 10 57 Rheumatic Fever ... ... 1 1 2 Meningitis 2 ... ... 1 3 Organic Heart Disease 28 16 13 14 71 Bronchitis 18 6 9 27 60 Pneumonia (All forms) 10 9 14 19 52 Other Respiratory Diseases 2 ... 3 4 9 Diarrhoea and Enteritis 1 4 5 5 15 Appendicitis and Typhlitis 1 ... 2 1 4 Cirrhosis of Liver ... ... ... 1 1 Nephritis and Bright's Disease 4 1 4 4 13 Syphilis 2 1 ... 1 4 Puerperal Fever ... 1 ... 3 4 Other Accidents and Diseases of Pregnancy and Parturition ... ... 2 3 5 Congenital Debility and Malformation, including Premature Birth 8 6 8 16 38 Violent Diseases (excluding Suicide) 4 2 4 2 12 Suicide 2 1 1 ... 4 Other Defined Diseases 56 57 36 50 199 Totals 185 133 150 203 671 51 TABLE 7. INFANTILE MORTALITY DURING THE YEAR 1920. Deaths from stated causes in Weeks and Months under one year of age. Causes or Death. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Tota1 under 4 weeks. 1-3 months 3-6 months 6-9 months 9-12 months Total d'ths under 1 yr. Measles ... ... ... ... ... ... ... ... 1 1 Whooping Cough ... ... ... ... ... ... 1 1 5 7 Meningitis (not Tuberculosis) ... ... ... ... ... 1 ... ... 1 2 Convulsions 2 ... ... ... 2 1 1 ... ... 4 Bronchitis ... 1 1 2 4 2 4 ... ... 10 Pneumonia (all forms) ... 2 ... 1 3 4 2 1 2 12 Diarrhoea and Enteritis ... 3 ... 1 4 4 3 2 2 15 Congenital Syphilis ... ... ... ... ... 1 1 2 ... 4 Injury at Birth 2 ... ... ... 2 ... ... ... ... 2 Congenital Malformation 2 1 1 ... 4 1 1 ... ... 6 Premature Birth 15 1 2 1 19 3 ... ... ... 22 Atrophy, Debility and Marasmus 1 4 ... ... 5 ... 1 1 1 8 Other causes ... ... 1 ... 1 1 4 ... 1 7 Totals 22 12 5 5 44 18 18 7 13 100 TABLE 8. INFANTILE MORTALITY—WARD DISTRIBUTION, 1920. Causes of Death. North East North West South East South West Total. Measles ... ... 1 ... 1 Whooping Cough 1 1 3 2 7 Meningitis (not Tuberculosis) 1 ... 1 ... 2 Convulsions ... 1 1 2 4 Bronchitis 2 2 ... 6 10 Pneumonia (All Forms) 2 l 5 4 12 Diarrhoea and Enteritis 1 4 5 5 15 Congenital Syphilis 1 3 ... ... 4 Injury at Birth 1 ... 1 ... 2 Congenital Malformation 1 ... 2 3 6 Premature Birth 4 6 4 8 22 Atrophy, Debility and Marasmus 2 ... ... 6 8 Other Causes 2 1 1 3 7 Totals 18 19 24 39 100 52 TABLE 9. CASES OF INFECTIOUS DISEASES NOTIFIED DURING THE YEAR 1920. Cases notified in whole District. At ages—Years. Total cases notified in each Ward. At All Ages Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 65 and upwards North East North West South East South West Scarlet Fever 176 2 36 114 15 9 ... ... 56 32 45 43 Diphtheria 141 2 29 87 10 12 1 ... 41 16 39 45 Pneumonia 20 1 2 1 6 5 4 1 5 2 3 10 Puerperal Fever 4 ... ... ... 1 3 ... ... 1 ... 1 2 Cerebro Spinal Meningitis 2 ... 2 ... ... ... ... ... 1 ... ... 1 Encephalitis Lethargica 2 ... ... ... 1 ... ... 1 ... 1 ... 1 Dysentery 1 ... ... ... 1 ... ... ... ... 1 ... ... Ophthalmia Neonatorum 15 15 ... ... ... ... ... ... ... ... 3 12 Erysipelas 17 ... 1 3 3 7 3 ... 6 1 3 7 Tuberculosis (Pulmonary) 103 ... 1 3 41 35 20 3 22 22 29 30 Tuberculosis (other Forms) 15 ... 2 8 3 2 ... ... 2 2 5 6 Malaria 4 ... ... ... ... 4 ... ... 1 ... 3 ... Totals 500 20 73 216 81 77 28 5 135 77 131 157 53 TABLE 10. CASES OF NOTIFIABLE DISEASES REMOVED TO HOSPITAL DURING 1920. North East North West South East South West Total Scarlet Fever 43 21 38 37 139 Diphtheria 31 14 32 35 112 Pneumonia ... 2 5 7 Puerperal Fever ... ... 2 1 3 Cerebro Spinal Meningitis 1 ... ... 1 2 Ophthalmia Neonatorum ... ... 1 1 2 Erysipelas 1 ... ... ... 1 Tuberculosis (Pulmonary) 17 14 18 26 75 Tuberculosis (other forns) 2 3 5 10 93 51 96 111 351 TABLE 11. OUTSIDE DEATHS AND PLACES OF OCCURRENCE. Isleworth Infirmary 90 Middlesex County Council Tuberculosis Hospital 13 Springfield Mental Hospital 12 West London Hospital 12 Middlesex Hospital 5 Queen Charlotte's Hospital 4 University College Hospital 4 St. Bartholomew's Hospital 4 Mothers' Hospital, Clapton 3 Clare Hall Sanatorium 3 Other Hospitals 40 Nursing Homes 6 Places other than Hospitals, Public Institutions or Nursing Homes 21 217 TABLE 12. INQUESTS. Held in the District 32 Causes of Death. Run over by a Lorry 2 Fatty Heart 11 Run over by a Train 2 Valvular disease of Heart 2 Suicide 2 Enlarged Thyrus Gland 2 Burns 2 Broncho-penumonia 1 Accidental drowning 1 Bronchitis 1 Fall from a ladder 1 Pleurisy 1 Injury at Birth 2 Intestinal obstruction 1 Accidental Fall 1 Deaths outside the District 12 Fracture of Thigh 2 Meningitis 2 Suicide 2 Cerebral Haemorrhage 1 Found drowned 1 Fatty Heart 1 Knocked down by taxi-cab 1 Broncho-pneumonia 1 Fall from an Aeroplane 1 54 TABLE 13. NOTIFICATIONS OF TUBERCULOSIS. Pulmonary 103 Other forms of Tuberculosis 15 The Notifications were from the following :— Infirmaries 22 Private Doctors 40 Sanatoria 44 Hospitals 42 Military Authorities 6 Other Institutions 3 Insured Cases 63 Non-Insured 55 Insured. Non- Insured. Sanatoria 31 12 Hospital 14 13 Infirmary 6 10 Applying for Sanatorium — — Discharged from Sanatorium 7 — Nursed at Home 4 20 Removed from District — — Removed to County Asylum 1 — Occupations Prior to Illness. Males. Females. Discharged Soldier 29 Housewife 16 Labourer 8 Clerk 7 Clerk 4 Laundress 3 Schoolboy 5 Domestic Servant 6 Painter 2 Schoolgirl 5 Engineer 2 Draper's Assistant 1 Railwayman 1 Dressmaker 1 Works Manager 1 School Mistress 1 Errand Boy 1 Electrical Works 1 Taxi Driver 1 Paper Works 1 Baker 1 Osram Lamp Works 1 Discharged Sailor 1 Faishion Artist 1 Stage Hand 1 Not any 5 Newsboy 1 Coal Porter 1 Hairdresser 1 Slaughterman 1 Ebonite Worker 1 Chemist's Assistant 1 Not any 6 TABLE 14. Priory Schools. Palmerslon Mission Health Visitors' Attendances 100 100 Number of Children who attended 585 576 Number of Attendances by Children 4529 4476 Children under 1 year of age 305 337 Children over 1 year of age 280 239 55 Ages of Children who commenced attendance in 1920 :— Priory Schools. Palmerston Mission Under 3 months 187 201 Between 3 and 6 months 72 32 „ 6 and 9 months 18 17 „ 9 and 12 months 28 21 „ 1 and 2 years 16 42 „ 2 and 3 years 14 22 „ 3 and 4 years 23 13 „ 4 and 5 years 22 6 Of the above children— 7 had attended for the first time in 1915 42 „ „ „ 1916 70 „ „ „ 1917 112 „ „ „ 1918 271 „ „ „ 1919 659 „ „ „ 1920 ANTE-NATAL CLINIC. Number of Times the Clinic was held 24 Number of expectant mothers who attended 75 Number of attendances made by expectant mothers 147 Number of cases admitted to Acton Hospital 3 Ante-Natal Visits. Number of Mothers visited 149 Number of Visits paid to Mothers 363 TABLE 15. ISOLATION HOSPITAL. Remaining in Hospital, January 1st, 1920 50 Remaining in Hospital, January 1st, 1921 38 Admitted during Year — Residents. Non- Residents Total. Scarlet Fever 139 72 211 Diphtheria 112 55 197 Measles 3 — 3 254 157 411 Deaths. Diphtheria 19 TABLE 16. DEATHS FROM MEASLES. Acton Lane 2 Church Path 1 Osborne Road 1 Southfield Road 1 Beaconsfield Road 1 Saville Road 1 Valetta Road 1 Eastfields Road 1 '-"I".... j-'.