C.I AC 439 (1) ACTON Middlesex ACT 26 Borough of Acton ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1923. "Acton Borough Post" Borough of Acton ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1923. 4 Census.—The Registrar General has issued two Reports on the 1921 Census which are of great interest to this district. For the first time certain details have been recorded of Acton. The population of the district increased from 57,497 in 1911 to 61,299 in 1921—28,317 males and 32,982 females. For the County of Middlesex the rate of increase was 11.2 per cent. in the intercensal period 1911-21; in Acton,, the rate was 6.6 per cent. The rate of increase varied from 2.7 per cent. in Wood Green to 126.1 per cent. in Kingsbury. The increase in the whole county was 126,537, but there was an excess of 124,038 in the number of births, so that the gain by migration was only 2,499. In Acton the increase was 3,802, but there was an excess of 6,361 in the number of Births over Deaths, so that there was a loss of 2,559 by migration. The following table gives the population, increase, and gain or loss by migration in the districts in Middlesex with a population over 50,000. CENSUS 1921. Population. Increase Amount. Excess of Gain or loss. Per Births over (—) by Cent. Deaths. Migration. Acton 61,299 3,802 6.6 6,361 —2,599 Ealing 67,755 6,533 10.7 4,772 1,761 Edmonton 66,807 2,010 3.1 9,133 —7,123 Enfield 60,738 4,400 7.8 6,384 —1,984 Hendon 56,013 17,207 44.3 5,567 11,640 Hornsey 87,659 3,067 3.6 4,854 —1,787 Tottenham 146,711 9,293 6.8 17,926 —8,633 Willesden 165,674 11,460 7.4 19,087 —7,627 Sex Ratio.—In the whole county the ratio of females to 1,000 males increased from 1,144 in 1911 to 1,166 in 1921. In Acton, the ratio of females has slightlv decreased. In 1901 there were 1216 females to 1,000 males: in 1911 the ratio was 1,166 to 1,000 and in 1921, 1,164 to 1,000. In the districts with population of over 50,000 inhabitants, the following ratios obtained in 1921. Acton 1,165 Ealing 1,344 Edmonton 1,064 Enfield 1,102 Hendon 1,216 Hornsey 1,319 Tottenham 1,109 Willesden 1,158 Wood Green 1,162 5 As a general rule the ratio of females to males is higher in those districts where the percentage of females who are not occupied in any extra, domestic work is also high. The only exception is Edmonton. But Edmonton is also exceptional in another respect as far as sex distribution is concerned. In all other districts the preponderance of male births is reflected in the figures for ages below four years of age. The heavier death-rate amongst males, however, results in equalising the sexes by about the tenth year, after which the females become more numerous than the males. In the whole county, the excess of females beyond the age of 20 is more marked than it was in 1911. Even at ages over 40 the increase in the excess is marked; but the bulk, as was to be expected, lies within the age period 20—39 years. The character of the district seems to have very little influence upon the sex distribution under four years of age. The figures for all the districts are fairly constant with the exception of Edmonton. The numbers of females to every 1,000 males under four years were as follows:— Acton 977 Ealing 980 Edmonton 1,000 Enfield 959 Hendon 944 Hornsey 984 Tottenham 951 Willesden 971 Wood Green 986 Interest in sex proportions, however, lies mainly in their incidence in the unmarried and therefore marriageable population; and the changes dealt with above in respect of the whole population have accordingly been extended to show the effect on the marriageable (i.e. the single and widowed) portion for age periods above age 20. The bulk of the excess is now shown to fall at ages over 40, notwithstanding the fact that very large increases in the excess have, owing to the events in the past decade, occurred at ages between 20 and 40. In the whole county the ratio of unmarried females per 1,000 unmarried males increased from 1,216 to 1,300 in the age group 20—29, and from 1,594 to 2,031 in the age group 30—39. In the age group 40—49 the ratio had increased to 2,473 to 1,000. In Acton the ratio in the two younger age groups was lower than in the county and higher in the age group 40—49. In the age group 20—29, the ratio was 1,245 unmarried females to 1,000 unmarried males; in the age group 30—39, the ratio was 1,865 "to 1,000, and in the age group 40—49 years, it was 2.547 to 1,000. In some of the districts it was much higher; for instance in Ealing the figures were:— 6 20—29 years, 1,628 unmarried females to 1,000 unmarried males. 30—39 years, 2,985 unmarried females to 1,000 unmarried males. 40—49 years, 3,963 unmarried females to 1,000 unmarried males. The contrast is always made between men and women of similar age constitution. Husbands, however, are generally older than their wives, the average being from 2—3 years, with a slight tendency to increase, and this should be borne in mind in considering the effect of changes of sex ratio upon the marriage probabilities of the future. Education.—A table has been inserted giving the number of persons of each sex attending educational institutions. The institutions attended are not necessarily situated in the same area as the persons attending them. With the exception of Enfield, Acton has a considerably higher percentage of children under 4 years of age attending school. This phenomenon possibly bears some relation to another table which is given on a later page, and in which the occupations are set forth. The complete figures for Acton are given as they form an interesting basis of comparison with the figures obtained in the Census recently instituted by the Education Committee:— Age last birthday. Total Population Persons Attending Educational Institutions. Whole Time. Part Time. Males. Females. Males. Females. Males. Females. All ages 28,317 32,982 5,453 5,387 115 168 0-4 years 2,520 2,464 166 150 3 7 5-9 „ 2,944 2,811 2,643 2,479 35 49 10-14 „ 2,818 2,897 2,400 2,450 29 33 15-19 „ 2,518 2,886 193 264 31 68 20-24 „ 2,124 2,865 36 25 10 6 25 & over 15,393 19,059 15 19 7 5 Occupations.—For the first time detailed tables giving the occupations of the inhabitants are published. The comparative tables are too elaborate for insertion, and the Registrar-General's knowledge of local conditions is insufficient to explain the incidence of specified occupations in certain localities. Among males there is little evidence of any specialization of industry in the tables. Two foci of the metal working trades may be noted in different parts of the county, Enfield and Edmonton on the one hand and Acton and Willesden on the other. The two 7 former are no doubt associated with the location of the Government Small Arms Factory at Enfield, as evidenced by the proper tion of gunsmiths. In Acton the number is caused by the number of motor and other engineering works in the Vale and the northern part of the area. The proportions per 1,000 of the total male population over 12 employed as metal workers in the 4 districts are as follows:— Enfield 144 Edmonton 121 Acton 127 Willesden 102 Locomotive drivers are naturally found in unusual numbers in Willesden, and 55 out of every 1,000 males over 12 years are employed as railway transport workers, and Wood Green came second with 37, and Acton and Hendon next with 32 each. Among both sexes laundry workers are far more numerous in Acton than in any other district. Among men over 12, 13 out of every 1,000, and among women over 12, 188 out of every 1,000 are employed as laundry workers. The next highest district is Willesden; but even in Willesden, where their proportion is not one-third of that of Acton, it is higher than in any London borough except Hammersmith. 85.8 per cent. of all males over 12 years of age in Middlesex are in some occupation and less than 15 per cent. are unoccupied or retired. The 3 districts (with over 50,000) in which there is the highest percentage of occupied males are Willesden with 88.1 per cent., Tottenham with 87.6 per cent., and Acton with 87.3 per cent. The lowest, though, Ealing, has a percentage of 84.2. In the county 33.4 per cent., or a third of the women over 12 years, are employed in some extra-domestic occupation, and of the total employed 17.1 per cent. of them were married or widowed. In this respect again Acton occupies a high place, the highest being Hendon with 37.7 per cent., and Acton second with 36.6 per cent. The lowest percentage is in Enfield with 31.2 per cent. In the matter of its number of married or widowed women occupied, Acton occupies the unenvious position of being considerably the highest in the county. 25.7 per cent., or roughly one-fourth of the women occupied being married or widowed. The next highest are Willesden and Tottenham with 18.4 per cent. and 18.1 per cent. respectively. This feature of our vital statistics has been emphasised on many occasions and is reflected in our returns, especially our infantile mortality returns. The phenomenon is almost entirely explained by the preponderance of laundry workers in the district, and is not due to any transient economic distress causing unemployment amongst men. 8 Anyone who knows the conditions of laundry employment is aware of the facility with which many women drift back to their old occupation after their marriage. Some women only leave temporarily for a short period before and after their confinement. In former years the remark was frequently made that Acton was a dormitory of London. At the time probably this remark was true, though until the last census, there was no exact information upon which an opinion could be based. It was at the Census of 1921 that occupied persons ir England and Wales were asked for the first time to give particulars of their place of work. In fact, this was probably the first occasion upon which statistics ot workplaces have been obtained and presented by any country in the world. In and around London masses of population move in tides of daily ebb and flow. These movements obviously have a direct bearing upon many difficult problems of traffic, transport and housing. Statistically considered, morever, the position is important. The resident population of any locality is no longer the sole matter of concern to that locality. During the day it may be peopled by a body of workers numerically exceeding and even differently composed from its so-called permanent population. In the large majority of the individual districts in and around London, the net movement is outward ; the tendency towards a high degree of concentration of the day population towards the centre of the region is well marked by the movements recorded in respect of the Metropolitan Boroughs, in 13 of which the population is increased during the day. The outstanding example is, of course, the City itself, which regularly expands and contracts between an insignificant night population of 13,709, and the more than thirty times as large number of 416,150 in the day, a number which takes no account of the large miscellaneous movements represented by visitors for shopping and other purposes, and by the traffic of all kinds passing continuously through the city in transit between areas on either side. Acton is a notable exception to most of the districts in Greater London. It is the only area with a population oevr 50,000 in the Home Counties outside the Metropolitan Area where more people come in daily to work than go out. Whereas 13,346 residents leave the district daily to follow their usual occupation, 14,575 come in for the same purpose. In the County of Middlesex there are only four districts jn which the inward movement exceeds the outward, viz., Greenford, Hayes, Staines and Uxbridge Rural. With the exception of West Ham, more persons come in to Acton to work than to any other area in the Home Counties outside the Metropolitan area, and in West Ham the outward movement, far exceeds the inward. More non-residents work within the area than residents. The total number of residents employed within the area is 13,501, compared with 14,575 non-residents. 9 The following table gives some of the particulars elicited at the Census:— Total Population enumerated in the area. Males 28,317 Females 32,982 Occupied persons over 12 years of age (and students over 18) enumerated in the area. TOTAL in the area. With workplaces With no fixed Workplace Workplace not stated. With workplace outside the area. Male 19,026 Female 9,775 Male 6,665 Female 5,636 Male 1,477 Female 297 Male 1,000 Female 380 Male 9,884 Female 3,462 Occupied persons over 12 years of age working in the area, but enumerated elsewhere in London or Home Counties Male 9,971 Female 4,604 Dwellings, Rooms and Families.—The detailed examination of the buildings in each area which is necessary at a Census to ensure the complete enumeration of all population, provides an opportunity for the collection of reliable data in regard to the housing accommodation. To avoid the ambiguity attaching to the use of terms such as "house," "tenement," etc., a new term "structurally separate dwelling" has been introduced as the housing unit serving as the basis of the returns. This term is defined as any room or set of rooms having separate access either to a street or to a common landing or staircase accessible to visitors. Thus, each flat in a block of flats is a separate unit; a private house which has not been structurally divided is a single unit, whether occupied by one family or by several. But where a private house has been structurally divided into separate portions within the meaning of the definition, each portion is regarded as a separate unit. The result has been a far more complete information than that which was obtained in the previous Censuses. Particulars are available as to the number and type of buildings, the number of structurally separate dwellings, the number of rooms in the dwellings, the number of private families occupying them, the number of rooms occupied, and the number of persons in the families, together with much valuable information derivable from the combination in various ways of these particulars. The first table inserted gives the building, dwellings, rooms and families. 10  Occupied by NonPrivate Families Occupied by Caretakers Vacant on Census Night Occupied by Private Families Total 1—3 Rooms 4—5 Rooms 6—8 Rooms 9 or more Rooms Dwellings Rooms Undivided Private Houses 29 2 242 283 2243 5157 947 8630 54742 Structurally Divided Private Houses .. .. 4 182 87 3 .. 272 908 Blocks of Flats, Tenements, etc. .. 1 50 1125 956 94 .. 2175 8008 Shops 4 .. 16 48 304 252 41 645 3620 Others 5 .. 5 24 36 34 4 98 481 Totals 38 3 317 1662 3626 5540 992 11820 67759 Vacant on Census Night .. .. .. 26 96 174 21 317 1900 Dwellings Occupied by One Private Family .. .. .. 1590 3133 3402 674 8799 47999 Dwellings Occupied by Two Private Families .. .. .. 46 338 1634 145 2163 13779 Dwellings Occupied by Three or more Private Families .. .. .. .. 59 330 152 541 4081 Total Dwellings Occupied (No.) .. .. .. 1636 3530 5366 971 11503 65859 By Private Families (per cent.) .. .. .. 14 31 47 8 100 .. Total Private Families therein .. .. .. 1682 4001 7732 1526 14941 .. 11 Structurally divided private houses are separately shown for the first time, with a view to affording an indication of the extent to which houses originally built for the occupation of single families have been structurally divided to provide separate and independent occupation for two or more families. There is evidence in the returns that it has not always been possible for enumerators to distinguish between buildings originally erected to comprise flats or maisonettes, and those subsequently converted for the purpose. Although not absolutely essential to gauge the value of housing conditions which obtain here, some standard of comparison is useful to estimate the advance or the retrogression which has occurred. It is rather difficult to compare exactly 1921 with 1911 as new terms were introduced in 1921. On the whole, the conditions are not so satisfactory in 1921 as they were in 1911, and the comparison with the whole of Middlesex does not reflect favourably upon Acton. In 1921, in Acton there were 14,941 families living in 11,820 dwellings. The average number of families per occupied dwelling is 1.26, which is the same figure as that of Middlesex. When we analyse this figure, though, it will be seen that the figure of 3 familes per dwelling in Acton is higher, and alters the character of the percentage. Middlesex Acton Families living in single occupation of separate dwellings 61% 58.8% Families living two to a dwelling 30% 28.2% Families living in dwellings containing three or more families each 9% 13% It must be remembered that in the census classification of families, a single lodger boarding separately from the occupier is regarded—as on previous occasions—as a separate family. A number obtained in this way will throw little light upon the condition of housing without an examination into the composition of the families and the extent of the accommodation comprised in the dwellings which they occupy. Analysing the dwellings occupied by private families according to the number of rooms in them, the tables show that: Middlesex Acton Dwellings with 3 rooms or less 6% 14% „ „4 to 5 rooms 40.4% 31% „ „ 6 to 8 rooms 45.5% 47% „ „ 9 rooms or more 8.1% 8% 12 The rooms counted are the normal living rooms, including kitchens and bed-rooms, but excluding sculleries, boxrooms, and rooms used for business and professional purposes. The percentage figures for 1911 and 1921 show that comparatively more families occupied one and two room tenements in the latter year than the former. Percentage number of families occupying the following number of rooms:— 1 2 3 4 5 6 & 7 8 & 9 10 & over Total 1911 5.4 7 23.7 16.8 12.6 22.1 8.8 3.6 100% 1921 6.3 9.3 25.3 18.3 12.6 18.9 7.2 1.9 100% The reduction in the percentage figures for dwellings with more than 7 rooms has no public health significance and probably bears no relation to the housing problem. The reduction is caused by other factors. Size of Family in Relation to Number of Rooms Occupied.— The following table gives the essential aspect of housing and overcrowding in a more striking manner than any of the other tables. In it the private families are analysed according to the number of persons in the family and also by the unit of occupation, i.e the number of rooms occupied by the family whether forming the whole or part only of a structurally separate building. 13 Number of Persons in Family Number of Private Families occupying the following Number of Rooms Total Private Families Population in Private Families Rooms Occupied Average Number of Rooms per Person 1 2 3 4 5 6 & 7 8 & 9 10 & over Number Per Cent. 1 406 146 133 66 31 57 17 .. 856 5.7 .. .. .. 2 286 461 732 447 251 385 125 27 2714 18.2 856 2021 2.36 3 169 410 900 612 355 589 219 50 3304 22.2 5428 10228 1.88 4 65 188 737 576 405 588 271 57 2887 19.3 9412 14030 1.42 5 12 91 563 386 305 462 160 41 2020 13.5 11548 13625 1.18 6 5 44 353 268 214 301 130 39 1354 9.1 10100 9672 0.96 7 1 25 213 171 134 176 74 17 811 5.4 8124 6734 0.83 8 1 11 112 100 82 130 45 18 499 3.3 5677 3967 0.70 9 1 5 48 52 48 69 18 13 254 1.7 3992 2569 0.64 10 .. 1 25 29 33 38 10 10 146 1.0 2286 1348 0.59 11 .. 1 7 18 15 16 5 2 64 0.4 1460 802 0.55 12 .. .. 3 1 3 4 .. 5 16 0.1 704 331 0.47 13 .. .. 1 1 4 7 .. .. 13 0.1 192 115 0.60 14 .. .. .. .. 1 2 .. .. 3 .. 169 70 0.41 15 and over .. .. .. .. .. .. .. .. .. .. 42 17 0.40 Total Private Families 946 1383 3827 2727 1881 2824 1074 279 14941 100 .. .. .. Population in Private Families 1859 4098 15373 11616 8650 12768 4783 1433 60490 .. .. .. .. Rooms Occupied 946 2764 11478 10907 9403 17995 8991 3045 .. .. .. .. .. 14 It will be seen that the table is too elaborate for a detailed comparison to be made with other districts, and even a brief analysis of the figures would take up too much space. Each vertical and horizontal column would require individual treatment. Possibly some explanation is necessary. Taken horizontally the first line means that there were at the census 856 separate families which consisted of only one person each. Some of these, of course, were lodgers and as previously explained were reckoned as separate families. Surprise might possibly be expressed that in 57 instances one person occupied 6 or 7 rooms, and in 17 instances one person occupied 8 or 9 rooms, but these figures are not in any way remarkable and are partly caused by the domestic servant problem. In some districts these figures are much higher and in Chiswick the number of single persons who occupy large houses alone is not only relatively but absolutely higher. In Ealing, the number is higher still. The figures are of more importance when taken vertically. If we again take the first line, it will be seen that 946 families live in one room each. A large number of these are lodgers, but one of the most striking results of the Census has been the uniform increase in the percentage of families living in tenements of less than 4 rooms each, and a consequent decrease in the percentage of those living in dwellings of more than 5 rooms each. The following table gives the percentage of families in Acton living in various units of population in 1911 and 1921. ROOMS. 1 2 3 4 5 6 & 7 8 & 9 10 & over Total 1911 5.3 7.0 23.7 16.8 12.6 22.1 8.8 3.6 100% 1921 6.3 9.3 25.5 18.3 12.6 18.9 7.2 1.9 100% One outstanding fact, though, should be borne in mind when considering these figures, and that is, the reduction in the average size of families which has taken place between 1911 and 1921. In 1911 in Acton the average number of persons per family was. 4.41 and in 1921, 4.05. This reduction in the average size of families is not local, and is disclosed by the Census returns for other parts of England and Wales. It is a natural consequence of the increase in the marriage rate in association with a heavily reduced birth-rate and an increased (allowing for war deaths) death-rate. The reduction in the size of families, while it may not abate the demands of individual families for separate dwellings, obviously justifies a review of the general position by reference to the reduced requirements of families in point of accommodation. This reduction in the average size of families explains another phenomenon. The increase in the number of families between 1911 15 and 1921 was greater than the increase in the number of dwellings in the same period, yet the increase of the percentage of the population living more than two persons to a room was only a slight one. The ratio of two or more persons per room has been selected as an approximate comparative index figure for the purpose of measuring the prevalence and distribution of overcrowding conditions, but obviously it cannot be accepted as an absolute standard or a definition of overcrowding; other factors enter, such as the size of the rooms, the age-distribution of the population including the number of children. In the intercensal period 1911—1921, there was an increase of 810 or 7.5 per cent. in the number of total dwellings in the district. In the same period there was an increase in the number of private families of 2,012 or 15.6 per cent. A reference to the table giving the number of persons occupying the different number of rooms will show that 6,478 were living more than 2 persons to a room. In 1911, the number was 5,947. The percentage of the total family population living more than 2 persons to a room in 1921 was 10.7 compared with 10.4 in 1911. This percentage naturally is higher in the 1, 2 and 3 room tenements. In the 1 room tenements the percentage was 21, in the 2 roomed cues it was 28, and in the 3 roomed tenements it was 20. In the 4 roomed tenements it dropped to 8 per cent. For comparative purposes the Registrar-General has adopted a standard based upon the number of rooms per persons in the whole of England and Wales. Based upon the England and Wales standard, the deficiency of rooms in Acton was 3,126 or 4.8 per cent. The average number of rooms per person in a dwelling does not depend on the size of the tenement but on the size of the family. In families of one person each the average number of rooms per person is 2.36, and this number steadily and continuously goes down till it reaches .4 in the family of 14. A considerable difference exists in the conditions of the different wards The population of the South-West Ward exceeds that of any other, but in area it is the least. The highest number of private families was in the North-East Ward, but the highest number of structurally separate dwellings was in the South-East Ward. The total number of rooms occupied was highest in the NorthEast Ward, but the highest average of rooms per person was in the North-West Ward. The greatest intercensal increase occurred in the North-East Ward, and the smallest in the South-East Ward. The ratio of females to males was lcwest in the South-West Ward with 1,092 females to every 1,000 males, and highest in the North-West Ward with 1,295 females to every 1,000 males. 16 In the following table the Ward distribution of the population in given:— N.-East. N.-West. S.-East. S.-West. Area in acres 1,082 789 255 179 Total persons 16,353 12,329 15,094 17,523 Males 7,663 5,371 6,907 8,376 Females 8,690 6,958 8,187 9,147 Persons per acre 15. 1 15.6 59.2 97.2 Private families 4,053 3,138 3,735 4,015 Population in private families 16,007 12,142 14,982 17,359 Structurally separate dwellings 3,050 2,551 3,092 2,810 Rooms occupied 18,418 16,384 17,297 13,430 Rooms per person 1.15 1.35 1.15 0.77 Population.—The Registrar General estimates the population at the end of June, 1923. to be 62,720, an increase of 330. For the twelve months ending December 31st, 1923, 84 new houses were erected. The number of Parliamentary electors on the Register in the autumn of 1923 was as follows:— MEN WOMEN TOTAL 17,062 14,332 31,394 For the corresponding period of 1922, the numbers were:— MEN WOMEN TOTAL 16,477 13,948 30,425 In view of these figures, it is probable that the Registrar General's estimate is under the actual figure. Outdoor Relief.—I am indebted to Mr. Harmsworth, the Clerk of the Guardians, for the figures relating to Poor Law Relief. The amount of out-door relief given by the Guardians for the parish of Acton was:— £ s. d. Ordinary Relief 6,016 3 1½ Unemployment Relief 3,380 10 5 £9,396 13 6½ There is a slight increase in the amount of the ordinary relief, but a very marked decrease in the amount of the unemployment relief. The amount of unemployment relief disbursed by the Guardians was less than 30 per cent. of that disbursed in 1922. 17 Births.—Table VII gives particulars of the births registered and notified in the district, and the births registered outside the district. The total number of births belonging to the district was 1,171, and the birth-rate was 18.6 per 1,000 inhabitants, as compared with 19.3 per 1,000 in 1922. This is the lowest birth-rate recorded in the district with the exception of that for the two years 1917 and 1918, when the birthrate was directly affected by the war. The birth-rate for England and Wales was 19.7, for London 20.2 and for the large towns including London 20.4. Forty-three children were born out of wedlock; this number corresponds to an illegitimate birth-rate of 36 per 1,000 births. Deaths.—368 deaths were registered in the district; of these 11 deaths were of non-residents; 243 deaths of residents occurred outside the district. The total number of deaths belonging to the district is 599. The nett number of deaths corresponds to a death-rate of 9.5 per 1,000 inhabitants, which is the lowest recorded death-rate for the district. The death-rate for England and Wales was 11.6 per 1,000, for London 11.2, and for the 105 large towns, including London, 11.6 per 1,000 inhabitants. Possibly these figures do not convey the facts in a very convincing and vivid manner, but the reduction of the death-rate to such a low figure denotes a vast amount of patient and ceaseless work in many directions. Compared with 1913, a reduction in the death-rate has occurred of 2 per 1,000 inhabitants, or a saving of 125 lives. There is an absolute reduction of 94 in the number of deaths in 1923 as compared with 1913. An inspection of the death-rates from different diseases shows that this reduction has not occurred uniformly from all causes. If we examine the causes of death in the last 10 years we find that the death-rates from certain diseases such as Cancer, Heart Disease, Bronchitis, Pneumonia and Tubercle have remained almost stationary. It is difficult to know how many mistakes are made in diagnosis. One curious instance occurred last year. Early in December a notification was received from a sanatorium that a man aged 41 years had been admitted and was suffering from Pulmonary Tuberculosis. He was in the sanatorium for a couple of weeks only as at the end of December he had been discharged from the institution, Evidently by this time the lung symptoms 18 had cleared up, and the certificate stated that he was possibly suffering from Laryngeal Tuberculosis; that is, the diagnosis was preceded by a mark of interrogation. The history of the case was indefinite. He had been found at Chertsey in October suffering from loss of memory and was then taken to the sanatorium and treated for tubercular disease of the throat. After his discharge from the sanatorium at the end of December, his throat became more troublesome, and he attended the Middlesex Hospital, when the condition was diagnosed as a malignant growth. He died in January. The doctor who made the post-mortem examination stated that he found death due to the effect of poisoning by some corrosive substance. The man must have swallowed a quantity of acid some months previously. Cancer.—The subject of Cancer has excited considerable attention both in the medical and the lay Press, and a memorandum was issued by the Ministry of Health in July, 1923. Further memoranda have been issued. A conference of the different authorities within the Union was convened by the Brentford Board of Guardians, and a Cancer Committee appointed. Although in the last 10 years there has been no appreciable increase in the deaths from Cancer in Acton, it is now generally admitted that Cancer is on the increase. The figures of Dr. Stevenson show that a natural increase has occurred, and not merely a statistical increase. He examined the figures for England and Wales for 1.917 and the previous 22 years, and found that a greater increase had occurred in Cancer of accessible sites than in that of inaccessible sites. For instance, Cancer of the tongue caused a mortality three or four times as great as it did 50 or 60 years ago. The same work was repeated in the United States and reported in the mortality statistics for 1920. The United States authorities arrived at precisely the same results—a greater increase of Cancer of accessible sites than of inaccessible. In spite of this, in the last 10 years at any rate, there has been no appreciable increase here. The death-rate per 1,000 inhabitants has varied considerably. The highest rates were in 1916, 1917 and 1922, when the death-rate was 1.15 per 1,000, and the lowest was last year when it was 84 per 1,000. It is unnecessary here to discuss the various theories as to the causes of the increase; unfortunately, it is admitted generally that the root cause or causes on which the occurrence of cancer depends are unknown. The memorandum of the Ministry suggested that local authorities should consider the question of providing facilities for diagnosis and treatment, and whether propaganda work should be undertaken which would result in persons suffering from the disease seeking early advice and treatment. 19 As far as this district is concerned, there is no lack of facilities for diagnosis or treatment. Our proximity to the large hospitals in London ana the homes of the recognised authorities upon the various forms of Cancer, places all the facilities for diagnosis and treatment within the easy reach of all patients. The Ministry of Health suggests that measures should be considered for improving the local facilities for clinical consultations and for pathological examination, for improving the local facilities for Cancer treatment (operative, provision of X-ray and radium treatment), and the provision of adequate arrangements for this purpose at local hospitals, institutions, etc., which serve the area. For reasons stated above, in this district, the lack of these facilities is not the chief difficulty. The chief difficulty in carrying out curative treatment lies in the reluctance of patients to seek early medical advice. In some cases there is a diffidence to seek medical advice. Some people have a suspicion, or even a belief, that there is something the matter with them, but hug the knowledge to themselves from dread of the truth. Probably, these people form but a small minority. In the majority of instances, Cancer in the early stages is painless, and the symptoms of the disease are only a slight deviation or exaggeration of what are considered normal processes. These slight symptoms are disregarded through ignorance of their significance. These early stages are the favourable ones for immediate operation. In any condition in which cancer is suspected, immediate and decisive action is necessary. Quack remedies are only a waste of time and money; at best, they are useless, and at worst, aggravate the disease. At the Conference, it was felt that there is a field for propaganda work in the education locally of the public, and that the two points around which this work should centre are the family doctor and the local public health authority. If early advice were sought, the one from whom this would be sought would be the general practitioner, but the complaint of the doctor is that the patients do not come to him at a sufficiently early stage to enable him to apply successful treatment. There are certain facts about Cancer which ought to be known, and the dissemination of the knowledge might save lives and alleviate much suffering, and one essential fact is that the patient should not postpone or delay seeking competent medical advice. By whom the advice should be given is a debatable question. It has been suggested that the ordinary agencies of public health departments should be utilised for this purpose, notably by instruction at Welfare Centres, and also by midwives, maternity and district nurses. The Royal Society of Medicine recommended that the British Red Cross Society might be asked to conduct a publicity campaign by means of lectures and phamplets. 20 It must be recollected that Health Visitors, Midwives and Maternity Nurses come intimately into contact with women at an age before Cancer is peculiarly liable to attack the body. Whatever action is taken, much caution is needed in announcements to the public on Cancer in order to avoid over-statement, the making of promises which are not warranted by evidence or the production of needless and mischievous apprehensions of Cancer. Certain common sense rules of prophylaxis could, without any danger, be emphasised. The liability of Cancer to follow chronic irritation of so many different types is remarkable, and leads to the supposition that beneath them all there lies some common factor—as yet unrecognised—which is fundamental to the passage of a chronic inflammatory and non-cancerous condition into one that is definitely cancerous. This consideration indicates that there are at least some provocative causes of Cancer which can be guarded against. Since Cancer occurs more commonly in certain sites, it is prudent to notice and remove causes for chronic irritation in those sites. In this category, for example, come the removal of rough stumps of teeth, or replacement of badly-fitting dentures; a change of habit, if smoking is found to produce soreness on the same spot of the lip or tongue; an alteration of clothing which causes irritation of particular regions of the body—for example the breast; the avoidance of constipation and like matters. Heart Disease.—In the table giving the causes of, and ages at, death, it will be noticed that organic heart disease has become one of the most important causes of death. Last year in this district 60 deaths were due to organic heart disease; in 1922, the figure was 78. These figures do not include rheumatic fever, diseases of arteries, embolism and chorea, in which directly or indirectly heart disease is the cause of death. Mortality tables place diseases of the heart in an unenviable position at the head of the list of causes of death. From an economic point of view, heart disease is the most important cause of death in the mortality tables. Owing to the incidence in different age periods the economic wastage in heart disease is greater than in most other diseases, particularly when one takes into account the years of invalidism that antedate the fatal issue in most cases of heart disease. With a causal condition that in the majority of cases is frankly infective something should be possible to mitigate the extent of these diseases. In the School Report attention has been drawn 21 to the importance of tonsillar sepsis and dental caries as aetiological factors in Rheumatic Fever; and as Rheumatic Fever is in the majority of instances associated with Heart Disease, any means which will reduce the incidence of Rheumatic diseases must ultimately react upon the frequency of Heart Diseases. In regard at least to acute rheumatism there is some evidence of the disease becoming less virulent as well as less common. Dr. Miller has pointed out in a recent paper that the percentage of hospital in-patients suffering with acute rheumatism has been almost halved in recent years. In addition to the work in the School Clinics and other centres there is a necessity to emphasise the importance of rheumatism, especially in children, and the desirability of prolonged rest after an attack of rheumatic fever. In a recent work issued by the Ministry of Health it is pointed out that permanent damage to the heart is much more likely to occur in second or recurrent attacks than in first attacks of rheumatic fever. Recurrence is much less likely to occur in those patients who have been able to have a prolonged convalescence from their first attack. Medical opinion has recently advised in favour of what amounts to bed sanatorium treatment for convalescent patients in special homes of recovery. These special homes of recovery, which differ entirely in their regime from the ordinary convalescent home, have been instituted in Birmingham, Liverpool, and in some other towns in this country. In New York, a society has been formed for the prevention and relief of heart disease. One curious fact has emerged from the activities of this society, viz., that Chorea or St. Vitus's Dance in its liability to leave permanent effects upon the heart was more difficult to control than ordinary rheumatic or throat cases. The subject of chorea in the schools is well worth the most serious consideration. Deaths in Public Institutions.—212 of the deaths of residents outside the district occurred in public institutions. In addition, 15 deaths of residents occurred in public institutions in the district. These numbers are exclusive of the deaths which occurred in nursing homes. 227 out of a total of 599, or 38 per cent. of the total deaths occurred in public institutions. SPECIAL CAUSES OF SICKNESS. Fur Rashes.—Mention should be made of the complaints received in the early part of the year from persons who had suffered from rashes on the face and neck, caused ostensibly by the wearing offurs. 22 A recurrence of the complaints occurred later in the year and also in the early part of 1924. In all cases the symptoms were similar. There was an eruption on the neck, and lower part of the face; the eruption was of an irritating character and persisted for a considerable time. In some of the cases in which the fur was not suspected, there was a recurrence of the symptoms, but invariably the eruption disappeared when the sufferer ceased wearing the fur. Frequently there was a difficulty in obtaining the fur which was supposd to be the cause of the trouble. In most cases, when the purchaser complained to the seller, the fur was exchanged and could not be traced. When the fur composed only the collar of a cloth coat, the difficulty of tracing was enhanced. As an instance of the difficulties encountered, when enquiries were made into the origin of one coat it was found that the completed coat was bought in the City of London. The fur was bought from a furrier in another area, and the coat was made on outworkers premises in a third area. We were fortunate in obtaining some of the implicated furs. These were sent to the Ministry of Health. Arrangements were made by the Ministry for the examination of these furs by an eminent chemist. As far as could be gathered, no cases of illness were found among the workers in these particular furs, but the difficulty of tracing was so great that no significance is attached to this fact. Moreover, the conditions under which the rash appears need not be present in the case of workers. The work of Dr. Prosser White of Wigan throws an interesting light upon these fur rashes. Dr. Prossor White is an eminent dermatologist, and has been carrying out investigations into the rashes which occur among fur workers, and bis conclusions have an important bearing upon rashes in fur wearers. I had the opportunity of seeing his original photographs of rashes in fur workers and the experimental rashes he had induced on himself and others, and these rashes appeared to be identical with those which had appeared amongst the wearers of the furs. The cause has not been found in all cases, but Dr. Prosser White's work has established the probability that the rashes which were complained of by wearers of furs in this district iast year were caused by one or more of the constituents of the dyes used in the industry. It was noticed that the victims had worn furs which had been dyed, and in most instances, these furs simply formed the collar of a cloth coat. The principal culprit is the coney seal, but the list of counterfeits recognised by the Fur and Skin Trading Section of the 23 London Chamber of Commerce extends to 20 or more varieties of furs. Certain furs become fashionable and in order to supply the demand for this particular kind of fur, imitations and substitutes are prepared. There may be only a limited supply of the natural coloured skin which is popular for the season, and the demand of fashion fosters the preparation of the counterfeits. Hare is dyed to represent sable or fox, kid dyed to represent Persian lamb or caracul, rabbit dyed to represent otter or mole, and numerous other skins are dyed to imitate the saleable or fashionable fur. It cannot well be called fraud, as in most cases the public are conscious and willing participator in the counterfeit, though possibly they are not aware of the processes through which the skin has to pass before it emerges in the final form in which it is sold. The process of preparation has become a very complicated one, and though, as a rule, the dyes are the cause of illness, any of the processes may be so negligently carried out as to result in injury to the wearer of the fur. It was suggested that the irritation of the skin was due to arsenic, and a good deal of unnecessary harm caused. The suggestion was probably made because of the large quantities of arsenic which the taxidermist employs, but the taxidermist uses special methods for the curing of his specimens. He applies white arsenic V> the fleshy side of the green skins. The taxidermist also employs a pickle, in which he steeps the dried pelts, and this pickle consists of arsenic, alum, strong sulphuric acid and water. In every instance of rashes in fur wearers, arsenic has been ruled out as. the cause. In one case, a mere trace was found on analysis and in another 1 in 20,000. This means that three pounds of the dyed fur contain about one grain of arsenic. Some furs have been sent for analysis, and particular mention was made that arsenic was not present. Arsenic is very seldom used at all in the curing of coney rabbit furs. The skins of sheep, goats, kids and other smaller animals are sometimes treated by the application of soaps before they come into the hands of the furriers. These soaps, which are rubbed into the fleshy sides of the pelts before they are dry, may contain arsenic, zinc or mercury. Usually salt alone, or mixed with alum, is the sole application. In any case, the chemicals should be. removed completely by the first washing. After washing, the skins are hung up to dry. The next operation is called "killing." Its object is to make the fur more absorbent and permit the dye Honors to penetrate to the very tips. For this purpose the whole skin is immersed in some alkaline solution for two or three hours. The treatment with lime gives the brightest and clearest colours on dyeing afterwards. 24 Following this process, washing with plenty of water is highly necessary. Any lime left in the furs forms a caustic dust when it becomes dry. A little acetic acid or formic acid will neutralise any traces of lime, but these acids must be removed by another washing. The next process is "mordanting." Mordants attract and fix the colours. For light colours this process is unnecessary, but to obtain deep colours, mordants are always required. Without them the shades are uneven and not so fast to light and rubbing. Metallic salts head the list of mordants either by themselves or together. If these metals are not completely changed into their oxides, the furs will give rise to rashes in the workers and wearers. The skins are now ready for the dyeing process, and according to Dr. Prosser White, it is during this process that residues are left which give rise to the skin troubles among the wearers of, and the workers in, furs. Dyeing is comparatively a new art, a new fashion in the fur industry. Aniline dyes are now used in almost every instance except for the cheapest black which are coloured by basic and acid dyes. The Berlin Aniline Company brought out three dyes under the name of Ursol, Metol, and Amidol. Derivatives of these are the dyes in general use at the present time. All these require, or depend upon, subsequent oxidation, and various oxidisers are used in the different trades. There are two methods of dyeing—the general or common method and the brush or topping method. The latter is much more liable to cause trouble, as the solutions used are much more concentrated, ranging from six to twelve times stronger than the liquors required in the general method. Any faults in technique will cause the liberation of the residues of the dying reagents in the dye bath and on the materials. Sometimes these harmful residues are in such quantities that the fur workers suffer very severely and the clothiers are warned before the furs are sent out to the public, but, as a rule, the furs do not give rise to a rash if the skin is dry. If moisture is applied, the rash appears. This explains the frequency with which the neck and face are attacked. The perspiration is sufficient to enable the dye to act as an irritant. Probably this fact explains the relative frequency in which cloth coats with fur collars were the cause of the trouble. The fur collars were turned up, especially when it rained. In these circumstances the rash was not limited to the neck, but occurred also in the lower part of the face. Where a fur cape had been worn, the rash was usually limited to the neck. In some instances, the rash soon disappeared when the patient ceased wearing the fur. In others, the rash persisted for a consider able time in spite of treatment. In one case which came under 25 my notice, the sufferer was away from her work for a couple of months. The prevention of these troubles in the fur industry is a difficult problem, and can only be done by the furriers taking extreme care in the finishing and dyeing processes with particular attention to washing. This is especially necessary after "brush dyeing." The furriers enjoy some degree of immunity because of the difficulty of tracing the furs to the origin. The retailer is not always able to trace the wholesaler from whom the fur was purchased, and between the wholesaler and the furrier, the skins may have passed through many hands, especially in the case of cloth coats trimmed with fur collars. A suggestion has been made that the symptoms—rashes—are due to "anaphylaxis." Anaphylaxis is a term used to indicate a hypersensitiveness some human beings acquire to certain animal and vegetable proteins. It has been invoked to explain obscure phenomena in certain diseases. In these cases, anaphylaxis can be ruled out, as the symptoms appeared only in skins which had been dyed, and have not been caused in the natural furs. HOSPITAL PROVISION. General.—The Acton Hospital in Gunnersbury Lane accommodates fifty beds and has a resident Medical Officer. The War Memorial of the district took the form of an extension to the Hospital, and the new buildings were opened in July, 1923, by Mr. Neville Chamberlain, who was the Minister of Health at the time. In addition to the general wards and the out-patient department, it also has private and semi-private wards which are reserved for " paying patients." Fever.—The Isolation Hospital has accommodation for 80 patients. The diseases treated are Diphtheria, Scarlet Fever, and Measles. Small Pox.—The district forms one of the constituent bodies of the Middlesex Small Pox Board. Nursing; Facilities.—In addition to the various nursing associations in the district, there is a district nurse resident in the general hospital, who is available for the home nursing of patients who do not require the whole-time services of a nurse, or who cannot afford the fees of a whole-time nurse. Ambulance Facilities.—There is a motor ambulance for the removal of infectious cases. An arrangement exists with the Chiswick Council for the use of the Chiswick Ambulance for the transport of street accident cases. 26 Infantile Mortality.—77 deaths occurred in children under one year of age. This number corresponds to an infantile mortality of 65 per 1,000 births. The infantile mortality is slightly higher than that of 1922, when it was 62 per 1,000 births. It is also slightly higher than that of London—60 per 1,000 births, but lower than that of England and Wales and of the 105 great towns including London—69 per 1,000 births. 38 of the deaths occurred in babies under one month old. 41 of the deaths were due to natal or ante-natal causes. 11 of the deaths were of illegitimate children and the illegitimate infantile mortality was 265 per 1,000 births. Maternity and Child Welfare.—The principal change has been the closer linking of the Child Welfare scheme with the School Medical Service. By arrangement with the Education Committee, children from the Child Welfare Centres have been referred to the School Dental Surgeon and School Oculist. 49 children under five years were treated by the dental surgeon, and twelve were treated by the school oculist. It was found in the inspection of entrants that a very large number of the children suffered from Dental Caries, and it is hoped by an extension of the work to reduce the percentage of those who are found to require treatment when they enter school. Ante-natal Clinic.—63 expectant mothers were examined at the Ante-natal Clinic, and four were treated at the Acton Hospital under the agreement between the Council and the Acton Hospital. Acton has no Maternity Home, but beds for complicated cases are provided at the Acton Hospital. In exceptional cases the whole or part of the fee of midwives is paid by the Council, and last year the fees of midwives were paid in sixteen instances. Milk (Mothers and Children Order) 1919.—The procedure followed in previous years was not altered. The scheme which is worked in co-operation with the Guardians has worked quite satisfactorily, and only in exceptional cases was free milk distributed by the Council. 2,329 packets of dried milk were distributed through the Believing Officers, and 432 packets were distributed by the Council to expectant mothers, and in exceptional circumstances where the recipients would not be eligible for Poor Law Belief. 27 These figures are a great reduction upon those of 1922; the reduction is mostly due to the improvement in the economic conditions which obtained in the district during the year. Day Nursery.—The Day Nursery is situated in Bollo Bridge Road. It has accommodation for 28 babies. In the year 4,281 attendances were made at the Nursery. Infectious Diseases.—Table V gives the notifications of Infectious Diseases for the year. There is again a reduction in the number of notifications. Scarlet Fever.—160 notifications were received but there was no death. 123 of the cases were removed to hospital. Diphtheria.—61 cases were notified, and there were 3 deaths. 49 cases were removed to hospital. As usual, there is a preponderance of cases in the South West Ward. Encephalitis Lethargica.—One case was notified. The patient lived in another district, but worked in Acton. Ophthalmia Neonatorum.—4 cases were notified and one was treated in hospital. In no instance was the sight permanently damaged. Pneumonia.—28 cases of Pneumonia were notified; 18 of these notifications were received from one doctor. Tuberculosis.—During the year 1923 there were 73 notifications of Pulmonary Tuberculosis and 24 of other forms of Tuberculosis. In the following table are given the notifications of Tuberculosis for the five years 1919-1923 among the principal groups of occupations in the district. MALES. Occupation Numbers employed Notifications in five years, 1919-1923 Rate per 100,000 Metal Workers 2768 31 1120 Clerks, Draughtsmen and Typists 1597 40 2505 General Labourers 1246 22 1765 Persons employed in Personal Service 866 11 1270 Railway Workers 686 9 1312 Road Transport Workers 1264 8 632 Salesmen, Shop Assistants 803 8 996 Electrical Makers and Fitters 544 7 1286 Painters 574 6 1045 Stage Hands and Musicians, etc. 192 5 2604 Boot Makers and Repairers 115 4 3498 Carpenters 330 4 1194 Compositors 361 3 831 Laundrymen 286 3 1049 Tailors 87 2 2299 28 FEMALES. Occupation Numbers employed Notifications in five years, 1919-1923 Rate per 100,000 Laundresses 1827 23 1258 Clerks, Typists, etc. 1437 16 1113 Domestic Servants 1754 13 741 Dressmakers 408 6 — Shop Assistants 615 4 1470 Metal Workers 99 3 3030 The ages of the new notified cases and the deaths were as follows:— Age Periods New Cases Deaths Pulmonary NonPulmonary Pulmonary NonPulmonary 1 — 8 1 7 5 1 3 — 2 10 — 4 — — 15 6 1 3 1 20 16 1 12 — 25 25 3 10 3 35 10 2 16 2 45 8 1 5 — 55 4 1 3 — 65 and over 3 — 4 — Totals 73 24 54 15 Isolation Hospital.—During the year 192 cases were admitted into the Hospital. On January 1st, 1923, there were 63 cases under treatment, and on January 1st, 1924, 37. During the year 213 were discharged, and there were 5 deaths. Of the cases admitted 169 were Acton cases. CASES ADMITTED. Scarlet Fever Diphtheria Measles Encephalitis Lethargica Acton 120 44 2 1 Wembley 4 11 2 — Hanwell — 7 — — Kingsbury — 1 — — 124 63 4 1 Total 192. 29 DEATHS IN HOSPITAL. Acton — 2 — — Wembley — 2 — — Kingsbury — 1 — — — 5 — — Total 5. SUPERVISION OF FOOD SUPPLY Milk Supply.—There are one cowshed and 80 dairies and milkshops on the register. Of the 80 premises from which milk is retailed, 8 are branches of one firm, and 2 of another firm; 21 of the registered purveyors have shops and rounds, 16 have rounds only, 5 are dairy shops. 3 are caterers of food primarily, and 35 have general shops. The latter only sell a small quantity. The Milk and Dairies (Amendment) Act 1922 came into operation in September, 1922. Section 2 provides that if the Council is satisfied that the public health is, or is likely to be, endangered by any act or default of any person who is registered or seeks to be registered as a retail purveyor of milk in relation to quality, storage or distribution of milk, notice must be served upon such person to appear before the Council not less than 7 days after the date of the Notice to show cause why he should not be removed from the register or his name not placed upon it. Provision is made for an appeal from the Council's decision if notice is given within 21 days. During the year, the Health Committee considered the question of registration of general shops. In many instances milk was sold in general shops. In some of these paraffin, vinegar, wood and other articles were sold and the milk was kept in a vessel on the counter not in any practical and efficient way protected from any contamination which might arise from the other articles. The Committee decided that in no instance would they register a person who sold milk in the same room as paraffin. In the majority of cases the owner of the premises gave up the sale of paraffin, but in six the sale of paraffin was probably more profitable than the sale of milk, and the Committee decided to strike these six off the register. No appeal was made against the decision of the Committee. It will be noticed that 16 purveyors have rounds only. As far as this district is concerned, the "round only" business is comparativly a new development. It owes its origin to many causes. 30 Eight licenses were granted to sell "certified milk" and one to sell "Grade A." Butchers and Slaughterhouses.—There are 1 registered and 2 licensed slaughterhouses in the district. There are 27 butchers in the district, but hardly any of the meat sold in the butchers' shops is slaughtered in the district. Most of the butchers obtain their meat from Smithfield. In one of the slaughterhouses very few animals are slaughtered. In the other two slaughterhouses the carcases are used for sausage meat. One is owned by Messrs. T. Wall and Son, Ltd., and the other by Messrs. Woodhouse Hume, Ltd. During the year the following articles of food were surrendered: 4 stone cat fish. 1 pig's carcase (290 lbs.) 1 side pork (90 lbs.) 1 pig's head. 3½ barrels crabs. 1 barrel Jersey potatoes 1 pig's head. 1 crate bananas. 1 box cod. 1 case cod. 1 pigs's carcase (4 sc. 11 lbs.) 29 crates plums (20 lbs. each crate). 2 small crates bananas. 1 pig's carcase (156 lbs.) 1 pig's carcase (26 sc. 13 lbs.) 1 sow (330 lbs.) Bakehouses.—There are 33 bakehouses in the district. Of these '-8 are underground. Increase of Rent and Mortgage Interest (Restriction) Act 1920.— The number of applications received under Section 2 of the Act was 19, and the number of certificates issued was 13. Some misapprehension exists as to the powers of the Council under this Act, and some confusion exists as to the work which can be included in the schedule in order to render the house reasonably fit for human habitation. It was taken for granted that the conditions which render a house reasonably fit for human habitation should vary according to the locality of the house, and it seems that some suggestion to that effect was made when the Bill was before the House of Commons. Smoke Abatement.—From the tabular statement it will be seen that 92 smoke observations were made and 23 notices served. 31 TABLE 1 COMPARATIVE RATES OF MORTALITY, 1923. Birth-rate 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 & Enteritis under 2 yrs. Total deaths under 1 year Causes of Death certified by Registered Medical Practitioners Inquest Cases Uncertified Causes of Death England and Wales 19.7 11.6 0.01 0.00 0.14 0.03 0.10 0.07 0.22 0.44 7.7 69 92.0 6.9 1.1 105 County Boroughs and Great Towns, including London 20.4 11.6 0.01 0.00 0.15 0.03 0.12 0.09 0.22 0.40 9.9 72 92.2 7.2 0.6 157 Smaller Towns (1921 Adjusted Populations, 20,000-50,000) 19.8 10.6 0.01 0.00 0.19 0.02 0.10 0.06 0.21 0.38 6.4 69 92.6 6.1 1.3 London 20.2 11.2 0.01 0.00 0.08 0.02 0.09 0.13 0.17 0.45 10.2 60 90.8 9.1 0.1 Acton 18.6 9.5 0.00 0.00 0.00 0.00 0.06 0.05 0.12 0.4 11.1 65 93.2 6.8 0.0 TABLE 2. VITAL STATISTICS FOR WHOLE DISTRICT DURING 1923 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 Uncorrected Number Nett Under 1 year of Age At all Ages Number Rate Number Rate of Non-Residents Registered in the District of Residents Registered outside Dist. Number Rate per 1,000 Number Rate per 1,000 i habitants 1918 66,000 (for Birth-rate) 923 954 14.5 611 10.3 16 277 76 78 872 14.7 59,000 (for Death-rate) 1919 64,306 (for Birth-rate) 950 1096 17.1 436 7.0 12 222 72 65 646 10.4 61,732 (for Death-rate) 1920 61,000 1442 1541 25.3 560 9.2 16 217 100 64 671 11 1921 62,000 1225 1314 21.1 445 7.1 .. 205 92 70 658 10.4 1922 62,390 1021 1203 19.3 404 6.5 14 214 75 62 632 10.1 1923 62,720 1047 1171 18.6 368 5.8 11 243 77 65 599 9.5 32 33 TABLE 3. ALL DEATHS, 1923. Causes of Death 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 North East North West South East South West Whooping Cough 4 4 .. .. .. .. .. .. .. 1 1 1 1 Diptheria 3 1 1 .. 1 .. .. .. .. .. 1 1 1 Influenza 8 1 .. .. 1 1 1 4 .. 2 1 4 1 Tuberculosis of Respiratory System 54 .. 1 .. .. 15 26 8 1 10 7 13 24 Other Tuberculous Diseases 15 .. 1 6 2 1 4 1 .. 3 3 4 5 Cancer (Malignant Disease) 53 .. .. .. .. 1 10 2 22 9 11 16 17 Rheumatic Fever 2 .. .. .. 1 .. 1 .. .. 1 .. .. 1 Diabetes 5 .. .. .. .. .. 2 1 2 .. 1 1 3 Cerobral Hemorrhage 43 1 .. .. .. .. 2 10 30 15 9 11 8 Heart Disease 60 .. .. .. 1 2 8 20 29 25 10 13 12 Arterio Sclerosis 8 .. .. .. .. .. .. 3 5 .. 1 5 2 Bronchitis 56 6 1 1 .. .. 3 15 30 18 9 13 16 Pneumonia (all forms) 39 1 4 2 1 3 5 12 11 4 8 13 14 Other Respiratory Diseases 7 .. .. .. .. .. 2 3 2 1 1 2 3 Ulcer of Stomach and Duodenum 4 .. .. .. .. .. .. 2 2 1 2 1 .. Diarrhoea (under two years) 13 13 .. .. .. .. .. .. .. 8 .. .. 5 Appendicitis 1 .. .. .. .. 1 .. .. .. .. 1 .. .. Cirrhosis of Liver 1 .. .. .. .. .. .. 1 .. .. 1 .. .. Nephritis 14 .. .. .. 1 .. 4 5 4 5 3 3 3 Puerperal Sepsis 3 .. .. .. .. 1 2 .. .. .. .. 1 2 Other Accidents and Diseases of Pregnancy and Parturition 5 .. .. .. .. .. 5 .. .. 1 .. 1 3 Congenital Debility, Malformation and Prematurity 34 34 .. .. .. .. .. .. .. 7 6 11 10 Suicide 11 .. .. .. .. 1 3 6 1 5 3 2 1 Other forms of Violence 14 2 1 .. 2 .. 2 5 2 7 2 1 4 Other Defined Causes 140 14 .. 1 4 5 17 20 79 40 34 34 32 Ill-defined or Unknown Causes 2 .. 1 .. .. .. 1 .. .. .. .. 1 1 599 77 10 10 14 31 98 136 223 163 115 152 169 34 TABLE 4. INFANTILE MORTALITY, 1923. Causes of Death Under 1 week 1—2 weeks 2—3 weeks 3—4 weeks Total under 1 month 1—3 months 3—6 months 6—9 months 9—12 months Total under 12 months Wards North East North West South East South West Diphtheria .. .. .. .. .. .. .. 1 .. 1 .. 1 .. .. Whooping Cough .. .. .. .. .. 2 .. 2 .. 4 1 1 1 1 Meningitis (not Tuberculous) .. .. 1 .. 1 .. .. .. 1 2 .. .. 1 1 Influenza .. .. .. .. .. 1 .. .. .. 1 .. .. 1 .. Convulsions .. .. .. .. .. .. 1 .. .. 1 .. .. .. 1 Bronchitis .. .. .. .. .. 2 1 2 1 6 .. .. 1 5 Pneumonia .. .. .. .. .. .. .. .. 1 1 .. .. 1 .. Diarrhoea and Enteritis .. 2 1 .. 3 3 3 2 2 13 8 .. .. 5 Congenital Syphilis .. .. .. .. .. 1 .. .. .. 1 .. .. 1 .. Overlaying .. .. .. .. .. .. .. .. .. .. .. .. .. .. Injury at Birth 6 .. .. .. 6 1 .. .. .. 7 3 .. 2 2 Congenital Malformation 1 .. .. .. 1 .. 1 .. .. 2 .. 1 1 .. Prematurity 17 1 .. 1 19 2 3 .. .. 24 6 4 4 10 Atrophy, Debility and Marasmus 4 .. 2 .. 6 1 1 .. .. 8 1 1 4 2 Other Causes .. 1 .. 1 2 1 1 .. 2 6 2 1 .. 3 28 4 4 2 38 14 11 7 7 77 21 9 17 30 35 TABLE 5. CASES OF INFECTIOUS DISEASES NOTIFIED DURING THE YEAR 1923. Notifiable Disease. Cases notified in whole District. At Ages—Years. In Wards. 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 160 1 25 102 22 10 .. .. 47 18 68 27 Diptheria 61 3 14 36 3 5 .. .. 10 13 10 28 Enteric Fever 3 .. 2 .. .. 1 .. .. 2 1 .. .. Pneumonia 28 1 5 3 4 5 9 1 2 1 12 13 Puerperal Fever 3 .. .. .. 3 .. .. .. .. .. 1 2 Cerebro-Spinal Fever 2 1 1 .. .. .. .. .. 1 .. 1 .. Acute Poliomyelitis 2 .. 1 1 .. .. .. .. .. .. 2 .. Encephalitis Lethargica 1 .. .. .. .. 1 .. .. .. 1 .. .. Ophthalmia Neonatorum 4 4 .. .. .. .. .. .. 2 .. .. 2 Erysipelas 16 .. .. .. 1 6 9 .. 2 3 5 6 Tuberculosis (Resp.) 73 .. .. 1 22 35 12 3 18 4 23 28 Tuberculosis (Other) 24 .. 8 7 2 5 2 .. 6 3 6 9 377 10 56 150 57 68 32 4 90 44 128 115 36 TABLE VI. CASES REMOVED TO HOSPITAL-1923. N.East. N.West. S.East. S.West. Total Scarlet Fever 35 10 54 24 123 Diphtheria 7 8 7 27 49 Enteric Fever 2 — — — 2 Pneumonia — — — 1 1 Puerperal Fever — — 1 2 3 Cerebro-Spinal Fever 1 — 1 — 2 Acute Poliomyelitis — — 2 — 2 Encephalitis Lethargica — 1 — — 1 Ophthalmia Neonatorum 1 — — — 1 Erysipelas — — — 1 1 Tuberculosis (Resp.) 10 3 15 25 53 Tuberculosis (Other) 4 1 4 7 16 60 23 84 87 254 TABLE VII. BIRTHS. Total Births. Males Females Legitimate 560 568 Illegitimate 22 21 582 589 Notified Births in District. Males 487 Females 470 Still-Births 29. Wards. North East. North West. South East. South West. Total. 267 141 188 361 957 Births Registered but not Notified. Males 33 Females 57. North East. North West. South East. South West. Total. 40 11 27 12 90 Born Outside District, 124. Number of Births Visited 803 Number of Births Re-visited 8,909 TABLE VIII. INFANT WELFARE CENTRES—1923. Health Visitors' Attendances 250 Number of Children who attended 1,486 Number of Attendances by Children 12,183 ANTE-NATAL CLINIC. Number of times Clinic was held 23 Number of Expectant Mothers who attended 63 Number of attendances made by Expectant Mothers 123 Number of cases admitted to Acton Hospital 6 37 Ante-Natal Visits. Number of Mothers visited 200 Number of Visits paid to Mothers 545 TABLE IX. INQUESTS. (Including Non-Residents' Deaths in District). Heart Disease 5 Suicide 11 Heat Stroke 3 Injury by Motor Vehicle 4 Dilated Heart 1 Accidental Fall 4 Diabetes 1 Found Drowned 2 Hæmorrhage into Kidney Cyst 1 Found Dead 1 Cerebral Hæmorrhage 1 Injury at Birth 1 Status Lymphaticus 1 Suffocation whilst asleep in perambulator 1 Ruptured Aneurysm 1 Ruptured Vena Cava 1 Death under Anæsthetic 1 Gastric Ulcer 1 Fractured Femur 1 Pulmonary Tuberculosis 1 Fractured Skull 1 Collapse of Lung 1 Obstruction of Pylorus from Swallowing Corrosive Poison 1 TABLE X. BACTERIOLOGICAL LABORATORY. Positive Negative Total Examinations (973) 171 802 Sent by Medical Practitioners (239) 36 203 Sent from Isolation Hospital (228) 57 171 Contacts (199) 36 163 Of These Positive Contacts. 19 were positive on the first occasion only. 12 „ second „ „ 5 „ third „ „ School Sore Throats. Positive Negative Cases Examined (264) 19 245 Four of the Positive sore throat cases had sufficient clinical symptoms to warrant removal to Hospital. FACTORIES AND WORKSHOPS. Premises Number of Inspections Written Notices Prosecutions (1) (2) (3) (4) Factories (including Factory Laundries) 97 34 — Workshops (including Workshop Laundries 403 65 — Workplaces (other than Outworkers' Premises) 38 13 — Total 538 112 Nil 38 Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects Found Remedied (1) (2) (3) Nuisances under the Public Health Acts:— Want of Cleanliness 34 34 Want of Drainage of Floors 7 7 Unsuitable or Defective Sanitary Accommodation 51 51 Total 92 92 HOME WORK. OUTWORKERS' LISTS, SECTION 107. Nature of Work. Lists received from Employers. Sending twice in the year. Lists Outworkers Contractors Workmen (1) (2) (3) (4) Wearing Apparel— Cleaning and Washing 1 — 4 Brush Making 2 11 — Stuffed Toys 2 67 — Total 5 78 4 TABULAR STATEMENT OF INSPECTIONS AND DETAIL OF WORK CARRIED OUT BY THE SANITARY INSPECTORS. Number and nature of Inspection made. House to house inspections 368 After infectious disease 374 On complaint, etc 903 Premises under periodical inspection 597 Re-inspections after notice served 8,314 Enquiry visits on notification of infectious disease 454 Classified statement of the number of Premises under periodical Inspection. Workshops 219 Slaughterhouses 3 Public House Urinals 37 Common Lodging Houses 1 Houses let in lodgings 103 Butchers' Shops 33 39 Fish Shops 24 Premises where food is manufactured 40 Milk purveyors 80 Cowsheds 2 Piggeries 4 Rag and Bone Dealers 4 Mews and Stables 22 Schools 11 Show Grounds 2 Houses dealt with under Section 28, Housing Acts. Houses in respect of which notices were served 244 Rendered fit by owners 244 Rendered fit by local authority nil Premises dealt with under Public Health Acts. Premises in respect of which notices were served 879 Premises in which defects were remedied by owners 879 Premises in which defects were remedied by local authority nil Detail of work carried out. Sanitary dustbins provided 572 Yards paved or yard paving repaired 228 Insanitary forecourts remedied 126 Defective drains repaired or reconstructed 74 Defective soil pipes and ventilating shafts repaired or renewed 53 Defective fresh air inlets repaired or renewed 41 Defective gullies removed and replaced by new 74 Rain water downpipes disconnected from drain 17 Dishing and Curb to gullies repaired and new gratings fixed 142 Defective W.C. pans and traps removed and replaced by new 69 Defective W.C. flushing apparatus repaired or new fixed 274 Defective W.C. seats repaired or new fixed 192 Defective flush pipe connections repaired 73 Insanitary sinks removed or new fixed 28 Sink waste pipes repaired or trapped 209 Insanitary wall surfaces over sinks remedied 133 Ventilated food cupboards provided 28 Drinking water cisterns cleansed 187 Defective covers to drinking water cisterns repaired or new fixed 43 Insanitary sites beneath floors concreted 14 Spaces beneath floors ventilated 172 Dampness in walls from defective damp-proof course remedied 195 Dampness from defective roofs, rain water, gutterings, etc., remedied 723 40 Defective plastering repaired (number of rooms) 613 Rooms where dirty walls and ceilings have been cleansed and redecorated 2,411 Defective floors repaired 217 Defective or dangerous stairs repaired 62 Defective doors and windows repaired 402 Defective kitchen ranges and fire grates repaired 274 Defective washing coppers repaired 128 Coal cupboards provided 21 New W.C. apartments provided 6 Accumulations of offensive matter removed 32 Drains unstopped and cleansed 145 Overcrowding nuisances abated 22 Drains tested, exposed for examination, etc. 141 Smoke observations taken 92 Smoke nuisances abated 23 Nuisances from foul pigs and other animals abated 19 Notifications of waste of water sent to Metropolitan Water Board 264 STAFF TO WHOSE SALARY CONTRIBUTION IS MADE UNDER THE PUBLIC HEALTH ACTS OR BY EXCHEQUER GRANTS. D. J. Thomas. m.r.c.s., l.r.c.p., d.p.h., Medical Officer of Health. (Medical Superintendent of the Isolation Hospital and School Medical Officer). M. W. Kinch. Member of the Royal Sanitary Institute, holds Meat Certificate; Senior Sanitary Inspector. (Inspector under Diseases of Animals Acts, and the Rag Flock Act). J. J. Jenkins. Cert. Sanitary Institute. Holds Meat ficate. Sanitary Inspector. (Inspector under Fabrics Mis-description Act). E. W. Brooks Cert. San. Inst. Sanitary Inspector. J. J. Matthews. Cert. San. Inst. Sanitary Inspector. Miss 4. Cooksey. Cert. San. Inst. Health Visitor. Miss J. Welsh Cert. San. Inst. C.M.B. Health Visitor. Mrs. Light. Clerk. I beg to thank all the members of the staff in the Public Health Department, not only for assistance in the compilation of the report, but for a record of conscientious service throughout the year. I am. Your obedient servant, D. J. THOMAS.