Ac.439(1)ACTON Act 27 MILDLESEY Borouggh of Acton. ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1924. Borough of Acton. ANNUAL REPORT OF THE Medical Officer of Health For the Year 1924. 3 ANNUAL REPORT OF THE medical officer of health FOR THE YEAR 1924. Municipal Offices, Acton, W.3. May, 1925. To the Mayor, Aldermen and Councillors of the Borough 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 1924. As far as possible, the tables have been arranged in a manner similar to the arrangement in previous years. The birth-rate is again lower than that of 1923, and is now below the general birth-rate for England and Wales. The death-rate is higher than that of 1923, and is the highest for the district since 1918. A higher death-rate has been general throughout the whole of the kingdom, and the rate here is below that of England and Wales. The Infantile Mortality is again lower, and constitutes a record for the district. The Tubercular death-rate, and the death-rate from Consumption are also lower, but there is a very marked increase in the number of deaths from Cancer. The following Table is a summary of the birth-rate and the death-rate from some of the principal causes of death:— Population. 02,980 Birth-rate 18.4 per 1000 inhabitants. Death-rate, all causes 11.2 „ „ „ Zymotic death-rate .46 ,, „ ,, Tubercular death-rate .89 ,, ,, ,, Death-rate from Consumption or Pulmonary Tuberculosis .74 ,, „ ,, Cancer death-rate 1.4 „ „ ,, Infantile Mortality 56 per 1000 births. 4 Population.—The Registrar General estimates the population at the end of June 1924, to be 62,980, an increase of 260. It is probable that this estimate is below the actual number of inhabitants in the district, but the figure given by the Registrar General has been retained, because it is the figure used for comparative purposes in the different returns issued by the General Register Office. There was an increase of 605 in the number of Parliamentary electors on the registers in the Autumn of 1924, as compared with the same electoral list of 1923. The numbers in 1924 were as follows:— Men. Women. Total. 17,408 14,591 31,999 The increase in the total number of Parliamentary electors is shown in the following table:— 1921. 30,350. 1922. 30,425. 1923. 31,394. 1924 31,999. It is possible that an increase in the number of persons living at a certain age-period may be disproportionate to the increase in the rest of the population. It may even occur that the increase in the number of persons living in an age-group may be greater than the total increase in the population of a district. A disproportionate increase at different age-periods would occur with a falling birth-rate and with emigration and immigration. Both a falling birth-rate and migration in and out of the district are in operation, but not to such an extent as to limit the increase of population to one age-period. During the year ending December 31st, 1924, 200 new dwelling houses were completed and occupied. At the Census which was taken on June 19th, 1921, the actual number enumerated in the district was 61,299. Owing to the abnormally fine weather in the summer of that year, some holiday movement was already in progress, and the Registrar General from the figures at his disposal made certain adjustments in the population of certain districts. The adjusted figure for Acton was 62,000. The estimated increase in the population since the Census is less than a thousand inhabitants, though in the 3 years 1922, 1923 and 1924, 406 new houses have been completed and occupied. 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:— 5 Ordinary relief £5,514 2 10 Unemployed relief 1,071 16 9½ Total £6,585 19 7½ There is a decrease in both amounts, compared with 1923, and a most marked decrease in the amount of unemployed relief. HOSPITAL PROVISION. General.-The Acton Hospital, Gunnersbury Lane, provides for the treatment of medical and surgical cases of both sexes. It is maintained chiefly by voluntary subscriptions, and the number of beds is 50. 456 in-patients and 3952 out-patients' were treated in 1924. Fever. The Isolation Hospital has accommodation for 80 patients. Nursing Facilities.-As recorded in previous reports, 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. 113 cases were visited by the district nurse in 1924, to whom 3,573 visits were paid, Ambulance Service.—For accidents, an agreement was made with the Chiswick Council for the use of the Chiswick ambulance. The Acton Council paid for the use of the ambulance in respect of street accidents where the ambulance was requisitioned by the police. This agreement was terminated in August 1924, and an arrangement was made with the Ealing Council for the use of the latter's ambulance until the Acton Council obtained its own ambulance. The new ambulance was purchased early in 1925, and is housed in a garage adjoining the Fire Station. For the removal of Infectious Cases, the Council has its own ambulance, which is housed in the Isolation Hospital. 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 1,158, and the birth-rate was 18.4 per 1000 inhabitants, as compared with 18.6 in 1923, and 19.3 in 1922. 6 The birth-rate for England & Wales wasl8.8, for London 18.7, and for the 105 County Boroughs and large towns including London 19.4. Throughout the Country the birth-rate is still showing a continuous decline, and Acton shows no exception to the general rule throughout the kingdom. Last year, with the exception of 18, particulars were obtained of the births belonging to Acton, whether registration had occurred inside or outside the district. It is therefore possible to give a fairly accurate birth-rate for each of the Wards. The Ward birth-rates were as follows: North-East. North-West. South-East. South-West 19.1 11.7 15.3 24.2 34 children were born out of wedlock; this number corresponds to an illegitimate birth-rate of 29 per 1000 births, compared with 36 in 1923. Not since 1910 has a lower illegitimate birth-rate been recorded for the district. One of the most marked features of Table VII has been the increased percentage of births which were notified. Only 19 births were registered which had not been previously notified, compared with 57 in 1923, 109 in 1922, and 66 in 1921. In the Autumn of 1923, the numerous infringements of the Notification of Births Act were discussed by the Maternity and Child Welfare Committee and different ways and means were suggested whereby an improvement could be effected. Doctors and Midwives were circularised, and an advertisement issued in the press. The result has been gratifying and the percentage of non-notified births in 1924, has been the lowest since the Act came into force. Deaths.—488 deaths were registered in the district; of these 11 deaths were of non-residents; 235 deaths of residents occurred outside the district. The total number of deaths belonging to the district is 715. The nett number of deaths corresponds to a death-rate of 11.2 per 1000 inhabitants, compared with 9.5 in 1923, and 10.1 in 1922. Although the figures appear unfavourable, there are factors which modify their character. A higher death-rate was common throughout the kingdom. Last year the death-rate of the whole of England and Wales was 12.2, of the 105 Great Towns, 12.3 and of London 12.1 per 1000 inhabitants. The greatest increase in the number of deaths occurred in old people. There were 286 deaths among persons over 65 years of age, compared with 223 in 1923, and in the age-periods 45—65 years of age, 180 deaths compared with 130 in 1923. There were slight increases in the age-periods 1-25 years, and a slight decrease 7 in the number of deaths in infants under 1 year and in the ageperiod 25—45 years. There was a higher death-rate in three of the wards and a lower one in the South-East Ward. The death-rate in each ward was as follows:— North-East. North-West. South-East. South-West. 12.2 11.8 9.2 12 Among the diseases which caused an increased number of deaths, the most prominent were Measles, Heart Disease and Arterio-sclerosis and Cancer. The increased number of deaths from Measles is dealt with on a later page. Measles is a disease which occurs in epidemic form practically every other year, and in this districtl924 was an epidemic year. The question of heart disease was referred to in last year's Annual Report. The increased number of deaths is probably not due to an increase in the incidence of heart disease, but to the more exact methods of diagnosis and to wider conceptions of the effects of heart disease and more especially to the importance of injury from infection of the heart muscle. The problem of the etiology and treatment of heart disease in early life has frequently been discussed of late, both in this country and in America. Although the need for fuller information regarding the whole etiology of rheumatic fever is recognised, there is general agreement on the need for prolonged convalescense after rheumatism if the heart is to be protected and the liability to recurrence lessened. In the course of inspection amongst school children, it is a too common experience to find that the parents have treated an attack of rheumatism as a trivial affair. In many instances the illness has been regarded as growing pains, but permanent damage has resulted to the heart. Cancer.—A very marked increase occurred in the number of deaths from Cancer. In last year's report it was stated that circulars and memoranda had been issued by the Ministry of Health and as a result of a Conference of the Local Authorities within the Brentford Union, a committee had been formed for the purpose of exploring any and every avenue which may lead to a diminution of the ravages of the disease. The Memoranda issued by the Ministry of Health emphasize the advice given by the local committee. The latter recommend the issue of leaflets pointing out the danger of delay in obtaining treatment and emphasizing the importance of removing any source of chronic irritation. 8 Memorandum 3 of the Ministry of Health contains certain facts relating to Cancer of the Breast and the results of operation in connection with this condition. In every case of Cancer of the breast, the problem of operation is one of primary importance, and two questions naturally arise, viz. the immediate risks of the operation and the chances of nonrecurrence of or cure of the disease. Under modern conditions, deaths directly attributable to the operation, if performed by skilful surgeons and in well-equipped institutions, have been reduced in the case of breast operations to a fraction of 1 per cent. This figure is reassuring in view of the fact, that at the present time early surgical interference affords the one chance for a patient suffering from cancer of the breast. Cases of cancer treated only with internal medicines, or external applications or by dietic methods are not being effectually treated. What measures of success may be expected from the operation? It is satisfactory to obtain figures from the Ministry of Health as these are authoritative and not biassed by the views of the actual operator. The Memorandum states with confidence that, even under the unsatisfactory conditions imposed by the late stage at which many cases come under surgical observation, the mean duration of life is prolonged several years. In the special circumstances of operation at the most favourable—that is, the earliest moment after recognition of a lump in the breast, there is an average prolongation of life amounting to many years. Although the term prolongation of life is used, it is certain, that cure, in the widest popular sense of the word, has frequently been effected by early operation, i.e., patients have lived ten, fifteen, twenty or more years and died ultimately of some other disease. Another Memorandum on Cancer issued by the Ministry of Health on the main lines which experimental cancer research has followed in recent years, is interesting to local authorities because of the bearing of such research on the necessity or desirability of disinfection after a death from Cancer. Certain broad conclusions, negative as well as positive, are deducible from the several branches of this work. From very early times men's minds have been exercised by speculation or conjecture on the causation of cancer, and within recent years an enormous amount of research work has been carried out, in order to ascertain the grounds on which the various conceptions and theories of the cause or causes are based. From an administrative point of view the two most important theories are those which may be called the infective theory and the chronic irritation theory. The underlying conception of the first theory is the presence of a microbe or microbes; it was supposed that cancer was due to 9 invasion by a parasitic microorganism and was therefore of an infective nature. The vogue of cancer houses and cancer areas was propagated as a result of this theory. None of the experiments inspired by this hypothesis has led to the production of a new growth of more than a temporary character, and we are justified in stating that disinfection of premises and clothing after a cancer death has no effect in the prevention of the disease. The theory of chronic irritation was propounded by Virchow, and is based on the conception that chronic irritation was of great causative importance in the production of cancer. The latter theory is the only one which has positive results to record. The substances which have given most results have been tar, paraffin and arsenic, but it is unlikely that any single chemical constitutent is solely responsible. The trend of these researches emphasizes the importance of the advice given by the local cancer committee to remove any source of local irritation either to the tongue, breast, bowels or any part of the body which may be liable to such irritation. Deaths in Public Institutions.-216 of the deaths of residents outside the district occurred in public institutions, and 40 deaths of residents occurred in public institutions in the district. These numbers do not include deaths which occurred in nursing homes. 256 out of a total of 715, or nearly 36 per cent. of the total deaths occurred in public institutions. Infectious Diseases.-On Table V. will be found the ageincidence and Ward distribution of the compulsorily notifiable infectious diseases. Scarlet Fever. There was again a diminution in the number of notified cases, but one death was allotted by the Registrar General, though the circumstances were such that the death could hardly be said to belong to this district. The death was that of a child 14 months old, and occurred in the Infirmary on July 9th, 1924. She was taken to the Infirmary on September 14th, 1923; so that not only the death occurred, but the illness was obviously contracted out of the district. As the child had resided in, and was moved from Acton to the Infirmary, the death was allotted to this district. Diptheria.-There was also a diminution in the number of notified cases of Diptheria, but the number of deaths is higher than that of 1923. As an instance of an extremely virulent kind of Diphtheria, in which an outbreak was probably cut short by prompt measures, I may mention the cases which occurred in the Acton Wells Infant Department in September. The circumstances 10 were noteworthy, not for the number of cases, as only 6 cases altogether occurred, but from the severity of the symptoms, as two of the children died. The first case was notified on September 26th, and the second on September 27th. Both children attended the same class, and on September 29th, all the children in this class, to the number of 56, were swabbed. Two swabs were found to be positive, and in one of them the culture was almost a pure growth of the Diphtheria bacillus. On further examination of one of the children in whose throat the germs had been found, she was found to be suffering from a sore nose and swollen glands of the neck. From her appearance there could be no doubt that she was a clinical case of Diphtheria that had been missed. The other children in the house were examined and in all probability, two of them had also suffered from a missed attack of Diphtheria. Swabs were taken and in both instances they contained the bacilli associated with Diphtheria. In the other case attending the class implicated, in which a positive swab was obtained, the child was probably only a carrier, but she was excluded from school until negative swabs were obtained. No further cases occurred in the school, and it seems probable, if not certain, that the two fatal cases arose from association with one or both of the children in which a positive swab was obtained and who were excluded as a result. This is not an isolated instance; similar incidents constantly occur. Possibly in no sphere of preventive medicine, can bacteriological knowledge be so successfully applied in the prevention of the spread of disease as in the case of Diphtheria. In almost every instance, the means and the methods adopted are successful, and yet, not infrequently we have complaints from parents. Sometimes they object to the swabbing of the throat, and frequently they protest in vigorous langauge against any suspicion that their children can in any way be responsible for the spread of the disease. Their objection, of course, is due to ignorance of the true facts or a misunderstanding of our motives. The fact that a child may have had an attack of Diphtheria which was missed, does not necessarily imply that the parents have been remiss or neglectful. The attack may have been so slight as to escape detection. Ophthalmia Neonatorum. 4 cases were notified. One of them was a severe case and was admitted into the Acton Hospital for treatment from June 26th to July 10th. All the four cases made a good recovery, and the sight was not permanently affected by the disease. Encephalitis Lethargica.—6 cases of Encephalitis Lethargica were notified, and 3 deaths occurred. Another of the cases 11 notified also died, but the death was certified to be Meningitis. The patient was admitted to the Infirmary, and the diagnosis of Encephalitis Lethargica was not confirmed by the Medical Superintendent. Only 2 of the patients recovered, but it is possible, and even probable, that other cases occurred in which the symptoms were of a mild character. One of the cases notified here, was of an extremely mild type, and the characteristic symptoms could easily have been missed by the doctor in attendance, had the latter not recently seen some other encephalitis cases. In another of the cases two specialists, who were called in, had failed to recognise the nature of the illness, and it was only when a third specialist who had had exceptional experience in this type of disease was called in that the illness was diagnosed as Encephalitis Lethargica. There are many reasons for the difficulties which may arise in the diagnosis of the illness. The most important is the endless variety which the symptoms show. The original conception of the clinical syndrome now known as encephalitis lethargica has broadened considerably with increased experience. In some quarters doubt has been expressed as to the existence of the disease as a separate entity. Some authorities have claimed that Encephalitis Lethargica, Spotted Fever and Infantile Paralysis are simply variants of Influenza. It is now generally admitted, though, that the disease is a separate entity, having well-marked and well-recognised symptoms. These symptoms vary not only in their severity, but also in their character. In severity the symptoms may vary from those of the mild type which is often missed and in which no after effects are left to those in which the disease is rapidly fatal. The symptoms also may be those of a generalized infection, or those more directly referable to the central nervous system. In the latter, lethargy is a prominent symptom in many of the cases ; the term lethargic is still used in describing the disease. This however, is by no means a constant symptom. Indeed, insomnia is an equally striking phenomenon in many cases, and in some patients both conditions may be present at different times. From a public health point of view, one of the most serious questions is the mental after effects of the disease. The conception of the disease has undergone very considerable modification since the earlier cases were met with in the spring of 1918. At that time the disease was regarded as a more or less acute affection, which, should the patient survive, left residue in its wake somewhat after the manner of infantile paralysis, although more or less oomplete recovery might be eventually anticipated in the majority of cases. 12 Further experience has demonstrated that the ultimate outlook is much more serious than was at one time supposed. In children, especially, mental changes result, persist and prove permanent. It is impossible at present to say what proportion of surviving cases exhibit after effects, whether mental or physical. It appears to be probable that mental after effects, especially in children, occur in a large proportion of the surviving cases. Despite the valuable statistics available, nothing definite can be deduced regarding any conditions that might dispose an individual to an attack. The disease appears however, to have selected more particularly those of either sex following sedentary occupations, while, as regards age incidents, the age-period 10-20 years has proved to be the most susceptible. The means and modes by which the infection of the disease is naturally carried from person to person remain obscure; very seldom can an attack in any individual be traced to the patient's contact with an obvious case of the disease. The hypothesis of the "healthy carrier" has been put forward, but it is obvious that no very definite lines of prophylaxis can be laid down until we have the means of determining the individuals who are the unconscious reservoirs of the poison. Small-pox.-No cases of Small-pox occurred in Acton during the year. Contacts of cases of Small-pox reaching the various ports were on several occasions notified by the port authorities, and were kept under observation until the incubation period had passed. Some cases of Small-pox in a neighbouring district involved the supervision of a large number of contacts in Acton. One of the sufferers was employed in a large factory in Acton, and another patient was employed in a large engineering factory on the borders, and a number of the employees resided in Acton. Tuberculosis.—There were 47 deaths from Pulmonary Tuberculosis and 8 deaths from other forms of Tuberculosis. During the year 85 notifications of Pulmonary Tuberculosis and 9 notifications of other forms of Tuberculosis were received. The Public Health Tuberculosis Regulations, 1924, came into force April 1st, 1925. Under Article 4 of the Regulations of 1921, the Medical Officer of Health was required to remove from the Tuberculosis Register the entries relating to notifications in respect of persons who have, to his knowledge, died or have ceased permanently to reside within the district. 13 In order to comply with the Regulations of 1924, a complete investigation was made into all the cases, which had been notified since the introduction of notification. Cases were removed in which after notification the diagnosis of tuberculosis is agreed not to be established, or the patient in due course attains a condition in which he may be regarded as cured of the disease. After making the necessary corrections and investigations, it was found that there were 198 cases of Pulmonary and Nonpulmonary tuberculosis in the district. During the year 35 patients suffering from Pulmonary Tuberculosis were treated at a Sanatorium under the Middlesex CoUnty Council scheme, and 11 at a hospital. In addition 5 cases of Surgical Tuberculosis were treated at a Hospital. Measles.—There were 16 deaths from Measles. This is the highest number of deaths from Measles in one year since 1917. In former Annual Reports it has been commented upon that Measles had become much less virulent. Possibly, this diminished virulence was partly due to the fact that the disease had for some years appeared in epidemic form in the summer. It is known that a summer epidemic of Measles is less fatal than a winter one. Not only are the lung complications less frequent, but the disease itself appears to be of a less virulent type. This is probably not a sufficient explanation. Last year the epidemic was entirely a winter one, and yet the fatality though higher than that of recent years, was much lower than formerly when a winter epidemic occurred. It is too soon to express any general opinion, because, Measles in former times has assumed degrees of virulence. Towards the end of last century and the beginning of this, throughout the kingdom the mortality from Measles became markedly increased. In the last decade, the mortality has been considerably lower. There does not seem to be much difference in the type of the disease. The reduced mortality may be related to another phenomenon, which is noticeable in our vital statistics. Comment is frequently made upon the greatly reduced infantile mortality, but although not so frequently commented upon, the reduction in the mortality in the age-period 1-5 years is almost, if not fully so marked. This is not the place to discuss the general question of the effect of infant welfare work upon the mortality between the ages of 1 and 5 years. There are or there were two schools of thought. On the one hand it was contended that the work of infant welfare was worse than useless, as it tended to perpetuate the weaklings. Figures have disproved this theory. It is now generally held that the infant welfare work results, not only in the saving of infant lives, but in an improved physique in later years. Formerly, when 14 the infantile mortality was high, the mischief extended beyond the age-period under 1 year. For every infant that was killed others were maimed and scarred. When the conditions under which the infants were reared were improved the results were observed not only in a reduced infantile mortality, but in a reduced mortality in the age period 2-5 years, and in an improved physique of the school entrants. It is possible that one explanation of the lowered mortality and fatality from Measles is associated not with a diminished virulence of the germ of Measles, but with a higher resistance of the individual. Last year's epidemic was in time and course a winter epidemic. The First case occurred on November 26th, but as far as can be gathered no extension of the disease beyond the affected house took place. On the re-opening of the schools after the Christmas holidays, several cases were reported from different schools. The epidemic lasted up to Easter and as stated 14 deaths occurred. MATERNITY AND CHILD WELFARE. Notification of Births Act. 1042 live births and 16 stillbirths were notified. The improved conditions and the lowered percentage of non-notified cases are referred to on a previous page of the report. It is satisfactory to note that last year over 98 per cent. of the births were notified within the statutory period. 779 of the births were visited by the Health Visitors, and the number of visits paid to the homes was 8,463. Infantile Mortality.—65 deaths occurred in children under one year of age. This number corresponds to an infantile mortality of 56 per 1,000 births. This is the lowest infantile mortality recorded in the district; on no other occasion has it been below 60 per 1,000 births. The rate for England and Wales was 75, for the 105 Great Towns 80, and for London 71 per 1,000 births. In the year, four unknown babies were found in the district 2 in the allotments near St. Dunstan's Avenue, I near Victoria Road, and 1 in a field near Old Oak Lane. If these were deducted, the infantile mortality would be 52 per 1,000 births. The Ward distribution of the infantile deaths was as follows:— North-East. North-West. South-East. South-West. 20 9 8 28 The Ward infantile mortality was:- North-East. North-West. South-East. South-West. 59 35 34 68 The infantile mortality of the North-East Ward is unduly high on account of the 4 dead infants found in the district and which really did not belong to Acton. All four were found in the North 15 East Ward. Deducting these, the infantile mortality of the North East Ward was 44 per 1,000 births. Although the infantile mortality of the South West Ward is higher, it shows even a greater improvement than that of the other wards. Health Visiting. During the year, 779 of the births were visited by the Health Visitors, and 8463 visits were paid to the homes of the children. In addition, 225 expectant mothers were visited, and 454 re-visits were paid in respect of this service. It has been explained that the Council does not distribute free milk as a routine proceedure; only in exceptional circumstances is milk provided free. An arrangement was made with the Guardians for the distribution of dried milk at two pence a packet under cost to children under 3 years of age. The Council, in exceptional circumstances, distributes free milk to expectant mothers, and last year 40 expectant mothers were supplied with 414 packets of dried milk. Maternal Mortality. A reference to Table III will show that 7 deaths of women occurred in child-birth-2 from Puerperal Sepsis and 5 from other accidents and diseases of pregnancy and parturition. Considerable attention has been paid in the past year to this important matter and the Ministry of Health issued a Circular to local authorities dealing with the question of Maternal Mortality associated with childbearing. The Circular was based upon Dame Janet Campbell's report on Maternal Mortality which was publi hed earlier in the year. This was the third report by Dr. Janet Campbell on the subject of Maternal Mortality, and dealt with the general subject of the causes of an excessive maternal mortality and the means of its reduction. Sir George Newman in his prefatory note to the report summarizes its outstanding features as follows:— 1.-Matornal Mortality is relatively excessive in England and Wales In respect of the proportion of Maternal Mortality, England and Wales compares unfavourably with Germany, Norway, Italy, Sweden and Holland. 2.-Since 1902, Maternal Mortality has not declined proportionately in the same degree as the general death-rate or the infantile mortality. The child-bearing mother is not sharing equally with the rest of the population in the improved public health. 3.—The risks to women in their first confinements are greater than in most subsequent confinements. 4.—The decline in the birth-rate has exerted a relatively small effect upon the degree of maternal mortality. 16 5.—Maternal deaths are due principally to sepsis (puerperal fever) and to other complications of pregnancy, but deaths due to the former have shown a greater decline since 1902 than those due to the latter cause. 6.—Excessive rates of maternal mortality are found in the aggregate in the most rural areas, and in highly industrial areas. Critical examination of the statistics pertaining to maternity and child welfare has brought to light the uncomfortable fact that although there has been in recent years an enormous saving of infant life, there has been no material alteration in the maternal death-rate.. No doubt the concentration of attention upon the infant and the remarkable results achieved have, in a measure, detracted attention from the maternal side of the question, but that is no reason why equal care should not be bestowed on both parties. One of the most striking characteristics of our mortality returns has been the steadv and continuous decline in the death-rate, and one of the most hopeful features of our sanitary history is that at certain ages—most noticeably in infancy—the rate of advance is not slacking, but even accelerating, while for certain diseases, especially tuberculosis, the temporary set back associated with the war-period is being overcome. But in the matter of death in childbirth, the mother has not shared equally with her child in the improvement of public health. The maternal deaths throughout England and Wales have varied from 3.55 per 1,000 births in 1918 to 4.81 in 1900. In Acton they have varied from .33 in 1901 to 7.52 per 1,000 births in 1916. Too much reliance should not, of course, be laid upon occasional local variations in mortality, but if we take any extended periods for comparison, the conditions cannot be regarded as favourable to this district. Prior to 1905, the figures for Acton are not reliable, as no outside deaths were included in the returns for the years 1898—1905. If we divide the period 1905-1924 into 5 periods of 4 years, the figures would be as follows:— 1905—1908. 3.74 maternal deaths per 1000 births. 1909—1912. 2.7 1913—1916. 4.53 ” ” ” 1917—1920. 4.59 ” ” ” 1921—1924. 4.6 ” ” ” 1924. 6.04 ” ” ” Compared with that of the whole of England and Wales, and with that of the Metropolitan Boroughs, the maternal mortality here is high. An examination of the distribution reveals some puzzling figures and does not lead to a definite conclusion. In the poor working class Metropolitan Borough of Shoreditch, the rate of mortality in 1919-22 (2.55) was the lowest but two of all the Metropolitan Boroughs, surpassed only by the City of 17 London-a very special district-1.66 and the working class Borough of Stepney (2.42). Both Hampstead and Lewisham with the lowest rates of infant mortality of the metropolis had higher maternal mortality rates than Shoreditch (with the highest rate of infant mortality). Maternal mortality does not seem to bear much relation to the percentage of married women engaged in extra-domestic duties. In the Metropolitan Boroughs, the lowest mortalities are in those districts which have the highest percentage of married women engaged in some extra-domestic occupation. In last year's report, figures were given showing the position of Acton in this respect. The relationship between these two factors has been discussed, but no definite conclusion can be drawn. Certain kinds of employment may be harmful. The nature of the work may be such as to exert a harmful effect upon pregnancy and child-bearing, as, for example, certain processes necessitating the use of lead; or the work may involve heavy lifting or abdominal strain or pressure, as in some operations in the tinplate industry or in weaving. In Acton there is no work which can be considered directly harmful. In spite of changes, the industry which employs most of the married women is the laundry industry, and in no part of the process are there conditions which can be regarded as directly or indirectly harmful. The effect of general sanitation and housing upon maternal mortality is not quite obvious. A sanitary wholesome dwelling is of obvious importance at the time of confinement, quite apart from its effect upon the general health of its inmates. One would expect the incidence of puerperal infection to be high under conditions of overcrowding, defective lighting, ventilation and drainage. In point of fact, insanitary conditions appear to have a less injurious effect upon maternal mortality than might be supposed. Domestic uncleanliness and lack of facilities and conveniences add enormously to the difficulty of applying effectual antisepsis and to the risks of operative procedure. Hence, in abnormal labours, every endeavour should be made to remove the patient to an institution before attempting instrumental delivery. It is desirable to refer to the clinical cause to which the majority of deaths are attributable, but it is important to lay emphasis upon the fact that the actual deaths form only a part, and perhaps a comparatively small part, of the whole problem of maternal mortality and morbidity. For every mother who dies, there are many more who are injured more or less seriously, more or less permanently. These preventable sequelae of child-bearing cannot fail seriously to reduce the health and capacity for work, to say nothing of the comfort and happiness of many working class women, and the elimination of such causes of sickness and disability is of little less importance than the reduction of the mortality. 18 The chief cause of death is Puerperal infection or Puerperal Fever, or Puerperal Sepsis. Puerperal Sepsis not only easily ranks as the prime cause of death amongst women in child-birth, but also leads to more subsequent injury in the case of survival than any other complication of child bearing. As it is in the nature of an external infection, it ought to be well within the scope of prevention. The discovery of the specific germ of septic infection by Pasteur and the development of the principles and practice of antisepsis by Lister, made possible the definite progress in the control and management of puerperal fever. The application of the new knowledge has led to the practical disappearance of puerperal fever from lyingin hospitals which were formerly devastated by epidemic infection. Similar success has not followed in the private practice of midwifery. Puerperal Fever is one of the compulsory notifiable infectious diseases, but it is well known that the system of notification as far as puerperal fever-is concerned has broken down and is worthless. It is probable that not more than 5 per cent. of the cases are notified. In some districts the deaths exceed the notifications. In this district the figures have been as follows in the last 3 years:— Year. Notifications. Deaths. 1924 5 2 1923 3 3 1922 2 1 The causes of this failure are probably many and complex. Some difficulty arises in defining clearly what is meant by puerperal fever as was shown by the discussion on this subject at the Royal Society of Medicine, and it is admitted that at an early stage it is not always possible to decide as to the cause of a rise of temperature. The chief cause of the breakdown of notification lies in the want of any means by which effective assistance can be rendered to the patient. The main object of notification is not so much to acquire statistical information, helpful though it may be at times, but to secure specialised treatment for the patient and to permit the early exercise of preventive measures. With the exception of the Infirmary, there is no provision for the institutional treatment of puerperal sepsis. Beds in maternity homes are mainly intended for non-infectious cases, and the facilities for isolation are limited. There is an objection on the part of patients to avail themselves of the facilities offered by the Poor Law authorities. The most important instrument within our reach to reduce maternal mortality is ante-natal care. This is true not only of puerperal sepsis, but more so of causes other than sepsis. Until ante-natal supervision is accepted by patients and their advisers as the invariable duty of the professional attendant engaged for the confinement, substantial progress towards the reduction of 19 nal death and injury will not be made. It is the key to success in any scheme of prevention, and it must be insisted upon in and out of season until it is no longer ignored or looked upon as a luxury for the well-to-do woman, but is recognised as a necessary and integral part of the management of every confinement case. The special value of ante-natal care, as far as puerperal sepsis is concerned, is to reduce the number of difficult labours, which always involve manipulation, and especially emergency operations. These render patients particularly liable to sepsis, partly from opportunity of infection, and also from damage to the tissues. Ante-natal examination also affords an opportunity for treating before the confinement septic infections from which the woman may suffer. It is disappointing to find how few patients, even primiparae, are examined before labour in the course of ordinary practice. The Council does not possess a maternity home. Some years ago the Council had an agreement with the authorities in charge of the Salvation Army lying-in-hospital in Clapton. The hospital is an excellent one and was very popular with the mothers who were confined there. Its popularity though, interfered with its utility, as far as Acton was concerned, on account of the big waiting list. Admission of Acton women became almost an impossibility and the agreement was terminated, or rather, it lapsed because no mothers were admitted. The Guardians established a private ward for confinement cases at Warkworth House, and a charge of two guineas a week was was made for cases admitted into these wards. For some reason or other, these private wards have been discontinued. Chiswick and Haling have a joint maternity hospital established in what was formerly the Chiswick Fever Hospital. At the start, outside cases were admitted, and some Acton mothers went there. This hospital now has a waiting list, and it is most difficult, if not impossible, for cases outside Chiswick or Ealing to be admitted. The Infirmary at Isleworth and Queen Charlotte's lyingin-hospital are the principal public institutions which receive cases from the district for normal confinements. Occasional confinements take place in other general and lying-in-hospitals. Of the measures suggested in the report, the Council has already adopted a scheme for ante-natal supervision, the provision of beds for complicated cases and the provision of nursing assistance in necessitous cases. As necessity arises, this part of the Council's scheme can be developed. The ante-natal supervision can be extended, and efforts made to encourage ante-natal hygiene through the centre. The 20 average numbers attending are small, but as the centre becomes better known to the midwives, probably more mothers will attend. The service for complicated cases at the Acton Hospital is efficient and quite satisfactory, and no cases have been refused admission. For administrative purposes, admission has had to be limited to those cases who have attended the ante-natal centre. The Council has no maternity Home. Maternity beds have been provided in various places, and have proved of undoubted value. The provision of beds for straight-forward or uncomplicated cases, owing to housing and other difficulties would supply a want which is present here. An Ante-natal clinic is held every other Thursday at the School Clinic buildings. The medical officer is Dr. Bell, and in 1923, 63 expectant mothers attended the clinic, making a total of 123 attendances. In addition, the Health Visitors visited 200 expectant mothers in their homes. In 1924, 59 expectant mothers attended, making a total of 98 attendances. Examination and advice will be of little use if the advice cannot be followed because of lack of hospital beds, or ready access to skilled medical or nursing aid. An agreement between the Council and the Acton Hospital has been in force for some years. Under this agreement abnormal cases are admitted into the hospital and last year 6 cases were admitted. The Council agrees to pay according to the following scale:-Ceasarean section, six guineas; Major operations, six guineas; Minor operations, three guineas. These sums are in addition to the maintenance free of five pounds per week. During the last 4 years, the following sums have been paid:— £ s. d. 1924—1925 98 17 4 1923—1924 109 1 0 1922—1923 151 0 3 1921—1922 62 17 0 1920—1921126 13 0 The Council also pays under certain conditions the fees of midwives; in 1923 the fees were paid in seventeen instances, and in 1924 in 10 instances. There is one other sphere which is becoming more popular, and that is, the provision of Dental treatment for expectant and nursing mothers. Extractions and stoppings are carried out on special days at the School Clinic, and through the kind instrumentality of Miss Loretz, the School Dental Surgeon, dentures are supplied at a very low cost. The dentures are paid for by the patients themselves. During 1924, 22 mothers were treated and 5 dentures supplied. 21 Day Nursery.-The Municipal Day Nursery is situated in Bridge Road. Practically no change has occurred in the general policy of the Council in respect of the Nursery. The Nursery was open on 211 occasions. On account of illness amongst the staff the Nursery was closed for a week. 304 children attended, and the total number of attendances was 3,224. Isolation Hospital.-During the year, 188 patients were admitted into the Hospital. On January 1st, 1924, there were 37 cases under treatment and on January 1st. 1925, 24. 194 patients were discharged and there were 7 deaths. The children's Hostel at Park Royal was opened during the year for the accommodation of school children visiting the Empire Exhibition at Wembley, and the Council entered into an agreement to receive cases of infectious disease which might occur among the children. During the year, 9 cases were admitted from the Hostel3 scarlet Fever, 2 Mumps and I each Measles, Chicken-pox, Stomatitis and Tonsilitis. It speaks well for the organisation of the method of obtaining information from Sanitary authorities to achieve This result—only 9 cases of proved and doubtful infectious illness in a total of over 70,000 children that visited the exhibition and stayed at the Hostel. During August, Hoy Scouts were camped in Wembley paddocks and for a few nights some companies were lodged in the Action Wells School. Three cases of Scarlet Fever, 1 case of Mumps and I case of Urticaria were treated at the Hospital. The following table gives the number of admissions:- Scarlet Fever. Diphtheria Mumps. Measles. Chicken Pox. Stomatitis. Urticaria. Croup Tonsilitis. Scarlet Fever and Measles. Total. Acton 81 37 — 20 - - - 1 1 - 140 Wembley 14 12 - 4 - - - - - - 30 Kingsbury 1 1 - - - - - - - - 2 Hendon - - - - - - - - - 1 1 Park Royal Hostel 3 - 2 1 1 1 - - 1 — 9 Scouts (Exhibition) 3 - 1 - - - 1 - - - 5 Wembley paddock (Army) - - - 1 - - - — - - 1 188 Patients Admitted During 1924. 24 patients remaining in Hospital on January 1st, 1925. 22 Supervision of Food Supply. The Middlesex County Council is the authority for the administration of the Food and Drugs Acts in the area, and I am indebted to Mr. Robinson, the Chief Officer of the Public Control Department for the following figures relating to Acton. List of samples taken during the year ended December 31st, 1924:— Article. Taken. Adulterated. Milk 242 6 Milk, separated 6 — Cream 5 — Butter 9 Beer 2 — Cocoa 1 — Coffee 3 — Cream of Tartar 1 — Potash, Bicarbonate of . 1 — Potash, Chlorate of 1 — Prepared Chalk 1 — Sauce 2 1 Vinegar 3 — 277 7 The figures given for adulterated samples include some adulterated informal samples in respect of which no proceedings could be taken. Milk Supply.—There are one cowshed and 88 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; lfi of the registered purveyors have shops and rounds, Hi have rounds only, 12 are dairy shops, 4 are primarily caterers of food, 38 have general shops, and 2 are general shops, but each has a round attached to the business. Slaughterhouses and Butchers.-There are 1 registered and 2 licensed slaughterhouses in the district. In the autumn of 1924, arrangements were made for the thorough inspection of all carcases slaughtered in the district. During the latter part of the year, the inspection of all carcases in one of the slaughterhouses took up most of the time of one inspector and another man to assist him. The importance of this work may be gauged from the following table, in which is given the quantity of food seized at the slaughterhouses. About 8 per cent, of the pigs slaughtered are affected with local tuberculosis; the most usual sites of infection are the glands of the head and the inguinal glands. When the submaxillary or cervical glands are affected the whole head is seized. It is a significant fact that the 23 centage of carcases affected with tuberculosis is higher in the case of pigs reared in dairying districts. As far as this district is concerned, it may be claimed that the inspection of the carcases is efficient and the complaint received is that it is rigid and stringent compared with the inspection made in some districts where sausages are made and bacon curing is carried on. In view of the experience obtained here and other places where systematic inspection is carried out, the laxity displayed in some areas is disconcerting. It is known that frequently, in the cooking of sausages, complete sterilization does not take place. On account of the tendency of the pig to generalized tuberculosis, it is urged that inspection of slaughterhouses where swine are killed should be efficient and st ingent. Where the carcases are converted into sausages, the necessity becomes more urgent. The following table gives the quantity of unsound food seized or surrendered during the year:- 303 pigs' heads. 40 pigs' carcases. 2 cows' carcases. 2 lambs' carcases. (j legs of Pork. 2 Fore quarters of Pork. 2 Trunks of Haddocks. 4 Fore quarters of Beef. 4 Hind quarters of Beef. 2 sets pigs' lungs. 1 cows' head. 9 cows' livers. 13 sets cows' lungs. 1 cows' heart. 1 cows' messentery. 1 Hind quarter of Pork. 2 kidneys. 22 bottles Chilli Sauce. Bakehouses.-There are 35 bakehouses in the district; 8 of these are underground. Inspection of Nuisances, Sanitary defects, etc. The table at the end of the report gives a detailed list of the inspections carried out during the year. Owing to the pressure of other work, houseto-house inspections were made only in 353 instances. Owing to the difficulties arising out of the shortage of houses, it is impossible to enforce rigidly the bye-laws made in respect of overcrowding. A larger number of houses was erected in 1924 tha..., any year since the War, but the supply does not meet the demand. The most urgent cases of overcrowding were remedied, and in every instance, the bye-laws relating to the separation of the sexes were enforced. TABLE 1. COMPARATIVE RATES OF MORTALITY. 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 Fox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Violence Diarrhoea and Enteritis under 2 years. Total Deaths under 1 year. Causes of Death certified by Registered Medical Practitioners. Inquest Cases. Uncertified Causes of Death. England and Wales 18.8 12.2 0.01 0.00 0.12 0.02 0.10 0.06 0.49 0.44 7.3 75 92.3 6.6 11 105 County Boroughs and Great Towns, including London. 19.4 12.3 0.01 0.00 0.18 0.03 0.12 0.08 0.45 0.40 9.2 80 92.5 6.9 0.6 157 Smaller Towns (1921) Adjusted Populations 20,00050,000) 18.9 11.2 0.01 0.00 0.08 0.02 0.09 0.06 0 50 0.36 6.2 71 93.3 5.5 1.2 London 18.7 121 0.01 0.00 0.29 0.03 0.11 0.12 0.36 0.44 8.4 69 91.3 8.6 0.1 Acton 18.4 11.2 0.00 0.00 0.25 0.01 0.03 0.08 0 34 0.19 4.3 56 94.7 6.3 0.0 24 25 TABLE 2. VITAL STATISTICS FOR WHOLE DISTRICT DURING 1924 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. Nett. Under 1 year of Age. At all Ages, Number Rate of Non-Residents Regi...............stered in the District. of Residents Registered outside District Number Kate per 1,000 Births. Number Rate per 1,000 Inhabitants. Number Rate 1919 64,306 for b'th rate. 01,732 for d'th rate. 1096 17.1 436 7.0 12 222 72 65 646 10.4 1920 61,000 1541 25.3 560 9.2 16 217 100 64 671 11.0 1921 62,000 1314 21.1 445 7.1 ... 205 92 70 658 10.4 1922 62,390 1203 19.3 404 6.5 14 214 75 62 032 10.1 1923 62,720 1171 16 6 368 5.8 11 243 77 65 599 9.5 1924 62.900 1158 18.4 488 7.7 8 235 65 56 715 11.2 26 table 3. AGES AT DEATHS, AND WARD DISTRIBUTION OF D EATHS IN 102' Causes of Death. All Ages Under 1 year 1 and under 2 2 and under 5 5 and under 15 15 and under 25 36 and under 45 45 and under 65 65 and upwards North East North West South East South West Measles 16 2 7 6 1 ... ... ... ... 1 1 6 8 Whooping Cough 2 2 ... ... ... ... ... ... ... ... 1 ... 1 Diphtheria 5 ... ... 1 3 1 ... ... ... 2 ... ... 3 Scarlet Fever 1 ... 1 ... ... ... ... ... ... ... 1 ... ... Influenza 22 ... 1 ... ... ... 2 11 8 6 9 3 4 Phthisis (PulmonaryTuberculosis) 47 ... ... ... ... 5 28 14 ... 14 8 11 14 Other TuberculousDiseases 8 ... 2 ... 1 2 2 ... 1 1 3 2 2 Cancer, Malignant Disease 92 ... ... 1 1 ... 6 33 51 33 16 22 21 Kheumatic Fever 4 ... ... ... 2 2 ... ... ... 1 ... 1 2 Diabetes 4 ... ... ... ... ... 1 2 1 ... 2 1 1 Cerebral Haemorrhage 46 ... ... ... ... ... 3 15 28 16 11 8 11 Organic Heart Disease 71 ... ... ... ... 2 13 25 26 25 15 14 17 Arterio-sclerosis 19 ... ... ... ... ... ... 6 13 3 8 4 4 Bronchitis 57 7 i ... ... 1 2 13 33 34 7 11 25 Pneumonia (all forms) 65 13 11 4 ... 2 5 13 17 13 8 15 29 Other Respiratory Diseases 10 ... 2 ... 1 ... 3 3 1 2 2 3 3 Ulcer of Stomach and Duodenum 6 ... ... ... ... 1 ... 4 1 1 1 2 2 Diarrhoea (under 2 years) 5 4 1 ... ... ... ... ... ... 1 1 ... 3 Appendicitis '2 ... ... 1 ... ... 1 ... ... 1 ... 1 ... Cirrhosis of Liver 1 ... ... ... ... ... ... 1 ... 1 ... ... ... Nephritis (Acute and Chronic) 17 ... ... ... ... ... 4 7 6 1 7 4 5 Puerperal Sepsis 2 ... ... ... ... ... 2 ... ... 1 1 ... ... Other Accidents and Diseases of Pregnancy and Parturition 5 ... ... ... ... 1 4 ... ... 2 ... 2 1 Congenital Debility and Malformation, Premature Birth) 26 26 ... ... ... ... ... ... ... 6 5 2 13 Suicide 6 ... ... ... ... 1 2 3 3 1 ... 2 Other Deaths from Violence 12 ... 1 2 1 1 1 2 4 4 1 1 6 Syphilis 1 ... ... ... ... ... ... 1 ... ... ... 1 ... Polioencephalitis 1 1 ... ... ... ... ... ... ... 1 ... ... ... Emcephalitis Lethargica 2 ... ... ... ... ...... 1 1 1 ... ... 1 Other Defined Causes 159 10 3 3 6 7 9 25 96 54 45 26 34 Causes ill-defined or unknown 1 ... ... ... ... ... ... 1 ... ... ... 1 ... Totals 715 65 30 18 21 26 89 180 286 208 154 141 212 table 4. INFANTILE MORTALITY DURING THE YEAR, 1924. Deaths from stated causes in Weeks and Months under One Year of Age. Causes of Death. Under 1 week 1-2 weeks. 2-3 weeks. 3-4 weeks. 1-3 months 3-6 months 6-9 months 9-12 months Totai. Wards. North East. North' West. South East. South West. Measles ... ... ... ... ... ... 2 ... 2 1 ... ... 1 Whooping cough ... ... ... - ... 1 1 ... 2 ... 1 ... 1 Bronchitis ... ... ... - 4 2 ... 1 7 5 ... ... 2 Pneumonia ... ... 1 - 6 2 2 2 13 3 1 4 5 Diarrhoea ... ... ... ... ... 3 1 4 1 I 2 Injury at Birth 8 ... ... ... ... ... ... ... 8 3 1 1 3 Congenital malformation 3 2 1 ... ... 2 ... ... 8 ... 2 1 5 Premature Birth 9 ... 2 ... 2 ... ... ... 13 4 2 ... 7 Atrophy, Debility and Marasmus ... ... ... 3 2 ... ... ... 5 2 1 1 1 Policencephatitis ... ... ... ... ... ... ... 1 1 ... 1 ... ... Basal Meningitis ... ... ... ... ... 1 ... ... 1 ... ... ... 1 Other Defined ... 1 ... ... ... ... ... ... 1 1 ... ... ... Totals 20 3 4 3 14 11 6 4 g5 'AO 9 8 28 TABLE 5. CASES OF INFECTIOUS DISEASES NOTIFIED DURING THE YEAR, 1921. Notifiable Disease. Cases notified in whole District At Ages—Yeats. Total cases notified in each ward. At all Ages. Under 1. 1 to 5. 5 to 15 15 to 25 25 to 45 5 to 65 65 and upwards. North-East. North-West South-East. South-West Scarlet Fever 105 24 65 10 6 ... ... 38 18 25 24 Diphtheria 45 11 22 11 1 ... ... 19 2 17 Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... Pneumonia 54 19 6 6 12 7 1 5 2 30 17 Puerperal Fever 5 ... ... ... 3 2 ... ... 2 ... 2 1 Cerebro Spinal Fever l ... ... 1 ... ... ... ... 1 ... ... ... Acute Poliomyelitis l ... ... ... ... 1 ... ... ... 1 ... ... Encephalitis Lethargica 6 ... ... ... 1 3 2 ... 3 ... ... 3 Ophthalmia Neonatorum 4 ... ... ... ... ... ... ... 2 1 ... 1 Erysipelas 22 ... 1 2 5 3 9 2 3 6 5 8 Tuberculosis, (Resp.) 85 ... ... 1 19 46 18 1 30 13 11 31 Tuberculosis, (Other) 9 ... 4 1 2 2 ... ... 5 ... ... 4 Total 337 7 59 98 57 76 36 4 108 48 75 106 28 29 table 6. CASES REMOVED TO HOSPITAL, 1924. N.East. N. West. S. East. S. West. Total. Scarlet Fever 31 15 22 17 85 Diphtheria 17 6 2 16 41 Pneumonia l 1 3 2 7 Puerperal Fever 2 — 2 1 5 Cerebro Spinal Fever 1 - — — 1 Acute Poliomyelitis — 1 — — 1 Encephalitis Lethargica 1 — — 1 2 Ophthalmia Neonatorum — 1 — 1 2 Erysipelas 2 — — 1 3 Tuberculosis (Resp.) 23 9 8 19 59 Tuberculosis (Other) 5 — — 3 8 83 33 37 01 214 table 7. births. Total Births. Males. Females. Legitimate 537 587 Illegitimate 14 20 551 607 Notified Births in District. N.East. N.West. S.East. S.West. Total. 288 145 214 395 1042 Still-births—16. Births Registered, but not Notified. Males. Females. Total. 9 10 19 N.East. N.West. S.East. S.West. Total. 11 I 5 2 19 Notifications week Received from:— Doctors. Midwives. Nurses. Parents. 556 434 74 21 Notifications of births received from Medical Officers of Health of other districts:— N.East. N.West. S.East. S.West. 38 6 16 16 Included in the Registrar General's figures, but of which no intimation was received during the year 21 Number of Births visited 779 Number of Births revisited 8463 Table 8 infant welfare centres—1924. Health Visitors Attendances 211 Number of Children who attended 1606 Number of attendances by children 11505 Number of Children under 1 year of age 844 Children who attended Clinic for the first time 762 Children who attended Clinic for the first time 724 Children treated at Dental Clinic 58 30 ANTE-NATAL CLINIC. Number of times the Clinic was held 21 Number of expectant mothers who attended 59 Number of attendances made by expectant mothers 98 Number of cases admitted to Acton Hospital 3 Mothers referred for dental treatment to Clinic 22 Mothers supplied with dentures 5 Midwives fees paid 10 Expectant mothers to whom dried milk was supplied 40 Numbei of packets of dried milk supplied 414 INQUESTS—Residents only. TABLE 9. Fatty degeneration of Heart 8 Heart disease—unspecified 6 Cerebral Haemorrhage 2 Pneumonia 2 Ruptured Gastric or Duodenal Ulcer 2 Rupture of Aorta 1 Infantile Convulsions 1 Arterio-sclerosis 1 Found dead in bed 1 Accidental fall 6 Suicide 5 Want of attention at birth 4 Run over by motor car 3 Accidental drowning 2 Accidental strangulation 1 BACTERIOLOGICAL EXAMINATIONS. TABLE 10. Positive. Negative. Total examinations (626) 59 567 Sent by Medical Practitioners 13 200 Sent from Isolation Hospital 22 156 Contacts 14 128 Of these Positive Contacts:— 12 were positive on the first occasion only. 1 was positive on the second occasion only. 1 was positive on the third occasion only. School Sore Throats. Positive. Negative. Cases 10 83 Four of the Positive Sore Throat eases had sufficient clinical symptoms to warrant removal to Hospital. Defects found in Factories, Workshops and Workplaces. Particulars. 1. Number of Defects. Found 2. Reinedied 3. Nuisances under the Public Health Acts:- Want of cleanliness 46 46 Want of drainage of floors 12 12 Unsuitable or Defective sanitary accommodation 78 78 Total 136 130 31 Home Work. Outwokkehs' Lists, Section 107. Nature of Work. 1. Lists received from Employers Sending twice in the year. Lists. 2. Outworkers. 3. Wearing Apparel— (Making, cleaning, washing, &c.) 2 59 Brush - making 2 4 Stuffed Toys 2 21 Total. 6 84 TABULAR STATEMENT OF INSPECTIONS AND DETAIL OF WORK CARRIED OUT BY THE SANITARY INSPECTORS. Number and nature of Inspections made. House-to-house inspections 353 After infectious disease 203 On complaint, &c 1223 Premises under periodical inspection 592 Re-inspections after notice served 8520 Enquiry visits on notification of infectious disease 238 Classified statement of the number of premises under periodical inspection. Workshops and workplaces 220 Slaughterhouses 3 Public House urinals 37 Common Lodging Houses 1 Houses-let-in-lodgings 103 Butchers shops 37 Fish shops 24 Premises where food is manufactured 40 Milk purveyors 80 Cowsheds 2 Piggeries 4 Rag and Bone dealers 4 Mews and Stables 12 Schools 11 Show Grounds 2 Houses dealt with under Section 28 Housing Acts. Houses in respect of which Notices were served 443 Rendered fit by owners 443 Rendered fit by local authority nil Premises dealt with under Public Health Acts. Premises in respect of which Notices were served 971 Premises in which defects were remedied by owners 963 Premises in which defects were remedied by Local Authority 8 32 Detail of work carried out. Sanitary dustbins provided 733 Yards paved or yard paving repaired 247 Insanitary forecourts remedied 154 Defective drains repaired or reconstructed 63 Defective soil pipes and ventilating shafts repaired or renewed 67 Defective fresh air inlents repaired or renewed 86 Defective gullies removed and replaced by new 61 Rain water downpipes disconnected from drain 19 Dishing and curb to gullies repaired and new gratings fixed 153 Defective W.C. pan and traps removed and replaced by new 02 Defective W.C. flushing apparatus repaired or new fixed 312 Defective W.C. seats repaired or new fixed 185 Defective flush pipe connections repaired 97 Insanitary sinks removed or new fixed 33 Sink waste pipes repaired or trapped 270 Insanitary wall surfaces over sinks remedied 124 Ventilated food cupboards provided 9 Drinking water cisterns cleansed 209 Defective covers to drinking water cisterns repaired or new fixed 51 Insanitary sites beneath floors concreted 11 Spaces beneath floors ventilated 163 Dampness in walls from defective damp-proof course remedied 154 Dampness from defective roofs, rain water gutterings, ' &c., remedied 651 Defective plastering repaired (number of rooms) 914 Rooms where dirty walls and ceilings have been cleansed and redecorated 3019 Defective floors repaired 266 Defective or dangerous stairs repaired 53 Defective doors and windows repaired 387 Defective kitchen ranges and firegrates repaired 383 Defective washing coppers repaired 136 Coal cupboards provided 24 New W.C. apartments provided 7 Accumulations of offensive matter removed 28 Drains unstopped and cleansed 221 Overcrowding nuisances abated 19 Drains tested, exposed for examination, &c. 122 Smoke observations taken 104 Smoke nuisances abated 27 Nuisances from pigs and other animals abated 25 Notification of waste of water sent to Metropolitan Water Board 291 33 STAFF TO WHOSE SALARY CONTRIBUTION IS MADE UNDER THE PUBLIC HEALTH ACTS OR BY EXCHEQUER GRANTS. D.J. Thomas. m.b.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 Certificate. 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 A. Cooksey. Cert. San. Inst. Health Yisitor. 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. Woodgates & Sons, Printers, South Acton, W.3.