ACT 32 1929 BOROUGH OF ACTON ANNUAL REPORT OF THE Medical Officer of Health TOGETHER WITH THE Report on the Medical Inspection of Schools FOR THE YEAR 1929 70499 1929 ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH FOR THE YEAR 1929. Public Health Department, Municipal Offices, Acton, W.3. To the Mayor, Aldermen and Councillors of the Borough of Acton. Ladies and Gentlemen, I herewith submit the Annual Report required by the Ministry of Health, together with the Annual Report upon the School Medical Services. The birth-rate is slightly higher than in 1928. The birthrate has for years shown a constant tendency to become lower, and probably the slightly higher rate for 1929 was due to the large number of persons of child-bearing age who have recently come to reside in the new houses in the North-East and North-West Wards. The death-rate is the highest recorded since 1918, and the cause of the high death-rate in both years was primarily due to an extensive outbreak of Influenza. Although the deaths certified to be due to Influenza numbered only 38, there was an increase in the number of deaths from other Respiratory Diseases such as Bronchitis, Pneumonia and Pulmonary Diseasfes. Another unsatisfactory feature of the vital statistics is the higher infantile-mortality. It is the highest infantile-mortality since 1917. There is a slight increase in the number of deaths from Respiratory Diseases, but the main increase is due to deaths from Premature births and Congenital Debility. 1929 4 For the first time since the pandemic in the early part of this century, Small-Pox appears in our statistics as a cause of death. These cases occurred amongst passengers of the Steamship Tuscania. There was only one death each from Scarlet Fever, Diptheria and Enteric Fever, but there were five deaths from Cerebrospinal Meningitis. Most of the latter occurred in the summer and suspicion was directed to the swimming baths as the source of infection. As a Departmental Committee has recently reported upon the hygiene of swimming baths, opportunity is taken of reviewing the question of the possible sources of pollution of swimming pools. The industrialisation of the northern part of the district continues and this brings in its train certain problems. Foremost am ng these is the housing problem. The demand for houses exceeds the supply, as those who are employed in the factories wish to reside as near their place of employment as possible. The prevention of atmospheric pollution by smoke has also become an urgent problem, and considerable time has been expended by the Inspectors on the work of prevention. The enforcement of the Smoke Prevention Acts requires considerable care, tact and ability, but it appears as if more drastic measures than moral suasion will be necessary before some of the owners appreciate that the Council is serious in its efforts to prevent atmospheric pollution. The following is a summary of the vital and other statistics for the year 1929. Area of Borough 2,305 acres. Population (estimated 1929) 65,200 Population (Census, 1921) 61,299 Number of inhabited houses (Census 1921) 11,820 Number of families or separate occupiers (Census, 1921) 14,941 Rateable Value (1st October, 1929) £653,721 Net produce of a penny rate (year ending 31st March, 1930) £3,165 5s. 4d. Total number of births registered 1,026 Legitimate 973 Illegitimate 53 Birth-rate per 1,000 inhabitants 15.7 Number of deaths 826 Death-rate per 1,000 inhabitants 12.66 Number of women dying in consequence of childbirth— Sepsis 1 5 1929 Other causes 2 Maternal mortality per 1,000 births 3 Deaths of infants under 1 year of age— Legitimate 76 Illegitimate 9 Infantile mortality per 1,000 births 82 Total Deaths Death-rate per 1,000 Population. Measles 0 0.0 Whooping Cough 14 0.2 Diphtheria 1 0.015 Scarlet Fever 1 0.015 Influenza 38 0.6 Tuberculosis of Lungs 52 0.8 Tuberculosis (other forms) 7 0.1 Tuberculosis (all forms) 59 0.9 POPULATION. The Registrar General estimates the population at the end of June, 1929, to be 65,200, an increase of 330 on the estimated population of 1928. As the Census will be due before the issue of the next Annual Report, it is unnecessary to enter further into the question of the correctness or otherwise of the different estimates. Usually the estimate of the Registrar General is more nearly correct than that made by the officers of the Local Councils. POOR RELIEF. I am indebted to Mr. Harmsworth, the clerk of the Brentford Board of Guardians, for the figures relating to Poor Relief. The total amount of out-relief distributed by the Guardians in the Borough was £5,875 13s. 8½d. No relief was given to unemployed during the year except in sickness or urgent necessity, and this was entered as ordinary relief. The amount distributed in out-relief remains fairly constant each year, but the amount given to unemployed persons has fallen from over £15,000 in 1922 to nothing in the last two years. There have been changes of administration to account for most of this reduction, but in recent years the amount of unemployment has been small, owing to the establishment of new factories in the district. SOCIAL CONDITIONS OF THE DISTRICT. The physical features and general charactcr of the district were described in the Survey Report of 1925. 1929 6 AMBULANCE FACILITIES The ambulance facilities are similar to those described in last year's report. A motor ambulance is provided for the removal of infectious cases to the hospital. There are two ambulances provided for accident and noninfectious cases. These are housed in a garage at the fire station and are available at all hours. A new ambulance was purchased by the Council in 1928, but the old one is still kept for emergencies. Last year the ambulance was called out to 485 street accidents, and on 457 occasions to private cases. Fees amounting to 3s. Od. were paid for the use of the ambulance for private cases. HOSPITAL PROVISION General.—The only general hospital in the district is the Acton Hospital, Gunnersbury Lane, which has an accommodation of 62 beds. It will be noticed that accommodation is placed at a higher figure than in former years. Last year the new Nurses Hostel was completed and opened on June 8th, and the alterations to the hospital necessitated by the removal of the nurses to the new hostel increased the accommodation by 12 beds; 5 of the beds were allocated to private patients, and 7 to general ward patients. 1,186 in-patients and 6,371 out-patients were treated last year. Like all districts in greater London, very extensive use is made of the facilities offered by the large general hospitals in London. Fever.—Acton Council Fever Hospital—80 beds. Small-Pox.—Acton was one of the constituent bodies which formed the Middlesex Joint Small-Pox Board. Under the Provisional Orders Confirmation Act of 1929, the Joint Board was dissolved from the 1st April, 1929, and the duties of the Board transferred to the Middlesex County Council. Tuberculosis. The Tuberculosis scheme is administered by the Middlesex County Council, which has sanatoria at Clare Hall and Harefield. Poor Law.—The Paiish is part of the Brentford Poor Law Union. The Union Infirmary, named the West Middlesex Hospital, is situated in Isleworth. Child Welfare, Consultation Centres.— (a) — Church Road. (b)—Palmerston Road. Every Monday and Wednesday afternoon at 2 p.m. (r) East Acion. Every Thursday afternoon at 2 p.m. (e/)—Steele Road. E very Tuesday afternoon at 2 p.m. Ante-Natal Consultation Centre.—School Clinic every 2nd and 4th Wednesday. Day Nursery. 169 Bollo Bridge Road. 1929 7 School Clinic.—Adjoining- Municipal Offices The above are provided and maintained by the Borough Council. Tuberculosis Dispensary.—School Clinic on Tuesdays at 5 p.m. and Thursdays at 10.30 a.m. Treatment Centres for Venereal Diseases.—Various Hospitals in London. The two latter are provided by the Middlesex County Council. SANITARY CIRCUMSTANCES OF THE AREA These have been noted in previous reports. All the inhabited houses are supplied from the mains of the Metropolitan Water Board. A few industrial works and the Public Baths obtain their water supply from deep wells. By arrangement with the London County Council the sewerage is discharged into the London Sewers. Storm water is filtered and emptied into the Thames. All the inhabited houses are provided with water closets and are drained into the main sewerage system. The house refuse is collected by the Council and burnt in the Destructor. Last year 18,008 tons of house refuse were collected and burnt. PROFESSIONAL NURSING IN THE HOME General.—There are two district nurses employed by the Acton Hospital, one of which is primarily engaged in district nursing. There are also nursing associations which provide nurses for different classes of cases. Midwives.—The Supervising Authority under the Midwives Act is the Middlesex County Council and from the County Council I understand that there are 14 certified midwives practising in the Borough. The following local acts, special local orders, general adoptive acts and byelaws relating to Public Health are in force in the district. LEGISLATION IN FORCE Adopted Infectious Diseases (Notification) Act, 1889 Public Health (Amendment) Act, 1890 Infectious Diseases Prevention Act, 1890 Notification of Births Act, 1907 Public Health Act, 1907 (Clause 50) Public Health Act, 1925 (Parts 2, 3, 4 & 5) The Acton Improvement Act, 1904 1889 1890 1899 1907 1921 1926 1929 8 New Streets and Buildings Removal of House Refuse Common Lodging Houses Slaughter Houses Nuisances, etc. Offensive Trades Tents, Vans and Sheds Removal of Offensive or Noxious Matters Houses Let in Lodgings Cleansing of Cisterns Employment of Children Fouling of Footpaths by Dogs Smoke Abatement 1925 1899 1898 1924 1924 1903 1906 1908 1925 1912 1920 1929 1930 HOUSING I have in previous reports referred to different aspects of of the housing question in the district, and this year I shall only briefly mention one of these aspects. As far as Acton is concerned, overcrowding is one of, if not the most serious factor in the housing problem. Overcrowding here is not the result of the post-war housing shortage; it has existed always and will exist as long as poverty exists. It has been aggravated recently by the establishment of large factories in the district, and the desire of those employed in the factories to be living near the place where they work. Owing to the industrialisation of the district we shall always be short of houses. But overcrowding occurs quite as frequently amongst those who live in the district and who work outside as amongst those who are both living and employed in the district. The basic cause of overcrowding is the inability to pay anything like an economic rent. Overcrowding and poverty usually go together. Low wages and large families also generally go together, and therefore the smaller the house the larger the family. When a young couple married, they rented a couple or more rooms in a house, and as the family increased in number they have been unable to rent a bigger flat or house. The flat they now occupy is probably controlled, and if they went to a larger flat, it would be decontrolled and a much higher rent would be asked of them. But even in those cases where the rent can be paid, landlords do not welcome a large family. Landlords frequently look upon a large family as a feckless one and think that the condition of the house will suffer in direct ratio to the size of the family. We sometimes come across a family, which because of its size cannot find better accommodation although a higher rent could be paid, but these are rare exceptions; the usual cause of 1929 9 ing is inability to pay a higher rent. Although cases of legal overcrowding may not frequently occur, yet there are many instances in which it is impossible to live a decent and healthy life. The standard ot overcrowding adopted by the Registrar General is frequently inadequate, and even a standard based upon the cubic space does not meet the difficulty, because sometimes the most important factor in overcrowding is the improper mixing of the sexes. It is not decent or conducive to health that boys and girls of 13, 14, 15 and even 18 years of age shou'd occupy the same bedroom, although the cubic capacity of the room would be adequate for the number of occupants. When these conditions are found, in every instance, the cause is an economic one. On another page, an instance is given of this kind of overcrowding and this is not an isolated case. TABULAR STATEMENT OF INSPECTIONS 8C DETAIL OF WORK CARRIED OUT BY THE SANITARY INSPECTORS. Number of Inspections and Action Taken. Total number of dwelling houses inspected for housing defects (Under Public Health or Housing Acts) (1) Dealt with by service of Informal Notice 539 (2) Dealt with by service of Statutory Notice under Section 3, Housing Acts 225 (3) Dealt with by service of Statutory Notice under Public Health Acts ... ... 220 Premises (other than defective dwelling houses) inspected for nuisances and miscellaneous defects (1) Dealt with by service of Informal Notice 761 (2) Dealt with by service of Statutory Notice under Public Health Act, &c. 117 Reinspections subsequent to service of Notice Enquiry visits on notification of Infectious Disease 1007 878 6934 362 Number of Premises under Periodical Inspection. Workshops and Workplaces 144 Bakehouses 29 Slaughterhouses 2 Public Health Urinals 37 Common Lodging Houses 1 Houses-let-in-lodgings 30 Butchers Shops 42 1929 10 Fish Shops 28 Premises where food is manufactured or prepared 33 Milk Purveyors 79 Cowsheds Nil Piggeries Nil Rag and Bone Dealers 8 Mews 4 Schools 11 Show Grounds Nil Rent Restriction Act. Number of Certificates granted 13 Detail of Work Carried Out. Sanitary Dustbins provided 663 Yards paved or yard paving repaired 170 Insanitary forecourts remedied 26 Defective drains repaired or reconstructed 51 Defective soil pipes and ventilating shafts repaired or renewed 88 Defective fresh air inlets repaired or renewed 65 Defective gullies removed and replaced by new 57 Rain water downpipes disconnected from drain 14 Dishing and curb to gullies repaired and new gratings fixed 230 Defective VV.C. pan and traps removed and replaced by new 85 Defective W.C. flushing apparatus repaired or new fixed 433 Defective W.C. seats repaired or new fixed 127 Defective flush pipe connections repaired 133 Insanitary sinks removed or new fixed 71 Sink waste pipes repaired or trapped 205 Insanitary wall surface over sinks remedied 124 Ventilated food cupboards provided 2 Drinking water cisterns cleansed 207 Defective covers to drinking water cisterns repaired or new fixed 86 Insanitary sites beneath floors concreted 9 Spaces beneath floors ventilated 139 Dampness in walls from defective damp-proof course remedied 128 Dampness from defective roof, rain water gutterings, etc., remedied 927 Defective plastering repaired (number of rooms) 583 Rooms where dirty walls and ceilings have been cleansed and redecorated 3592 Defective floors repaired 151 Defective or dangerous stairs repaired 28 11 1929 Defective doors and windows repaired 236 Defective kitchen ranges and fire grates repaired 241 Defective washing coppers repaired 173 Coal cupboards provided and repaired 15 New W.C. apartments provided 7 Accumulations of offensive matter removed 42 Drains unstopped and cleansed 415 Overcrowding nuisances abated 10 Drains tested, exposed for examination, etc 94 Smoke observations taken 205 Smoke nuisances abated on service of notice 14 Nuisances from pigs and other animals abated 7 Notifications of waste of water sent to Metropolitan Water Board 207 INSPECTION AND SUPERVISION OF FOOD. Milk Supply. There are 79 dairies and milkshops on the register. There are at present no cowsheds in the Borough and all the milk is produced outside the district. The number of milk retailers in the district is exactly the same as that registered in 1928, but during the year the Health Committee revised its methods of procedure in respect of the conditions under which registration would be granted. Seven years ago the Council also considered the whole question of the sale of milk in general shops, and it was then decided that as a general principle the sale of milk and paraffin oil should not be permitted in the same shop, and notices were served upon the occupiers of certain general shops asking them to discontinue the sale of paraffin oil where milk was being sold. There were at the time sixteen general shops where milk and paraffin oil were being sold on the same premises. The occupiers of five of these premises decided that the sale of the oil was more profitable than the sale of milk and they ceased to sell the latter and were removed from the register. The occupiers of the other eleven premises discontinued the sale of paraffin and continued on the register. The Council has discountenanced the sale of milk on premises where other articles which create dust are also sold. Although milk is in itself an outstanding food, it is easily contaminated and may become a vehicle or carrier of infection. Milk is an excellent medium for the growth and the multiplication of certain kinds of germs of disease. For these reasons, every care should be taken to observe the utmost cleanliness of premises where milk is being stored or sold. The Council has discouraged the sale of milk in general 1929 12 shops, but in view of the changed conditions, it is doubtful if it can uphold the view that nothing but articles of food shall be sold in a shop registered for the sale of milk. In 1923, the conditions under which milk was stored and distributed were such that it was considered unsafe to allow such distribution to take in general shops. But the conditions have entirely changed in the last 10 years. For years public health authorities have been urgent in their demands for a pure milk supply, and they are still asking for many improvements, but it is no exaggeration to state that the methods of production and distribution of milk have in recent years produced a quiet revolution. I do not think this has been mainly due to the action of public health authorities, because their powers were limited, but it has been brought about largely by the pressure of economic factors. The methods of production and distribution of milk which had been general in the past not only retarded the growth of the consumption of milk but were also responsible for very serious losses. These losses to the milk industry through souring alone, have been enormous. It would be interesting to know the relative loss to wholesalers and retailers through souring, say in the hot summer of 1911 and last year which also was a dry, hot year. Whatever the causes, changes have taken place and the old taunt that milk was undiluted sewage no longer applies. The improvement has taken place in all directions, from the udder of the cow to the feeding bottle and milk jug. The changes with which we are more directly concerned are those in the methods of storage and distribution. Formerly the milk to the houses was carried through the streets in churns, and measured out into jugs. The filling of the jugs was necessarily done in the open street and the milk was liable to contamination by dust or any other material. The churns were cleaned by the retailer and his facilities were not always of a superior kind. In the shops the milk was kept in a large china receptacle and the latter was sometimes covered and sometimes uncovered. The retailer did not always have at hand sufficient quantities of hot water or steam for cleansing purposes. These methods of distribution have almost entirely disappeared. Most of the milk to the houses is delivered in sealed bottles, and in the shops a large quantity of milk is sold in sealed bottles. In some milk shops, milk is still being sold out of a china receptacle. The distribution in bottles is a great advance on the old method, but it is not ideal, and some of its disadvantages have already become apparent. The cost, because of breakages is great, and for soem 13 1929 reason or other a large number of bottles remain uncollected. These of course are commercial and economic conditions, though these have an indirect influence on the public health. Any condition which enhances the price of milk will tend to a lower consumption. But the most serious factor from a public health point of view is the risk of milk being delivered in unwashed or improperly sterilized bottles. Some of the smaller retailers have not the means of sterilizing the empty bottles, but this difficulty can be overcome by the purchase of the milk in bottles from the wholesalers. It may be objected that this may mean a further hold of the large wholesalers and trusts upon the milk supply. This is true, but almost every development in milk distribution gives a stronger hold to the big concerns. The small retailer cannot hope to have milk conveyed in large glass-lined tanks, except through the large wholesalers, and other conditions might be mentioned. Another objection to the glass bottle is the possibility that it may be filled from a churn in the street without any washing of any kind. Instances of this practice have been reported to the Committee and although it is a legal offence, proceedings were not taken. During last year a new development in the distribution of milk was made possible by the manufacture of what is called the Sealcone. The Sealcone is a container of light, but very strong cardboard, freshly made and sterilized for each delivery of milk and destroyed after use. The cardboard is carried through a bath of boiling wax so as to make it sterile. It is then formed into a cone, filled with milk and hermetically sealed to prevent leakage or contamination. Once the seal has been applied no dirt can reach the milk inside nor can the milk escape. Only by cutting the container can the milk be removed. This makes it impossible to adulterate the milk, or to tamper with it in any way. It also makes it impossible to use the Sealcone twice. Once it has been used it must be destroyed. This method of distribution is mentioned to emphasize the fact that the glass bottle is not the last word in clean distribution, but if properly handled, there is not much chance of contamination if the milk is sold in sealed bottles only, over the counter and at the consumer's door. BAKEHOUSES There are 29 bakehouses in the district; of these 6 are underground bakehouses and were occupied before the passing of the Factory Act of 1901. MEAT INSPECTION There are two slaughter-houses in the borough; in one of 14 these, pigs alone are slaughtered, and in the other no pigs are slaughtered. The inspection of the carcases in these two slaughter houses takes up a considerable amount of the time of the officers of the Council as a perusal of the following tables would suggest : UNSOUND FOOD SURRENDERED DURING 1929 Diseased Meat Tuberculosis. Pigs. 9 Carcases with Heads. 2 Legs of Pork 96 Heads. 124 lbs. of Pork. 6 Forequarters of Pork. 128 Plucks. 4 Hindquarters of Pork. 2480 lbs. Chitterlings Bovines 11 Carcases of Beef. 2 Breasts of Veal. 2 Calves' Carcases -with Offal 1 Brisket of Veal. 28 Forequarters of Beef. 37 Ox Offals. 4 Hindquarters of Beef. 46 .sets Cows' Lungs with 1 Top Piece of Beef. l. Hearts. 4 Rumps of Beef. 41 Ox Heads and Tongues. 6 Loins of Beef. 42 Ox Livers. 2 Flanks of Beef. 5 Ox Mesenteries. 2 Middle Ribs of Beef. 1 Ox Tripe. 4 Briskets of Beef. 5 Calves' Heads. 257 lbs. of Beef. 54 Calves' Plucks. 2 Hindquarters of Veal. 1 Calf's Liver. 1 Hindquarter of Veal. 1 Calf's Kidney. Parasites. Bovines. 83 Ox Livers. 2 Ox Kidneys. 1 set Ox Lungs with Heart. 1 Calf Pluck. 20 sets Ox Lungs. 59 Sheep's Plucks. 54 Sheeps' Livers. Sheep. 115 sets Sheeps' Lungs. Pleurisy. Bovines. 1 Forequarter of Veal. 2 sets Calves' Lungs. 9 Breasts of Veal. 13 sets Ox Lungs II Calves' Plucks. Hearts. 6 sets Calves' Lungs with Hearts. Sheep. 5 Forequarters of Mutton. 14 Sheeps' Plucks. 14 Breasts of Mutton. with 15 1929 Bruising. Pigs. 1 Hindquarter of Pork. 4 Legs of Pork. 2 Loins of Pork. 1 Belly of Pork. Bovines. 2 Sides of Beef. 3 Ribs of Veal. 3 Hindquarters of Beef. 2 Breasts of Veal. 4 Shanks of Beef. 1 Calf's Liver. 25 stones of Beef. 7 Calves' Kidneys. Fracture and Bruising. Bovines. 1 Forequarter of Beef. 1 Hindquarter of Veal. Sheep. 1 Hindquarter of Lamb. 1 Leg of Mutton. Arthritis. Bovines. 2 Shoulders of Veal. 2 Knuckles of Veal. 2 Legs of Veal. Sheep. 1 Hindquarter and Flap of Mutton. 1 Leg of Mutton. Congestion. Pigs. 1 Carcase with Head. Bovines. 2 Ox Offals. 1 Calf's Liver. 2 Calves' Plucks. 2 sets Calves' Lungs with Hearts. Cirrhosis. Bovines. 27 Ox Livers. 1 Calf's Liver. Sheep. 3 Sheeps' Livers. Moribund. Pigs. 1 Carcase with Head. Bovines. 2 Cows with Offal. 15 Calves with Offal. Sheep. 5 Carcases with Offal. A bscesses. Pigs. 1 Short Hindquarter of Pork. 16 1929 Bovines. 5 Calves' Plucks. 2 Calves' Heads. 23 Calves' Livers. Sheep. 2 Sheeps' Heads. Actinomycosis. Bovines. 20 Ox Heads and Tongues. 3 Calves' Heads. Pneumonia. Bovines. 2 sets Calves' Lungs. 1 set Stirk's Lung's. Fractured. Sheep. 3 Ribs of Mutton.. 1 Shank of Mutton. Emaciation and Dropsy. Bovines. 2 Ox Carcases with Offal. Sheep. 11 Sheeps' Carcases with Offal. Nephritis. Bovines. 2 Stirks' Kidneys. 3 Calves' Kidneys. Hydro-Nephrosis. 2 Stirks' Kidneys. 2 Calves' Kidneys. Cavernous A ngioma. 6 Ox Livers. Pericarditis. 2 Ox Hearts. Aden itis. 5 Calves Livers. Melanosis. 1 Calf's Pluck. Died : Traumatic Pericarditis and Extensive Bruising'. 1 Cow's Carcase with Offal. 1 9 2 9 17 Pseudo Hodgkins Disease. 1 Calf's Carcase with Offal. Pyæmia. 1 Calfs Carcase with Offal. Pleurisy and Pneunonia. 1 Calves' Carcase with Offal. 1 set Ox Lungs. Fatty Infiltration. 1 Calfs Liver. Jaundice. 2 Calfs Plucks. Bacteriol Necrosis. 1 Calfs Liver Pleurisy and Dropsy. Sheep. 1 Sheep's Carcase with Offal. Caseous Lymphadenitis 1 Hindquarter of Lamb- Unsound. Pigs. 1 Carcase with Head. Utlicaria. 1 Head. Other Foods. Unsound. 15 Turkeys. 12 stones of Dogfish 3 tins of Prawns. 18 stones of Catfish Parasites. 1 Ostend Rabbit. 18 1929 TABLE II. NUMBER OF PIGS CARCASES INSPECTED FROM 1ST JANUARY TO 31ST DECEMBER, 1929, WITH ANALYSIS OF SURRENDERS ON ACCOUNT OF DISEASE (TUBERCULOSIS). 1929 No. of Carcases Inspected. No. of Heads Diseased. No. of Carcases Diseased. No. of Sides Diseased. No. of Fore Quarters Diseased. No. of Hind Quarters Diseased. No. of Lags Diseased. No. of Shoulders Diseased. Plucks (Lungs, Livers and Hearts). Mesenteries, Stomachs and Intestines. Pieces of Pork. Weights. lbs lbs. tons cwts qrs. lbs. January 1716 21 1 — — — 1 — 19 304 128 4 3 14 February 1162 14 1 — — — 3 — 11 168 — 6 2 11 March 1279 9 - - - - - - 13 280 — 1 1 12 April 1268 7 1 — 4 - 1 - 13 224 12 5 3 26 May 1231 9 - - - 1 - - 11 224 49 2 0 20 June 352 2 - - - - - - 4 120 *— 1 0 12 July 759 3 1 — — — 1 — 10 208 20 2 0 12 August 724 7 — — 2 — 1 — 8 112 30 1 1 4 September _ 930 4 1 — - 3 — - 7 152 45 7 1 21 October 1966 12 - — — 2 — — 12 296 22 Dust Destructor November 1716 14 4 — — — — — 8 176 136 14 1 9 December 1693 7 3 — — — — — 12 216 — 10 0 27 Total 14,996 109 12 6 6 7 — 128 2,480 442 2 17 2 0 1929 19 TABLE III. Counties from which animals were consigned, and percentage diseased (1st Jan.—31st Dec. 1929). County No. of Towns from which Animals were consigned No. of Carcases Inspected No. of Animals Diseased Percentage of Animals Diseased Berkshire 3 28 - - Bedfordshire 2 50 - - Buckinghamshire 1 3 - - Cambridgeshire 7 950 14 1.47% Cheshire 1 12 — - Devonshire 2 51 - - Dorsetshire 7 2143 27 1.25% Essex 5 430 2 .47% Gloucestershire 2 89 - - Hampshire 17 934 7 .75% Hertfordshire 1 10 - - Huntingdonshire 2 203 1 .49% Ireland 1 423 — - Leicestershire 1 20 1 5.0 % London 1 15 - - Middlesex 12 299 3 1.0% Norfolk 18 3066 31 1.03 % Nottinghamshire 1 51 — - Somerset 8 1063 15 1.41% Staffordshire 1 19 .1 5.21% Suffolk 21 4756 29 .61% Surrey 2 11 — - Sussex 2 210 1 .47% Warwickshire 1 109 2 1.81% Wiltshire 2 33 — — Total 121 14,996 .134 1.61 % BIRTHS. Table VII. gives particulars of the births registered and notified in the district, and the births belonging to the district which have occurred and been registered outside the district. The total number of births are those registered during the calendar year and are corrected for inward and outward transfers. This number is 1026, and the figure is obtained at the end of the year from the Registrar General, and is equal to a birth-rate of 15.77 per 1000 inhabitants. This rate is slightly higher than that of 1928, but lower than that of England and Wales and of the 107 great towns, of which Acton is one. The birth-rate is exactly the same as that of the County of London. 1929 20 The birth returns received from Registrar General do not permit of the allocation of the whole of the births into wards but the difference between them and the notified births is so small as to be negligible. The ward birth-rate is based upon the notification figures. The birth-rate in the different wards was:— Not th-East. North- West. South-East. South- West. 16 14.3 10 20.3 Until the census figures are published it is impossible to give the age distribution of the population in the different wards. It is probable, though, that there is a relatively larger number of newly married couples in the North East and North West Wards than in the South East and South West Wards, and the birthrate in the two former wards is not comparable to that of the two latter wards. The birth-rate in the South West Ward is relatively and actually much higher than that of the other wards. The number of births registered, but not previously notified is slightly higher than, that of 1928, but lower than that in the years immediately preceding 1928. The Child Welfare Committee has had this matter under consideration, and has endeavoured to obtain an improvement. 53 children were born out of wedlock, which number corresponds to illegitimate birth-rate of 5-1°lo of the total births. This is a higher illegitimate birth-rate than that of 1928. 25 still-births were notified. DEATHS. 540 deaths were registered in the district; of these 21 were of non-residents. 307 deaths of residents occurred outside the district. The total number of deaths belonging to the district is 826, which corresponds to a death-rate of 12.7 per 1,000 inhabitants. The death-rate is nearly 2 per 1,000 higher than that of 1928, but is lower than that of England and Wales, of London and of the 107 great towns including London. Ward Distribution. North East. North West. South East. South West. 230 193 171 232 Death-Rate of each Ward. North East North West. South East. South West. 12.1 14.1 11.3 13.2 Causes of Death. Influenza.—There was an increase in the number of deaths from all Respiratory Diseases. There were 94 deaths from Bronchitis and 56 from Pneunomia. Although only 38 deaths were 21 1929 registered as due to Influenza, yet a large number of the deaths from Bronchitis and Pneumonia were directly or indirectly caused by the Influenza epidemic which occurred in the spring of the year. It has been explained in former reports that the altered age distribution of the population will tend towards a higher death-rate, but this factor will produce a steady, but hardly perceptible rise. Last year the sharp rise was chiefly due to the outbreak of Influenza which occured in the first quarter. The epidemic was the most serious experienced since the pandemic of 1918-1919 and made its appearance in London about the end of January, the maximum death-rate being reached about the middle of February. Throughout the months of November and December, 1928, the Registrar General's returns gave no cause to anticipate the advent of a severe epidemic of Influenza. It will be remembered that in the Annual report of 1928, I remarked upon the favourable statistics for the fourth quarter and especially the very low infantile mortality. But there was disquieting news from America, and it is surmised in some quarters that the disease was imported from that country. The mode of transmission of Influenza is necessarily inferential, but there is no mystery about it and it follows the normal laws of an ordinary infectious disease. The rapidity, though, with which epidemic influenza travels and the large number of persons attacked within a short period gave rise to early conjecture that the disease was borne by the wind, or at least that it was dependent on general atmospheric or even cosmic conditions which affected nearly simultaneously large masses of people. Others have called Influenza a blast from the stars. These beliefs have died nard, and there are still to-day observers who maintain that the occurrence of widespread and mysterious flutcuations in susceptibility furnish and adequate explanation for the rise of pandemics. Modern students of Influenza, however, regard Influenza as a typical infectious disease due to a living, if yet unknown microorganism. Whatever the origin of pandemics, whatever the possible predisposing effect of ocscure factors, there need be no hesitation in accepting the fact that Influenza is a germ disease spread largely if not wholly, by human agency There is no evidence that water or milk ever serves as a vehicle of infection, or that the virus resists drying for a considerable period and is transmitted In dust. While no precise information exists as to the relative importance of active cases, convalescent cases or healthy carriers, in spreading infection, there is reason to believe that persons suffering from the disease in its early stages are particularly likely to convey the infection to others. It cannot be said that the epidemic took the authorities unawares. The disquieting news from America made it desirable for the Ministry of Health to draw the attention of local sanitary 1929 22 authorities to the possibility of an outbreak of more than usual magnitude. This was done in the first week of January by the issue of a circular and a copy of the Ministry's memorandum on Influenza. I circularized the local doctors, and a meeting of the local doctors was held in the Committee room of the Council Offices on January 17th. Certain suggestions were made by the doctors present and these were practically all adopted by the Council. Arrangements were made with the authorities of the Acton Hospital for the home nursing of the more serious cases. The hospital has two nurses for the nursing of district cases, and one of these was detailed to nurse influenza cases referred by a doctor, and the Council paid the Hospital authorities at the rate of 2/- per visit. It was felt by the doctors that the services of domestic helps would in the majority of instances be more useful than those of a nurse, and arrangements were made with three very suitable persons to carry out this part of the work. Arrangements were also made with the Education Committee for the supply of meals from the Cookery Centres to families should the necessity arise. It was pointed out by some of the doctors that in an extensive epidemic a difficulty arises in the treatment of non-panel members of a family. If a person who was not on a panel and whose means were such that payment for medical services would seem remote sent for a doctor to visit him, the doctor might reply that he was really too busy to take on any more patients and refer the case to some other doctor. It was not reasonable for a doctor to take on an emergency patient at such a busy time when all doctors were "run off their legs." The Council decided that in suitable cases it would pay the agreed doctors' fees for attendance upon such patients. Fortunately the epidemic was not so severe or so extensive here as it was in certain other areas. The services of the nurse and of the domestic helps were utilised, but the other emergencies did did not arise. It is possible that these measures may have alleviated some of the suffering, but in the field of prevention little real progress has been made. The causal organism of Influenza has not been discovered, and it is not always possible to differenciate between a common cold and genuine Influenza. Influenza is spread by personal contaqt and droplet infection," but from the nature of the disease it is not practical to enforce measures of rigid isolation on a large scale with any prospect of success. The opportunities for self-protection by individuals, though, lie in the line of isolation avoidance of crowds and of direct contact with influenza patients and with all persons suffering from " colds". The advice contained in the Report of the Chief Medical Officer of the Ministry of Health 1929 23 may be reproduced. When Influenza is epidemic, the public should obey the ordinary rules of hygiene. The work of the world must be carried on and workers cannot always avoid crowds or association with those suffering from coughs and colds. They will be doing their duty to themselves and to their fellows in epidemic periods if they shun their risks as much as possible by refusing to go to crowded evening assemblies and by declining to pay unnecessary visits to sick friends. Persons who practise the rules of health, keep themselves fit and take all possible care to avoid "droplet" infection from mouth or nose are likely to preserve resisting powers which, if they do not carry them unscathed throughout the epidemic, will moderate the intensity of their symptoms and the liability to pulmonary complications if the disease is eventually contracted. Cancer.—There is a slight increase in the number of deaths from cancer, and in two successive years the number of deaths in each year has exceeded a hundred. It is known that in most civilised countries, the crude recorded cancer mortality is rising. At the present time it is highest in some of the smaller European countries-—Denmark, Holland and England, but in Switzerland, which has one of the highest cancer mortalities, the rate has been stationary for forty years past. But although the crude death-rate from Cancer is rising there are many falacies in such a statement. The recorded rise in cancer mortality has been increasingly greater at the later age periods. There is no increase below 30 years of age. During the past decade the age at death has risen considerably, and increasing longevity, especially an increase in the later age periods, will cause a marked rise in apparent cancer mortality. A longer span of life means a greater chance of dying of cancer. No comparative statistics of cancer are therefore of value, which do not eliminate differences of age composition of the populations by giving specific death-rates at the different age periods. At the last census the age constitution of the population of Acton differed considerably from that of the previous one and the change in continually in operation. Out of 106 deaths which occurred last year 35 were in persons between 45 and 65 years of age, and 61 in persons over 65 years of age Of the deaths over 65 years of age from Malignant Disease, 21 were between 65 and 70 years, 21 between 70 and 75, 13 between 75 and SO, 2 between 80 and 85, 2 between 85 and 90, and 2 between 90 and 95 years of age. It is at these higher ages, that the increase in deaths from Cancer has occurred. Another factor which has to be taken into consideration is the situation of the growth. The improved methods of diagnosis 1929 24 probably account for some of the apparent increase. The principal organs affected were— Stomach 22 Pancreas 6 Bowels 18 Bladder 6 Breast 10 Prostate 5 Uterus and Ovary 8 Aesophagus 4 The increase has been most marked in the organs of the digestive track and of course it has been naturally inferred that this is due to some dietetic faults and changes. It must also be remembered that the improved methods of diagnosis are more -applicable to these internal organs. It is probably true that there is some increase in the incidence of Cancer apart from improved diagnosis and age incidence, in spite of the enormous amount of research work which has been, and is still being done. Considerable attention has been given to the question of radium treatment of Cancer. Radium is one of the rare metals which occurs in nature in exceedingly small quantities, and has the property of emitting rays. The rays emitted are of three kinds, and the short penetrative Y rays have little or no therapeutic value and produce harmful effects. The exact mechanism of the action of radium on the body-tissues at present remains unrevealed, and it still remains true that early diagnosis and prompt surgical treatment are the important factors in the successful treatment of Cancer. The discovery of radium greatly enhances the prospects of success by operation, but radium-therapy has not and may never replace operative measures entirely. In certain regions radiumtherapy is becoming a recognised method of treatment of early Cancer ; in other regions it is being tried with a hopeful degree of success. The Report of Sir George Newman summarises the position as follows. By the use of radium alone when applied in the appropriate quantity with suitable filtration and for the proper period, the disappearance of the primary cancer can be effected in a greater or less proportion of cases in certain regions of the body, namely, the skin, cervix of the uterus and the mouth. For practically all other regions sufficient experience has not yet been accummulated to show that similar effects can be secured though it is reasonable to assume that with advances in knowledge such results may become practicable. Uncertified Deaths. Last year there were two deaths which had not been certified either by a medical practitioner or by a Coroner. One of these deaths occurred in the North of England where the patient was on a holiday. The death was certified as due to servere Cerebral Hemorrhage. The other occurred in the Infirmary and was due to Inanition. This is the first occasion for 25 1929 some years in which an uncertified death has appeared in our returns. Usually all the deaths are certified either by a doctor or by the Coroner. INFECTIOUS DISEASES. Scarlet Fever. The total number of Scarlet Fever cases notified was slightly less last year than that of 1928,-—235 in 1929 compared with 243 in 1928. There was one death from the disease, and this death was complicated by other conditions. In 1928 there was no death. These figures suggest the mild character of the disease, and this in itself, as was pointed out in last year's report, constitutes one of the difficulties in its control. Another difficulty is our lack of knowledge of the bacteriology of Scarlet Fever, and until we know more about it, the disease will remain one of the most difficult to control. A few years ago, the Doctors Dick of Chicago isolated a hasmoloytic streptococcus which was claimed to be the cause of Scarlet Fever. Since then at least four types of agglutinable and a group of non-agglutinable streptococci have been isolated from Scarlet Fever cases. Are these distinct species and are there many different Scarlet Fevers? Clinically, of course, we have different types of Scarlet Fever. From the same neighbourhood and even from the same house, we frequently have the disease in varying degrees of virulence, and this does not suggest that there is any true correspondence between the types of the parasite found by the bacteriologist and the types of the disease found by the clinicians. Such variation of resulting reaction may come about by differences in the normal flora of the throat, whether such be favourable or antagonistic to the growth or toxity of Dicks' streptococcus or whatever organisms may cause the disease. It is difficult to believe that the types of organisms cause a distinct type of disease. In spite of the varying degrees of virulence in the patients who are admitted to the Hospital, a second attack of Scarlet Fever, whilst the patient is in Hospital, is very rare, and multiple attacks are too rare for the epidemiologist to believe that there is more than one Variety. There was only one case admitted to the Hospital last year in which a history of a previous attack was given, and only one case in which the patient suffered from a second attack whilst in hospital. A patient was admitted with a definite rash, a sore throat and a typical tongue. He peeled in the usual way, but in the fourth week after admission, he again had a typical attack of Scarlet Fev er, and peeled the second time. Such instances are exceedingly rare, and would occur far more often if the clinical varieties corresponded to the bacteriological findings. 1929 26 The death which occurred in the hospital is interesting from the fact that it is now recognised that Scarlet Fever is only one of the various responses to infection with the virus of hæmolytic streptococcus. It is admitted that hæmolytic streptococci produced many disorders beside Scarlet Fever, though all these streptococci are not all of the same species. It is impossible to separate Scarlet Fever from some forms of Puerperal Fever, Erysipelas and Septicemia, either bacteriologically or epidemicologically. There are varieties of uterine infection which are in many respects identical with some cases of Scarlet Fever, though all uterine streptococcal infections are not similar. The death from Scarlet Fever was that of a woman, who after her confinement developed Scarlet Fever. She also exhibited some signs of uterine infection which were not in any way prominent, and the most prominent signs were those associated with Scarlet Fever. As far as could be ascertained she had not been in contact with .any case of Scarlet Fever. She had not, of course, been out of the house within the usual incubation period of Scarlet Fever, and she had been visited by no one who was suffering from any symptoms suspicious of sore throat. Many of the older medical practitioners were chary of attending cases of Scarlet Fever if they expected to be called to a confinement case, and their reluctance can be explained by the newer findings of bacteriology. They did not have the benefit of the present day bacteriological research, but their experience taught them that some relationship existed between Scarlet Fever and uterine infection. These bacteriolgical investigations may also have an important bearing upon our treatment of contacts, though, at the present time it is difficult to fit in some of the conditions found with the results of bacteriological research. One of the most constant phenomena found in the examination of contacts is the presence of sore throats in those who have been in contact with Scarlet Fever cases A sore throat is of course one of the symptoms of Scarlet Fever, but it is associated with other symptoms—fever, rash, peculiar condition of the tongue, etc. But in Scarlet Fever contacts, sore throat with no other associated symptoms is a very constant and frequent condition. What is the association of Scarlet Fever with non-specific sore throat which we constantly see and note ? Does the streptococcus mutate with sufficient rapidity to cause Scarlet Fever in one host, indefinite sore throat only in a second, and Scarlet Fever again in a third? Whatever views we may hold as to the cause of these sore throats, in Scarlet Fever contacts we have to recognise their occurrence and their treatment causes anxiety. On one morning I examined 12 contacts belonging to 3 different families. Five of these had injected fauces and palate, 1929 27 in 4 of these the tongue was in the desquamative stage characteristic of Scarlet Fever. The parents stated that the children had had a slight sore throat but were positive that no rash of any kind had appeared. In one of the cases the mother was a patient in the hospital and there was no one at home to look after the contact, who was a boy. I took him into the hospital and he peeled profusely. In the second case the mother of the boy as expecting to be confined very shortly, and he was also taken into the hospital. He also peeled but not profusely, and if peeling were not looked for it might easily be overlooked It would simplify matters if a specific germ were isolated as the invariable cause of Scarlet Fever. The contacts could then be swabbed and our procedure based upon some scientific principle. At the present time the treatment of these contacts is dependent upon the experience of the examiner. I do not exclude from school all contacts who have a slight sore throat, but in some instances I do exclude and keep under observation contacts who have sore throats but who have none of the other associated symptoms of Scarlet Fever. Every case is treated upon its own merits or demerits. These considerations alone are sufficient to explain the want of success in the stamping out of Scarlet Fever. Because the numbers which Scarlet Fever at the present time kills or damages are negligible, we have epidemiologists who argue that it makes very little difference how Scarlet Fever is treated; whether it be treated as a dangerous infectious disease with segregation in hospital, control of contacts and clinical treatment of the most modern kind or whether it is neglected and the sufferers" allowed to do what they like, go where they like and receive no treatment or inhibition whatever. The men who argue in that way are either bacteriologists or epidemiologists, pure and simple. They do not envisage all aspects of the disease and the part it plays in the life of the individual and the community. The housing problem is such that few acute diseases can be treated in the homes and when this disease is infectious and complications can occur weeks after the subsidence of the acute symptons, the difficulties of nursing the patients in the home can well be imagined. No general hospital or public institution of course will take the cases on account of the danger of spread of the disease. Under the present social conditions, there is no option to the provision of special hospitals. Possibly segregation of the cases, on account of the difficulties above enumerated and others which have been pointed out in other reports, will not prevent the spread of the disease, but it remains the only practical method of dealing with it. When Fever Hospitals were instituted, the total extinction of Scarlet Fever was devoutly hoped for, but as our knowledge of 1929 28 the disease increases, this consummation may appear impossible, but we can in other ways limit the mischief which the disease may cause, and the inconvenience it may entail. Diphtheria. 48 cases of Diptheria were notified and one death occurred from the disease. In 1928, 78 cases were notified with 7 deaths. Although the number of cases notified was less than that of 1928, the most marked difference was in the lessened virulence of the disease. Tuberculosis. 73 cases of Pulmonary Tuberculosis and 12 cases of other forms of Tuberculosis were notified during the year. There were 52 deaths from Pulmonary Tuberculosis and 7 deaths from other forms of Tuberculosis. The death-notification interval of the 52 patients who died of Pulmonary Tuberculosis in 1929 was— Information from Death returns 6 Notification dated same day as the Death Certificate 1 Died within 1 month after notification 5 Died within 3 months after notification 3 Died within 6 months after notification 4 Died within 12 months after notification 2 Died between 1 and 2 years after notification 4 Died between 2 and 3 years after notification 9 Died over 3 years after notification 18 Of the deaths where information was received from the death returns 1 occurred in the district and 5 outside. The doctor who did not notify the case had also two other cases in which the notifications were received only 9 days before the date of death. The other cases in which information was derived from the death returns were outside cases, and in some of them there was a reasonable excuse. One was found dead on a railway line, and a post-mortem examination revealed the condition. Another had only been recently admitted to a general hospital and a post-mortem examination revealed general tuberculosis as well as marked pulmonary lesions. The fourth case died in a Mental Institution in the North of England and the fifth and sixth deaths occurred in a Workhouse Infirmary. Five of the 7 deaths from Tubercular diseases other than Pulmonary Tuberculosis were not notified. 4 of these deaths were from Tubercular Meningitis and occurred in Public Institutions, and the fifth was from a Tubercular Spine. There is room for improvement in the matter of notification from a few of the doctors. Most of the doctors notify the case 29 immediately, and at the present time there is seldom any resentment at notification on the part of the patients or their friends. Notification has been in force sufficiently long to have brought about an appreciation on the part of the public of the object and value of notification. The public know that there is a Tuberculosis Scheme, but only in a vague sort of way; they do not know the details; in what way the scheme deals with diagnosis, treatment and prophylaxis; these details are very frequently only brought to their notice as the result of the information imparted when inquiries are made after notification. The inquiries are made in a discreet manner, and if the patient is able to obtain, if necessary, expert advice and sanatorium treatment no further action is taken by us which would appear irksome. The delinquent doctors, therefore, are lacking in their care of the patient as well as in their public duty by neglecting to notify the cases early and promptly. Another difficulty which occasionally arises and militates against the success of the Tuberculosis Scheme is the housing difficulty. This matter has been referred to in other reports. Housing accommodation is not sufficient to meet the demand, and even if there were sufficient accommodation, economic conditions are such that the sufferers are not in a position to pay the rent. In some cases there is actual legal overcrowding in the families of those who suffer from Consumption. For instance, the mother of a family was notified and the family consisted of husband, wife and 5 children aged respectively 11 years, 10 years, 8 years, 6 years and 3 years. The house in which they lived belonged to the wife's mother and the latter sub-let two rooms. We arranged with the patient's mother so that her daughter should have a separate bedroom when discharged from the sanatorium. But there are other factors than housing accommodation in this case and I have mentioned it because it is typical of many others. The social and economic factors are quite as important. The husband was a general labourer earning under three pounds a week. If he had to rent a decontrolled flat of such a size as to allow his wife a separate room, the rent would be at least 25s. per week. But with a family of 5, and especially with a consumptive wife, he would find it extremely difficult to obtain a flat or house at a reasonable rent. The case also illustrates the harmful effects of repeated pregnancies at short intervals. It may be assumed that these repeated pregnancies and insufficient nourishment and rest had rendered the mother peculiarly vulnerable to the germs of Tuberculosis. On December 31st the following is a statement of the particulars appearing in the Register of cases of Tuberculosis. 1929 30 Pulmonary. Non-Pulmonary. Number of Cases of M. F. Total M. F. Total Total T.B. on the Register at the commencement of the 4th Quarter. 109 106 215 25 16 41 256 Number of Cases notified for the first time during the 4th Quarter. 8 7 15-1 1 16 Number of Cases removed from the Register during the 4th Quarter. 17 8 1-1 9 Number of Cases remaining on the Register at the end of the 4th Quarter. 116 106 222 24 17 41 263 During the year the Tuberculosis Officer removed 67 cases of pulmonary Tuberculosis and 13 cases of non-pulmonary Tuberculosis from the Register. These are of course in addition to the cases removed on account of death. In the beginning of the year a complete revision of the register was made and in the returns for the first quarter 52 cases of pulmonary and 11 cases of nonpulmonary Tuberculosis were removed from the register. During the year, the Tuberculosis Officer examined 56 new cases of pulmonary Tuberculosis and 6 new cases of non-pulmonary Tuberculosis. 37 patients were admitted to Sanatoria under the County Scheme and 26 were admitted to Hospitals. Ccrebro-Spinal Fever. 6 cases of Cerebro-Spinal Fever occurred and there were 5 deaths. 4 of the cases were notified in the end of July or the beginning of August, and as their occurrence was in some quarters associated with the Public Baths, I append the special report which was made upon these cases. (l) F. K. age 10 years. Notification dated 26.7.1929. Death 27.7.29. This child was taken ill on Monday evening July 22nd and was seen in the house by a doctor on July 23rd. She was admitted to the Acton Hospital on July 24th and died on July 27th. The Meningo-coccus was isolated from the Cerebro-Spinal Fluid by Dr. Braxton Hicks. This was the only examination made of the Cerebro-Spinal Fluid; a specimen was not sent to Dr. Teale of the University College Hospital. (Dr. Braxton Hicks is the pathologist and bacteriologist to 31 1929 the Acton General Hospital. Dr. Teale is the bacteriologist appointed by the Middlesex County Council to examine the cerebro-spinal fluid of Meningitis cases and the swabs of contacts of patients suffering from Cerebro-Spinal Fever). The immediate home contacts were examined on July 31st and all were found negative; that is, the Meningo-coccus was not found in the secretions of the Naso-pharynx. (2) J. M. aged 9 years. Notification dated 26.7.1929. Death 29.7.1929. She was taken ill on Wednesday July 24th. She was seen in her home on that date by a doctor and admitted to the Acton General Hospital on July 26th. She died on July 29th. The Meningo-coccus was isolated from the Cerebro-Spinal Fluid by Dr. Braxton Hicks on July 26th. The specimen sent to Dr. Teale on the same date was negative. The immediate home contacts were swabbed on July 31st and all were found negative. (3) C W. age 13 years. Notification dated 9.8.1929. Death 2.9.1929. This child was taken ill on July 31st, but was much worse on August 1st. She was attended by a doctor on August 1st, 2nd, 3rd and 4th, and was admitted to the Acton General Hospital on August 4th. Dr. Woodwark, one of the physicians of the Royal Waterloo Hospital for Women and Children, saw the child as a consultant and offered to admit her to the Royal Waterloo Hospital. The offer was accepted and she was treated there. She died on September 2nd, and inquest was held by Dr. Ingleby Oddie at the Lambeth Coroners Court. (4) M. L. age At years. Notification dated 28.8.1929. Death 27.8.1929. This child sickened on August 23rd and was attended by a doctor. On August 26th the child was removed to the Acton General Hospital. The Cerebro-Spinal Fluid was examined by Doctor Braxton Hicks and Dr. Teale on August 27th and the Meningo-coccus was found. On August 30th the home contacts were swabbed and found negative. Two other cases have also been mentioned in the newspapers, and though the illness in these was not caused by the Meningo-coccus, I am including a short account of these cases. S.C. age 17 years. Attended 2nd Class Acton Baths on the evening of July 10th—became ill on July 11th with sickness and diarrhoea—attended by a doctor on July 12th. The patient was delirious and died on July 16th. The death certificate was given as Lobar Pneumonia, the primary cause of death, and Pneumo-coccal 1929 32 Meningitis the immediate cause. Meningitis, in young people especially, is not a very rare form in which Pneumonia terminates in death. I have seen the doctor and he informs me that there were no symptoms of Cerebro-Spinal Meningitis. The second case was that of C.M.D age 11 years, attending Southfield Road School. She attended the 2nd Class Acton Baths on July 12th. On July 13th she was feverish, shivering and slightly delirious during the day. She was seen by a doctor on July 13th; on July 14th the nose bled profusely and the bleeding continued for 4 or 5 days. There was a good deal of ear ache and discharge from the right ear. There were no symptoms of Meningitis. The doctor diagnosed the case as a strepto-coccal infection of the nose and throat. She went to Lincoln for convalescence, and when seen on September 18th, the girl appeared quite normal. Contact with each other—The four persons live at some distance from each other, and there does not seem to have been any contact between any of them. It was at first thought that there might have been contact between F.K. and J.M. but as the result of the publication of the particulars in the Newspapers, Mrs. K. told me she had made enquiries of her nieces and she was positive that F. K. did not know J.M. F's two cousins were with her at the baths on the Saturday morning, and they knew J.M. but F. did not and her cousins did not speak to J. Schools.—Three of the four children attended school ; the fourth was under school age. F.K. attended South Acton Girls'School, J.M. Rothschild Junior and C.W. Priory Girls School. Bacteriology. — F.K. Meningo-coccus found by Dr. Braxton Hicks and not examined by Dr. Teale. J.M. Meningo-coccus found by Dr. Braxton Hicks, not found by Dr. Teale. C.W. Meningo-coccus found by Dr. Braxton Hicks, and the Bacteriologist of the Royal Waterloo Hospital; not found by by Dr. Teale. M.L. Meningo-coccus found by Dr. Braxton Hicks and by Dr. Teale. Previous History.—Three of the girls had been perfectly healthy previous to the occurrence of this illness. There was no history of any naso-pharyngeal catarrh. In the third case the child had sore throats. Contacts.—All the contacts that were swabbed were negative, but we were considerably handicapped in our search for contacts by the fact that the schools were closed for the holidays, when knowledge of the illness reached us. At first the only contacts which we could swab were the home contacts. When the schools were 1929 33 opened after the holidays, the immediate school contacts were examined and swabbed. All the swabs proved negative, but in several there had been a history of naso-pharyngeal catarrh. Some of these were swabbed a second time, but the result was negative. Baths.—Three of the girls attended the 2nd Class Acton Baths. F.K. and J.M. attended the Baths on Saturday morning July 20th. During part of the time probably the two girls were in the baths together. F.K. was in the bath earlier than J.M. but when F.K. and her friends came away J.M. was then in the bath. F.K. attended the baths on Monday afternoon with the class from School. J.M. attended the baths on Monday evening. J. did not attend with the School class. The girls were not in the baths at the same time on Monday. C.W. attended the baths on July 22nd with the School class from the Priory School and she was also in the baths on July 26th. The water in the baths is obtained from a deep well, 500 feet deep. The well water on every occasion it has been chemically analysed has been found to be particularly pure. On August 29th, a sample of the well water was examined at the Laboratory of the Ministry of Health, and the report stated that in the well water the bacillus Coli was absent in 50 cubic centimetres of the water. Centrifugal deposits from thet wo samples of bath water plated on suitable media, yielded no pneumo-cocci or hæmolytic streptococci. A suggestion has been made that the well may be contaminated by percolation from the cemetery in Churchfield Road. This cemetery is situated about 100 yards to the north-west of the well. The chemical analyses and the above bacteriological analysis would be sufficient to disprove any such possibility. But the conformation and character of the ground would also make such a contingency not only remote but impossible. The well is sunk through impervious clay and the clay extends right up to the surface of the well. The following are some of the details of the strata of the bore-hole. Depth below ground level. Strata. Thickness of Strata. Other details. 0 Yellow Clay 21ft. 6 ins. (14 in. casing and 21ft. 6 ins. Blue Clay 77 ft (8 in. rising main. 23 ft. 6 ins. 12 in. casing 98 ft. 6 ins. Claystones 6 ins. 99 ft. Blue Clay 112 ft. 6 ins. 211ft. 6 ins. Mottled Clay 49 ft. 254 ft. Start of 8 in. rising main. 1929 34 260 ft. 6 ins. Black Pebbles 4 ft. 6 ins. 267 ft. 6 ins. Thanet Sands 13 ft. 274 ft. Suction Point. 280 ft. 6 ins. Green Sand 2 ft. 282 ft. 6 ins. Green Flints 6 ins. 283 ft. Chalk 217 ft. 289 ft. Start of 12 in. casing. 500 ft. - Bottom of bore hole. It may be taken as proved that the water as it enters the bath is free from polution or contamination. The water in the 1st and 2nd class baths is changed every other day. During the late spell of hot weather the baths were very extensively used. The attendances at the 2nd class baths in and around July 20th were as follows :— July 18th 653 July 19th 621 July 20th 581 July 21st 43 Sunday July 22nd 576 The water was changed on the night between July 19th and July 20th, and again on the night of July 22nd. Although the attendances on Saturday July 20th and Monday July 22nd were not quite as high as on the previous Thursday and Friday, over a thousand persons used them on Saturday and Monday. C. W. attended the bath on July 22nd, but in view of the date of the onset of symptoms that date can have no bearing upon her illness. She also attended the baths on July 26th and the attendances around that date were as follows:— July 25th 393 July 26th 324 July 27th 357 The water was changed before the baths were opened on July 25th and on the night of July 26th. Before we consider any further relation of the baths to these cases of Meningitis it may be desirable to insert an account of the disease of Meningococcal Meningitis. This disease goes under different names such as Cerebrospinal Fever, Epidemic Cerebro-Spinal Meningitis, Spotted Fever, Meningococcal Meningitis, etc. These names give some clue to the nature of the disease. Its most characteristic feature is an inflamation of the covering of the brain, accompanied by a rash on the skin. The mortality from this cause in England and Wales first distinguished in 1911, varied only between 9 and 11 per million I929 35 living during 1911 to 1914, and then suddenly increased to 45 in 1915. After that it gradually fell to 7 in 1923, and has been between 7 and 11 in 1928 and 1927, so that the level of 15 years ago has been established. The mortality since 1923 has been slightly on the upgrade. The number of deaths in England and Wales from the disease since 1923 have been 1923 284 1926 365 1924 301 1927 430 1925 354 1928 438 Although the illness occurs usually in epidemics, sporadic or endemic cases occur frequently as these figures show. Outbreaks are relatively common in America and in the continent of Europe, but since the war there have been no extensive outbreaks in tnis country. There were extensive outbreaks in Glasgow and Belfast in 1907. During the European war a large increase occurred not only among the troops but also among civilians. Some authorities were of opinion that the disease was introduced from Canada, or at any rate, that a virulent strain was imported. The disease is compulsorily notifiable, but it is obvious from the statistical review of the Registrar General that all cases are not notified. In 1928 there were 438 deaths from the disease in England and Wales, but only 412 notifications were received. Last year there was no district in which the disease was very prevalent. 75 cases were notified in London and 22 in the County of Middlesex. This disease is most common in children, the incidence being highest in children under 5 years of age. The ages of the persons who died from the disease last year was as follows :— Under Over 1 1—2 2—5 5—15 15—25 25—45 45—65 65 year. years, years, years. years. years. years, years. 140 54 52 78 52 37 22 3 From the death returns it appears that the disease is slightly more prevalent amongst males than females. The numbers of deaths for the past four years were as follows:— 1928 246 males, 192 females 1927 259 „ 171 „ 1926 211 ,, 154 ,, 1925 202 „ 152 ,, The disease is caused by a germ called the Meningo coccus or diplo-coccus intra-cellularis, discovered by Weischelbaum in 1887. There are probably many strains of this germ, and at least four different kinds have been isolated. The germ is not very tenacious, in fact, it is a very delicate organism, very easily killed by heat or cold. Cultures die readily, and sub-cultures are necessary every few days if the specimens are to be kept. It will 1929 36 not grow on any media at temperatures under 25° Centigrade (about 77° Fahrenheit): it dies at a temperature of 23° Centigrade. Special media have to be prepared for its growth and extra precautions are necessary in order to obtain specimens f it. When diphtheria patients, for instance, are swabbed, the nose or throat is swabbed and the swab sent to the laboratory and there transferred to the growth media. But in the search for the meningo-coccus, the swabs must be taken from the back of the nose, and transferred immediately to the growth media. If the swabs were taken to the laboratory and transferred in the ordinary way, the drying and cooling would be sufficient to kill the germ and no growth would result. The germ is found in the cerebro-spinal fluid and brain coverings of persons suffering from the disease, but only occasionally from the secretions of the nose and throat. This probably explains why the infection very rarely takes place directly from patient to patient. The grerms are very rarely isolated from the naso-pharynx of those suffering from the disease. Even in carefully studied outbreaks it is exceptional for infection of a patient to be ascribable to any known case of cerebro-spinal fever. In other words, direct association with the sick is neither a necessary nor even a common factor in contracting cerebro spinal fever. The spread of the infection usually takes place through the medium of a third person or ' carrier ". The germ is very frequently found in the nose and throat of "carriers," that is, persons who harbour the germs, but who are suffering from no symptoms. There is evidence to the effect that meningococci are to be found in the nasopharynx of persons living in areas in which there has been no outbreak or epidemic of cerebro-spinal fever. In outbreaks of the disease where contacts have been swabbed the percentage of "carriers" may be very high. Possibly nearly 3°/o of the population may be harbouring the germs, though in the majority of the cases the germs are quite harmless. Different figures are given where extensive swabbing has been done, and the percentages vary from two to ten per cent. So long as the germs remain in the nose and naso-pharynx, they give rise to no symptoms or at any rate to nothing more serious than a slight catarrh. It is only when the organisms gain entrance to the brain cavity that symptoms of meningitis occur. It is not known what the conditions are which determine the migration of the organisms from the naso-pharynx into the brain cavity. It is surmised that some changes occur in the mucous membrane which enable the organisms to penetrate the protective barrier. If a person does not harbour the g-erms, but comes in contact with a "carrier", a susceptibility to the disease would render the person liable to contract the disease. The immunity which the 37 1929 "carrier" enjoys does not extend to the susceptible person. Alternatively, it is possible that a change of pressure such as occurs in a person diving might conceivably determine the migration of the germ in a "carrier" from the naso-pharynx into the meninges. These are, of course, only surmises but have been put forward by certain authorities who have investigated epidemics of the disease. That various depressent experiences may determine an attack of disease is known and cases of encephalitis following vaccination have been reported from different parts of the country. What light does the life history of the meningo-coccus or the epidemiology of cerebro-spinal fever throw upon the occurrence of these cases in Acton ? It can be stated quite definitely that the infection in every instance must be direct from person to person. The meningo-coccus will not grow in bath water ; in fact it cannot survive in such a medium or such a temperature which obtains in Public Baths. The only possible conditions under which infecttion could take place in the bath water would occur if a "carrier" took in some water through her nose, spat it out of her mouth and a susceptible person immediately inhaled that same water through her nose. Such a theory is really too grotesque to be considered seriously, but it is the only possible way in which ordinary bath water could be the medium of spread. If infection had taken place in the baths, the only two persons who could have been infected together would be F.K. and J.M., and that date would be on July 20th. J.M. may have been infected on July 22nd, but it is extremely doubtful if F.K. could have been infected as late as July 22nd. C.W. was probably infected as early as July 22nd. The incubation period is very rarely over a week, and she was not taken ill until July 31st. Other circumstances could be mentioned which would point against the probability of the baths being the medium of infection. The three sufferers were all girls, but on July 20th and July 22nd, the baths were also used by boys and men. On Saturday, July 20th, the 2nd class baths were reserved for ladies from 9 a.m. to 12.30 p.m. and from 12.30 p.m. until closing time, men only were allowed to use them. On July 22nd men only used the 2nd class baths up to 2 p.m. and ladies only from 2.0 p.m. to closing time. From the elementary schools on July 22nd, 157 girls and 139 boys attended. On the two days it may be assumed that quite as many men and boys attended as women and girls and yet infection was limited to girls. Again the three cases all live south of the main Uxbridge Road, but the baths are attended by persons from all parts of the Borough. 1929 38 The number is too small to attach importance to the sex distribution or the situation of the houses of the sufferers, but they all point to a source of infection other than the baths. Unfortunately we have not been able to trace the source of infection, but as previously stated, we were handicapped in our search in one direction by the fact that the schools were closed during the holidays, and if the "carriers" were school girls it is quite possible for the nose and throat to be free at the end of the holidays. Public Baths. Although it is probable that the water in the Swimming Baths had no connection with the occurrence of the foregoing cases of Cerebro-Spinal Meningitis, it may be desirable to discuss the matter more fully at the present time. In recent years there has been an immense increase in the popularity of swimming, and the condition of the swimming bath water has become a matter of interest and importance to a large and increasing number of the inhabitants of the Borough. Until quite recently most of the work in connection with the pollution and purification of water in swimming baths has been done by American authorities and most of the literature dealing with bacterial standards appears to be of American origin. It appears that in America much greater effort is expended in examination of the conditions prevalent in swimming bath water, though it is not equally clear that these conditions themselves are in fact more satisfactory than in this country. Certain means of measuring the possible contamination have been introduced : of these the most important are the bathing load and the standards of bacterial purity. The bathing load is found by dividing the total number of bathers in a given time by the capacity of the pool in thousands of gallons. It is a method of easy application, but not very reliable as so many factors enter into the amount of pollution. A standard of bacterial purity is more difficult to measure, but is more reliable. Water from an indoor swimming bath may afford the most varying bacterial counts according to the number and cleanliness of the bathers and the treatment which it has received. The temperature of the water which usually lies between 70° and 74° Fahrenheit, has considerable influence on the count, owing to the more rapid multiplication of most bacteria at the higher temperatures, whilst the temperature of the outside air appears also to exercise considerable influence, probably largely due to the increased secretion of sweat in hot weather on the per. . sons of the bathers prior to bathing. 39 1929 In this country no bacterial standard has been adopted. The standards of bacterial purity vary in different parts of the United States. The most recent standard is that of the Joint Committee on Bathing places of the Americ in Public Health Association and conference of State Engineers, and quoted in the Ministry of Health's Report. Until quite recently in Acton we had no need to adopt any standard of purity as we had an abundance of water. The water is supplied from a deep well, and the water in both swimmingpools was changed every other day. Even in the hottest and driest summers the water was always fairly clean. There was plenty of water and general drought made no difference. The well water never failed. The increasing popularity of the swimming baths has altered conditions and now, in the second day, the cleanliness of the pool leaves much to be desired. The purification of the water is under consideration, but there are more or less obvious provisions with regard to the structure of the baths, the habits of the bathers, the exclusion of diseased persons and other points which can be improved. The most drastic recommendation is that all bathers should take a complete soap and water bath before entering the swimming pool. Probably we are far from this ideal yet, but it is an ideal, never-the-less, which we should set up. There are too many people who regard a bathe in the Public Swimming Bath purely as an ablution process, and every means should be used so as to educate the users to the fact that they should be as clean as possible before entering the pool. It may be taken as certain that the water which is used at the bath is particularly pure when it is pumped. Reference is made to this matter in a previous paragraph, and no anxiety need be felt about the contamination of the well. In the Council's swimming baths a large portion of the dirt found in the water is carried in from without by the boots of the bathers, spectators and staff. The side paths of the bathing pool are used by the bathers both for entrance to and exit from the boxes and for walking round the baths. The side paths are almost always covered with visible dirt in suspension in water, and although drainage for these paths away from the pool is provided, a considerable quantity of pollution reaches the water on the bathers' feet. The only way to avoid this entirely, of course, is to have entrances to the boxes from outside and separate from those by which the bathers enter the water. This is impossible in the Council's baths. The original planning precludes any possibility of re arrangement so as to obtain the separate entrance to the boxes. But it would be possible to set aside rooms where the boots and stockings could be divested before entering the baths. There is a room adjoining the first class 1929 40 swimming pool which could be fitted up with lockers and the boots and stockings stored. This room leads directly to the deep end of the first class swimming pool. It would require an attendant there, but the only entrance could be made at that door, and an extra attendant would not be amiss in the busy part of the day Another advantage of this arrangement would be that the pressure on the capacity of the bath would be relieved during busy periods, because less time would be spent in the boxes, dressing and undressing. An objection has been raised to this proposal on account of the restrictions which it would impose upon the bathers and any restrictions might interfere adversely with the attendances Everybody is most anxious to popularise swimming and nothing should be unreasonably done to affect adversely the attendances at the baths, but I am inclined to think the only persons who would resent such a procedure would be those who would be ashamed to have their feet seen. In time most of those who attended would have washed their feet before coming to the bath or would use the shower bath before entering the pool. Once the public appreciated that everything was being done to provide clean water and to keep it clean in the swimming pool, the effect of any re sonable restrictions would rather be an increase in the popularity of the baths. Costumes are a source of dirt and more particularly of discolouration of the water. In former years the rule was observed that new costumes were not allowed to be used unless they had been previously steeped in boiling water; as the ladies' costumes became more elaborate this rule was not so strictly observed. But it is no infrequent sight to see a trail of colour in the wake of a swimmer using a new costume. Fortunately the new elaborate bathing costumes are made of some woollen material and this is not so likely to lose its colour as cotton. It is necessary to make some regulation to prevent the use of new coloured bathing costumes which are liable to lose their dye until they have been steeped in boiling water. In the Report of the Ministry of Health considerable importance is attached to the efficient washing and sterilisation of bathing slips and especially towels. In our baths we have the means to wash and sterilise the slips and towels, but the Committee should consider the question whether temporary additional labour should not be secured during the rush periods. From a health point of view, possibly the most serious source of pollution is from the persons of the bathers. The water of swimming baths is liable to be contaminated from the various secretions and excretions of the bathers using the bath, and also with living bacteria from the same sources. Contaminating organic matter is present on the skin of bathers, especially during 1929 41 the hot weather, in the hair, in the secretions of the nose and throat, from all of which sources it may be introduced into the water. The presence of these organic matters has the effect of converting the water into a culture medium, so that any bacteria introduced, even in small numbers, must soon undergo rapid multiplication. The skin is probably the chief source of bacterial contamination, and here again the presence of increased sweat and dirt in hot weather certainly involves an increased number of bacteria on the skin surface, and this in hot weather increases the possibilities of contamination from this source. Most, if not all of these organisms are no doubt non-pathogenic, and therefore harmless from the point of view of causation of disease. But even the contamination from the skin could be lessened if a more extensive use was made of the spray bath before entering the water. Since short hair in women has become the vogue the heads of the girls are much cleaner than in former days, but unfortunately the wearing of caps by women is not so universal as it used to be, and the Committee might consider the compulsory wearing of caps by all young girls. Caps are worn always by grown-up women. Mucus from the mouth and nose and saliva contaminate the water. A good deal of the spitting which occurs in the swimming pool is unnecessary, is done in ignorance and could be avoided. The taking in of water into the mouth and spurting it out into the bath is unnecessary and filthy. Notices are put up against spitting but they might be more frequent and prominent. Although there is the possibility that intestinal organisms may play a part in contamination, this is not so frequent a cause as that which arises from micturition in the bath. It is well known that micturition occurs involuntarily with some persons on entering cold water, and possibly this cannot entirely be avoided, but the greater part of the contamination from this source could be prevented if all bathers used the urinals and closets immediately before entering the swimming pool. Most grown-up persons use these conveniences but the greatest difficulty arises from the children who come in classes. They are only allowed a certain time inside the baths, and the closets on the side of the secondclass baths are not sufficient in number. There are only two closets together with the urinal, and this is not sufficient. The conveniences on the side of the first-class baths are also not very conveniently situated, or at any rate not conspicuous, and notices could be posted calling attention to their situation, and the desirability of always using them before entering the pool. It must not be inferred from the foregoing that swimming baths are responsible for the spread of much disease. The danger of the transmission of disease by polluted water in swimming baths 1929 42 has been greatly exaggerated, but it is held by some that the danger does exist. As some prominence has been given to this aspect of the question in recent reports it may be desirable to examine it more fully. Several instances of epidemics and isolated instances of intestinal diseases, including Enteric Fever and Dysentry have been recorded. The best known was that reported in 1908 by Dr. Reece to the Local Government Board of a small epidemic of Enteric Fever at the Royal Marine Depot at Walmer. In this case it was clearly proved that the outbreak was due to the sewage polluted water which supplied the swimming pool. In all cases reported the cause of the disease lay in the pollution of the water not from persons bathing, but from discharges of recognised cases of the disease in question which had access to the water at other points or in general sewage pollution. The conditions are therefore not analogous to those obtaining in the Council's swimming baths and therefore can be ignored. It is almost universally admitted that skin diseases are not transm tted by means of the water in swimming baths. If transmitted at all, it can only be by towels, costumes and seats rather than by water. The Council's baths are provided with a good laundry and the towels and slips are always boiled. There are certain improvements which could be suggested such as the replacement of the mangle by a calendar and possibly a little extra labour during the rush hours. Some epidemics of conjunctivitus have been reported from America, but in this country no authentic instance is recorded. Complaints have been received from some baths of inflamed and smarting eyes, but these have usually occurred where chlorination of the water has taken place and sufficient care had not be n observed in the dosage, and too much free chlorine was present in the water. It is the throat and ear affections which give the chief gravamen to the charge of dissemenating disease against swimming baths. Dr. Dan McKenzie in the Lancet stated that the prevalence of ear diseases during the bathing season is well-known to surgeons, but it occurs as frequently amongst open air bathers as it does amongst those using closed baths. Middle-ear disease occurs most frequently amongst those who have previously suffered from an affection of the ear, and also amongst tho-e who bathe infrequently. It is uncertain which of the two factors plays the chief part, namely whether infection takes place from organisms present in the water and derived from the naso-pharyngeal or other secretions of other bathers, or whether the action of bathing is to cause an infection of the patient's middle ear, owing to unhealthy conditions of his own naso-pharynx, and the passage of organisms up the eustachian tubes as the result of sniffing and of the changes in pressure incidental 43 l929 to immersion of the head in water. Most authorities believe that the latter factor plays the chief part and that the action of bathing is to cause an infection of the patient's middle ear owing to unhealthy conditions of his own naso-pharynx. Some doctors in Acton have told me that they have cases of sore throat in the summer which they attribute to bathing-. We have exceptional facilities for watching any ill effects in school children and I have not come across any authentic cases of sore throats or otitis media which could be attributed to the baths. These sore throats and discharging ears are caused by germs called streptococci and as these germs are found in polluted bath water, the possibility of transmission of these diseases by water must be admitted. The really extraordinary thing is that there are not more cases reported when one considers the vast number who use swimming baths as part of the curriculum, and are subject to medical supervision. In their case it would appear to be impossible that an outbreak of disease would not be traced to its source if a swimming bath was responsible for spreading infection on a large scale. It may be assumed that the danger of the spread of disease is a small one, and this risk might be avoided entirely by the use of chemicals. It has been found that a very high bacterial standard of purity may be obtained by the chlorination of the water. Chlorination has been applied for the sterilisation of water from a sewage polluted river at a public bathing beach with satisfactory results. In this country, Dr. Alexander of Poplar, recommended the use of electrolytic fluid, a mixture of hypochlorites which is added in such amount as to yield 0.5 parts cf chlorine per 1,000,000, the bath water not being filtered, but changed periodically, and this method was used in Poplar. A few baths are treated with copper sulphate. These methods are condemned in the Report of the Ministry of Health as they do not get over the difficulty of dirty water, and the procedure as it cloaks the inevitable appearance and masks the dour of deterioration enables the same water to be used for a longer period without refilling. This last objection would not apply very forceably here as the water is always changed every other day. Chlorination alone will not clarify the water, but it will probably destroy any germs which would cause diseases. With the increase in the popularity of swimming, the Committee may at some future date have to consider the question of filtration, but a great improvement can be effected if certain obvious rules and common sense regulations are strictly enforced. Small-pox. Two cases of Small-pox were notified and both were fata!. The patients were husband and wife and came to this country from 1929 44 Khartoum, on board s.s. Tuscania. They joined the ship at Port Said on March 23rd. The Tuscania left Bombay where severe Small-pox was prevalent on March 14th, and called at Suez, Port Said, Marseilles and Gibraltar. On March 17th, a seamen fell ill, and on March 18th another sailor became ill. These cases were not diagnosed as Small-pox until the steamer reached Marseilles on March 27th, where one of the seamen was landed, but died soon after in hospital. Before the illness had been diagnosed as Small-pox about 450 passengers had disembarked and had left Marseilles. On receipt of the information that the illness was Small-pox the ship's surgeon vaccinated a large number of the passengers and crew on board the ship. When the ship arrived at Liverpool, the other sick seamen was diagnosed as suffering from Small-pox and the usual procedure adopted. Altogether 53 cases of Small-pox were reported from different places—47 primary (i.e. contracted on the ship) and 6 secondary. Ten primary cases and two secondary cases proved fatal. The Tuscania arrived in Liverpool on April 1st and four of the passengers (husband, wife and two children) came to Acton. We called at Ihe address which had been given in Liverpool, but were unable to see any of the passengers. On April 9th, I was asked by a doctor to see a women at the address named. When we arrived there, the woman was dead. The woman was pregnant and aborted on April 8th, and on April 9th she died of Haemorrhagic Small-pox. There was a purpuric rash on the body which was the prodromal rash of Hæmorthagic Small-pox. The focal rash of Small-pox was only beginning to appear. In a room upstairs was the husband who had been ill since April 6th or 7th. The characteristic rash of Small-pox was appearing on the face and body. He was at once removed to the Metropolitan Asylums Board's Small-pox hospital where he died on April 16th of Confluent Small-pox. The two children appeared free of symptoms and were vaccinated. All the contacts were vaccinated or revaccinated, and no further cases occurred. Owing to the severity of the disease there was no objection on the part of the contacts to vaccination. Some confusion has arisen in the minds of some people regarding the Small-pox which occurred on the Tuscania and the Small-pox which is now prevalent in London. The Small-pox which occurred amongst the passengers and crew of the Tuscania was what is called the Eastern or Asiatic type of the disease, and this still remains extremely virrulent in its character But its very virulence is a help to prevent its spread. 1929 45 The disease which is prevalent in the East End of London is of an extremely mild type, and its very mildness defeats all efforts to limit its spread. The four cases which occurred here in 1928, belonged to the mild category, but no cases of this type occurred in 1929. ISOLATION HOSPITAL. During the year 419 cases were admitted into the Hospital compared with 400 in 1928. On January 1st, 1929, there were 48 cases in the Hospital and on January 1st, 1930, 75. 390 were discharged and there were 5 deaths. The following is a list of the cases admitted :— Acton Wembley Kingsbury Total Scarlet Fever 203 102 9 314 Diphtheria 42 50 11 103 Measles — 2 — 2 245 154 20 419 Scarlet Fever. 314 cases of Scarlet Fever were admitted and there were two deaths. The circumstances in which one of the deaths occurred are referred to in another paragraph. One of the most important advances in the treatment of Scarlet Fever has been the introduction of the Scarlet Fever Antitoxin. The specific serum has now come into general use for the treatment of the toxaemia met with early in the disease, but some difference in the practice of administration exists. We have not used it in every case which was admitted into the Hospital last year, but only in those cases where temperature was fairly high, or the pulse abnormally rapid on admission, but we have regretted sometimes that it was not used in the mild cases. In several cases, the early use of the serum is of the utmost importance, and almost invariable, there is a dramatic drop in the temperature and the pulse rate within twenty-four hours. In the mild cases, in which the serum is not given, very frequently the temperature will not settle for many days, and it is these cases that one regrets the serum was not given early. There is a concensus of opinion that the best results from the serum are obtained when it is given early. One aspect which has not been settled is the effect of the serum upon the septic complications of the disease, and this aspect is important from the view point of administration. Some medical superintendents claim that administration early in the disease decreases the chances of septic complications, 1929 46 and in some hospitals, the usual period of detention has been considerably reduced, but to any one who is well acquainted with the vagaries of Scarlet Fever convalescents the figures adduced do not carry much weight. One writer stated that he had released from isolation over 20 cases whose quarantine time from the onset of illness varied from 17 to 24 days. This is quite possible, but in the next 20 cases, although the conditions upon discharge may have appeared similar, he may have many of these latter devoloping complications or giving rise to "return" cases. We have reduced the usual period of quarantine from six weeks to five weeks, and so far the percentage of return cases does not seem to be higher than it was when the longer period was observed. Of the 314 cases admitted the average stay in the hospital was 39.33 days. Some of the cases were in for a very long period—the longest being in for 132 days, and another for 126 days. The majority of the cases were discharged within 5 weeks. I have excluded the outside cases in estimating the return" cases. 203 were admitted from Acton into the hospital during the year. Some of these were discharged in 1930, but as this report is written in May, any return cases from these would be included. 8 return cases occurred, and the dates were as follows :— Infecting case discharged from Hospital. Return case notified. 19/4/29 6/6/29 15/6/29 28/6/29 29/10/29 14/11/29 30/10/29 20/12/29 26/11/29 1/12/29 4/12/29 16/12/29 28/12/29 4/1/30 25/2/30 17/4/30 Diphtheria 103 cases of Diphtheria were admitted and there were 3 deaths. The death-rate from Diphtheria was very low, and was due to the early administration of antitoxin, although, naturally, with such a low percentage mortality, there were many mild cases admitted, there was a considerable percentage of severe and very severe cases. In every instance where the disease was diagnosed, and antitoxin administered, early, the patient recovered. The importance of early administration of antiioxin in severe cases cannot be too strongly emphasized. Some doctors still wait for the result of a bacteriological examination before they notify a case. A bacteriological examination may be necessary in mild cases, but 1929 47 when the symptons and signs are obvious, the doctor should remember that early notification is necessary. BACTERIOLOGICAL EXAMINATIONS Positive. Negative. (a) For Diphtheria Total Examinations—901 83 818 Sent by Medical Practitioners 33 298 do. (re-examinations) 4 70 Sent from Isolation Hospital 32 252 do. (re-examinations) 2 3 Convalescents (1st Swabs) 1 17 do. (2nd Swab) 1 — do. (3rd Swab)' 1 — do. (4th Swab) 1 — Contacts 0 59 do. (2nd examinations) 0 19 Precautionary Swabs 0 15 School Sore Throats 6 64 do. (2nd Swab) 5 — do. (3rd Swab) 1 — School Contacts 0 21 (d) For Ringworm uphill. Positive. Negative. Total Examinations—3 3 0 (c) For Tubercle Positive. Negative. Total Examinations—218 ••• ... 28 ... 190 MATERNITY AND CHILD WELFARE. Infantile Mortality 85 deaths occurred in children under one year of age. This number corresponds to an infantile mortality of 83 per 1,000 births. The infantile mortality is higher than that of England and Wales and that of the 107 Great towns and of London. It is the highest infantile mortality which we have had in Acton since the termination of the War. When we come to examine the cause of death, we find that in 51 of the deaths, the death was due to a pre-natal cause such as premature births, inanitation, congential debility etc. Into all these deaths, enquiries are carefully made, and though the mothers state the premature birth was brought about by some accident, such as a fall in the house, or a fright or some other innocent or trivial cause, there is reason to believe that other 48 causes have been in operation. Formerly, extra domestic labour carried on into late pregnancy was supposed to have considerable influence in bringing: about a premature birth. It is quite conceivable that employment of married women in laundries, which involved prolonged periods on their feet and in an upright position would be conducive to premature birth, but such conditions are now rare and in very few instances were the mothers employed in laundries or in any other industrial employment. An examination of the distribution of deaths from prematurity and other pre-natal causes would suggest that extra domestic labour is not now an important factor. The relative incidence of deaths from pre-natal causes is Jower in the South West Ward than in the other Wards. We hear nowadays a good deal about birth-control and instruction in contraceptive methods, but there is another aspect of the question which is sometimes ignored. There is no doubt that the taking of abortifacients is a very frequent practice. It would not be desirable or wise to name the drugs which are being used, but from enquiries we have made, we know that it is a very prevalent practice. It is not known to what extent this practice is responsible for the high number of deaths from pre-natal causes, and I do not think it possible to make any estimation, because the necessary information would not be forthcoming. It is only a small proportion of the women who will admit that they have resorted to this practice in order to procure the expulsion of the foetus. In a discussion which took place upon Birth Control at a recent Conference, it was suggested that the medical aspect of control was limited to the effects of different contraceptive methods upon the health of the mother. But no mention was made of the abortifacients when contraceptive methods were not practised, and the effects upon the health of the mother when these drugs were taken. It is possible that the use of abortifacients may have an influence upon the number of deaths from pre-natal causes, but it is difficult to suggest in what way the practice may be combated. There was a slight rise from deaths of the Respiratory system; this rise was probably due to the very severe weather experienced in the early part of the year. Pre-natal Clinic The Clinic is held once a fortnight in the School Clinic and Dr. Bell is in charge. 23 sessions were held with a total of 144 attendances. There is an agreement with the Acton General Hospital for the reception of complicated cases of pregnancy and during the year 2 patients were admitted under the scheme. 49 1929 Welfare Centres Towards the end of the year a new child welfare centre was opened at premises rented from the authorities of the Wesleyan mission in Steele Road. The appointment of another Health Visitor necessitated a re-arrangement of the districts, and a new centre was opened in Steele Road. It was found necessary to arrange for a weekly opening of the Centre in East Acton School. There are now six sessions held weekly, 2 each in Church Road and Palmerston Road and one each in East Acton School and Steele Road. In connection with the new appointment of a HealthVisitor the work is jointly school medical and infant welfare. Miss Sorlie undertakes in addition to the visiting of infants under 5 years of age, certain school medical work in Rothschild Road and Beaumont Park Schools. Miss Woosnam, in addition to her school medical services, does the infant welfare work in the East Acton area and attends the Infant Welfare Centre in the East Acton School. This arrangement obviates overlapping in the visits . to the homes, and I hope will tend to efficiency. Day Nursery The Nursery was open on 231 occasions, and 4,134 wholeday and 94 half-day attendances were made. The Nursery is open on 5 days of the week, but last year it was suggested that a Saturday morning opening would prove a convenience to some of the mothers. The experiment was tried, and the Nursery was opened on a Saturday morning for 8 weeks. On 8 occasions 1 child attended. The reasons for the non-success of a Saturday morning opening is not far to seek. Most of the mothers are occupied in work which does not necessitate going away on the Saturday morning. In the laundries, for instance, the married woman seldom works on a Saturday morning, and even where the employment of the mother necessitates her leaving her home on a Saturday, there is frequently a school girl who looks after the baby. The trial, I think, proved that at the present time there is no real necessity for a Saturday morning opening of the Day Nursery. Conditions may change and our procedure may have to change with the altered conditions. 1929 50 TABLE 1. BIRTH-RATE, DEATH-RATE, AND ANALYSTS OF MORTALITY DURING THE YEAR 1929. Rate per 1,000 Population Annual Death-rate per 1,000 Population Rate per 1,000 Births Percentage of Total Deaths All Causes Enteric Fever Small Pox Measles Scarlet Fever Whooping Cough Diphtheria Influenza Violence Diarrhoea and Enteritis (under 2 yrs.) Total deaths under 1 year Certified by Registered Medical Practitioners Inquest Cases Certified by Coroner after P.M. No Inquest Uncertified Causes of Death Live Births StillBirths England and Wales 16.3 0.68 13.4 0.01 0.00 0.08 0.02 0.15 0.08 0.74 0.55 8.1 74 91.5 6.1 l.5 0.9 107 County Boroughs and Great Towns, including London 16.6 0.69 13.7 0.01 0.00 0.12 0.02 0.19 0.09 0.76 0.50 10.9 79 91.8 5.8 1.9 0.5 156 Smaller Towns (1921 Adjusted Population, 20,000—50 000) 16.0 0.71 12.3 0.01 0.00 0.06 0.02 0.15 0.07 0.71 0.45 5.9 69 92.6 5.4 1.0 1.0 London 15.7 0.53 13.8 0.01 0.00 0.04 0.02 0.26 0.08 0.69 0.56 10.7 70 89.5 6.8 3.7 0.0 Acton 15.7 0.38 12.7 0.01 0.03 0.00 0.01 0.21 0.01 0.59 0.54 5.9 83 94.0 3.8 2.1 0.02 1929 51 TABLE 2. VITAL STATISTICS FOR THE WHOLE DISTRICT DURING 1929 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 Number Rate of Non-Residents Registered in the District of Residents Registered outside Dist. Number Rate per 1,000 Births Number Rate per 1,000 Inhabitants 1924 62,980 1158 18.4 488 7.7 8 235 65 56 715 11.2 1925 63,110 1047 16.5 446 6.8 18 241 80 76 669 10.6 1926 63,040 1098 17.4 422 6.7 15 250 60 55 657 10.4 1927 63,750 1026 16.1 445 6.9 21 280 62 60 704 11.04 1928 64,870 1003 15.4 479 7.4 29 244 55 55 694 10.7 1929 65,200 1026 15.7 540 8.3 21 307 85 83 826 12.7 1929 52 TABLE 3. AGES AT DEATH, AND WARD DISTRIBUTION OF DEATHS IN 1929, Causes of Death Age in Years Ward Distribution AllAges 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 14 5 5 3 1 - — — - 5 3 1 5 Scarlet Fever 1 — — — — - 1 — — — 1 - - Diphtheria 1 — — — 1 - — — — — 1 - - Small-Pox 2 — — — — - 2 — — — — 2 - Enteric Fever 1 - - 1 — — — - - 1 Cerebro Spinal Meningitis 5 — — 1 3 1 — — — 1 1 - 3 Amoebic Dysentery 1 — — — — - 1 — — — 1 - - Influenza 38 1 - 2 1 2 5 10 17 14 10 11 - Tuberculosis of the Respiratory System 52 — — — — 11 22 17 2 9 7 9 27 Other Tubercular Diseases 7 1 — — 4 - 1 1 — 1 — 2 4 Canver, Mailignant Disease 106 - — — 1 - 9 35 61 36 30 14 26 Rheumatic Fever 3 — — — — 2 1 — — 2 1 - - Heart Disease 71 — — — 1 1 7 26 36 23 15 17 16 Cerebral Hæmorrhage 31 — — — — — 3 6 22 10 8 5 1 Arterio-Seelerosis 40 — — — — — 1 8 31 8 9 13 10 Diabetes 8 — — — — — — 3 5 2 2 1 3 Bronchitis 94 7 2 2 1 1 3 24 54 27 17 21 29 Pneumonia 56 9 4 5 1 2 8 16 11 13 7 9 27 Other respiratory Diseases 6 — 1 — — — 1 2 2 2 2 1 1 Diarrh£a 6 6 — — — — — — — 1 2 2 1 Ulcer of the Stomach and Duodenum 4 — — — — 1 — 3 — - - 3 1 Appendicitis 5 — — — — 1 2 1 1 2 1 2 - Alcoholism 1 — — — — — — — 1 — - 1 - Cirrhosis of the Liver 6 — — — — — — 5 1 1 2 - 3 Acute yellow Atrophy of Liver 1 — — — — 1 — — — — - 1 - Nephritis 19 — — — — — 3 7 9 4 1 9 5 Puerperal Sepsis 1 — — — — 1 — — — — - - 1 Other Diseases of Pregnancy & Parturition 2 - - - - 2 — — 1 - - 1 Prem. Birth, Cong. Malformation & Debilty 51 49 — 1 1 — — — — 15 13 9 14 Suicide 4 — — — — 1 1 1 1 1 1 1 1 Other deaths from violence 31 2 — — 2 5 5 11 6 8 9 11 3 Other defined Diseases 158 5 - — 3 7 10 18 115 45 48 26 39 Total 826 85 12 14 20 37 89 194 375 230 193 171 232 53 1929 TABLE 4. INFANTILE MORTALITY 1929. Causes of Death Ages Wards Total 1 week 1—2 weeks 2—3 weeks 3-4 weeks 1-3 months 3—6 months 6—9 months 9—12 months North East North West South East South West Whooping Cough 5 1 3 1 4 | Bronchitis 7 1 2 1 3 1 3 3 Pneumonia 9 1 1 7 1 1 7 Influenza 1 1 1 Diarrhœa 6 1 1 1 1 2 1 2 2 1 Congenital Debility 2 1 1 2 Congenital Malformation 2 1 1 2 Inanition 5 2 1 1 1 2 3 Marasmus 3 2 1 2 1 Premature Birth 31 15 5 1 4 6 10 9 4 8 Injury at Birth 2 2 1 1 Strangulation 1 1 1 Meningitis 1 1 1 Mastoiditis 1 1 1 Enlarged Thymus 1 1 1 Meleana Neonatorum 1 1 1 Congenital Syphilis 1 1 1 Tubercular Menigitis 1 1 1 Congenital Hydrocephalus 1 1 1 Overlaying 1 1 1 Intussusception 1 1 1 Septic Infection 1 1 1 Anencephalus 1 1 1 Total 85 22 9 1 8 16 7 9 13 23 16 18 28 1929 54 TABLE 5. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1929. Notifiable Disease Cases notified in whole District, At Ages—Years Ward Distribution. At all Ages Under 1 1 to 5 6 to 15 16 to 25 26 to 45 46 to 65 Over 65 N.E. N.W. S.E. S.W. Small Pox 2 ... ... ... ... 2 ... ... ... ... ... 2 Scarlet Fever 235 ... 63 129 26 16 1 ... 70 28 42 94 Diphtheria 48 ... 4 26 5 3 ... ... 7 6 10 25 Typhoid 2 ... ... ... ... 2 ... ... ... ... 1 1 Paratyphoid B. 5 ... 1 1 3 ... ... ... 1 ... ... 4 Pneumonia 44 ... 4 3 8 15 10 4 14 3 13 14 Puerperal Fever 2 ... ... ... ... 2 ... ... 2 ... ... ... Cerebro-Spinal Fever 6 ... 1 3 2 ... ... ... 1 2 ... 3 Poliomyelitis 1 1 ... ... ... ... ... ... ... 1 ... ... Dysentery 1 l ... ... ... ... ... ... 1 ... ... ... Ophthalmia Neonatorum 7 7 ... ... ... ... ... ... ... 2 ... 5 Puerperal Pyrexia 10 ... ... ... 5 5 ... ... 5 1 1 3 Erysipelas 18 ... ... ... 3 6 7 2 5 4 1 8 Tuberculosis (resp.) 73 ... ... 1 24 31 17 ... 22 7 8 36 Tuberculosis (other) 12 ... 5 3 1 1 2 ... 4 3 2 3 Totals 466 9 78 166 77 93 37 6 133 57 78 198 55 1929 TABLE 6. CASES REMOVED TO HOSPITAL N. East. N. West. S. East. S. West. Total. Scarlet Fever 57 20 39 86 202 Diphtheria 7 5 8 24 44 Typhoid — 1 1 — 2 Paratyphoid B. 1 1 — 1 3 Pneumonia — 1 — 6 7 Puerperal Fever 1 — — — 1 Cerebro-Spinal Fever 1 2 — 3 6 Dysentery 1 — — — 1 Puerperal Pyrexia 2 1 — 1 4 Erysipelas — — — 5 5 70 31 48 126 275 TABLE 7. BIRTHS Male. Female. Total Births 543 483 Legitimate 517 456 Illegitimate 26 27 Ward Distribution of the Births notified in the District. North East. North West. South East. Smith I Vest. Total. 230 151 120 310 811 Outside Births notified. North East. North IVest. South East. South West. Total. 69 34 30 44 177 Births Registered but not previously notified. North East. North West. South East. South West. Total. 5 9 1 5 20 Still Births Inside 18. Outside 7. Notifications were received from— Doctors and Parents 691 Midwives 322 TABLE 8. INFANT WELFARE CENTRES, 1929. Health Visitors' Attendances 230 Number of Children who attended 1719 Number of attendences by Children 13910 Number of Children under 1 year of age 791 Number of Children over 1 year of age 921 Children who attended for first time 821 Children treated at Dental Clinic 155 56 Children treated at Ophthalmic Clinic 3 Mothers treated at Ophthalmic Clinic 2 Children treated for Enlarged Tonsils and Adenoids 3 TABLE 9 ANTE-NATAL CLINIC. Number of attendances by Dr. Bell 23 Number of Expectant Mothers who attended 88 Number of attendances made by Expectant Mothers 144 Mothers referred for Dental treatment at the Clinic 40 Mothers supplied with Dentures 9 Expectant Mothers to whom Dried Milk was supplied 16 Number of packets of Dried Milk supplied 179 TABLE 10 INQUESTS. Inquests—32. Struck by a motor vehicle 14 Accidental drowning 1 Suicide 3 Strangulation 1 Knocked down by a train 2 Overlaying 1 Accidental fall 2 Death from Anaesthetic 1 Fall from a bicycle 1 Septicaemia from cut on hand 1 Fall from a tower wagon 1 Fall on head 1 Yellow atrophy of liver 1 Struck by a brick 1 Cerebro-spinal meningitis 1 Coroner's Certificates after Post-Mortem without Inquest—17. Heart Disease 5 Bronchitis 1 Cerebral Haemorrhage 4 Enlarged Thymus 1 Pneumonia 3 Septic infection of Phthisis 2 Umbilical Stump 1 FACTORIES, WORKSHOPS AND WORKPLACES. 1.—Inspection of Factories, Workshops and Workplaces including Inspections made by Sanitary Inspectors. Premises. Number of (1) Inspections. Written Notices, (2) (3) Factories 107 19 (including Factory Laundries) Workshops 315 26 (Including Workshop Laundries). 1929 57 Workplaces 23 4 (Other than Outworkers' Premises). Total 445 49 2.—Defects found in Factories, Workshops and Workplaces. (1) (2) (3) Particulars. Found. Remedied. Nuisances under the Public Health Acts Want of Cleanliness 19 19 Want of Ventilation Nil Nil Overcrowding Nil Nil Want of drainage of Floors 1 1 Other Nuisances 14 14 Sanitary Accommodation :— Insufficient 4 4 Unsuitable or defective 23 23 Not separate for sexes — — Offences under the Factory and Workshop Acts:— Illegal Occupation of underground Bakehouses Nil Nil Other Offences Nil Nil Total 61 61 3.—Outwork in unwholesome premises, Section 108 Nil HOUSING Number of Houses erected during the year:— (a) Total (including number given separately under (b) 501 (1) With State assistance under the Housing Acts :— (i) By the Local Authority Nil (ii) By other bodies or persons 124 1.—Unfit Dwelling Houses. Inspection. . (l) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 1007 (2) Number of dwelling houses which are inspected and recorded under the Housing (inspection of District) Regulations 1910, or the Housing Consolidated Regulations, 1925 688 (3) Number of dwelling houses found to be in a state so dangerous or injurious as to be unfit for human habitation Nil 1929 58 (4) Number of dwelling- houses (exclusive of those referred to under the preceding- Sub-Head) found not to be in all respects reasonably fit for human habitation 984 2.—Remedy of Defects without Service of formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Loca1 Authority or their Officers 539 3.—Action under Statutory Powers. A.—Proceedings under Section 3 of the Housing Act, 1925. (1) Number of dwelling houses in respect of which notices were served requiring repair 225 (2) Number of dwelling houses which were rendered, fit after the service of formal, notices,:— (a) by owners 225 (b) by locg.1 authority in default of owners, Nil (3) Number of dwelling houses in respect, of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil B.—Proceedings under Public Health Acts (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 220 (2) Number of dwelling bouses in which defects were remedied after service of formal notices:— (a) by owners 220 (b) by local authority in default of owners Nil C.—Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925. (1) Number of representations made with a view to making of Closing Orders Nil (2) Number of dwelling houses in respect of which Closing Orders were made Nil (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwellinghouses having been rendered fit Nil (4) Number of dwelling houses in respect of which Demolition Orders were made Nil (5) Number of dwelling- houses demolished in pursuance of Demolition Orders Nil 1929 59 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 Officerof Health (Medical Superintendent of the Isolation Hospital and School Medical Officer). M. W. Kinch. Member of the Royal Sanitary Institute, holds Meat and Smoke Certificates ; Chief Sanitary Inspector (Inspector uncier Diseases of Animals Acts and the Rag- Flock Act1. J. J. Jenkins. Cert. Sanitary Institute; holds Meat and Smoke Certificates, Sanitary Inspector. (Inspector under Fabrics Mis-description Act). E. W. Brooks. Cert. Sanitary Institute. Sanitary Inspector. J. J. Matthews, Cert. Sanitary Institute ; holds Meat Certificate, Sanitary Inspector. Miss A. Cooksey. Certificate Sanitary Institute. Health Visitor. Miss J. Welsh. Certificate Sanitary Institute, c.m.b., Health Visitor. MissB. G. Sorlie, s.r.n. Certificate Sanitary Institute, c.m.b., H.V. Diploma, Health Visitor. Miss A. Woosnam. s.r.n. c.m.b., Health Visitor. Mrs. Light. Clerk. I have again to thank all the members of the Public Health Department for ungrudging assistance during the year. I am, Your Obedient Servant, D. J. THOMAS.