CT AC4413(I)BARAES BARN (Later Mun.B.) Annual Report on the Health, Sanitary Conditions, etc., of the URBAN DISTRICT OF BARNES, for the Year 1916. by B. C. Stevens, a.d,, f.r.cs.e., d.p.h., Medical Officer of Health Barnes, S.W R. W. Simpson & Co., Ltd., Printers, 15 High Street, 1917. Urban District Council ot Barnes. BARN 2 Urban District Council of Barnes. Annual Report on the Health, Sanitary Conditions, etc., of the URBAN DISTRICT OF BARNES, for the Year 1916. by b. C. Stevens, w.d., f.r.c.s.e, d.p.h., Medical Officer of health JBarnes, S.W.: R. W. Simpson & Co., Ltd., Printers, 15 High Street, 1917. THE Urban District Council of Barnes. Public Health Department. Staff. Medical Officer of Health, Medical Superintendent of Isolation Hospital, Tuberculosis Officer, etc. Bertram Crossfield Stevens, F.R.C.&. (Kdin.j, D.P.H (Oxon.), M.D.. M.S. (Dunelm), L.R.C.P. (Lond.) Assistant School Medical Officer Surrey Education Committee. Medical Officer, Child Welfare Centre and Day Nursery. Sanitary Inspector and Inspector of Housing, T. Grylls, Senior Assistant Sanitary Inspector and Assistant Inspector of Bousing, *C. H. Robinson, R.P.C., Cert. San. Insp. Exam. Board. Junior Assistant Sanitary Inspector, C. W. Slade, A.R.S.I. Matron of the Hospital, Miss L. Wood (Resigned). Health Visitor and Tuberculosis Nurse, Miss Williams. * Absent on Military Service. Statistical Memoranda for 1916. Area—Barnes 1,067 acres „ Mortlalse 1,583 „ 2,650 Tidal waters of foreshore 133 2,517 *Population (approximately) 34,745 *Birth Rate 164 per 1,000 Residential Death Rate for 1916 7.3 ,, After adding deaths of residents * district Death dying outside the district and' q.ij Rate for 1916b deducting those of noil.residents i ' " (.dying in the district Zymotic Death Rate .3 „ Pulmonary Tuberculosis (Residents only) 1.03 „ Infantile Death Rate 68.4 per 1,000 births Census Population, 1901 17,900 1911 30,377 Rateable value—Agricultural land £1,790 ,, „ Other Hereditaments £282,033 Assessable Value £261,920 General District Rate 3/6 Poor Rate—Barnes 3/5 „ ,, Mortlake 3/6 Id. in the £ for District Rate Purposes produces £1,047. ANNUAL REPORT. The Council House, Mortlake, S.W. The Chairman ami Members oj the Barnes Urban District Council. Gentlemen, I beg to submit my annual report for 1916. This year the tables of Vital Statistics will be compiled by the Registrar General. My duty, therefore, consists in giving you purely local figures so far as 1 have them at my disposal, and also to make the report a concise but complete record of the year's work for information and future reference. Although we have been under.staffed, 1 trust that we have coped with the extra work thrown on the department by recent legislation, to your satisfaction. The two inspectors and the Health Visitor have worked consistently hard through the year. Infectious disease is lower, the death rate and infantile mortality are lower, and great efforts are being made to preserve infant life, as the birth rate is also lower. 1 am, Gentlemen, Your obedient servant, January, 1917 B. C. Stevens. 6 Vital Statistics. VITAL STATISTICS. The Registrar General is undertaking this duty this year, and his tables will be found in an appendix to the Report. The population I still estimate as the same as in 1914, viz. 34,745. The exodus of men being counterbalanced by the natural increase of the population, viz., the excess of births over deaths, and by the influx of new comers to the district. Very few houses remain empty, there being about 7,800 inhabited houses in the district. The Births notified in the district number 570, compared with 636 for 1915. The Births will probably continue to fall for a few years owing to the present social and economic conditions. For 1916 the rate is 16 4 per 1,000 of the population, compared with 18.3 in 1915. The Deaths of residents in the district number 256, compared with 287 in 1915. This gives a residential death rate of 7.3 per 1,000, compared with 8'2 in 1915. This is a strictly residential death rate, and does not include people who have died elsewhere and given a Barnes or Mortlake address. This rate is 9.7, compared with 10.9 in 1915. Deaths from the principal Zymotic Diseases number 11 in 1916, compared with 28 in 1915. The district Infantile Mortality or deaths under 1 year number 37, compared with 55 in 1915. This gives a death rate of 68 4, compared with 83 8 in 1915. The deaths from Tuberculosis of the Lungs in 1916 number 36, compared with 29 in 1915. Deaths From Cancer number 29, compared with 22 in 1916. The number of illegitimate births number 24, with 11 deaths, compared with 27 in 1915, with 14 deaths. VACCINATION AND SMALL.POX. Fifteen per cent, of the school children are unvaccinated, and exemption certificates are obtained for 25 per cent, of all children born in the district. In order to prevent the spread of small.pox, every individual should be twice successfully vaccinated. The present half.and.half measures are a common danger, as a person, say, vaccinated once Vital Statistics. 7 in infancy may contract the disease in a mild form, be undetected and spread the disease far and wide, whereas, if he had not been vaccinated at all he would get the disease badly, be very ill, would be recognised at once, and promptly isolated, while all contacts would be immediately vaccinated. INFECTIOUS DISEASES. The notifications of infectious disease were considerably m lower than in the previous year. Measi.es and German Measles. The compulsory notification of these diseases began in January, 1916. 229 cases of Measles and 200 cases of German Measles were notified either by parent or doctor. That there were only two deaths speaks well for the home visiting and advice given by the Health Visitor. In certain cases attended by medical men where isolation was not properly enforced, notice thereof was taken by the Medical Officer of Health. My report to the Public Health Committee on the utility of notifying these diseases is set out below. Measles and German Measles. Report on Public Health (Measles and German Measles) Regulations ' 1915, 50 far as they concern the Urban District of Barnes. The notice states that:— " The above regulations came into operation on 1st January, 1916, and shall then apply and have effect in this district and shall be enforced and executed by the Local Authority. " The object of the Public Health (Measles and German Measles) Regulations, 1915, and of the requirement as to notification, is the protection of the children." There are two surprises in these regulations. Firstly, that German Measles (Rubella), should be included and Whooping Cough left out; and, secondly, that the word " German " should be allowed to qualify the second disease. 8 Vital Statistics. The objections to the inclusion of Rubella, or German Measles, founded on experience are:— (a) It is not dangerous to life. (b) It is not essentially a disease of infancy. (c) It is treated by everyone, including doctors, as a trifling indisposition. (d) The patient—often feeling perfectly well—is not going to be properly isolated for 3 weeks. (e) The disease need not be confused with ordinary Measles, and is in fact quite dissimilar With regard to Measles the case is very different:— (a) It is a dangerous disease to infancy. {b) It requires careful nursing. (c) It requires one week in bed, one week in the bedroom, and one week in the house. Here notification has been valuable in that it has secured medical attention and visits from the Health Authority. The age groups for Measles show that one-fourth of the cases were in children up to and including 5 years of age. One half occurred in children of school age, and one-fourth in youth and adult age in equal proportion. The age groups for Rubella (German Measles) show that only one-sixth of the cases occurred in children up to and including 5 years of age. Between one-half and two-thirds occurred in children of school age, and one-fourth in youth and adult age in equal proportion. The large proportion of cases among school children would seem to indicate that if notification was useful in their cases, it was in enforcing absence from school until the period of infectivity was over, and so keeping down the spread of infection. At the same time, three weeks appears too long for Rubella; probably a fortnight is sufficient for the patient and three weeks for the contacts. In the case of Measles three weeks isolation is necessary, not so much to prevent infection as to prevent any such complication as bronchopneumonia. Measles is probably not infectious after the rash and catarrhal symptoms have subsided, and Rubella probably becomes Vital Statistics. 9 harmless after the rash has gone and the neck glands have subsided. In both Measles and Rubella the patient is infectious before the rash appears, and therefore before the disease becomes manifest. Disinfection is not done as a routine measure in all cases, but only if desired or thought necessary. One infant school only was closed during the present outbreak. The outbreak this year has been mild, whereas in 1915 there were more severe cases. The poorer parts of the district have been singularly exempt. LOCAL GOVERNMENT (EMERGENCY PROVISIONS) ACT, 1916. (Chap. 12), Section 5. Sub-Section (a), of the above Act, is as follows: — " The fee to be paid to a medical practitioner for a certificate or notification sent by him to a Medical Officer of Health in respect of a case of disease to which the Infectious Disease Notification Act applies, occurring in his private practice, shall be One Shilling and no more." Scarlet Fever. 94 cases of this disease were notified, compared with 137 in 1915, and 154 in 1914. 81 of these were removed to hospital, 77 to the Council's Isolation Hospital, and 4 to other hospitals. One was a military case, and one was wrongly diagnosed, and turned out to be cellulitis of the neck, and died of pycemia. There were no deaths in the District from Scarlet Fever. A small outbreak in one school necessitated its closure for ten days, after which no further cases arose. Diphtheria. 34 cases of this disease were notified compared with 41 in 1915. 10 Vital Statistics. 25 of these were admitted to our hospital, when 2 were found not to be diphtheria. One case proved fatal. Several cases were admitted from a private school, some of whom were " carriers " detected after swabbing all the boarders and staff. If antitoxin were injected early, and in every case of doubt, there would be very little need for tracheotomy, and practically no deaths. Enteric Fever, Thanks to pure water and sound drainage enteric or typhoid fever continues to remain almost a negligible quantity in the District. Two cases were notified—one was removed to hospital, the other nursed at home—both recovered. Erysipelas. The notification of this disease to the Public Health Authority is not of much practical value, and might with economical advantage be deleted from the list of compulsorily notifiable diseases. Eight cases were notified, and one was removed to the Infirmary. Puerperal Fever. Only one case was notified, and that was a fatal one. Puerperal Fever should disappear as personal and domestic cleanliness improves, and with the attendance of properly qualified midwives and medical care. Ophthalmia Neonatorum. Only one case was notified. This disease should be rigidly kept under by careful attention to the infant's eyes by a properly qualified person immediately on its birth. Cerebro-Spinal Fever. Three cases were notified, and one removed to hospital. One case was fatal. This disease is spread by " carriers " only, and is likely to occur where there is overcrowding. Tuberculosis. 11 The organism causing Cerebro-Spinal Fever can be detected either by swabbing the throat or by withdrawing fluid from the spinal cord. Acute Poliomyelitis (Infantile Paralysis). Three cases of this disease were notified, with no fatalities. The germ of this disease probably gains admission to the nervous system by means of the upper air passages. Pulmonary Tuberculosis. 55 cases of this disease were notified compared with 60 in 1915; 66 in 1914; and 74 in 1913, thus showing a steady improvement. The Tuberculosis Dispensary and Wards in the Isolation Hospital Grounds provides treatment for these cases. During 1916, 120 new cases attended the Dispensary for diagnosis or treatment, many of whom were found not to be tubercular. In addition to these, 47 were carried over from 1915 for further treatment. In the hospital 30 of the more advanced local cases were treated. From my experience of this disease the following deductions are summarised:— That the high ideals and principles governing the efficient treatment of tuberculosis are at present subservient to the commercial and economic side of the question. Theoretically, no expense should be spared in the treatment of this disease; practically, we are hemmed in on all sides by the limitations of our powers of expenditure. That " after-care " and " colonization " schemes could, when once established, be made partially, if not wholly, self-supporting. That the return of the average patient to his home after a limited course of treatment seems very often indeed the undoing of the good he has derived from institutional treatment. That I have no faith in domiciliary treatment, and that the man who can run a working man's home on Sanatorium lines is a genius, and that it cannot be done, or anything approaching it, so long as human nature is what it is. 12 Tuberculosis. That the advanced case wants humouring, for his mentality is often unstable and his ideas and fancies are queer. This state is often aggravated if the patient knows he is doing badly. If he can leave his bed let him do so, feed him with varied and tasty dishes, and keep his mind interested on things outside himself. That well-marked cases in young people usually run a rapid downhill course, owing to an absence of natural or acquired immunity. That no curative properties can be ascribed to tuberculin, nor does its effect appear to be so good without the adjuncts of rest, good food, and fresh air. Tuberculin is not required at all where the patient can be got to do graded work under medical supervision, which at present is only possible in a Sanatorium. That a number of gardeners appear among the patients, and that the soil or manure they work in may be a contributory factor. That patients should not be sent to a seaside resort, where the sand " bloweth where it listeth." Sand is not a soothing application to the inflamed throat and bronchial tubes. That strong and influential "after-care" committees seem to be wanted to follow up the comsumptive when he returns home. . Also a tuberculosis " unemployment " bureau would be useful in finding suitable work for consumptives who cannot, or are not allowed, to follow their old occupations. The committee should see that the patient— < (a) Has a bedroom to himself; (b) Moves to a suitable house ; (c) Gets proper nourishment and medical treatment. (d) Destroys all expectoration ; (e) Convinces his employer that with reasonable care he is not infectious. That the question of employment after discharge is a difficult one, with barriers of prejudice and ignorance to be first broken down. On the other hand one has to balance the hope of the patient taking advantage of his training and practising it, against the risk of his not doing so, and thereby infecting his fellow workmen. Is the risk justifiable ? Tuberculosis. 13 That more than half the patients who come for treatment are in the prime of life, and therefore of greatest value to the State, and that many of the cases ought to he discovered earlier than they are. That tuberculosis is essentially a disease of environment, aggravated, doubtless, by an hereditary predisposition, and that it behoves us to keep a very watchful eye on all "contacts" in a home where there is an " open " case of pulmonary tuberculosis. That cases of blood-spitting and pleurisy are nearly all tubercular, and that influenza, followed by pneumonia, is often the forerunner of tuberculosis. That one-fourth of the patients admitted to a hospital for advanced cases have previously had institutional treatment without any permanent benefit. That so long as the consumptive is allowed to return to his home the scheme devised by the Government for controlling the spread of the disease will, to some extent, fail. Farm colonies are the ideal scheme for the permanent sequestration of all marked and incurable cases. RECENT PUBLIC HEALTH LEGISLATURE. The Local Government Board have issued a General Order dated 13th May, 1916, entitled The Public Health (Tuberculosis) Regulations, !916. This order states that:— Article 2. (a) Every Medical Officer of Health shall send to the Army Council, Whitehall, London, in the form shown on the Schedule in this Order, a list containing the names and other specified particulars of all tuberculosis male persons entered in the register kept by the Medical Officer of Health in pursuance of sub-division 2 of Article 11 of the Regulations of 1912 who were between the ages of eighteen and forty-five years on the first day of January, 1916. (6) Every Medical Officer of Health shall send to the Army Council the name and other specified particulars of every tuberculous male person between the ages of sixteen and forty-five years hereafter entered in the said register within a week after the entry is made therein. 14 Tuberculosis. It is apparent that not much use is made of this information, for recruits are still called up and examined by the Recruiting Medical Board, and sometimes referred to our Dispensary for confirmation or opinion. The Tuberculosis (Domiciliary Treatment in England) Order of 1916 states that from January, 1917, with regard to cases of consumption treated at home :— Article II.—The treatment shall be carried out under the care and direction of a Medical Practitioner, subject to the following conditions, and to such other conditions as we may in any case from time to time approve; that is to say :— (1) That the Medical Practitioner attend each patient at such intervals as may be necessary in the interest of the patient. (2) That the Medical Practitioner give the patient such instructions as are required as to his mode of living, diet, rest, and work, and as to precautions necessary to protect the patient against re-infection. (3) That the Medical Practitioner prepare and transmit to the Consulting Officer at such reasonable intervals, not being less often than than once in every three months, as may be arranged between them, a report in regard to each patient in the Form set forth in the Schedule to these Regulations. (4) That the Medical Practitioner make arrangements with the Consulting Officer for each patient to be examined by the Consulting Officer not less often than once in every twelve months. (5) That the Medical Officer confer with the Consulting Officer at such times and in such circumstances as may be arranged between them in regard to patients under the care of the Medical Practioner. (6) That the Medical Practitioner from time to time inform the Medical Officer of Health of the Sanitary District in which the patient resides, of any circumstances known to the Medical Practitioner which may affect adversely the Hospital Administration. 15 sanitary conditions under which the patient is living, and in respect to which action by the Medical Officer of Health or of the Sanitary Authority would, in the opinion of the Medical Practitioner, be necessary or desirable. VENEREAL DISEASES. The treatment of these diseases on the basis of voluntary notification by the patient to a qualified medical practitioner is controlled by the Surrey County Council. Hospital treatment has been arranged for, also the microscopical examination of suspected material, also the free supply of anti-syphilitic remedies to those competent to use them. Medical men not conversant with the technique of the remedial measures may have instruction free of charge. Afternoon and evening clinics are to be held at the various London Hospitals, where consultants, medical practitioners, and patients may meet. MALIGNANT DISEASE. Cancer is a new growth arising generally at the site of tissues subjected to prolonged irritation, as in the breast, the tongue, the lips, the entrance and exit to the stomach, various angles and narrow places in the intestines, also the liver. It may also supervene on the irritation or erosion set up by ulcers or other indolent sores. Cancer is on the increase all over the civilised world, and it may be said that the longer one lives the more likely is one to die of cancer. In this District there were 29 deaths in 1916 compared with 22 in 1915. HOSPITAL ADMINISTRATION. The Hospital is situated in South Worple Way, and contains blocks for Scarlet Fever, Diphtheria, Typhoid Fever, and Tuberculosis. It also contains a Tuberculosis Dispensary, Bacteriological Laboratry, Coroner's Court and Mortuary, and a Disinfecting Apparatus. 16 Hospital Administration. The Staff consists of the Matron, one Sister, six Probationers, Domestic and Laundry Staff, Ward Maids, Porter and Portress, and two Gardeners. There is accommodation for fifty patients in all. Tuberculosis Wards. —14 patients were carried over from 1915, and of these 5 died during 1916. 70 fresh cases were admitted during 1916; of whom 21 died in Hospital, 13 were sent onto Sanatorium, and 6 are known to have died at home. 8 of the cases were re.admissions in the 70 admissions; 30 were local and 40 were from other parts of the County of Surrey. Of the 26 deaths in Hospital, 8 were residents and 18 non.residents. Dispensary.—120 new cases attended for diagnosis or treatment, many of whom were found to be not tuberculous, and 47 old cases were carried over from 1915 and continued treatment. 23 patients were sent on to Hospital or Sanatorium. 123 visits were paid to patients' homes. Scarlet Fever.—13 cases were carried over from 1915. 77 cases, including 1 soldier, were admitted in 1916 with no deaths; 1 case of cellulitis sent in as a case of scarlet fever was fatal. Diphtheria.—Only 25 cases were admitted, including 6 from one private school, some of whom were " carriers " only. Four cases were simple tonsillitis only. There was only one death during the year. Tracheotomy was required in one case, and was successful. Enteric Fever (Typhoid).—Only one case was admitted, which recovered. Cerebro.Spinal Fever.—One case admitted with recovery. DISINFECTION BY STEAM. Civil. Mattresses and Beds 95 Bed Clothing and other Clothing 859 954 Hospital Administration. 17 Military. Heavy Articles 105 Smaller Kit 123 228 These articles were brought and fetched by the Military Authorities. HOSPITAL DISINFECTION. Two changes of clothing disinfected for all patients and in serious cases, the bedding also. After death of a consumptive patient the bedding is disinfected. MORTUARY AND CORONER'S COURT. 39 Inquests were held ; 21 on residents and 18 on nonresidents. In 15 deaths the cause was "natural," in the others, " violence." A new set of rules controlling the duties of the Porter and Gardeners was drawn up, and approved by the Hospital SubCommittee and the Public Health Committee. In May Miss Wood was appointed Matron, in place of Miss Carothers, who resigned after having held the post for five years, and whose faithful services were appreciated and recorded by the Council. Arising out of the fact that soldiers were billetted in the District, the following instructions were printed and circulated:— TREATMENT FOR THE DESTRUCTION OF VERMIN. Arrangements should be made for the bathing of affected individuals and other inmates of infected tents and houses. Two teaspoonfuls of " Kerol " or " Jeyes' Fluid " should be used in every gallon of water. After drying themselves, men to lather their bodies with "Cresol" soap solution, especially over the hairy parts, and allow the lather to dry on. 18 Hospital Administration. Shirts to be washed in " Cresol " soap solution made with boiling water. Tunics and trousers to be turned inside out and rubbed with some lather, especially along the seams. Lather to be allowed to dry on garments. Or Stavesacre Ointment might be rubbed on the body or clothes. All clothes and kit will be disinfected at the Isolation Hospital, South Worple Way, Mortlake. Infected bed linen can be dealt with by hanging on lines and the room fumigated with sulphur candles. Cresol Soap Solution is made as follows Jeyes' Fluid, 1½ ozs.; soft soap (or cheap vaseline), lbs.; and water, 10 gallons Any further information must be obtained from the Public Health Department. B. C. STEVENS, M.D., D.P.H., Medical Officer of Health, In the Hospital Laboratory the following work was done by the Medical Officer of Health:— BACTERIOLOGICAL EXAMINATIONS. Result. Diphtheria. Typhoid Fever. Pulmonary Tuberculosis. Other Diseases. Totals. Positive 22 — 40 3 65 Negative 82 2 75 1 160 Totals 104 2 115 4 '225 Infant Welfare. 19 MATERNITY AND CHILD WELFARE. As this is the paramount subject in public health administration this year, it will be referred to more fully than other subjects. The Urban Council, having recognised the importance of the whole question of life-saving, has made considerable progress recently. The Child Welfare Scheme has been concentrated under one roof at Afon House, High-street, Mortlake, where a Day Nursery has been started upon a voluntary basis, and controlled by a voluntary committee. The children are received daily at a cost of 6d. per head; the rooms are well equipped, and the matron and two assistants (salaried), together with voluntary help, look after the interests of the children while the mothers go out to work. The usual attendance varies from 12 to 18 daily, and it is hoped that, with an increase of staff, more children will yet be received. The Medical Officer of Health visits daily to see that the children are healthy. 1 his is essentially a war-time scheme, and it is generally admitted that, in natural times, the place of the mother is at home with her children, except in a few exceptional cases. In the same house the Surrey Educational Committee hold their medical, ophthalmic, dental, and attendance clinics for the school children of the district. The District Council also hold their Child Welfare Centre there, when women and their children receive advice from the Health Visitor and the Medical Officer of Health. The District Council now have a scheme for acquiring a ward for necessitous or complicated cases of pregnancy. They have also agreed that if it should become necessary to admit a case of Puerperal Fever, and providing that we had the room for such a case, an extra nurse trained in maternity work would have to be engaged for the necessary period at a fee not less than two guineas per week. If this scheme was amalgamated with the one proposed by the Child Welfare Committee, viz., providing a bed for a complicated or necessitious case of pregnancy, one half the cost is recoverable from the Local Government Board. 20 Infant Welfare. With reference to the above paragraph, the Sub-Committee suggest that should a case of this disease arise in the district, and there is accommodation in the Hospital, that the Medical Superintendent be empowered to take in such case and engage a temporary nurse for that purpose. That the Child Welfare Committee be asked to incorporate in their scheme for Ante-Natal Treatment now under discussion, provision for treating this disease with a view to obtaining a grant towards the expenses. Under the same restrictions an urgent case of measles would also be admitted to the Hospital at the discretion of the Medical Superintendent and with the approval of the Hospital Committee. Under the Notification of Births Act there was in 1915 a difference of 140 between the births notified and those registered. To avoid this in future I got the Registrar to furnish me weekly with the names and addresses of all children born in the district, with the result that the figure (140) has been reduced to 28 in 1916. ANTE-NATAL WORK. The progress in this direction is slow, but is gradually improving, the difficulty being to get knowledge of expectant mothers. I wrote to the local midwives and to the authorities controlling district visitors, but without success. With regard to the midwives, another friendly conference is about to be held, and more success is hoped for. The basis of the non-success is an imaginary misunderstanding between the Midwives' Association as to interference and overlapping. The time does not yet seem ripe for the general notification of pregnancy ; it must at present be voluntary only. The Health Visitor visits all the expectant mothers she hears of, and gives them verbal and printed advice on diet, abuse of stimulants, work and leisure, rest and sleep, fresh air, cleanliness, and preparation for confinement, and encourages them to come to the Centre and bring the baby as soon as they can go out. In April, 1916, a successful " Mothercraft Exhibition" was held for three days at the Technical Institute, together with Infant Welfare. 21 lantern lectures and baby show. The exhibition was lent by the Women's Imperial Health Association, and we were helped by the Women's Co-operative Guild and several ladies in the district. The Price of Food.—The following report was submitted by the Health Visitor:— " On making inquiries of the mothers with regard to milk and increased price, and whether the children are having less milk or milk puddings, I find it is not the price of milk that the mothers feel only, but everything else. The very poor never have bought much milk, using chiefly the condensed milk. They have only had a half-pennyworth or a pennyworth at a time, so that they have not felt the increased price of 2d. per quart. The better class of people still get the same quantity as before, not feeling the extra price of milk so much as sugar, bread, and potatoes, and coal for cooking purposes. The poor people are feeling the price of bread and sugar, and it has been very difficult to get any facts about anything else, that being the main thought in their minds. I do think that something out to be done about sugar, that is food that children require more than adults, and the grocers have not much sugar to sell, so of course sell to their best and regular customers, and the poor have to go without. The same with the meat; one mother told me she had not had a bit of meat for weeks. The cheap bits of trimmings they used to be able to buy cheaply can no longer be got, as the butchers do not trim the joints, and in that respect, as well as with sugar, the poor have to go without, as they cannot afford the full price of meat. Also the better class are buying the cheaper joints and bones, and the poor have no chance at all. Milk puddings are not made much now, not because of the milk, but the sugar. Puddings require an amount of sugar that cannot be spared out of the small amount of sugar they can get. Milk puddings take rather a long time cooking, which means gas or coal being burned a long time. At one house 1 was in this last week they were living in a small back room because the fire grate took less coal than the kitchen range, and a pan of potatoes was cooking on the fire, which was the family dinner." 22 Infant Welfare. It was decided that the report be forwarded to the Local Government Board, urging that the Board should make such arrangements as will enable the people to purchase sugar, according to the number in family, through some other agency than the grocers, who have in many instances undoubtedly taken advantage of the situation. HEALTH VISITOR'S REPORT. During 1916 there were 570 births in the district, of which 542 were notified by doctors or midwives. Nine were still-born. 270 infants were visited by the Health Visitor in their homes, and advice given on the care and feeding of children, a printed leaflet being left for the mother to read. 1761 visits were made to the infants at the homes during the year. The babies born in the two previous years are still visited at intervals, and advice given about children up to five years old. 2417 visits made during the year were as follows :— Infants 1761 Measles 396 Tuberculosis 155 Expectant mothers 87 Other visits 18 2417 On inquiring into the feeding of 245 infants, 117 were breast fed; 55 were breast and bottle fed; 42 bottle fed; 31 had moved and address not known. There were more babies bottle fed and partly bottle fed during the year, owing to the fact of the mother going out to work. There has been plenty of work for the women, and the mothers, owing to food being dear, in many cases have had to go out to work, but it has not been good for the homes, the homes and feeding of older children being of secondary consideration when other work has had to be done. There were 37 deaths during the year under one year old ; 13 died before they were fourteen days' old. Infant Welfare. 23 There were 6 deaths from diarrhoea during the summer, 5 more than the year before. The babies do not seem to have much resistance against disease, as they seem to be rather a nervous lot of babies, owing, perhaps, to the nervous tension of the mothers before baby was born. All the babies who died from diarrhoea were bottle fed. The Health Visitor had visited 19, and inquired into feeding of the babies who died ; 15 were bottle fed and only 4 breast fed, which means that mothers putting the baby on the bottle to go out to work will increase the death-rate among infants. Ten of the deaths were illegitimate children, 3 in one of the homes for illegitimate children, and two were found dead on the Common or in gardens. During the year 1916 85 new babies came to the Child Welfare Centre, which brought the number on the register to 179 and during the year the Centre was open on 44 Thursdays, and the attendance of mothers and babies were: Babies, 390 ; mothers, 476 ; children over one year, 241. Of the 85 new babies, 27 were from Barnes and 58 from Mortlake. The feeding of the new babies attending the Centre: Breast fed, 51 ; bottle, 32 ; breast and bottle, 2. Forty children over one year were brought by the mothers to see the doctor, and 117 attendances were made, some of them being seen by the doctor at regular intervals during the year. Older children are weighed now as well as the babies. A banana crate, charts, clothing, and health literature are on view each Thursday, and books have been sold to the mothers on the care of children. Patterns of children's clothing are given to the mothers when required. Dried milk, milk foods and Virol are all sold to the mothers at cost price, or less than cost price in some cases. Four trusses and belts have been provided for the babies, and a belt for a mother, the money being repaid weekly by the mothers. One baby has had plaster of Paris bandages applied to deformed feet to straighten them, the baby having been sent first to hospital, but they were too busy to apply them at hospital. The attendance at the Centre has steadily improved throughout the 24 Sanitary Administration. year, especially since the Exhibition of Mother Craft and Baby Show in April, which was a success, and made the Centre much better known. Expectant mothers do not make much use of the Centre for consultation. Expectant mothers do not like mixing with other mothers who are strangers to them, especially with the first baby. Fifty expectant mothers were visited in their homes, and printed leaflets and advice given to them. There were three deaths among the babies who attended the Centre (1 tubercular, 1 diarrhoea, 1 overlaid). Although there were some very delicate babies attending the Centre, the mothers followed out the directions and advice given, and the babies have improved. 155 visits were made to the homes of tuberculosis patients for inquiring into the patients and seeing that the treatment was being carried out, and 95 attendances were made at the Dispensary. 396 visits were made for measles and German measles, and instructions given re infection and disinfection. HOUSE AND TOWN PLANNING, &c. The routine inspection of dwelling houses has gone on as usual this year, and various structural defects have been remedied. The number is seen in the table drawn up by the Inspector of Nuisances. No Closing Orders were made. Twenty houses were demolished with the consent of the Local Government Board, viz., 14 in Long-row (Malthouse Area), which had been allowed to become ruinous by the owner, and 6 in Waring's Buildings (Malthouse Area). In one case a Demolition Order was determined, the house having been rendered fit for human habitation. ALLOTMENTS. Now that there is likely to be a lot of waste land under cultivation, the improvement in the appearance of such spaces will greatly add to the amenities of the district, and the householders will have extra facilities for the burying of garbage and other refuse, and so relieve the amount of refuse at present taken to the destructor. Sanitary Administration. 25 Table showing the general work done by the Public Health Department during 1916, and in the preceding two years. Nature of Work Done. 1914 1915 1916 No. of House to House Inspections - 1530 2565 ,, Various other visits 1164 1773 1140 ,, Defects Notified 624 377 287 ,, Houses cleansed 226 63 87 ,, ,, ,, after Infectious Disease 70 35 54 ,, Disinfections performed 340 150 447 ,, Drains unstopped 20 23 26 m tt repaired 14 8 3 ,, ,, reconstructed 24 19 1 ,, Defective closet pans and traps 21 13 5 ,, ,, dust receptacles replaced 75 41 43 ,, Flushing tanks repaired 40 37 24 ,, Waste pipes trapped and repaired 19 11 3 ,, Cisterns cleansed and covered 29 23 3 ,, Taps provided on rising main 35 8 7 Offensive accumulations removed 7 6 1 ,, New sinks provided 20 9 5 ,, Roofs and eaves' gutterings repaired 45 41 29 ,, Yards paved and paving repaired 37 15 3 ,, Dampness remedied 25 9 3 ,, Manholes made watertight 10 3 — ,, Mica valves made good 6 5 4 ,, Receptacles for manure provided 2 1 - ,, Cases of overcrowding abated 4 3 2 ,, Houses found unfit for habitation 15 — - ,, Bakehouse inspections 33 33 33 ,, Dairy inspections and Milkshops 144 140 105 ,, Licensed slaughter house inspections 8 2 4 ,, Factory and Workshops inspections 323 321 334 ,, Visits to Infectious Diseases 286 242 635 ,, Complaints received 85 79 38 ,, Statutory Notices served 8 3 5 ,, Summonses to abate Nuisances 1 0 ,, Premises licensed for storage of Petroleum 25 22 22 Re-inspections are not included in this table. TABLE showing the number of certain places under the Council's supervision, and the visits made to them during 1916. [ BARNES. MORTLAKE TOTALS. No. Visits. No. Visits. No. Visits. Places where petroleum is stored 9 18 12 24 21 42 Servants' Registry Offices 5 5 7 7 12 12 Marine Stores 2 4 1 2 3 6 26 Sanitary Administration. DAIRIES AND MILKSHOPS. These are visited quarterly and are generally fairly well kept. One or two new dairies in East Sheen have been constructed on modern and up-to-date lines. No. Xo. of Visits. Dairies and places where Milk is sold ... 35 Quarterly. Other premises where food is prepared or sold for human consumption:— Visits. Defects Found. Defects Remedied. Restaurants 34 3 3 *Fishmongers 37 4 4 Butchers... 50 4 4 *Including Fried Fish Shops. HOUSES LET IN LODGINGS. Houses let in lodgings are principally in West Road, Hampton Square, Mortlake, and Stanton Road, Barnes. I find that the occupiers are responsible in a great measure for the dirty and dilapidated condition of some of the flats. Stanton Road in particular. Houses Let in Lodgings. Defects Defects No. Visits. Found. Remedied. 49 98 68 61 BAKEHOUSES. The number of bakehouses is 13, and they have been inspected quarterly, and are generally well kept. SCHOOL NOTES. The full report of the work done in the elementary schools of the district is sent to the Surrey Education Committee. A brief abstract of the report may be of local interest. Sanitary Administration. 2 7 Sixty visits were paid to the schools by the school doctor ; two were closed for Infectious Disease. The Public Health Department visited the homes of 325 school children suffering from Infectious Disease. The diseases comprised measles (116); German measles (126): scarlet fever (53); diphtheria (62); tuberculosis (7) ; cerebro spinal fever (1). At the Attendance Clinic 334 attendances were made by school children; 153 children were examined by request of the Attendance Officer, and 187 certificates were given. At the School Medical Clinic 32 new cases attended, while the total attendance of old and new cases numbered 330, the cases treated being chiefly skin diseases, sore eyes, and running ears. In the schools, 1,025 children were medically inspected, as a routine group, and 164 as a special group. The chief defects noted in the 1,025 routine cases were :— Unsatisfactory clothing 14.8 per cent. ,, footgear 138 „ Want of soap and water 11 .3 „ Nutrition below standard 18 7 „ Enlarged tonsils .. 3.6 „ Adenoids (marked) 107 „ Ear discharge 1.8 „ Teeth, four or more decayed 17.6 „ „ sound 36.3 „ Pretubercular 1.6 „ Heart disease .58 „ Skin disease 1.6 „ Dull or backward 3.5 „ Mentally defective .45 „ Poor vision 1.2 „ Bad vision 3.4 „ Squint .17 „ Poor hearing 1.4 „ Bad hearing 97 „ Unvaccinated .15 ,, 28 Sanitary Administration. A whole time school nurse is needed for a district of this size, in order to assist the doctor at the school inspection, and to do some home visiting and following up of cases of illness or conagious disease. Two days a week are given to the inspection of heads, etc., at present, and a half day at the School Clinic. In cases of Scabies and vermin a cleansing station is neeessary, when clothes can be disinfected and the children bathed. Compulsory powers are also needed to seize and disinfect the bedding of such cases. The power is at present only permissive. REPORT OF SANITARY INSPECTOR FOR 1916. Mr. Grylis reports:—167 Preliminary Notices, dealing with 287 Nuisances were served during the year 1916, and it was found necessary to serve 5 statutory notices only. 2,565 house-to-house inspections were made, and 1,140 various other visits. FACTORIES AND WORKSHOPS The number of factories in the district is 20, and 32 inspections have been made. No notices have been received during 1916 from H. M. Inspector. The number of workshops is 208, and 289 inspections have been made. There are 15 outworkers, their work chiefly consisting of ladies' outfitting. Sanitary Administration. . 29 Table showing the work done by the Sanitary Inspectors during 1916, with regard to places under the Factory and Workshops Act, 1901. BARNES. MORTLAKE. TOTALS. No. Visits. Xo Visits. No. Visits. A.—FACTORIES— Brewery ... ... 1 2 1 2 Electric Light Works ... ... 1 1 1 1 Printers 1 2 1 1 2 3 Wheelwright ... ... 1 2 1 2 Motor Works 3 6 2 4 5 10 Golf Club Maker ... ... ... ... ... ... Engineering Works 2 2 1 1 3 3 Packing Case xMaking 1 1 ... ... 1 1 Ladies' Outfitter 1 1 ... ... 1 1 Anglo-Belgian Manufac. Co. ... ... 1 3 1 3 Beverley Works Munition 1 3 ... ... 1 3 Miralite, L.T.D. ... ... 1 1 1 1 Flour Store ... ... 1 1 1 1 Metal Foundry 1 1 ... ... 1 1 STEAM AND ELECTRIC LAUNDRIES — Over 40 employees 1 2 1 2 2 4 Under 40 employees 2 4 4 8 6 12 B.—WORKSHOPS— Tailors 8 8 7 7 15 15 Dressmakers and Milliners 7 7 5 5 12 12 Shoemakers 10 10 20 20 30 30 Cycle and Motor Works 4 4 6 6 10 10 Saddlers 1 1 1 1 2 2 Photographers 1 1 2 2 3 3 Smiths 3 3 3 3 6 6 Umbrella Makers ... ... 2 2 2 2 Upholsterers 2 2 1 1 3 3 Picture Frame Makers ... ... 1 1 1 1 Watch Makers 3 3 2 2 5 5 Metal Worker 1 1 ... 1 1 Model Maker 1 1 1 1 Outworkers 5 10 30 13 15 23 Knitting Co 1 1 ... ... 1 1 Furrier 2 2 ... ... 2 2 HAND LAUNDRIES — Under 40 employees 3 6 3 6 6 12 BAKEHOUSES— 3 0 10 30 13 39 C.—DOMESTIC WORKSHOPS Dressmakers 10 10 17 17 27 27 Laundries 9 27 9 21 18 48 D.—WORKPLACES- Stable Yards 5 8 2 2 7 10 Restaurants 5 10 9 14 14 24 Totals 97 146 125 179 222 325 30 Sanitary Administration. NO. OF CASES OF INFECTIOUS DISEASE VISITED. Disease. Barnes. Mortlake. Totals. Scarlet Fever 35 61 96 Diphtheria 20 15 35 Erysipelas 2 4 6 Enteric Fever 1 1 2 Pulmonary Tuberculosis 22 31 53 Other Tuberculosis 4 8 12 Cerebro Spinal Fever I 1 2 Totals ... 85 121 20G NO. OF DISINFECTIONS MADE. Scarlet Fever 48 69 117 Diphtheria 17 28 45 Measles 95 70 165 Hospital ... 12 12 Various 15 19 34 Pulmonary Tuberculosis 25 47 72 Enteric Fever 1 1 2 Totals ... 201 246 447 REGISTER GENERAL'S FIGURES FOR 1916 Total Births 590 (including 39 illegitimate) Infantile Deaths 33 Deaths 337 Deaths from Pulmonary Tuberculosis 35 Deaths from Cancer 31 Deaths from chief Zymotic Diseases ) including Diarrhoea ) 15 Population for Death Bate 31960 Population for Birth Kate 34773 Birth Rate 1708 Death Rate 105 Infartile Mortality 624 Tuberculosis Death Rate 109 Cancer Death Rate o97 Zymotic Death Rute 04