BARN 55 Urban District Council of Barnes. Annual Report on the Health, Sanitary Conditions, Etc., of the URBAN DISTRICT OF BARNES, for the Year 1918, by B. C. Stevens, m.d., f.r.c.s.e, d.p.h., Medical Officer of Health. Barnes, S.W.: R. W. Simpson 8 Co., Ltd., Printers, 15 High Street, 1919. THE Urban District Council of Barnes. Public Health Committee. Coun. Bates „ Day „ Firmston „ Hampton (Chairman) „ Harding „ Hinton Coun.Jackson „ Jones „ Kitley „ Lambert „ Maynard „ Medus Coun. Moonan „ Pike „ Shearman „ Sparkes „ West Hospital Sub=committee. Coun. Bates Coun. Jackson „ Firmston (Chairman) „ Kitley Coun. Pike „ Powell Coun. Day „ Harding Child Welfare Committee. Coun. Jackson (Chairman) „ Jones Coun. Lambert „ Pike. Medical Officer of Health, Tuberculosis Officer, Medical Superintendent of Isolation Hospital, Medical Officer Child Welfare, Centre and Day Nursery, School Medical Officer, Bacteriologist. B. C. Stevens, M.D., F.R.C.S., D.P.H. Senior Sanitary Inspector. Mr. Grylls. Assistant Sanitary Inspectors, Messrs. Perchard and Slade.* Matron of the Hospital, Miss Pearson. Health Visitor, Miss Williams. * Absent on Military Service. Statistical Memoranda for 1918. Area—Barnes 1,067 acres „ Mortlake 1,583 „ 2,650 Tidal waters of foreshore 133 2,517 Population as estimated to middle of 1917 by Registrar General For Births 36,223 For Deaths 32,495 Residental Death Rate for 1918 11.3 per 1,000 *District „ „ „ „ 12.4 *After adding deaths of residents occurring outside the district and deducting deaths of non residents occurring in the district. Birth Rate 12 per 1,000 of population Death Rate from Infectious Diseases(including influenza) 36 per 1,000 „ „ „ Pulmonary Tuberculosis .8 „ „ „ „ Cancer 1.07 „ „ „ „ Pneumonia .9 „ Infantile Death Rate 91 per 1,000 births Census Population, 1901 17,900 „ „ 1911 30,377 Number of Inhabited Houses 7,950 Rateable Value—Agricultural land £1,6781 £283,873 „ „ Other Hereditaments £282,1951 Assessable Value £262,029 General District Rate 4/- in the £ Poor Rate—Barnes 3/9 „ „ „ Mortlake 4/2 „ Id. in the £ for District Rate purposes produces £1,060. ANNUAL REPORT. The Council House, Mortlake, S.W. To the Chairman and Members of the Urban District Council of Barnes. Gentlemen, I beg to submit my Annual Report for the year 1918. It is still necessarily curtailed. Work under the Housing and Town Planning Act is still in abeyance, but should shortly improve. It is hoped that 150 new houses will be erected shortly, and that some undesirable areas will be cleared to make room for new houses. Good housing accommodation is the first important step towards lessening the number of cases of Tuberculosis. The proportion of slums to good property in this district is fortunately small, but could be made smaller, and this ratio perhaps accounts for the fact that although Tuberculosis has increased generally throughout the country, it is not the case in this district. Infectious disease has also kept remarkably low, except for the pandemic of Influenza, and a spring outbreak of Measles. Once labour is available and material at hand, building should progress on garden city lines and the amenities of the district preserved. I trust that this report will show that the staff of the Public Health Department (though short handed still), have, so far as their resources have allowed them, carried out their duties satisfactorily. I beg also to acknowledge the help of the other officers of this Council in Hospital and other matters. I am, Gentlemen, Your obedient Servant, B. C. STEVENS. 6 General. RECENT PUBLIC HEALTH LEGISLATION. RECOMMENDATIONS AND ORDERS. A register of the blind by the L.G.B. Juvenile organisations Committee by the Home Office. Mothers' Pensions. Treatment of Discharged Sailors and Soldiers (Pensions Board). Medical certificates for men appearing before National Service Medical Boards. Notification of males of military age suffering from Tuberculosis to the Chief Commissioner of Medical Services at the Ministry of National Service. Notification by the Chairman of any National Service Medical Board of Tuberculosis to the M.O.H. of the district from which the case came. Notification to the L.G.B of cases of Malaria, and facilities given for microscopic examinations of the blood. A uniform form of certificate or notification by Medical Practitioners for all notifiable infectious diseases. Reports to the L.G.B, on Epidemic Influenza. Exclusion of School children from Cinemas, etc., and the ventilation and resting of such places. The compulsory notification of Acute Encephalitis Lethargica and Acute Polio-Encephalitis (cases producing an unusual group of cerebral symptoms). The Midwives Act, 1918, contains several important alterations and a new scale of fees for medical assistance. This should be under Local Control, but it is so far controlled by the County, which is the Local Supervising Authority. VITAL STATISTICS FOR 1918. Total registered Births are 438, which gives a birth rate for the year of 12.03, the lowest yet recorded. The Infantile Mortality or number of deaths under 1 year 7 Vital Statistics. after accepting 2 deaths of infants dying outside the district is 40, representing a rate of 91 per 1,000 births. Several of these deaths were directly due to illness or shock on the part of the mother The registered deaths among civilians resident and dying in the district number 368, giving a residential death rate of 11.3 per 1,000 of the population. After adding deaths of residents, who died outside the district, and after deducting deaths of nonresidents dying in the district, the net deaths number 404, which represents a rate of 12.4 per 1,000 of the civilian population. The increased death rate is almost entirely accounted for by the severe Influenza epidemics. The causes of the Infantile Mortality are set out in the following table:— Measles, 3; Meningitis, 3; Diarrhoea, 7 ; Premature Birth, 13 ; Whooping Cough, 1 ; Bronchitis, 1 ; Malformations, 1 ; Other Causes 2 ; Influenza 1; Pneumonia 4 ; Marasmus 4. The population as reckoned for birth rate is 36,223, and that for the death rate as 32,495. COMPARATIVE FIGURES for 1918 shew:— Birth Rate Death Rate Infantile Mortality Rate Eng. and Wales 17.7 17.6 97 96 great towns including London 17.6 18.1 106 148 smaller towns 18.0 16.1 94 London (only) 15.8 18.7 107 Barnes 12.03 12.4 91 In London the death rate exceeds the birth rate, a most serious condition. In Barnes the number of births only exceeds the net deaths by 34. The suggested remedy is to build houses and thereby encourage marriages and family life, also secure good employment by starting 8 Vital Statistics. new industries and giving good wages, at the same time reducing the cost of food and living generally. Birth Rate in proportion to population in Barnes:— Year Births Deaths Nat. Increase Population 1912 700 291 409 32,000 1913 736 350 386 33,386 1914 754 336 418 34,745 1915 656 380 276 34,745 Birth 32,288 Death 1916 510 337 253 34,288 Birth 31,900 Death 1917 481 356 125 36,2231 Birth 32,4951 Death 1918 438 404 34 „ „ The higher figure represents population as reckoned for Birth Rate, the lower for Death Rate estimations. Whilst the Death Rate keeps fairly steady the Birth Rate is steadily declining and the natural increase or the excess of births over deaths is diminishing almost to vanishing point. Birth Rate Death Rate Year Barnes Eng. and Wales Barnes Eng. and Wales 1912 21.8 23.8 9.0 13.3 1913 22.07 23.9 10.5 13.4 1914 21.7 23.6 9.6 13.6 1915 18.8 21.9 10.0 15.1 1916 17.08 21.6 10.5 14.0 1917 13.2 17.7 10.9 14.4 1918 12.0 17.7 12.4 17.6 INFANTILE MORTALITY RATES (i.e. deaths under 1 year) Year Barnes Eng. and Wales Per 1,000 Births 1912 58.5 95 „ „ „ 1913 84.2 109 „ „ „ 1914 63.6 105 „ „ „ 1915 83.8 110 „ „ „ 1916 68.4 91 „ „ „ 1917 68.6 97 „ „ „ 1918 91.0 97 „ „ „ 9 Vital Statistics. VACCINATION RETURNS. I am indebted to Mr. Raggett, the Vaccination Officer, for the following figures:— Births Vaccinated Percentage Vaccination 1918 438 231 53 per cent. 1917 484 296 61 „ „ Two infants out of every five in this district are unvaccinated. Let us hope that under the new Ministry of Health the Vaccination Acts will be re-modelled or we may live to regret it. POOR LAW RELIEF. I am indebted to Mr. Pratt, the Relieving Officer, for the following figures:— 1918 120 orders were issued for medical attendance. 66 „ „ „ „ admission to workhouse and Infirmary. 1917 The orders were 135 and 79 respectively. The Military Service Acts have diminished pauperism. DEATHS IN INSTITUTIONS OUTSIDE THE DISTRICT. Year Ending 31st December, 1918. Males 88 Females 10 TABLE I. Vital Statistics of whole District during 1918 and previous Years. Name of District—Barnes Urban. Year. Population estimated to middle of each year. Births. Total Deaths Registered in the District. Transferable Deaths Xett Deaths belonging to the District. Uncorrected Number. Nett. Number. Rate. Of nonresidents registered in the District. Of residents not registered in the District. Under 1 year of age. At all ages. Number. Rate per 1,000 nett births Number. Rate Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1913. 33,386 718 736 22.07 294 8.8 29 85 62 84.2 350 10.5 1914. 34,745 734 754 21.7 276 7.9 28 88 48 63.1 336 9.6 1915. 33,516 636 656 19.5 287 8.2 38 93 55 83.8 380 11.3 *1916. 34,773 570 570 17.0 256 7.3 37 118 38 62.4 337 10.5 31,960 *1917. 36,223 481 481 13.2 264 8.2 31 123 33 68.6 356 10.9 32,495 *1918. 36,223 438 438 12.0 368 11.3 41 108 40 91 404 12.4 32,495 *Higher Figure. —Birth Rate population. Lower Figure.— Death Rate population (civilian only). 11 Infectious Diseases. INFECTIOUS DISEASES. GENERAL REMARKS. THE INFLUENZA EPIDEMICS. This pandemic disease broke out in this district in July and October. Details of the deaths are set out below. As the disease is not notifiable there is no information as to the number of individuals attacked, but it was very considerable. The school children alone numbered 525 cases. In several cases girls lost their hair after the illness. The influenza germ attacked first, and this was followed by the pneumonia germ, and then other septic or blood poisoning germs gained an entrance into the lungs and blood streams. The causes of the high rate of mortality were increased virulence on the part of the germ and lowered resistance on the victim. In round numbers 100,000 deaths were caused in Great Britain, and 6,000,000 deaths in the world generally. The Public Health Committee recommended the Council to make provision in the hospital for cases of Pneumonia, to obtain help of the Health Visitors in the homes and to make Influenzal Pneumonia notifiable, and this was done and confirmed by the Local Government Board, which expressed its satisfaction as to the measures taken. By order of the L.G.B. children from schools closed for Influenza are forbidden to attend picture palaces or other places of amusement. These places, moreover, are to be well flushed with fresh air at intervals of four hours. Large posters were circulated in the district giving advice on Influenza, and the doctors were asked to notify cases complicated by pneumonia. All schools were closed both in July and October, and the senior school children addressed by the M.O. H. before breaking up. When the next outbreak occurs, the whole population should have learnt what to do. 12 Infectious Diseases. INFLUENZA MORTALITY, 1918. Males 31. Females 50. Total 81 (residents dying in the district). males. females. total. Under 1 year 1 1 1 to 5 years 6 2 8 5 to 15 years 4 9 13 15 to 25 years 6 8 14 *25 to 65years 13 27 40 Over 65 years 2 3 5 31 50 81 *Group with heaviest mortality. After adding 11 deaths among residents dying outside the district, and deducting 4 deaths of non-residents dying in the district, the net deaths are 88. At a rough estimate there would be about 4,000 cases in this district during the year. Death was accelerated by the following complications:— Pneumonia 54 (4 septic) Bronchitis 8 Heart Disease 5 Pregnancy 4 Tuberculosis 2 Pyrexia 1 Toxaemia 1 Epilepsy 1 Asthma 1 Pleurisy 1 Oedema of lungs 1 Uterine hemorrhage 1 81 (Local only) 13 Infectious Diseases. Diseases compulsorily notifiable in this district are .— Small-pox. Scarlet Fever or Scarlatina. Diphtheria or Membranous Croup. Enteric Fever or Typhoid Fever. Continued or Relapsing Fever. Puerperal Fever. Measles and Rubella. Acute Polio-Myelitis (infantile paralysis). Epidemic Cerebro-Spinal Meningitis (Spotted Fever). Erysipelas. Acute Encephalitis Lethargica. Acute Polio-Encephalitis. Post Influenzal Pneumonia. Epidemic Summer or Infective Diarrhoea. Pulmonary Tuberculosis. Other Tuberculosis (non-pulmonary). Plague. Malaria. Ophthalmia Neonatorum. Cholera. Dysentery. Pneumonia. Trench Fever. Cases Notified During 1918. *Scarlet Fever—32 cases. Barnes 13; Mortlake 19. Of these 25 were admitted to Hospital, and there was one "return case." The proportion of females to males was as 4 is to 1. Diphtheria—29 cases. Barnes 14; Mortlake 15. Of these 28 were admitted to hospital. Three died, one shortly after admission. Six cases was admitted from one school. The proportion of males to females was equal. Erysipelas—2 cases. Barnes 1; Mortlake 1. *One case of Septic Tonsillitis admitted as Scarlet Fever, died in hospital. 14 Infectious Diseases. Puerperal Fever—3 cases. Mortlake 3. One died in Isleworth Infirmary. Enteric Fever or Typhoid—Nil. Cerebro-spinal Fever,—2 cases. Barnes 1; Mortlake 1. One case removed to hospital, recovered. One case died outside the district in hospital. Ophthalmia Neonatorum—2 cases. Barnes 2. Acute Polio-myelitis —1 case. Barnes 1. Pneumonia (post influenzal)—1 case. Barnes 1. (Since compulsory notification). Voluntary notifications led to 12 cases being admitted to Hospital, with 4 deaths, including two expectant mothers. Males numbered 4 and females 8. Average age 30 years. Measles—Notifications by medical practitioners, 620 cases. Barnes 239; Mortlake 381. Cases ascertained from other sources number Barnes 21; Mortlake 126. Total 767. There were 13 deaths. Cases admitted to hospital 6, including 4 from a private school. No deaths in hospital. The cases visited by district nurses, and paid for by the Council, were 14 in Mortlake and 2 in Barnes. Posters dealing with Measles have been freely circulated in the district, and there is now no excuse for parents or doctors not notifying the Health Department. The death rate from all Infectious Diseases (including influenza) is 3.6 per 1,000 of population. PULMONARY TUBERCULOSIS. Primary notifications number 58.—Barnes 27; Mortlake 31. Secondary Notifications 5 Number attending Dispensary 19 „ sent to Hospital 14 „ „ Sanatorium 14 Receiving domiciliary treatment 7 Left the district 4 63 Of these 58 notifications, 13 died the same year. 15 Infectious Diseases. OTHER TUBERCULOSIS. 17 cases.—Barnes 8; Mortlake 9. There were 3 deaths. Residential deaths from Tuberculosis during 1918—26 nett. 42 Deaths were registered locally; of these 22 belonged to other districts and are deducted, while we have to add 6 other deaths of residents dying outside the district. This leaves 26 nett deaths, equal to a rate of 8 per 1,000 of the population, which is very satisfactory when compared with England and Wales. TUBERCULOSIS. Remedies. Immediate better and ample housing accommodation, including the demolition of old property. Houses 12 to the acre with plenty of light and air space. No house should have less than 3 bed rooms if there are any children. There should be licenses granted for sub-letting and then only afteivproper investigations Sufferers from consumption should be segregated and colonised. More centres for diagnosis and treatment should be established and sufferers should be better controlled as to their habits and mode of life by legislation. The building of flats is to be deprecated ; it is begging the whole housing question. They may be useful for old or childless couples, or for bachelors and spinsters. What this country should be out for is to build houses for family life, because it is on decent family life that the character of the individual and the strength of the nation are founded. The question of cost of land would be well repaid in the increased health, happiness and freedom of the people. Gardens or allotments should be acquired as they give scope for healthy exercise, economy and thought. I am convinced that the past epidemics of Influenza will send up the incidence rate of Tuberculosis quite appreciably. 16 Infectious Diseases. TUBERCULOSIS. Pulmonary Tuberculosis has increased generally during the period of war as shown below:— males females total deaths (england & wales) 1911 21,985 17,247 39,232 1912 21,568 16,515 38,083 1913 21,034 16,021 37,055 1914 21,812 16,825 38,637 1915 23,630 18,046 41,676 1916 23,238 18,307 41,545 1917 23,670 19,443 43,113 Before the outbreak of war a steady decline was going on, but from 1914 onwards there has been a steady increase, and the proportion of females to males has increased. Causes:— 1. There are 100,000 discharged tuberculosis soldiers. 2. Increased female employment in factories. 3. Overcrowding due to sub letting and want of sufficient and healthy housing accommodation, 4. War conditions generally; such as stress, anxiety and privations. Local figures shew no increase of either notifications or deaths. notified. deaths. 1911 38 30 Average annual deaths—29. 1912 112 28 1913 74 33 1914 66 38 1915 60 19 1916 55 85 1917 54 27 1918 58 26 THE MEASLES EPIDEMIC. There were 742 cases of Morbilli and 25 of Rubella, with 15 deaths, including 2 outside the district. The epidemic was not expected, as there had been one the previous year, and epidemics of this disease are usually bi-ennial. 17 Infectious Diseases. Pneumonia was the usual cause of death, and this is best prevented by keeping in bed and by attention to oral hygiene. Strenuous efforts were made to prevent the spread of the disease and Health Visitors and District Nurse were kept busy. Delay or neglect in notifying cases, especially secondary cases, was vexatious at times. Hospital accommodation has been provided for cases who cannot be properly nursed at home. Printed precautions have been widely circulated by mean* of the schools and by posters throughout the district. The mortality was not heavy considering the severity of the epidemic. There is still a general tendency to regard Measles as a trivial complaint and to let the patient up and about too soon. The safe rule is one week in bed, one week more in the bedroom, and one week more before mixing with the healthy. If this were rigidly followed out, there would be few deaths and few complications. In order to get notifications of secondary cases of Measles, which are often not attended by doctors, a postcard is left with the parents to post on to the Health Authority, and this will be followed up by an early visit. CANCER. 23 Deaths have been registered locally. There are 12 others who have died in places outside the district—Total 35. This represents a death rate of 1.07 per 1,000, and is greater than that from Tuberculosis of lungs. Cancer cannot be considered to be contagious, nor a disease of locality or environment. It is due to a proliferation of body cells and their invasion of the adjacent tissues. By some subtle influence these cells instead of multiplying in just sufficient numbers to repair the body waste, have their balance between supply and demand upset, multiply more rapidly than is healthy, and a neoplasm or morbid growth results. If these growths ulcerate a more or less offensive discharge occurs. In these cases it is desirable that the bedding should be disinfected or destroyed, 18 Child Welfare. A printed leaflet pointing out early signs of disease, and the dangers of delay will be given to enquirers. VENEREAL DISEASES. The campaign against these diseases is now being energetically pursued. There are, however, two schools of thought, one is for abjuring restraint and continence, moral teaching, early marriage, and general educative measures. The other is for the general use of such preventive precautions as will greatly lessen the risk of infection. Quack treatment is forbidden and early treatment at Venereal Clinics urged. A few local cases have been seen and recommended to the evening clinic at the West London Hospital, Hammersmith. Medical men in the district are also treating patients on modern lines. Men under military control are getting prompt treatment. These diseases should be made compulsorily notifiable (in strict confidence) to the Health Authorities. MOTHER AND CHILD WELFARE. Under the extended scheme of the Surrey County Council, a second Health Visitor was appointed for the Barnes side of the Urban District. The Committee making the selection have been unfortunate in not securing a really good worker, and a change was made after 5 months. After a short interval a second nurse was appointed, but broke down in health and had to resign. The result has been that the school work and infant visiting in Barnes has not been so well done as was expected. However, a fresh health visitor has been appointed, and things will doubtless improve. So far as Mortlake is concerned the work has gone on satisfactorily Miss Williams has now worked in this capacity for five years, and has done, and is doing, good work. 438 Births were registered, or 43 less than in 1917 Of these 51 were not notified by the doctor or parents, and had to be written to. Mortlake 264 Births. Barnes 173 Births. Visits in this connection, and including children up to 5 years, number 941 in Mortlake and 353 in Barnes Child Welfare. 19 Mothers were encouraged to attend the child welfare centre, on Monday and Thursday afternoons, where demonstrations, consulta. tions and Medical advice were given. The Centre was opened on 96 occasions in the year, the babies making 1,385 attendances. 112 New babies were entered in the register, 71 from Mortlake and 41 from Barnes. Of these 51 were breast fed and 61 bottle fed. Leaflets dealing with nursing, maternity, and simple ailments were freely disposed of; and Virol, ointments, dried foods, etc sold 53 older children, but under school age, attended for medical treatment, making 168 attendances, several of these receiving hospital letters. In home visiting of infants it was found that the proportion of breast fed to bottle ied babies was as 3 is to 2. Infant deaths under one year number 38, plus 2 dying outside the district; 13 of these died in their first fortnight and 15 were prematurely born. There were 3 deaths among 15 illegitimate born. ANTENATAL WORK. This work is gradually increasing, 36 expectant mothers were found and 80 visits paid to them. Facilities were provided for them in the way of getting meat, butter and milk. 20 mothers saw the medical officer and sometimes brought other children ; in 2 cases arrangements were made for the former at a maternity hospital. In this connection it would be advisable to arrange for a dental clinic for expectant mothers, and no doubt letters could be obtained admitting such cases to a dental hospital. A very successful Baby Show was held at the Ranelagh Club by kind permission of the Club Committee. TUBERCULOSIS. 98 Visits were paid to patients' homes, and contacts advised to attend the dispensary. Extra rations were also obtained for these patients. 20 Child Welfare. MEASLES. 534 Home visits were made during the spring epidemic, advice given and nursing help obtained, and beds provided at the Hospital. Deaths 15, including 2 outside the district. INFLUENZA. 66 Visits were made to the homes, and some nursing undertaken. With Influenza and Measles it should be mentioned that during epidemics extra nursing help is required, otherwise the ordinary work must be neglected. In recent years the extra help has been unobtainable owing to the shortage of nurses. SCHOOL AND CLINIC WORK. A good deal of the Health Visitors' time is spent at the various clinics, viz : Eye, Teeth, Medical and Attendance, some 200 visits were made. In Mortlake also 268 visits were paid to the schools and over 10,000 children examined for cleanliness ; 88 were excluded and 14 parents were prosecuted. 80 Visits were also made at the Tuberculosis Dispensary. SUGGESTIONS FOR HOME HELPS, 1. Women of good character and approved by the L.A. 2. Should have 3 months' training at a school for mothers, or at least a certificate of having attended a course of lectures on Home Nursing. 3. Instruction to include needlework, cooking, temperature taking, laundry, domestic economy and hygiene, and the elementary principles of sociology. 4. A register of such applicants to be kept by the L.A. 5. L.G.B. will refund half the salaries of approved and registered " Helps." The Child Welfare Committee has been reconstituted according to L.G.B. suggestion, and now contains 8 members of the Council and 4 ladies representing various women's organisations. The Day Nursery continues to do good work in the district by taking care of children whose mothers go out to work, Their Child Welfare. 21 second annual report can be obtained on application to the Hon. Secretary, Afon House, High Street, Mortlake, S.W. 14. POODS, ETC. MILK (MOTHERS' AND CHILDREN) ORDER, 1918. As I was appointed to administer the provisions laid down in this order, I have to report that during 1918, 33 nursing or' expectant mothers were secured an adequate supply of cow's milk and that a part of the cost was borne by the Council, in each case according to its needs. Extra Rations for Expectant Mothers have been given to such mothers as have attended the Antenatal Clinic. This order applies to meat or butter coupons. SPECIAL RATIONS FOR INVALIDS. As a Member of the Food Committee I give an opiniou on these applications as to their suitability for extra rations. TUBERCULOSIS. RATIONS. As Tuberculosis officer I have filled up many of these forms securing extra milk, fats and meats for dispensary patients. Those in hospital are also provided for liberally. With regard to the Margarine, about which there is some prejudice, 102 parts of Margarine are equivalent in food value to 100 parts of butter. DRIED MILK FOR INFANTS. Dried milk is extensively used at the Child Welfare Centre and found to be most satisfactory, and is infinitely safer than cow's milk as ordinarily sold in towns. There is not the danger of Diarrhoea, especially during the warmer months. The full-cream variety is always used. Scurvy and Rickets are not seen to result, but as an extra precaution the vitamines missing from fresh healthy cow's milk are supplied in the form of Virol and fruit juice. Cows' Milk will be tolerably safe when we are sure of: — 1. Clean Shippons, cows, and farm hands. 2. Sterilised covered Milk Pails. 22 Sanitary Administration. 3. No handling of the milk at the farm beyond transfer from sterilised pail to sterilised churn. 4. Rapid transit from farm to town in clean cool vans. 5. Distribution of milk to consumer in sterilised vessels, with as little handling as possible. Farmers do not understand sterilisation; this can only be done by steam jets. They only strain the milk with the result that, owing to the strainer getting foul, strained milk is 40 times worse than unstrained milk and sours more quickly. We are selling dried milk to the people generally, when, owing to deficiency in the local retail supply, they are going short ; there being no priority scheme in this district at present. The National Food Kitchen has proved a very successful undertaking. The Central Kitchen in Mortlake, and the 6 depots in the district, have been on the whole well-served, and must have effected considerable economy of food and fuel in the homes. The quality of the food is excellent, and the cooking also. All classes of the community have availed themselves of the advantages supplied by the Kitchen. SANITARY ADMINISTRATION. The water supply is that of the Metropolitan Water Board and continues to be of a high standard of purity. Sewerage is conducted on the water-carriage system with separate pipes for storm water. The sewage is dealt with at the works of the Barnes and Richmond Joint Station on the boundary of the Urban District and a clean effluent discharged into the Thames. This has been gone into in detail in a previous report. It is hoped that the street scavenging and dust-bin refuse will shortly be conveyed by motor vehicles to the Council's Destructor. The question of destruction of refuse versus salvage is now engaging the attention of the Council. All places where food is stored, prepared or sold, have been visited by the Inspectors who report more fully elsewhere. Structural and sanitary defects found on house inspection have Hospital Administration. 23 been attended to by the landlords and repaired as far as the limited labour resources are available. Under the House and Town Planning Act one basement dwelling was condemned as unfit for habitation, and others are black-listed. Should a case of Smallpox occur, it would be removed to the Guildford, Godalming and Woking Joint Hospital Boards' Hospital at Whitmoor, Surrey. HOSPITAL ADMINISTRATION. The hospital contains 58 beds, including shelters for Tuberculosis cases, and is open to receive cases of Scarlet Fever, Diphtheria, Enteric Fever, Measles, Cerebro-Spinal Fever, Meningitis, Infective Diarrhoea, Tuberculosis of lungs, and Post-Influenzal pneumonia. Considerable difficulty has been experienced in keeping the hospital going, owing to incomplete and inadequate nursing and domestic staffs, neither of which has been up to strength the whole year. The best women and nurses have been claimed by the War Office, and the tinge of romance about war nursing is a source of attraction to some. Apart from Tuberculosis the demand on the hospital beds has not been heavy, though the additional nursing of Pneumonia cases was a great strain on the staff. The coming year promises better in regard to the nursing staff. The garden has been made to yield considerable produce for the hospital. A considerable sum of money will have to be spent this year (1919) on repairs and decorations to the hospital as there are several years' dilapidations to make good, and reserve stock to make up. This is the result of keeping expenses down during the war, an effort not fully appreciated by those who do not administer. 24 Hospital Administration. The work done includes:— TUBERCULOSIS. Admissions 94 Carried over from 1917 11 Total 105 cases. Of these 17 cases improved and went home. 12 remained in the same condition and went home. 10 got worse and went home at own request. 19 sufficiently improved to be recommended for further treatment in a Sanatorium. 26 died. 3 were re-admitted, and the balance remain in the hospital. The Local Cases included in the above numbers are :— Mortlake 12 Improved 8 Died 4 Barnes 4 Improved 2 Died 2 DIPHTHERIA Five cases carried over from 1917. Admitted 28 cases (6 from one School) Died 3, including one case brought in dying. SCARLET FEVER. 13 cases carried over from 1917. Admitted 25 cases. Died 1, " Return Case " 1. " Septic Throats "—Admitted either as Diphtheria or Scarlet Fever. 5 cases. 1 Death. MEASLES. Admitted 6 cases (4 from one school). No deaths. CEREBROSPINAL FEVER. 1 case admitted, recovered 25 Hospital Administration. ENTERIC FEVER. 1 case carried over from 1917, recovered. INFLUENZAL PNEUMONIA. Admitted 12 cases. Died 4. 2 of the cases were "expectant mothers"; in one case the infant was born prematurely and survived, after attention at the Dav Nurserv. LABORATORY. The number of bacteriological examinations made at the Council's laboratory during the year are set out below. Result. Diphtheria. Typhoid Fever. Pulmonary Tuber- " culosis. Other Diseases. Totals. Positive 30 — 29 2 61 Negative 75 — 96 2 173 Totals 105 — 125 4 234 STEAM DISINFECTOR. The number of articles disinfected at the hospital, in the steam disinfector during the year are set out below. Heavy lots 76 Light lots 50 Bedding destroyed 10 lots MORTUARY. The number of post mortem examinations and inquests made in the Council's Mortuary are set out below. Inquests 28. Residents 15 Males 10 Non-residents 13 Females 18 Verdicts. Natural Causes 9 Accidental 8 Found Drowned 6 Insane 3 Misadventure 1 Malnutrition 1 28 26 Hospital Administration. TUBERCULOSIS DISPENSARY. The Dispensary is situated in South Worple Way, just within the Hospital ground, but approached from the road. It is open twice weekly for sessions of two hours. Since its inception nearly 1,000 cases have been registered as attending for an opinion or diagnosis. During 1918, 130 new cases were registered many of whom were not found tuberculous. The attendances made by old and new patients during the year were :— Insured persons 458 Non-insured 214 Dependants 319 Total 991 The dispensary serves the double purpose of a clearing house and a treatment centre, and cases are subdivided as follows:— (a) No lung trouble evident. (b) Cases for observation. (c) Cases for treatment while continuing at work. (d) Cases for hospital. (e) Cases for sanatorium. (f) Cases for opinion to recruiting and pensions authorities. (g) Cases for treatment elsewhere. REPORT OP THE SANITARY INSPECTOR FOR 1918. 1614 house to house inspections have been made, as compared with 1302 in 1917, and 4018 various other visits, as compared with 2007. 172 preliminary notices dealing with 244 nuisances were served during the year 1918, and 11 statutory notices. Landlords have been as leniently dealt with as possible during the past year, owing to the lack of labour, and notices only served where actually necessary. The Bakehouses have been well kept. The number of Factories in the District, 25; the number of Workshops, 109 : the Sanitary Administration. 27 number of Bakehouses, 24; and Domestic Workshops, 12. They are all in a satisfactory condition. Very few cases of notifiable cases of infectious disease have occurred in Hampton Square, but from its confined space, want of circulation of air and low ceiling rooms make it an unhealthy area. If 20 houses in the middle of the Square could be swept away, it would vastly improve the conditions. West Road is in constant need of supervision from the slackness of the Owner doing the necessary work, and from the dislike of soap and water of some of the tenants. In Barnes a block of flats in Stanton Road requires constant attention, the Landlord does little or nothing without compulsion, and consequently the houses are more or less in a dirty state, partly also the fault of the tenants. Flats are not desirable dwellings for the poorer class ; in a house of their own many can be educated up to cleanliness. Beyond the fact that St. Ann's Passage containing 20 houses, should be cleared away, and a half-dozen in Railway side, there is nothing special to call attention to. FOOD INSPECTIONS. Very careful inspections of Butchers' and Fishmongers' premises have, from time to time, been made by the Assistant Inspector. Seven cases of fish and five lots of butchers' meat, bacon and poultry of various weights were condemned as unfit for human food. A butcher in Sheen Lane, Mortlake, was prosecuted for having bad meat in his safe, and fined £20. 28 Sanitary Administration. Table showing number, and number of visits made. Factories and Workshops. BARNES MORTLAKE. TOTALS. No. Visits. No. Visits. No. Visits. A.—FACTORIES— Brewery ... ... 1 1 1 1 Electric Light Works ... ... 1 1 1 1 Printers 1 2 1 2 2 4 Wheelwright ... ... 1 2 1 2 Motor Works 2 4 1 2 3 6 Engineering Works 1 1 1 1 2 2 Anglo-Belgian Manufac. Co ... ... 1 2 1 2 Beverley Works Munition "5 10 ... ... 5 10 Miralite, L.T.D. ... ... 1 2 1 2 Goggle Manufac 1 1 ... ... 1 1 Aircraft Co ... ... 3 3 3 3 MantleWorks ... ... 1 3 1 3 Flour Store ... ... 1 2 1 2 Chocolate manufac 1 2 ... ... 1 2 Metropolitan Foundry 1 1 ... ... 1 1 STEAM AND ELECTRIC LAUNDRIES — Over 40 employees 1 2 1 2 B.—WORKSHOPS— Tailors 4 4 7 7 11 11 Dressmakers 8 8 11 11 19 19 Shoemakers 6 6 21 21 27 27 Cycle Works 1 1 8 8 9 9 Saddlers 1 1 I 1 2 2 Smiths 2 2 2 2 4 4 Umbrella Makers ... ... 2 2 2 2 Upholsterers ... ... 1 1 1 1 Watch Makers 2 2 2 2 4 4 Metal Worker 1 1 ... .. 1 1 Uudertaker 1 1 ... 1 1 Aeronautical Works 1 2 ... 1 2 Outworkers 12 12 14 14 26 26 HAND LAUNDRIES — Under 40 employees 3 6 2 4 5 10 BAKEHOUSES— 3 6 9 18 12 24 C.—DOMESTIC WORKSHOPS Laundries 8 16 8 16 16 32 Dressmakers 6 6 6 6 12 12 D.—WORKPLACES - Stable Yards 4 8 6 12 10 20 Restaurants 8 16 11 22 19 38 Totals 84 121 124 168 208 289 29 School Notes. Table showing the general work done by the Public Health Department during 1918. Nature of Work Done. No. No. of House to House Inspections 1614 ,, Various other visits 4018 ,, Defects Notified 274 ,, Houses cleansed 60 ,, ,, ,, after Infectious Disease 16 ,, Disinfections performed 159 ,, Drains unstopped 10 „ ,, repaired 7 ,, Defective closet pans and traps 8 ,, ,, dust receptacles 33 ,, Flushing tanks repaired 21 ,, Cisterns cleansed and covered 24 ,, Offensive accumulations removed 3 ,, Roofs and eaves'gutterings repaired 40 ,, Dampness remedied 15 ,, Mica valves made good 7 ,, Bakehouse inspections 24 ,, Dairy and Milkshops inspections 32 ,, Licensed slaughter house inspections 56 ,, Factory and Workshops inspections 207 ,, Visits to Infectious Disease 192 ,, Complaints received 66 ,, Statutory Notices served 11 ,, Summonses to abate Nuisances 1 ,, Premises licensed for storage of Petroleum 16 SCHOOL NOTES, 1918. ATTENDANCE CLINIC. (Held twice weekly.) 884 attendances were made by children referred by the teachers or the attendance officer. Letters from Mr Chambers (the attendance officer) referred to 266 absentees, of whom 196 were given certificates, and are included in the total of 884. 70 children did not present themselves at the clinic, suggesting that the warning from the attendance officer, to obtain a medical certificate or attend school, had the desired effect of attaining the second objective. GENERAL TREATMENT CLINIC. Held once weekly. A small fee is payable by the parents, 30 School Notes. The diseases treated were ringworm, deafness, external eye diseases and other skin diseases. First Term 37 cases with 136 attendances. Second Term 48 cases with 260 attendances. Third Term 38 cases with 199 attendances. Total 123 cases with 595 attendances. Clinics are also held periodically for treatment of vision and teeth. MEDICAL INSPECTION. The routine inspection of the three age groups has gone on without interruption right through the war The re-examination of those children found defective has not been so fully conducted having consideration for the understaffed and overworked teachers This is to a large extent the work of the care committees, and thanks to their energies a large number of children have been treated for general ailments, defects of teeth and vision, enlarged tonsils, adenoids, etc.I do not agree with those who maintain that the nutrition of school children has not suffered during the war. In this district I think it has been slightly lowered. In the provinces it may be different, but I believe that the huge floating population of London has deprived the suburbs of foodstuffs. Eggs, milk and fruit have been scarce and very dear, the coarse bread is only nourishing when properly digested, and has been, in cases of weak digestion, unsuitable. Then again the nervous tension of the parents has been reflected upon the children in some cases. With regard to dental caries, there is ample work in this district for a whole time dentist. The dental treatment of certain age groups only, takes too long to cover the ground and many children leave school without an opportunity of getting treatment. With regard to the commoner ailments of children, I should like to see cards issued containing a brief description of the disease, the danger of neglect, and hints on simple treatment. Such cards mean much more than the note usually given to obtain treatment. School Notes. 31 Cards should be issued for the Vision, Teeth, Ear Discharge, Scabies, Ringworm, Impetigo and Malnutrition. (Measles, Whooping Cough and the verminous conditions, are already dealt with by leaflets). The general care and tidiness of the children has not been up to the standard usual in this district and is probably explained correctly by the fact that the mothers are much less at home owing to war conditions; and to the increased cost of clothing. It is also desirable that caretakers should be taught how to clean schools on some dustless system, either by vacuum cleaners or by the use of a dust allayer. A cleansing station has been erected in the Council's Depot for the convenience of soldiers on leave, its uses might be extended to school children suffering from Itch or verminous conditions. Notifications received from Head Teachers concerning children absent on account of infectious or contagious disease (sufferers and contacts) comprise the following :— Influenza 545 Measles 241 Mumps 207 Whooping Cough 100 Chicken Pox 42 Ringworm 21 Scabies 8 Diphtheria 4 Scarlet Fever 3 Other Diseases 4 Coughs and Colds 50 The school attendance has been greatly diminished this year owing to the prevalence of Measles in the spring term and to out. breaks of Influenza in the summer and winter terms. SCHOOL CLOSURE has been necessary on five occasions and was practically general in the schools in the district during the Influenza outbreaks in July and October. Individual schools were closed in January, February and March for infectious diseases. 3 2 School Notes. During the year, 973 (including 18 "special") school children were medically inspected and, of these, 372 were recommended for medical, dental or ocular treatment, some of the defects were : — 1. Malnutrition, 114 ; i e., below standard. 2. Uncleanliness, Head, 103; Body, 128; (chiefly want of soap and water). 3. Defective Vision, 53. 4. Defective Hearing, 26, including 5 of ear disease. 5. Enlarged Tonsils, 65, not all requiring operation. Enlarged Adenoids, 15, „ „ „ ,, 6. Organic Heart Disease, 8. 7. Anæmia, 21. 8. Pretubercular, 16. 9. Teeth (4 or more decayed), 155. 10. Skin Diseases, 36. Number of children who received medical, dental, ocular, or surgical treatment :— Special Inspection EYES. July 1917 to July 1918, 196 examined and 156 supplied with glasses. Special Inspection TEETH. July 1917 to July 1918, 742 recommended, 250 attended clinic. 375 refused treatment. 34 attended privately, the others failed to keep appointments. General Medical Inspection. 372 recommended and 156 treated. Children moving from one district to another or even from one school to another, come without their medical schedules very often and their previous medical record is thereby lost. Some system which will not break down should be in vogue so that when a child leaves one school for another the schedule accompanies him. MEASLES. Surprise has often been expressed by magistrates hearing school cases, that children are allowed to attend school when there is Measles in the house. The practice usually adopted is to exclude (a) the sufferers, (b) the contacts attending Infant schools, (c) older School Notes. 33 children if they have not had Measles. In other words children over 7 years who have had measles may attend school even though there is Measles in the house. My own view is, either let all contacts attend school, or all stay at home. Under trained supervision the former expedient should not be attended with more risk than the latter. MENTAL DEFICIENCY ACT. As Medical Inspector under the Act, 1 have examined 4 mentally defective children and recommended them for special schools or institutional treatment. In this connection the Surrey Voluntary Association for the care and supervision of the mental defective, does useful work. The Secretary is Councillor H. A. Pike, 52 St. Leonards Road, Mortlake. SANITARY. The schools have been inspected by the Sanitary Inspector and various small defects found and remedied. Some of the defects are architectural and permanent. In some cases the closets were not kept clean. In one school the heating apparatus was found defective and remedied. At Mortlake Council School and at East Sheen Council School part of the playground is often under water and requires asphalting and draining in each case. / APPENDEX TO ANNUAL REPORT. REGISTRAR GENERAL'S FIGURES FOR 1918. Civilian Population— For Birth Rate 35279 „ Death Rate 31486 Births (actually registered in the District) 438 Deaths 404 Infantile Deaths under 1 year 40 Aged Persons' Deaths 135 Deaths in Public Institutions 88 Birth Rate for Barnes 12.09 Death Rate for Barnes 12.4 Infantile Death Rate for Barnes 91.03 Death Rate for England and Wales 17.6