BARN 53 Urban District of Barnes. the Annual Report of the Medical Officer of Health for the year 1922 E. A. Freear Wilkes, M.K.c.s.Eng. L.R.c.p.Lond, D.p.H.Camb. Medical Officer of Health. THE Urban District Council of Barnes. Public Health Committee. Mr. Aldis Mr. Harding (Chairman) Mr. Maynard „ Barton „ Hinton ,, Medus „ Bates „ Jackson „ Pike „ Capbll „ King „ Pittman „ Cash „ Kitley „ Stanley Sparkes „ Pirmston „ Lane ,, West „ Gordon Dr. Mackintosh Major Williams „ Green Mrs. Macna.mara Public Health Department. STAFF. Medical Officer of Health, E. A. Freear Wilkes, M.R.C.S.Eng., L.R.C.P.Lond., D.P.H.Camb. Chief Sanitary Inspector, C. S. Perchard, Cert.R.San.Inst. (Certified Inspector of Meat and other Foods.) Assistant Sanitary Inspector, C. W. Slade, Cert.R.San Inst. Health Visitors, Miss Parnell. Miss Denson. Matron of the Isolation Hospital, Miss Pearson. Clerk, C. Wells. SUMMARY OF CONTENTS. PAGE 1. Vital Statistics 2 II. Notifiable Infectious Diseases 15 III. Non-notifiable Infectious Diseases and Other Causes of Sickness 31 IV. Maternity and Child Welfare 32 V. Schools and Medical Inspection of School Children 37 VI. Health Visitors 38 VII. Nursing Arrangements, Hospitals, and other Institutions available for the District 40 VIII. Laboratory Work 44 IX. Public Health Staff 45 X. Sanitary Administration 46 XI. Housing 61 Summary of Statistics for the Year 1922. Area of the District in Acres:— Total area 2,650 Area excluding tidal waters and foreshore 2,519 Population (Registrar-General) 34,130 Density of Population per Acre 13.6 Number of Inhabited Houses (1921) 7,958 Persons per Inhabited House 4.3 Number of Births 574 Legitimate, 548; Illegitimate, 26 Birth Rate (Registrar-General) 16.8 Number of Deaths 377 Death Rate (Registrar-General) 110 Number of women dying in, or in consequence of, childbirth:—from sepsis, 1; from other causes, 2. Number of Deaths of Infants Under 1 Year of Age 29 Infantile Mortality Rate per 1,000 Births 50.5 Rate , for . Legitimate Infants 39 Illegitimate Infants 308 Deaths from Zymotic Diseases 15 Zymotic Death Rate 0.44 Deaths from Measles (all ages) 2 ,, ,, Whooping Cough (all ages) 4 ,, ,, Diarrhœa (under 2 years of age) 2 Deaths from Phthisis 27 Phthisis Death Rate 0.77 Rateable Value £298,442 0 0 Sum Represented by a Penny Rate £1,106 17 6 Public Health Department, Council House, Mortlake, S.W. 14. May, 1923, To the Chairman and Members of the Urban District Council of Barnes. Gentlemen, I have the honour to submit my Annual Report for the year' 1922, recording the sanitary conditions of the District, and the preventive measures taken for safeguarding the health of the inhabitants, and improving the environmental conditions under which they live. The report has been prepared in accordance with the instructions of the Ministry of Health as regards particulars to be included in the Annual Reports of Medical Officers of Health. The order of subjects followed in my Annual Report for 1921 has been retained for ease of reference. The presentation of this report affords me the opportunity of expressing my appreciation of the support which I have received from the Chairman and Members of the Council, and of thanking the chief Sanitary Inspector and other members of the staff of the Public Health Department and the Staff of the Isolation Hospital for their efficient service and loyal co-operation during the past year. 2 I. VITAL STATISTICS. Vital Statistics of whole District during 1922 and previous Years. Year. Population estimated to middle of each year. R.G Births. Total Deaths Registered in the District. Transferable Deaths Nett Deaths belonging to the District. Uncorrected Number. Nett. Of nonresidents registered in the District. Of residents not registered in the District. Under 1 year of age. At all ages Number. Rate. Number. Rate per 1,000 nett births Number Rate Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 *1917 36,223 481 509 11.1 261 8.2 31 143 35 68.6 376 11.6 32,495 *1918 36,223 438 481 12.3 368 11.3 41 110 42 87.3 437 11.4 32,495 *1919 37,193 475 513 13.8 299 8.4 36 88 46 89.6 351 9.5 35,704 †1920 37,127 762 777 20.9 309 8.3 31 103 52 66.9 381 10.3 †1921 34,010 618 651 19.1 316 9.3 34 106 42 64.5 388 11.4 †1922 34,130 520 574 16.8 289 8.5 27 115 29 50.5 377 11.0 †Population as estimated by the Registrar General, and upon which the rates in the year are based. *Population as estimated by the Registrar General for the calculation of Birth-Rates (higher figures) and Death-Rates (lower figures Rates in Columns 5 7. and 13, are calculated per 1000 of estimated population. 3 Vital Statistics. Birth-rate, Death-rate, and Analysis of Mortality during the year 1922, with corresponding rates for England and Wales, 105 Great Towns, 155 Smaller Towns, and for the County of London for comparison. The mortality rates refer to the whole population as regards England and Wales, but on'y to civilians as regards London and the groups of towns. Birthrate per 1,000 Total Population. Annual Death-rate per 1,000 Population rate per 1,000 Births. Percentage of Total Deaths. All Causes. Enteric Fever. Small-pox Measles. Scarlet Fever. Whooping Cough- Diphtheria. Influenza. Violence Diarrhœa and Enteritis (under 2 years). Total Deaths under One Year. Deaths in Public Institutions. Certified Causes of Death. Inquest Cases. Uncertified Causes of Death. England and Wales 20.6 12.9 0.01 0.00 0.15 0.04 0.16 0.11 0.54 0.44 6.2 77 25.6 92.7 6.2 1.1 105 Great Towns, including London (1921 Census Populations exceeding 50,000) 21.4 13.0 0.01 0.00 0.22 0.05 0.19 0.13 0.56 0.41 7.6 82 32.9 92.6 6.7 0.7 155 SmallerTowns(1921 Census Populations 20,000—50,000). 20.5 11.7 0 .01 0.00 0.10 0.03 0.15 0.09 0.58 0.35 5.6 75 16.9 93.6 5.1 1.3 London 21.0 13.4 0.01 0.00 0.35 0.07 0.25 0.25 0.57 0.45 7.1 74 48.7 92.1 7.8 0.1 Barnes Urban District 16.8 11.0 0.00 0.00 0.06 0.12 0.12 0.09 0.44 0.36 3.5 51 27.1 93.1 6.9 0.0 4 Vital Statistics. POPULATION. The population of the Barnes Urban District as enumerated at the last three Censuses is given in the following table:— 1901. 1911. 1921. Persons 17,821 30,377 34,281 Males 8,069 13,624 15,001 Females 9,752 16,753 19,280 The estimated mid-yearly population for 1921 was given by the Registrar General as 34,010, and the estimated mid-yearly population for 1922 as 34,130. This estimate allows for an increase in the population of only 120 persons for the year. The density of population has nearly doubled during the last twenty years. It is now 13 6 persons per acre, whereas in 1901 it was only 7.l persons per acre. BIRTHS. The number of births registered in the District during the year was 520. After correction for inward and outward transfers the nett number of births was 574 and the Birth Rate for the District was 16.8 per 1,000 of the population. The Birth Rate for the year for England and Wales was 20 6, and for London 21.0. Distributed according to sex and legitimacy the births were as follows:— Male. Female. Total. Legitimate 291 257 548 Illegitimate 12 14 26 Total 303 271 574 5 Vital Statistics. The birth rate of Barnes fell rapidly and continuously during the war, decreasing from 22.1 in the year prior to the commencement of the war to a minimu+m of 13.3 in 1918, during which year the birth rate was actually lower than the death rate. In 1920 the birth rate again returned to a high figure, being 20.9; this high level has, however, not been maintained—the birth rate fell in 1921 to 19.1, and this year shows a further marked decline to 16-8. The birth rate for London, and that for England and Wales, has fallen since 1920 in about the same proportion. The birth rate for 1922 is contrasted with that of the previous ten years, and with the figures for England and Wales and for London in the following table:— Birth Rate per 1,000 of Population. Year. Barnes Urban District. London. England and Wales. 1912 21.8 24.5 23.9 1913 22.1 24.5 24.1 1914 21.7 24.3 23.8 1915 19.5 23.6 21.9 1916 17.0 21.5 20.9 1917 14.1 17.9 17.8 1918 13.3 16.0 17.7 1919 13.8 18.2 18.5 1920 20.9 26.5 25.4 1921 19.1 22.3 22.4 1922 16.8 21.0 20.6 Notification of Births Act. 1907. The number of births registered in the District during 1922 was 520, and of this number 472, or 92 per cent., had been notified in accordance with the requirements of the Act. The number of notifications of births received during 1922 was 504, and the sources from which these notifications were received is given below:— Notified by Medical Practioners 210 „ „ Midwives 284 „ „ Parents or other persons 10 6 Vital Statistics. Still births notified numbered 19: 11 were notified by Doctors and 8 by Midwives. The object of the Notification of Births Act is to enable the Medical Officer of Health to receive information of the birth of a child as early as possible. Before the passing of the Act this information was obtained from the weekly returns of the Registrar of Births; a period of six weeks is allowed in which to register the birth of a child, and in a great many cases registration is postponed until near the end of this period; this meant that in many cases the child was six or seven weeks old before the Medical Officer of Health became acquainted with the fact of its birth. A very large percentage of infants die before reaching this age, and others have been permanently injured by the neglect and ignorance that are such common causes of infantile mortality. Notification provides the information which enables the Medical Officer of Health to put into action the work of the Health Visitors and the various measures under the Maternity and Child Welfare Act at the most opportune moment for effecting a diminution of infant mortality, and it is to be regretted that those in attendance at the birth do not comply with the requirements of the Act in every case. The percentage notified in accordance with the Act during 1922 (92 per cent) has improved compared with the previous year. Medical Practitioners and Midwives practisiug in the District have been written to, reminding them of their obligations under the Act, and I hope there will be in future few omissions to notify. DEATHS. The number of deaths registered in the Urban District during the year was 289. Of these 27 were deaths of persons who were not "residents" of the District, and 262 were deaths of "residents." To obtain the correct number of deaths, representing the true mortality amongst the population, it is necessary to add 115 deaths of "residents" whose deaths occurred outside the Urban. District. The corrected number of deaths belonging to the district = 377. 7 Vital Statistics. This number represents a death rate of 11.0 per 1,000 of the population. The death rate for the year for England and Wales was 12.9, and for London 13.4. The death rate for 1922 is contrasted with that for the previous ten years, and with the death rates during the corresponding period for England and Wales, and for London, in the following table Death Rate per 1,000 of Population. Year. Barnes Urban District. London. England and Wales. 1912 9.0 13.6 13.3 1913 10.5 14.2 13.8 1914 9.6 14.4 14.0 1915 11.3 16.8 15.7 1916 10.5 14.7 14.4 1917 11.6 15.7 14.4 1918 13.4 19.2 17.6 1919 9.5 13.6 13.7 1920 10.3 12.4 12.4 1921 11.4 12.4 12.1 1922 11.0 13.4 12.9 The death rate for the District has been consistently lower than that for London, or England and Wales. The death rate was higher during the years of the war, reaching its highest point in 1918, in which year the death rate even exceeded the birth rate for that year. Since 1918 the death rate has fallen. The death rate of 11.0 for 1922 (calculated on a population of 34,130 as estimated by the Registrar-General from the 1921 census), appears high in comparison with the death rate for 1920 and for previous years, but the census of 1921 has shown that the Registrar-General's figures for the population for the years prior to the census had been over-estimated. As a matter of fact the deaths numbered 384 in 1920, 388 in 1921, and 377 in 1922, being approximately equal for the three years, and allowing for a natural increase in the population, the death rate for 1922 would be slightly lower than that for 1920. 8 Vital Statistics. Causes of Death. The total (corrected) deaths for the whole District are shown in the accompanying table on the Opposite page, classified under various causes of death, and, in addition, distributed for age, sex and locality. Certain causes of death which are important in themselves or because they are responsible for a large proportion of the total mortality, have further reference made to them in the following table:— Cause of Death. Number of Deaths in previous 5 years. Deaths in Death Rate per 1,000 Population for 1922. 1917 1918 1919 1920 1921 1922 Barnes Urban District. Londnn. Zymotic (Epidemic) Diseases 13 31 12 25 16 15 0.44 1.07 Influenza 2 86 24 7 8 15 0.44 0.57 Bronchitis 22 26 27 28 27 27 0.77 1.14 Pneumonia 13 29 23 21 27 25 0.71 1.45 Tuberculosis 41 35 30 20 35 30 0.85 1.24 Cancer 54 35 39 39 56 1.17 1.31 Heart Disease 48 38 35 31 31 46 1.31 1.70 Bright's Disease 14 6 4 12 6 12 0.34 0.34 Puerperal Fever 1 2 1 4 — 1 0.03 0.03 Diseases and Accidents of Child-birth 1 3 2 2 0.06 0.03 Premature Birth, &c. 11 20 22 18 19 8 0.23 0.53 Violence 11 11 15 14 7 12 0.34 0.34 Zymotic Diseases The diseases included under the heading of zymotic diseases are Small-pox, Enteric Fever, Measles, Scarlet Fever, Whooping Cough, Diphtheria, and Diarrhoea under two years of age. These diseases were responsible for 15 deaths, representing a zymotic death-rate of 0.44 per 1,000 of population, contrasted with a zymotic death-rate of 1.07 for London and 0.60 for England and Wales. Table shewing Causes of, and Ages at, Death during the year 1922. Causes of Death. Nett Deaths of Residents whether dying within or outside the District. Deaths of Residents Dying in the Urban District. Deaths of Residents Dying outside the Urban District. Nett Deaths in or belonging to whole District at subjoined ages. Deaths in or belonging to Localities (at all ages). Total Deaths Sex Distribution. Deaths in Institutions. All Ages. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15. 15 and | under 25 25 and unter 45. 45 and under 65. 65 and upwards Barnes Mortlake Male. Female. Enteric Fever - - - - - - - - - - - - - - - - Small-pox - - - - - - - - - - - - - - - - Measles 2 — 2 - - - - - - 1 1 1 1 1 1 1 Scarlet Fever 4 - 1 1 1 1 — - — 1 3 2 2 4 4 — Whooping-Cough 4 2 1 — 1 — - - — 1 3 1 3 — 3 1 Diphtheria and Croup 3 — 1 — 2 — — - — 1 2 1 2 3 3 - Influenza 15 — - 1 — 1 3 3 7 9 6 8 7 — 14 1 Encephalitis Lethargica — — — — - — - — — — — — — — - — Meningococcal Meningitis - - - - - - - - - - - - - - - - Pulmonary Tuberculosis 27 - - 1 - 4 14 6 2 11 16 14 13 9 19 8 Other Tuberculous Diseases 3 - — 1 1 — 1 — - 1 2 1 2 3 — 3 Cancer, malignantdisease 41 - - - - - 1 16 24 19 22 18 23 14 27 14 Rheumatic Fever — — — — — — — — — — — — — — — — Diabetes 7 — - — — 1 1 3 2 4 3 2 5 2 4 3 Cerebral Haemorrhage 28 - - - - 1 1 3 23 13 15 12 16 7 17 11 Heart Disease 46 - - — 2 1 2 18 23 12 25 19 27 7 39 7 Arterio-sclerosis 10 - - - - - - 3 7 7 3 6 4 1 9 1 Bronchitis 27 2 — — — — - 2 23 21 15 8 19 4 22 5 Pneumonia (all forms) 25 2 5 1 — — 4 7 6 8 17 15 10 6 16 9 Other diseases of Respiratory organs 3 - - - - - 1 1 1 2 1 2 1 1 3 — Ulcer of Stomach and Duodenum 7 — — - 1 — 1 2 3 4 3 1 6 1 3 4 Diarrhoea and Enteritis 2 2 — — — — — — — 1 1 1 1 — 2 — Appendicitis and Typhlitis 2 — — — — — 1 - 1 2 — — 2 - — 2 Cirrhosis of Liver 3 - - - - - - 3 — - 3 1 2 - 3 — Nephritis and Bright's Disease 12 - — — — 1 2 6 3 3 9 8 4 6 6 6 Puerperal sepsis 1 — — - - — 1 - — — 1 — 1 — 1 — Other accidents and diseases of Pregnancy and Parturition 2 - - - - - 2 - - 2 - - 2 - 2 - Congenital Debility and Malformation, including Premature Birth 8 8 - - - - - - - 2 6 3 5 1 5 3 Suicide 4 - - - - - 1 3 - 2 2 3 1 1 3 1 Violent Deaths,excluding Suicide 12 2 — - 1 - 3 2 4 10 2 8 4 1 9 3 Other defined diseases 77 10 - - 4 1 9 22 31 28 49 36 41 28 45 32 Causes ill defined or unknown 2 1 — 1 - - - - - 1 1 2 — — 2 — All causes 377 29 10 6 13 11 48 100 160 166 211 173 204 102 262 115 9 Vital Statistics. The death-rate for each of the seven zymotic diseases is given separately below:— Disease. Barnes. London. England & Wales. Small-pox 0.00 0.00 0.00 Enteric Fever 0.00 0.01 0.01 Measles 0.06 0.35 0.15 Scarlet Fever 0.12 0.07 0.04 Whooping Cough 0.12 0.25 0.16 Diphtheria 0.09 0.25 0.11 Diarrhoea (under 2 years) 0.06 0.13 0.13 As the zymotic death rate is, with certain reservations, taken as an indication of the sanitary condition of a district, the above statistics show a very favourable position. 2 deaths occurred from Measles, 4 from Scarlet Fever, 4 from Whooping Cough, 3 from Diphtheria, and 2 from epidemic Diarrhoea. Bronchitis, Pneumonia and other diseases of the respiratory organs were responsible for 55 deaths. Tuberculosis. Pulmonary Tuberculosis caused 27 deaths, a death-rate of 0.77 per 1,000 of population. Nine of these deaths occurred in Institutions—3 in the Isolation Hospital, 3 in the Poor-law Infirmary, and 3 in other institutions outside the District. It will be seen that a large proportion of the deaths from this disease, an infectious and to a large extent preventable one, occurred amongst persons in the early and middle periods of adult life, 18 of the deaths being of persons between 15 and 45 years of age. Cancer. There were 41 deaths from Cancer, 14 occurring in institutions outside the District. Puerperal Fever. One death occurred from this disease during the year. Diseases and Accidents of Child Birth. There were two deaths from this cause. 10 Vital Statistics. Deaths in Public Institutions. Of the 377 nett deaths assignable to the District, 102, or 271 per cent, occurred in Public Institutions. In England and Wales, 25'6 per cent, of the total deaths, and in London, 48-7 per cent, of the deaths occurred in Public Institutions. Of the 262 "residents" who died in the District, 11 died in an Institution, viz., the Isolation Hospital. Of the 115 "residents" whose death occurred outside the District, 91 died in Public Institutions, 52 of them dying in the Richmond Poor-law Institution, and 39 in other Institutions beyond the District (namely, 30 in General and Special Hospitals, 4 in Mental Hospitals, and 5 in Poor-law Institutions). Inquests. Inquests were held in respect of 26, or 6.9 per cent, of the 377 deaths assignable to the District. The causes of death in these cases were as follows:— Deaths from suicide 4 Violent deaths, excluding suicide 10 Deaths from natural causes 12 Infantile Mortality. The deaths of infants under 1 year of age numbered 29, representing a rate of Infantile Mortality of 51 per 1,000 registered births, the Infantile Mortality rate for England and Wales being. 77 and for London 74 per 1,000 registered births for the corresponding period. Infantile Mortality has steadily declined during the past twenty years, and, although many factors have contributed in effecting the marked decrease which has occurred in the number of deaths annually of infants under 1 year of age, the very gratifying fall in the death-rate is largely a direct consequence of the excellent work performed in connection with the Maternity and Child Welfare Centres and by Health Visitors in their home visiting. 11 Vital Statistics. The decline in the rate of Infantile Mortality in Barnes from 127 per 1000 registered births in the quinquennium 1901-1905 to 51 in the present year is shown below. The rates for London and for England and Wales are given for comparative purposes. Period. Barnes. London. England & Wales. 1901-1905 127 139 138 1906-1910 91 114 117 1911 95 129 130 1912 59 91 95 1913 84 105 108 1914 63 104 105 1915 84 114 110 1916 65 89 91 1917 69 104 97 1918 87 108 97 1919 90 85 89 1920 67 75 80 1921 65 80 83 1922 51 74 77 Compared with the Infantile Mortality rate for this District of 134 per 1000 registered births in 1904, the rate of 51 for the present year shows a reduction of 62 per cent. The rate of Infantile Mortality for 1922 is considerably below the lowest rate ever recorded in the District. This exceptionally low death-rate amongst infants is partly consequent on the fact that, owing to the unusual wet weather that prevailed, summer diarrhoea, a disease exceptionally fatal to infants, did not become epidemic to any great extent. Notwithstanding this favourable circumstance, the small number of deaths from other causes which contribute to the infantile death-rate is satisfactory to record. The causes of death in infants dying under one year of age are analysed in the accompanying table (on page 13), which shows the distribution for age groups and for localities. It will be observed that of the 29 deaths, 11 occurred amongst infants belonging to Barnes and 18 amongst infants belonging to' 12 Vital Statistics. Mortlake, but it is to be borne in mind that the number of births in Barnes to those in Mortlake is approximately the proportion of 2 to 3. Of the 29 total deaths, 6 were deaths of infants who, though belonging to this District, died outside the Urban District. Considering the age-periods in which the deaths occurred, it is extremely important to note that in the case of 16 deaths, representing over50 percent, of the total mortality, death occurred before the infants had reached the age of 4 weeks, and of these 16 deaths, as many as 11 occurred during the first week of life— more than one-third of the total deaths. It is evident that to effect any further reduction in the infantile death-rate, it is necessary for preventive measures to be brought to bear at the earliest possible moment of an infant's life, and even before birth, especially in respect of those causes of mortality operating at so early a stage of its existence. To this end the work under the Notification of Births Act and the Maternity and Child Welfare Act are directed. Considering the causes that led to the death of these 29 infants, 4 were newly-born infants on whom inquests were held, having been "Found Dead," and 4 others died before they were one day old from Premature Birth or Congenital Malformations. From the same causes 6 other infants died, on the 2nd, 4th, 5th, 9th, and 11th days respectively, making a total of 14 deaths from these causes before the 11th day after birth. Six other infants died at the age of one month, the causes of death in these cases being Premature Birth, Convulsions (2), Diarrhoea, Bronchitis, and Syncope following an operation. Twenty of the infants had therefore died by the time this age had been reached. In the remaining 9 infants who died between two and twelve months old, the causes of death were Marasmus, Bronchitis, Broncho-pneumonia (2), Whooping Cough (2), Diarrhoea, Syphilis, and Intussusception. The rate of Infantile Mortality amongst illegitimate infants is very much higher than amongst legitimate infants. Of the 29 deaths that occurred under 1 year of age, 8 were deaths of illegitimate infants. 13 Vital Statistics. Infant Mortality during the Year 1922. Nett Deaths from stated Causes, at various Ages, under 1 Year of Age. Calse of Death. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3 4 Weeks. Total under 4 Weeks 1-3 Months. 3-6 Months 6 9 Months. 9-12 Month®. Total under 1 Year. Barnes. Mortlake. Deaths in the Urban District. Deaths outside the Urban District. Deaths in Institutes Small-pox - - - - - - - - - - - - - - — Chicken-pox — — - - - - - - - - - - - - — Measles - - - - - - - - - - - - - - — Scarlet Fever - - - - - - - - - - - - - - — Whooping Cough - — — — — — — — 2 2 — 2 2 — — Diphtheria — — — — — — — — — — — — — — — Erysipelas - - - - - - - - - - - - - - — Tuberculous - - - - - - - - - - - - - - — Meningitis - - - - - - - - - - - - - - - Abdominal - - - - - - - - - - - - - - - berculosis - - - - - - - - - - - - - - - Other - - - - - - - - - - - - - - - lous Disease - - — - — — — — - - — - — — — Meningitis (not - - - - - - - - - - - — - - — Tuberculous) - - - - - - - - - - - - - - — Convulsions - - — — — 2 — — - 2 2 — 2 — — Laryngitis - - - - - - - - - - - - - - — Bronchitis - - — 1 1 — — — 1 2 1 1 2 — — Pneumonia (all forms) - - - - - - 1 1 - 2 - 2 - 2 2 Diarrhœa and Enteritis - - - - - 1 1 - - 2 1 1 2 - - Gastritis - - - — - — — — - — — — — - — Syphilis - - - — — — 1 — - 1 — 1 1 — — Rickets - - — — — — - — - — — — — — — Atropyh Debility and Marasmus - - - - - 1 - - - 1 - 1 1 - - Premature Birth 3 - — - 3 1 — — — 4 — 4 1 3 2 Congenital Malformations 2 1 - - 3 - - - - 3 2 1 3 - - Injury at Birth — - — — — — — — - — — — — — - Atelectasis 4 1 — — 5 — — — - 5 1 4 5 — - Suffocation (overlaying) - - - - - - - - - - - - - - - Violence 2 — — — 2 — — — 2 2 2 — 2 — - Other causes — 1 — 1 2 — 1 — — 3 2 1 2 1 1 All causes 11 3 - 2 16 5 4 1 3 29 11 18 2 3 6 5 Nett Births in the Year: Total Births, 574; Legitimate,548; Illegitimate, 26. Nett Deaths (under 1 year): Total Deaths, 29; Legitimate Infants, 21; Illegitimate Infants, 8. Infantile Mortality Rate: Total, 51; Legitimate, 39; Illegitimate, 308, 14 Vital Statistics. There were 548 births of legitimate children during 1922, and only 21 deaths occurred amongst legitimate infants under one year of age, whereas in the case of illegitimate infants, whilst there were only 26 illegitimate births, the number of deaths of illegitimate infants numbered 8 in the year. This gives an Infantile Mortality rate amongst legitimate infants of 38 per 1,000 legitimate births contrasted with a rate amongst illegitimate infants of 308 per 1,000 illegitimate births registered. Illegitimacy increased during the years of war, and the rate of Infantile Mortality amongst these infants rose to a very high figure. Illegitimacy has since decreased, but the mortality rate remains high. The following table gives the figures for the period 1914-1922. Year. Proportion of Illegitimate Births per 1,000 Total Births Registered. Infantile Mortahtw Deaths of Legitimate Infants per 1,000 Legitimate Births. Deaths of Illegitimate Infants per 1,000 Illegitimate Births. 1914 50 63 83 1915 43 65 519 1916 52 48 380 1917 81 54 238 1918 86 83 132 1919 51 70 461 1920 41 56 312 1921 51 58 182 1922 45 38 308 In the ease of all illegitimate births notified, the infants are specially "follovved-up" and kept under supervision to endeavor to reduce the high death-rate amongst them. Notifiable Infectious Diseases. 15 2. NOTIFIABLE INFECTIOUS DISEASES. The following are the Infectious Diseases cumpulsorily notifiable in the District, and the number of cases notified during 1922 is given for each disease. Diphtheria 65 Scarlet Fever 100 Enteric Fever — Puerperal Fever 1 Erysipelas 6 Continued Fever — Relapsing Fever — Typhus Fever — Small Pox — Cholera — Plague Tuberculosis 62 Cerebro Spinal Fever — Acute Poliomyelitis — Opthalmia Neonatorum 3 Measles 590 Rubella — Encephalitis Lethargica — Acute Polioencephalitis — Malaria — Dysentery — Trench Fever Pneumonia 29 Anthrax — Table showing the Notifications of Infectious Diseases received during 1922 arranged in four-weekly periods:— Four weekly period ending Diphtheria. Scarlet Fever. Pneumonia. Erysipelas Ophthalmia Neonatorum. Measles. Pulmonary Tuberculosis. Non-pulmonary Tuberculosis. Puerperal Fever January 28 6 16 4 1 — 42 3 — – February 28 8 13 2 — 114 9 1 — March 25 2 13 3 — 1 239 6 1 — April 22 7 5 3 — — 87 4 3 — May 20 15 12 4 2 – 48 5 1 — June 17 2 10 1 — — 16 6 — — July 15 5 4 1 — 1 5 2 3 1 August 12 6 7 2 — — 23 7 — — September 9 2 3 1 — — 3 1 1 — October 7 1 6 3 — 1 3 2 — — November 4 5 6 3 — — 5 4 — — December 2 2 4 2 3 — — 1 — — December 31 4 1 — — — 5 2 — Totals 65 100 29 6 3 590 52 10 1 16 Notifiable Infectious Diseases. Table showing the distribution in age-groups of the cases notified during 1922, the number of cases removed to hospital, and the total numbers of deaths in the District from these diseases. Diseases. Total Cases Notified. Ages, in years. Parish. Removed to Hospital. total Deaths of Residents. § Under 1 year. 1 to 2. 2 to 3. 3 to 4. 4 to 5. 5 to 10. 10 to 15 15 to 20 20 to 25. 25 to 35 35 to 45. 45 to 65. 65 and over. Barnes Mortlake. Diphtheria 65 — — 3 2 2 25 17 8 3 2 2 1 — 23 42 61 3 Scarlet Fever 100 — 3 2 2 3 39 29 10 6 4 1 1 — 44 56 85 4 Puerperal Fever 1 — — — — — — — — — — 1 — — — 1 — 1 Pneumonia 29 2 2 — — — 5 2 — 1 2 5 9 1 5 24 — 25 Erysipelas 6 — — — — — 1 1 — 1 1 1 1 — 2 4 1 1 Opthalmia Neonatorum 3 3 — — — — — — — — — — — 1 — 2 — Measles 590 13 57 37 29 37 367 40 7 1 2 — — — 193 397 — 2 Tuberculosis: (a) Pulmonary M. 24 — — — — — 2 2 — 2 7 6 5 — 12 12 — 14 F. 28 — — — — — 1 — 4 4 9 7 1 1 10 18 — 13 Total 52 — — — — — 3 3 4 6 16 13 6 1 22 30 23‡ 27 (b) Non- Pulmonary M. 3 — — — — — 1 2 — — — — — — 2 1 — 1 F. 7 — — — — — 3 — 1 1 2 — — — 2 5 — 2 Total 10 — — — — — 4 2 1 1 2 — — — 4 6 — 3 All Diseases ... 856 18 62 42 33 42 444 94 30 19 29 23 18 2 294 562 171 96 ‡ 23 Pulmonary Tuberculosis patients were removed to Institutions—14 to Sanatoriums and 9 to Barnes Isolation Hospital. § The deaths recorded in this column are the total corrected number of deaths assignable to the District; in the case of Pneumonia and Tuberculosis the deaths recorded are not necessarily deaths of persons recorded as notified during the year. Notifiable Infectious Diseases. 17 For purposes of comparison of the incidence of notifiable diseases occurring in the District, a Table is given below of the cases notified during 1922 and during the previous 10 years. Year. 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 Diphtheria 56 67 56 41 34 28 29 42 103 90 65 Scarlet Fever 109 95 153 137 94 37 32 88 69 108 100 Enteric Fever 2 1 2 3 2 6 — — 3 1 — Puerperal Fever 1 — — 6 1 — 3 2 4 — 1 Erysipelas 12 16 11 12 8 8 2 13 13 6 6 Continued Fever — — — — — — — — — — — Relapsing Fever — — — — — — — — — — — Typhus Fever — — — — — — — — — — — Small-pox — — — — — — — — — — — Cholera — — — — — — — — — — — Plague — — — — — — — — — — — Tuberculosis, P. 106 74 66 60 55 54 58 44 35 52 52 „ Non-P. — 28 22 9 — 14 17 12 6 4 10 Cerebrospinal Fever — — — — 3 4 2 2 — — — Poliomyelitis 1 2 — 4 3 — 1 — — — — Ophthalmia Neonatorum (Not Notifiable) 2 2 1 3 2 3 3 1 3 Measles and Rubella (Not Notifiable) 429 743 620 159 570 44 590 Encephalitis Lethargica (Not Notifiable) 2 1 5 — Polio encephalitis „ „ „ — — — — Malaria „ „ „ 18 12 — — Dysentry „ „ „ 1 1 — — Trench Fever „ „ „ 3 1 — — Pneumonia „ „ „ 67 35 34 29 Anthrax „ „ „ — — — — 18 Notifiable Infectious Diseases. DIPHTHERIA. The usually severe epidemic of Diphtheria which commenced in this district in the autumn of 1921, and which was associated with and followed on the appearance, in epidemic form, of Diphtheria in the County of London, was declining at the end of that year. Through January and February of 1922 the epidemic continued to decline, and in March there was very little Diphtheria in the District. An outbreak of limited proportions occurred during April and May, but from then onwards until the end of the year the number of cases occurring were comparatively few. The number of cases notified during the year was 65, of which 61, or 94 per cent. of the cases, were removed to Hospital; only 4 cases were treated at home. Every case where it was considered isolation and treatment could not be effectively carried out at home was removed to Hospital. The incidence rate (cases per 1,000 of population) was 1.90, compared with 1.37 for England and Wales, and 3 38 for London. Had the incidence rate in Barnes corresponded to that in London, there would have occurred in the District 115 cases, and an incidence-rate in the District corresponding to that of England and Wales would have given only 48 cases. Three deaths occurred, representing a mortality rate per 100 cases of 4.61, compared with a rate of 8.00 per cent. for England and Wales, and 7.44 per cent. for London. Of three fatal cases one died 3 days after admission from acute toxæmia; in the other two cases death was due to heart failure associated with diphtheritic paralysis. In a large proportion of the case? admitted to Hospital the disease was of a severe type. The majority of the severer cases were sent into Hospital at the beginning of the illness, and a fatal issue was avoided by the early administration of Antitoxin ; a small number of cases unfortunately still come into Hospital rather late in the course of the disease, and even where a fatal termination is avoided in these cases the illness is liable to be far more serious and more protracted than it otherwise would be. To enable an early diagnosis to be arrived at and to secure prompt administration of antitoxic serum, Notifiable Infectious Diseases. 19 logical outfits are supplied, and inoculated swabs from suspected cases are examined bacteriologically by the Public Health Department for Medical Practitioners free of charge, and diphtheria antitoxin is supplied to Medical Practitioners on request. Every case notified is carefully investigated by an Officer of the Health Department, and the effective preventive measures outlined in my Annual Report for 1921 (page 23) have been continued throughout the past year. The 65 cases of Diphtheria notified came from 62 separate families; in 59 of these families only one case occurred in each family. In the other three families there were two cases in each family; in each of these instances the second case had contracted the disease before the removal of the first case to Hospital. In no instance did another occupant of the house become infected after removal of the patient to Hospital and subsequent disinfection of the premises had been carried out, and in no instance did a second case occur subsequent to a patient's return home after discharge from Hospital. Table showing thenumberof notifications of Diphtheria received during 1923, the number of cases removed to Hospital and the number of cases treated at home, arranged in four-weekly periods:— Four-weekly period ending: Number of cases notified. Number of cases removed to Hospital. Number of cases treated at home January 28 6 6 — February 25 8 7 1 March 25 2 2 — April 23 7 7 — May 20 15 14 1 June 17 2 2 — July 15 5 3 2 August 12 6 6 — September 9 2 2 — October 7 1 1 — November 4 5 5 — December 2 2 2 — December 31 4 4 — Total 65 61 4 20 Notifiable Infectious Diseases. Table showing the number of cases of Diphthera notified and the incidence rate (cases per 1,000 of population), the number of cases and the percentage of cases removed to Hospital, and the number of deaths and the mortality-rate per 100 cases during the past 10 years:— Year. Number of Cases Notified. Number of cases removed to hospital Number of Deaths. Incidence Kate. Cases per 1,000 of Population. Percentage Removed to Hospital. lity Rate per 100 cases. 1913 67 43 2 2.01 64 % 3.00 1914 56 40 — 1.61 71 0.00 1915 41 32 1 1.22 78 2.44 1916 34 25 1 1.06 74 2.94 1917 28 27 1 0.86 96 3.57 1918 29 28 3 0.89 97 10.34 1919 42 38 4 1.27 90 9.52 1920 103 56 7 3.07 54 6.80 1921 90 77 1 2.88 84 1.10 1922 65 61 3 1.90 94 4.61 SCARLET FEVER. Scarlet Fever was epidemic in the District at the commencement of the year 1922. The severe epidemic which had occurred in the last quarter of 1921 was then on the decline, and the number of fresh cases continued to decrease through the first four months of the year; there was a slight increase in prevalence of the disease in May and June, and from then throughout the rest of the year the cases notified markedly decreased in number. The number of cases notified during the year was 100, nearly three-quarters occurring during the first half of the year; 85 per cent. of the cases were removed to Hospital In 15 of the cases the home circumstances were such that effective isolation could be carried out at the patients' homes, and these cases were not removed. The incidence-rate (cases per 1,000 of the population) was 2.93—that for England and Wales being 2.85 and for London 3.81. Four deaths occurred, representing a mortality-rate per Notifiable Infectious Diseases. 21 100 cases of 4 00, compared with a rate of 1.40 per cent. for England and Wales and of 1.74 per cent. for London. A larger proportion than usual of the cases admitted were suffering from the disease in a severe form; in several of these the disease was of the toxic type, complicated by unusually early and severe nephritis, and to this circumstance the high percentage mortality is to be attributed. Of the four fatal cases two died from acute toxæmia on the second day after admission, one from acute nephritis with suppression of urine on the sixth day after admission, and in the fourth case death was due to uraemic convulsions on the third day after admission. The 100 cases notified came from 90 families. In 83 families one case only of the disease occurred in each family. In 5 families two cases of the disease occurred in each (in each of these families the second case had become infected from the first case before the latter's removal to Hospital). In one instance, where two families occupied separate floors in one house, investigations following the notification of a case of scarlet-fever led to the discovery of six other cases—each of these children had suffered from the disease in a mild form, no medical advice had been sought, and the cases had remained undiagnosed, and were found on examination to be disquamating; all were removed to Hospital. There was no "return case" of Scarlet Fever during the year. The preventive measures taken have been of the same character as those carried out during 1921, details regarding these will be found on reference to my Annual Report for that year (page 23). 22 Notifiable Infectious Diseases. Table showing the number of Notifications of Scarlet Fever received during 1922, the number of cases removed to Hospital, and the number of cases treated at home arranged in four-weekly periods:— Four weekly period ending Number of cases notified. Number of cases removed to Hospital Number of cases, treated at home. January 28 16 13 3 February 25 13 11 2 March 25 13 13 — April 22 5 3 2 May 20 12 9 3 June 17 10 6 4 July 15 4 4 — August 13 7 7 — September 9 3 3 — October 7 6 6 — November 4 6 5 1 December 2 4 4 — December 31 1 1 — Totals 100 85 15 Table showing the number of cases of Scarlet Fever notified and the incidence-rate (cases per 1,000 of population), the number of cases and percentage of cases removed to Hospital, and the number of deaths and mortality rate per 100 cases during the past 10 years:— Year. Number of Cases Notified. No. of Cases removed to Hospital. Number of Deaths. Incidence Rate Cases per 1,000 of Population. Percentage removed to Hospital. Mortality Pate per 100 Cases. 1913 95 82 — 2.85 86 0.00 1914 153 119 — 4.40 78 0.00 1915 137 111 3 4.09 81 2.19 1916 94 81 2 2.94 86 2.13 1917 37 35 — 1.12 95 0.00 1918 32 25 1 0.99 78 3.13 1919 88 63 — 2.65 72 0.00 1920 69 57 1 2.02 83 1.45 1921 108 83 1 3.18 77 0.92 1922 100 85 4 2.93 85 4.00 Notifiable Infectious Diseases. 23 ENTERIC FEVER. No case of Enteric Fever occurred in the District during 1922. The comparative freedom of the District from Enteric Fever is significant and is undoubtedly due to the safety of the water supply and to the almost universal adoption throughout the District of a water carriage system of sewage disposal. Cases occurring in the District are generally contracted outside the District, often in less sanitary areas, and the disease, once imported, does not gain a foothold. The cases notified during the previous 5 years were 6, 0, 0, 3 and 1 respectively. Comparative figures are:—Incidence Rate (cases per 1,000 of population)—Barnes, 0.00; London, 0.06; England and Wales, 0.06. Mortality Rate per 100 cases—Barnes, 00 per cent.; London, 16.6 per cent; England and Wales, 18.0 per cent. SMALL-POX. No case of Small-pox occurred in this District. During the year 962 cases were notified in England and Wales, and the disease was present in the Country throughout the year. An outbreak occurred in the County of London in September, and cases continued to arise in London, and in some of the surrounding Sanitary Districts, until the end of the year; in all 62 cases were notified in London, and 20 of these cases proved fatal. In view of the occurrence of cases of Small-pox in neighbouring Sanitary Areas, special preventive measures were taken in the District. The public were informed by posters and handbills of the importance of protecting themselves and their children by vaccination, or re-vaccination; contacts coming into the area were kept closely under observation, and as Chicken-pox was prevalent at this time, cases of the disease which were not being medically attended, were visited to ensure that a mild case of modified Small-pox should not escape detection by being mistaken for one of Chicken pox. 24 Notifiable Infectious Diseases. Vaccination. The following return as to Vaccination during 1922, has been supplied to me by the Vaccination Officer for the District:— Births 524 Certificates of successful Vaccination 528 Certificates of exemption (statutory declarations) 157 Certificates of Insusceptibility 1 Removals from District 20 Postponements (health of Child) — Certificates of Insusceptibility from Public Vaccinator — Certificates of infectious disease or condition of house — MEASLES. Measles was made compulsorily notifiable throughout England and Wales in January, 1916, but ceased to be notifiable on January 1st, 1920. The disease however has remained a notifiable one in this District by reason of the City of Leeds, &c. (Measles and German Measles) Regulations, 1920. An outbreak of Measles occurred at the commencement of the year, rapidly assuming epidemic proportions. During January 42 cases were notified, during February 114 cases, and during March the number notified reached the high figure of 239 The number of cases then rapidly decreased, 87, 48 and 16 cases respectively being notified during the next three months. The total cases notified during the year was 590, 40 only of these occurring during the last six months. The age-distribution of the cases is interesting and important. Of the 590 notified cases 173 ware infants under 5 years of age, 277 cases were children of 5 to 7 years of age—the age of attendance at the Infants' Schools, 109 were of 8 to 10 years of age, that is in attendance at the Junior Mixed Schools, and only 21 cases occurred amongst children of 11 to 14 years of age in attendance at the Central Schools. Eleven cases only were over school age. The attack rate of measles is usually highest in the third, fourth and fifth years of life, whilst the death rate caused by the Notifiable Infectious Diseases. 25 disease is highest in the first and second years of life. After the age of five years the death rate caused by it is relatively very small. It is therefore of the utmost importance to adopt special measures aimed at ensuring increased safety for children under five so as to postpone attacks of measles to a later age when it is less fatal, or to avoid attacks by specially protecting young children until they have attained a less susceptible age. The cases were mainly, fortunately, mild in type; the two deaths which occurred were deaths of infants between 1 and 2 years of age. It was found necessary to close one Infants' School and the Day Nursery for a short period to prevent the spread of the disease. The number of cases notified in each of the previous 5 years was in 1917, 743 cases; 1918, 620 cases; 1919, 159 cases; in 1920, 570 cases; and in 1921, 44 cases respectively. Two deaths occurred, corresponding to a death-rate of 0.06 per 1,000 of the population, contrasted with 0.35 for London, and 0.15 for England and Wales. The important steps, apart from precautionary measures to limit as far as possible the spread of the disease, are to endeavour to persuade the parents to obtain medical treatment in all cases and, by instructions to the parents, to secure for the patient the care in nursing which is so important in avoiding the serious complications of the disease. These are the steps, amongst others, taken by the Health Visitors in their work of "following up" the cases notified, and this work had most beneficial results. Notification is obligatory upon the parent unless the case has been already notified by a Medical Practitioner in attendance. Unfortunately in many cases a doctor is not called in, and, in a certain proportion of these, the parent fails to notify the case to the Medical Officer of Health. It is on this account that the arrangement whereby Head Teachers are required to notify to the Medical Officer of Health and to the School Medical Officer the names and addresses of all children absent from School and believed to be suffering from, or contacts of, a case of infectious disease, are of the utmost importance. It is only by this means that the majority of unnotified cases can be brought to the notice 26 Notifiable Infectious Diseases. of the Medical Officer of Health. Whilst the majority of Head Teachers, I am pleased to say, act with promptitude in reporting the cases, some of them fail to appreciate their responsibilities in these matters. A school cannot be expected to be other than a potent agent in the spread of infectious disease unless there is this co-operation between Head Teachers and the Public Health Department. PNEUMONIA. The number of cases notified in 1921 was 29, contrasted with 67, 35 and 34 respectively in 1919, 1920 and 1921. Priorto 1919 the disease was not notifiable. Cases notified from the homes of families in poor circumstances are visited by the Health Visitors, and where the conditions are such that a case cannot receive appropriate nursing and treatment at home, the patient is removed to the Isolation Hospital for treatment, providing there is accommodation at the time. PUERPERAL FEVER. One case of Puerperal Fever was notified during the year, and the case proved fatal. The notifications for each of the preceding 5 years numbered 0, 3, 2, 4 and 0 respectively. ERYSIPELAS. Six cases only of Erysipelas were notified, and 1 death occurred from this disease. The number of notifications for each of the previous 5 years being 8, 2, 13, 13 and 6 respectively. OPHTHALMIA NEONATORUM. Three cases of Ophthalmia Neonatorum were notified, contrasted with 3, 3, 2, 3 and 1 respectively in the previous 5 years. Two of the cases were treated in Hospital, and, fortunately, no impairment of vision resulted in either of the cases notified. Ophthalmia Neonatorum is an inflammation of the eyes of newly-born infants, the eyes becoming infected at the time of birth or subsequently by conveyance of infection from the hands of the mother or nurse. The disease is to be regarded with the utmost Notifiable Infectious Diseases. 27 gravity as it results only too often in partial loss of sight or complete blindness. Ophthalmia Neonatorum is the cause of the blindness of over 40 per cent. of the inmates of our Institutions for the Blind. In consequence of its importance the disease was made notifiable by doctors and midwives in 1914. I am convinced that a certain proportion of these cases are not notified in accordance with the requirements of the Public Health (Ophthalmia Neonatorum) Regulations, 1914, and in the event of any such cases of non-compliance with the Regulations coming to light I shall advise the Council to institute proceedings against the person failing to notify. TUBERCULOSIS. During the year 52 cases of Pulmonary Tuberculosis and 10 cases of Non-pulmonary Tuberculosis were notified, representing an incidence-rate (cases per 1,000 of population) of 1.53 for Pulmonary Tuberculosis and of 182 for all forms of the disease. The number of notifications from this disease during the previous 10 years is shown in the table on page 17. The number of deaths assignable to this district, after correction for transferable deaths, from Tuberculosis was 30 (27 being due to the pulmonary form of the disease and 3 to the non-pulmonary form), representing a death-rate of 0.85 per thousand of population for all forms of Tuberculosis, and of 0.77 per 1,000 of population for Pulmonary Tuberculosis. Notification of Tuberculosis. Of the 30 deaths from Tuberculosis assignable to this District during 1922, in 7 of them the case had not been notified as one of Tuberculosis during the patient's lifetime, giving a ratio of nonnotified tuberculosis deaths to total tuberculosis deaths of 23 per cent. Of the 7 non-notified deaths 5 were "Inward Transfers," these deaths from tuberculosis having occurred outside the District; inquiries from the Medical Officer of Health of the districts in which the deaths took place showed that the cases had not been notified in those districts. Two of the non-notified deaths were those of residents whose death actually took place in the District. 28 Notifiable Infectious Diseases. Preventive Work in relation to Tuberculosis carried out by the Council. (1) Home Visiting.—The home of every patient notified is visited by a Health Visitor with the object of giving instructions and advice as to prevention, and of inquiring into the home conditions. Sanitary defects discovered are reported to the Health Department for remedy. The homes of 71 tuberculosis patients were thus visited during the year, and 254 re-visits were made, making a total of 325 home visits by the Health Visitors in connection with patients suffering from tuberculosis. (2) Sputum outfits are supplied for the patient's use if required. (3) Disinfectants are supplied from the Public Health Department. (4) Disinfection at the home is carried out after death, or on a patient's admission to an institution, and on such other occasions as are necessary. (5) To assist in the early diagnosis of cases, specimens of sputum are examined bacteriologically at the Council's laboratory free of charge. There were 163 specimens of sputum examined during the year. Treatment—Dispensary and Institutional. The Surrey County Council is the Local Authority responsible for the treatment (institutional, dispensary, and domiciliary) of all tuberculosis cases within the Urban District, and statistical returns as to the work carried out are furnished to the County Medical Officer, and will be published in his Annual Report. Close co-operation between the Medical Officer of Health and the Tuberculosis Officer has been laid stress upon by the Ministry of Health as being essential, and the Ministry suggested that the Tuberculosis Officer should, for the purpose of Tuberculosis Notifiable Infectious Diseases. 29 Regulations, act as an Officer of the Sanitary Authority under the direction of the Medical Officer of Health. Being Medical Officer of Health and Tuberculosis Officer for the District, the advantages of the Ministry's suggestions are obtained. Two Health Visitors carry out, amongst other duties, the work of Tuberculosis Nurses. By arrangement with the Surrey County Council, a Tuberculosis Dispensary is provided in the Isolation Hospital Grounds, and advanced cases, from the County area, as well as from the Urban District, are admitted to a special Tuberculosis Block at the Hospital. Tuberculosis patients in this District are also sent away to other Sanatoriums under the County Scheme. Tuberculosis Dispensary. Patients attend under the following circumstances:— (1) Cases attending for examination for the purpose of diagnosis. (2) Contacts attending for examination and observation. (3) Doubtful cases attending for re-examination and further observation until a diagnosis is made. (4) Patients suffering from tuberculosis who are under medical treatment by their own doctor, and who attend periodically for supervision. (5) Patients who are tuberculous, and who, being unable to afford medical treatment, attend for treatment at the Dispensary. During the year 165 patients attended at the Dispensary. Of these patients, 78 were patients who had attended the Dispensary previously and 87 were new cases. Of the 87 patients attending for the first time, 24 were found to be suffering from tuberculosis, 28 were considered not to be tuberculous, and 35 were recommended to attend for re-examination and further observation, as the diagnosis was not definite at the time of their first attendance. The total number of attendances made by patients during the year was 513. 30 Notifiable Infectious Diseases. The number of patients recommended from the Dispensary for institutional treatment was 23; 9 being admitted to a Hospital for advanced cases and 14 sent away to Sanatoriums. Tuberculosis Block—Isolation Hospital. The cases under treatment during 1922 as in-patients are summarised in the subjoined table:— Male. Female Total Casts. Resident in Barnes. Resident. Total cases under treatment during 1922 21 20 41 10 31 Patients under treatment on January 1st, 1922 2 2 4 l 3 Patients admitted during the year 19 18 37 9 28 Patients discharged 9 14 23 6 17 Transferred to sanatorium 2 1 3 1 2 Returned home 7 13 20 5 15 Patients died 7 2 9 3 6 Patients still under treatment, December 31, 1922 5 4 9 1 8 The majority of patients admitted to the Hospital are suffering from pulmonary tuberculosis in an advanced stage of the disease. The reason for admission in many of the cases is to provide proper treatment and nursing when this cannot be obtained at the patient's home, and, frequently, the object of admission is to prevent infection of other members of the patient's family when the patient cannot be provided with adequate isolation at home. Of the 41 cases under treatment during the year, 10 were residents from the Barnes Urban District, and 31 were admitted from other Sanitary Areas in Surrey. Three of the patients so far improved under treatment as to admit of their transference to a Sanatorium. Non-Notifiable Infectious Diseases. 31 Twenty patients were discharged to their home (7 of these were much improved in health, in 6 the disease was stationary, and in 7 the disease was further advanced). Nine patients died in Hospital, a high mortality consequent on the type of case admitted. Patients sent to Sanatoriums. The number of patients from the Barnes Urban District admitted to Sanatoriums during the year was 14; 13 were cases of pulmonary tuberculosis, and 1 was a case of the non-pulmonary form of the disease. OTHER NOTIFIABLE DISEASES. No notifiable diseases other than those above referred to were notified during the year. 3. NON-NOTIFIABLE INFECTIOUS DISEASES AND OTHER CAUSES OF SICKNESS. There have during the year been no cases under this heading of sickness and invalidity which have been specially noteworthy in the District, with the exception of whooping-cough and influenza. WHOOPING COUGH. Whooping-cough was prevalent during the first four months of the year, its incidence falling mainly on infants and very young children. All cases reported were followed up by the Health Visitors, and exclusion from School of the patient and contacts effected. To obtain information of the existence of whooping-cough, the disease being non-notifiable, the Medical Officer of Health has to depend largely on the co-operation of Head Teachers in reporting cases, or suspected cases, of the disease amongst scholars. Effective measures for preventing or limiting the spread of this disease cannot be taken unless Head Teachers promptly report all cases as they occur in their schools. There were 4 deaths from this disease representing a deathrate of 0.12 per 1,000 of population, contrasted with a death-rate of 0.25 for London and 0.16 for England and Wales 32 Maternity and Child Welfare. INFLUENZA. Influenza was again prevalent in this District in 1922, and was of a severe type in a large proportion of cases. The serious complications were in the main pulmonary. A stock of influenza vaccine was kept at the Health Department available for Medical Practitioners wishing to use it. Deaths of Barnes residents from influenza numbered 15, representing a death-rate of 0.44 per 1000 of population, the death-rate of 0.57 for London and 0 54 for England and Wales. POOR LAW MEDICAL RELIEF. The following is a summary regarding Poor Law Relief for persons in this District during the year 1922:— (1) The number of orders issued for Medical Attendance 177 (2) The number of orders issued for sion to the Workhouse and Infirmary 143 (3) The number of deaths which have occurred amongst Barnes and Mortlake residents in the Poor Law Institution 52 4. MATERNITY AND CHILD WELFARE. The Notification of Births Act, 1907, was adopted in Barnes in 1913. In 1917 an arrangement between the Barnes Urban District Council and the Surrey County Council was made, whereby the Surrey County Council became the Authority responsible for the Maternity and Child Welfare work within the Urban District, and the various services and arrangements for attending to the health of mothers and young children under the Maternity and Child Welfare Act are made by the County Council as a part of the County Scheme. In practice, part of the services, namely, the Maternity and Child Welfare Clinics and the Home Visiting, are undertaken by Maternity and Child Welfare. 33 the Medical Officer of Health, as Medical Officer to the Maternity and Child Welfare Centre, and by two Health Visitors, whose duties also include other branches of public health work in the District. There is thus secured the fullest co-ordination in all spheres of preventive work. Assistance is also given at the Centre by voluntary helpers. The above infant welfare work is supervised by a local Maternity and Child Welfare Committee, consisting of members of the Barnes Urban District Council and additional co-opted members. The importance of further reducing the rate of Infantile Mortality, and of conserving the infant life of the population, make it desirable that adequate provision should be made for the welfare of both mother and child, even at the present time when strict economy in expenditure is enjoined on Local Authorities. Infant welfare work during 1922 has been very thoroughly carried out, and has undoubtedly been effective in assisting to secure the very favourable low death-rate amongst infants for the year. The work carried out is summarised below:— Home-Visiting. The homes of all newly-born infants amongst the working classes have been visited by the Health Visitors as soon as possible after birth. They were revisited as often as the circumstances of the particular cases indicated. An endeavour was made to persuade as many mothers as possible to attend at the Infant Welfare Centre, and the Health Visitors kept in touch with those infants whose mothers, for one reason or another, either could not or did not attend at the Centre. Notifications in respect of 504 births were received during the year (210 notifications from Doctors, 284 from Midwives, and 10 from parents or other persons). Of the 504 infants whose births were notified, 345 were visited in their homes by the Health Visitors, and 358 re-visits were made to the homes of such of those infants as appeared to require "following-up." It will be seen that 68 per cent. of the total births notified were home visited; a very satisfactory proportion. 34 Maternity and Child Welfare. Maternity and Child Welfare Centre. The Maternity and Child Welfare Clinics have been held weekly in premises, admirably suited to the work of the Clinics, at the Technical Institute, North VVorple Way, Mortlake. The work carried out at the Child Welfare Centre during 1922 has been highly satisfactory, and has proceeded on the following lines:— All infants and children attending the Clinics have been regularly weighed and kept under observation, so that any departure from normal health might be discovered at the earliest stage. All infants and children at their first attendance at the Clinic, and subsequently whenever appearing to be ailing or not making satisfactory progress, have been seen by the Medical Officer, and advice given to the parents. Educational work, which is essential to the proper conduct of an Infant Welfare Centre, has been both individual and collective: individual advice has been given by the Health Visitors and by the Medical Officer at consultations with mothers, and collective instruction has been given by Officers on the Staff, in the form of lectures and addresses to mothers on the care and management of their children. One of the chief aims at the Centre has been to encourage breast-feeding. Infants' foods for artificial feeding have been supplied at the Centre at cost price to mothers in cases in which continuance of breast-feeding has been found to be impossible or has already been abandoned. Infants' foods are supplied to mothers only on the recommendation of the Medical Officer. The number of new cases, the total number of infants and young children attending at the Centre, and the total attendances made by them during the year are set out below:— Number of new cases under 1 year 130 Number of new cases, 1 to 5 years 45 Total new cases (infants and children — under 5 years) 175 Maternity and Child Welfare. Number of infants under 1 year attending 185 Number of children, 1 to 5 years attending 97 Total number (infants and young children under 5 years) attending 282 Attendances made by infants under 1 year 2188 Attendances made by children, 1 to 5 years 893 Total attendances of infants and children under 5 years 3081 Attendances made by mothers 3305 35 The average attendance per week at the Maternity and Child Welfare Centre of infants was 61 per week, and the average attendance of mothers, 65 per week. I called attention above to the fact that 63 per cent. of all births notified were home-visited. It is satisfactory to note that, as a result of these home-visits, in 40 per cent. of the infants visited the mothers were induced to bring their babies to the Child Welfare Centre. It is evident from an analysis of the above figures what a large amount of work is being done in the District under the Maternity and Child Welfare Act, work that is effective in assisting to reduce the rate of Infantile Mortality and in building up a stronger and healthier generation. Ante-natal work has not developed to any great extent: a comparatively small number of expectant mothers have attended at the Centre for consultation with the Medical Officer. It is difficult to get in touch with expectant mothers in the first instance, and the facilities afforded are not yet widely known to them. As so much of the mortality amongst infants occurs during the first few weeks of life, ante-natal work is of the utmost importance. Other Services provided under the Maternity and Child Welfare Act. The other services for which the County Council make provision under the Maternity and Child Welfare Act, are administered 36 Maternity and Child Welfare. as part of the general County Scheme, and are enumerated hereunder:— Maternity Hospital provision, or beds in a Hospital for complicated cases of pregnancy, or for the treatment of complications arising after parturition, whether in the mother or the infant, and for cases where the home circumstances are unsuitable for the confinement. The provision for payment for skilled medical assistance in the home in the case of necessitous women for whose confinement a doctor has been called in by a midwife. Home-helps in cases where a person is needed to look after the home during the lying-in period, whether the confinement takes place at home or in a hospital. Convalescent homes for mothers and their infants. Homes for widowed, deserted and unmarried mothers, and for illegitimate children. The County Council accept responsibility for charges incurred in the provision of the above services provided that the charges are reasonable and the parents contribute according to their means. Further reference to the above will be found in the summary of institutions, etc , available for the District given later in this report and in the Annual Report of the County Medical Officer for Surrey. Day Nursery. The Barnes and Mortlake Day Nursery, which is supported by voluntary contributions, takes care, by day, of infants and young children under the age of 5 years whose mothers go out to work. An account of the work of the Nursery will be found in the report of the Voluntary Committee who manage it. The Urban District Council make a contribution of £100 per annum towards the cost of this Institution. It is important to remember that it becomes difficult to prevent the spread of infectious diseases where numbers of very susceptible young children under 5 years of age are in frequent and close contact. The younger the children the greater is the mortality from these diseases, especially Measles or Whooping-cough: ninety Schools and School Medical Inspection. 37 per cent. of deaths from Measles and its complications occur under the age of 5 years. The attendance of an infant at a Day Nursery amongst numbers of other young children coming daily to the Nursery from separate homes, adds enormously to its opportunities for infection, and this is particularly so in times of epidemics. During the epidemic of Measles an outbreak occurred in March amongst the infants and young children attending at the Day Nursery. In all eighteen infants and young children who had been in attendance at the Day Nursery were reported to have contracted the disease. The Day Nursery was closed for a period on my advice with a view to checking the spread of the disease. In order to prevent as far as possible the spread of infectious and contagious diseases amongst children at the Day Nursery I instituted, in co-operation with the Committee of the Day Nursery, arrangements whereby inquiry would be made as to the reason for absence in the case of every child ceasing to attend at the Nursery and, in the event of infectious or contagious diesease being alleged or suspected as the cause of non-attendance, for this fact to be reported to me so that, after investigation, infectious children could be excluded from the Day Nursery and their contacts excluded from school or vice versa. By co-operation in this way exclusion can be effected at an earlier date in many cases of notifiable infectious diseases without waiting for the receipt of the formal "notification," and in the case of non-notifiable infectious diseases exclusion can be carried out on account of disease, the existence of which in the family might otherwise never be ascertained. 5. SCHOOLS AND SCHOOL MEDICAL INSPECTION. There are 14 Public Elementary Schools and 19 Private Schools in the District. Both the Public Elementary and the Private Schools have been inspected by the Sanitary Inspector and, in addition, for the purpose of special investigations, by me personally. The water supply, sanitary accommodation and general sanitary conditions were, on the whole, very satisfactory. Several 38 Health Visitors. sanitary defects found were brought to the notice of the responsible person or authority for remedy. Careful investigations have been made into outbreaks of infectious diseases, and a very thorough organisation has been in practice for detecting infectious disease amongst scholars, and for ensuring, by exclusions from school, that neither convalescents from infectious diseases nor their contacts return to school before they can safely do so without risk of spreading infection to others. School closure was resorted to in the case of only one school (an Infants' Department) on account of the prevalence of Measles amongst the scholars. There are approximately 3,500 children in attendance at the 14 Public Elementary Schools, and the medical inspection of these children has been carried out by me under the Surrey County Council Scheme. The general inspection of the children for defective conditions requiring parental attention has been carried out by the Health Visitors, and a summary of their work will be found included under the heading of "Health Visitors." The School Clinics (Minor Ailments, Eye and Dental Clinics) have been conducted at the new Centre at the Technical Institute, where the accommodation is excellent for the purpose. The details of the work of Medical Inspection, of the School Clinics, and of the Health Visitors' work in the Schools, are furnished to the County Medical Officer for inclusion amongst the statistical returns contained in his Annual Report. 6. HEALTH VISITORS. Two whole-time Health Visitors are employed in the District, and work under the supervision of the Medical Officer of Health. Their duties include:— 1. Inspection of children in the Public Elementary Schools, 2. Attendance at (a) School Clinics; (b) Maternity and Child Welfare Clinics; (c) Tuberculosis Dispensary. Health Visitors. 39 3. Home-visiting in connection with:— Notified Births; Child Welfare in respect of children under 5 years; School children found defective, etc.; Infectious diseases, e.g., Measles, Whooping-cough, etc. Tuberculosis cases; Supervision of mentally defective children. A tabular summary of the work carried out by the Health Visitors during the year is given, together with the figures for the previous year for comparison:— School Inspection. 1921. 1922. Schools Inspected 14 14 Visits to Schools for Inspection of Children 565 508 Inspections of Children for defects 29,187 29,401 Children excluded for verminous conditions 390 257 Home visits to defective Children School Clinics. 153 246 Attendances by Health Visitors at School Clinics 251 164 Attendances by Children at School Clinics 2,844 2,239 Notified Births. Notifications received 568 504 Visits to notified births (1st visits) 338 345 Re-visits to Infants under 1 year and to Children under 5 years 832 358 Maternity and Child Welfare. Attendances by Health Visitors at Child Welfare Centre 188 94 Attendances of Infants under 1 year 2,061 2,188 Attendances of Children 1 to 5 years 1,173 893 Attendances of Mothers 3,167 3,305 Tuberculosis Work. Attendances by Health Visitors at the Dispensary 114 103 Home visits to Tuberculosis patients 76 325 Infectious Diseases. Home visits to cases of infectious disease 91 422 The amount of work in the District to be undertaken by Health Visitors is very large, and more than two Health Visitors are necessary to effectively carry out this work. 40 Summary of Nursing Arrangements. 7. SUMMARY OF NURSING ARRANGEMENTS, HOSPITALS AND OTHER INSTITUTIONS AVAILABLE FOR THE DISTRICT. (1) Professional Nursing in the Home. (a) General Nursing. Two District Nurses, employed by the Barnes Nursing Association and the Mortlake Nursing Association respectively, are engaged in General Nursing work in the homes of the poorer inhabitants. General Nursing work of this nature is undertaken in this District entirely by Voluntary Associations; neither the Urban District Council nor the Surrey County Council have made any arrangements in this respect. (b) For Infectious Diseases. No provision has been made for the actual nursing of cases of infectious disease in the homes of the poor. The services of the above-mentioned District Nurses are not available, as they are debarred from attendance on patients suffering from infectious diseases. Cases of Scarlet Fever, Diphtheria, or Enteric Fever are always removed to the Isolation Hospital if the circumstances are such that the patients cannot be effectively isolated and properly nursed in their homes. With regard to other infectious diseases, however, in epidemic times when accommodation in the Hospital may not be available, skilled nursing in the home is of the utmost value in lessening the mortality amongst cases of a severe type. This is applicable to cases of Measles, for instance, with severe complications, occurring in the homes of the poor ; in such cases no nursing assistance is at present available. (2) Midwives. There are nine Midwives practising in the District—four of these are resident within the District, and five, although resident outside the Urban District, occasionally practise in Barnes. There are no Midwives working in the District employed by or subsidised by a Public Health Authority, and I do not consider such provision is needed. Summary of Nursing Arrangements. 41 (3) Clinics, Treatment Centres, etc. Name of Clinic, etc. Address. Days of attendance. Provided by. (a) Situated in the District: Maternity and Child Welfare Clinic Technical Institute, North Worple Way, Mortlake Thursday, 2.30 Surrey County Council School Clinics— Attendance Clinic „ Monday, 10 „ Minor Ailments Clinic „ Wednesday, 2 „ Eye Clinic „ Monday, 2 „ Dental Clinic „ Tuesday, 2 „ Tuberculosis Dispensary South Worple Way, Mortlake Wednesdays, 6 Friday, 10 „ Day Nursery Afon House, High Street, Mortlake Daily, Monday to Saturday Vo1untarysub- scriptior (b) Situate outside District Venereal Diseases Clinics Richmond Royal Hospital Males. Tuesday and Friday, 6 Females, Tuesday & Friday, 5 Surrey County Council West London Hospital,Hammersmith Daily 5.30 „ And at 21 other Hospitals in the County of London Various times as advertised „ (4) Hospitals provided or Subsidised by the Urban District Council or by the Surrey County Council. (1) Tuberculosis— (a) Institution situated within the District. Barnes Isolation Hospital By agreement between the Surrey County Council and the Barnes Urban District Council, a Tuberculosis Pavilion containing 12 beds, to accommodate 6 male and 6 female patients, is provided for the reception of cases from Barnes District and from the remainder of the Administrative County of Surrey. 42 Summary of Nursing Arrangements. (b) Institutions available situated outside the District. Patients suffering from tuberculosis may be sent at the cost of the Surrey County Council to the following Institutions:— Sanatoria: Cambridge Tuberculosis Colony, Papworth. Crooksbury Sanatorium, near Farnham, Surrey. Fifty beds, all reserved for Surrey patients. Croydon Borough Sanatorium. Holy Cross Sanatorium, Shottermill. King Edward VII. Sanatorium, Midhurst. Mount Vernon Hospital Sanatorium, Northwood. Preston Hall Training Colony, Aylesford, Kent. Royal National Hospital, Ventnor. Royal National Sanatorium, Bournemonth. St. Catherine's Home, Sanatorium, Ventnor. Hospitals: Alexandra Hospital for Children suffering from HipDiseases. Brompton Hospital. City of London Hospital, Victoria Park. Lord Mayor Treloar's Hospital, Alton, for surgical cases only. Royal Sea Bathing Hospital, Margate, for surgical cases only. St. Peter's Home, Woking. St. Thomas's Hospital, London, for surgical cases only. St. Anthony's Hospital, Cheam, for surgical cases; also some Sanatorium beds for men. (2) Maternity. The Surrey County Council have arranged for Hospital beds for women needing special treatment during confinement to be available at the following Hospitals, all of which are situated outside the District:— Clapham Maternity Hospital. General Lying-in Hospital, York Road, Lambeth. Reigate and Redhill Hospital. Royal Surrey County Hospital, Guildford. Queen Charlotte's Lying-in Hospital, Marylebone. South London Hospital for Women, Clapham Common. (3) Children's Hospital. There is no Hospital situated within the District for the treatment of diseases of children. The Royal Hospital, Richmond, the Putney Hospital, and the West London Hospital, Hammersmith, are mainly resorted to for these purposes,. Summary of Nursing Arrangements. 45 but, in addition, use is made of the General and Children's Hospital situated in the County of London. An annual donation is made by the Barnes District Council to the three Hospitals first mentioned. It is frequently found to be a difficult matter to secure Hospital treatment for patients resident in this area; provision to meet this deficiency is desirable, and I consider would best be made by increased facilities for treatment at existing institutions. (4) Fever Hospital. The Barnes Isolation Hospital, situated in South Worple Way, Mortlake, is provided by the Council for the treatment of cases of infectious disease, and has accommodation (on the Ministry of Health's basis) for 40 cases apportioned as follows:— 12 beds for Scarlet Fever, 14 beds for Diphtheria. 14 beds for the purpose of observation, isolation of cases of cross infection, or treatment of infectious diseases other than Scarlet Fever or Diphtheria. (5) Smallpox Hospital. Hospital accommodation for cases of Smallpox arising in this District is provided, by arrangement with the Surrey County Council, at the Smallpox Isolation Hospital at Clandon, Surrey. The removal of cases to the Hospital by ambulance is undertaken by the Surrey County Council at the cost of the Barnes District Council. (6) General Hospitals.—There is no general hospital situated within the District. Use is made of the Richmond and Putney Hospitals, and of the General and Special Hospitals situated in the County of London. Increased facilities for both in-patient and out-patient treatment of cases of non-infectious diseases are urgently required, and, here again, as in connection with the lack of provision for the treatment of children's diseases referred to above, I am of opinion that further provision made should be by increasing the facilities for treatment at already established institutions. 44 Laboratory Work. (5) Institutional Provision for Unmarried Mothers, Illegitimate Infants and Homeless Children. This provision under the Maternity and Child Welfare Act is made by the Surrey County Council in Institutions which are outside the District. (6) Ambulance Facilities. (a) For Infectious Cases. Two horse ambulances are provided by the Council for removal of cases of infectious disease to the Isolation Hospital, one for patients suffering from tuberculosis, and one for other cases of infectious disease. A motor ambulance in place of the last-mentioned horse-drawn ambulance would be far more efficient; it would enable patients to be more promptly removed into hospital, a very important step particularly in times of epidemic. (b) For Non-infectious and Accident Cases. The Council have provided a motor-ambulance which is primarily intended for use in case of accidents, when no charge is made. It may also be hired for residents of the District, for the conveyance of non-infectious cases to hospital, etc., upon the payment of a nominal scale of charges, according to distance. These fees may be remitted in necessitous cases. 8. LABORATORY WORK, Etc. Bacteriological examinations of swabs for the detection of diphtheria bacilli and of sputum for the presence of tubercle bacilli are undertaken at the Council's laboratory. Pathological outfits are provided by the Council for practitioners' use, and specimens sent by medical practitioners from patients in the district are examined free of charge. Examinations undertaken during the year amounted to 688, for diphtheria bacilli 525, for tubercle bacilli 163. Diphtheria antitoxin is supplied from the Public Health Department to Medical Practitioners applying for it for their patients resident in this district: antitoxin supplied in this way is charged for at cost price unless the patient to whom it was Public Health Staff. 45 administered is subsequently transferred to the Isolation Hospital, in which case no charge is made. A stock of Influenza Vaccine is kept in the Public Health Department, and is supplied to Medical Practitioners on request. 9. PUBLIC HEALTH STAFF. In addition to carrying out the duties of Medical Officer of Health of the Barnes Urban District, 1 act as Medical Superintendent of the Isolation Hospital and as Tuberculosis Officer for the District, and also carry out the work of School Medical Inspection and Maternity and Child Welfare, under the Surrey County Council Scheme within the Urban District. Sanitary Inspectors. The services of Mr. T. Grylls have been retained by the Council as Consulting Sanitary Inspector. The Chief Sanitary Inspector holds the Sanitary Inspectors' Certificate of the Royal Sanitary Institute, and in addition, a Certificate as an Inspector of Meat and other Foods. The Assistant Sanitary Inspector holds the Sanitary Inspectors' Certificate of the Royal Sanitary Institute, and his duties are mainly in connection with infectious diseases. Health Visitors. There are two whole-time Health Visitors employed in the District: their duties include those of School Nurse and Tuberculosis Nurse, work under the Notification of Births Act, and in connection with Maternity and Child Welfare and Infectious Diseases. Both Health Visitors are trained nurses and hold the Certificate of the Central Midwives Board and the Health Visitors' Certificate of the Royal Sanitary Institute. Clerical Staff. One whole-time shorthand-typist clerk is employed in the Public Health Department. Isolation Hospital Staff. The staff consists of the Matron, one Sister, and eight trained Nurses: there are, in addition, a lodge-porter, a disinfecting officer, a boiler attendant, a gardener, and eight domestic servants included in the permanent staff. Other Staff. Rat Officer (whole time); Public Mortuary Attendant ; Superintendent and Matron of Cleansing Station (part time). The Officers to whose salary contribution is made under the Public Health Acts or by Exchequer Grants are the Medical Officer of Health, the Chief Sanitary Inspector, and the two Health Visitors. 46 10. SANITARY ADMINISTRATION. The fallowing is an account of the work undertaken during the year by the Sanitary Department under the various Public Health Acts, Bye-laws and Regulations (including the Adoptive Measures given below), and of the action taken. Particulars furnished by the Sanitary Inspector under Article XX. of the Sanitary Officers (Outside London) Order, 1910, are included. List of Adoptive Acts, Bye-laws and Local Regulations relatingto Public Health in force in the District, with date of adoption. Adoptive Acts. Portion Adopted Date of Adoption, Infectious Diseases (Prevention) Act, 1890 The Whole Act 13th Mar., 1894 Public Health Acts (Amendment) Act, 1890 Part II. 28th Sept., 1897 Part III. 11th July, 1893 Housing of the Working Classes Act, 1890 Part III. 8th Dec., 1896 Private Street Works Act, 1892 The Whole Act 8th Aug., 1893 Small Dwellings' Acquisition Act, 1899 The Whole Act 12th Dec., 1899 Public Health Acts (Amendment) Act, 1907 Part II., III., IV. 14th July, 1908 (except Sec. 66) Notifications of Births Act, 1907 The Whole Act 8th July, 1913 Byelaws Regulations, etc. New Streets and Buildings Prevention of Nuisances Cleansing of Earth Closers, &c Removal of Filth through Streets Offensive Trades (Fish-Fryers) Slaughter Houses Public Mortuary Common Lodging Houses Houses Let in Lodgings Domestic Servants1 Registries Tents, Vans and Sheds Fire-escape in Factories and Workshops Dairies,Cowsheds and Milk Shops Notification of Measles, &c. Notification of Human Anthrax Statute. P.H. Act (Amend.) Act, 1890 Public Health Act, 1875 Public Health Act, 1875 P.H. Act (Amend.) Act, 1890 P.H. Act (Amend ) Act, 1907 Public Health Act, 1875 Public Health Act, 1875 Public Health Act, 1875 Housing & Town Planning Act, 1919 P.H Act (Amend.) Act, 1907 Housing of Working Classes Act, 1885 Factory & Workshops Act, 1901 Dairies, Cowsheds, and Milk Shops Order, 1885 City of Leeds (Measles and German Measles) Regulations, 1920 Infectious Diseases (Notification) Act,1899 Date coming into Operation. 15th April, 1914 17th Dec., 1894 21st Feb., 1906 22nd Mar., 1912 28th May, 1913 17th Dec., 1894 23rd Dec., 1895 19th June, 1912 11th July, 1922 10th Aug., 1909 27th Nov., 1897 24th April, 1908 13th Oct., 1903 8th Mar., 1920 5th Mar., 1921 Sanitary Administration. 47 Table showing the number and nature of the inspections made by the Sanitary Inspectors during 1922, the number of notices served in respect of defects found in the course of inspection, and the number of notices complied with:- Nature of Inspections. Number of Premises Visited. Number of Visits of Inspection and Reinspection. Action taken in respect of defective conditions. Informal Notices. Statutory Notices. Number issued. Complied with. Number issued. Complied with. Milkshops 24 50 3 3 — — Butchers' Shops 26 298 5 5 — — Fishmongers and Poulterers 16 201 — — — — Greengrocers 22 67 4 4 — — Cooked-provision shops 6 12 — — — — Restaurants 14 28 2 2 — — Fried-fish Shops 5 60 2 2 — — Slaughterhouses 1 97 — — — — Bakehouses 13 28 4 4 — — Chocolate Factory 1 2 1 1 — — Factories 3 8 2 1 — — Workshops 86 86 — — — — Workplaces 14 14 — — — — Home-workers 29 34 — — — — Schools 33 33 — — — — Dwelling - houses (including houses let in lodgings):— (1) House - to - House Inspection 185 1504 134 65 33 25 (2) Inspected on complaint 254 2746 320 294 15 15 (31 Inspected in course of other work:— (a) Housing work, etc. 170 (b) For infectious Diseases 277 379 48 Sanitary Administration. Table of Defective Conditions Remedied. Drainage. Drains inspected on complaint 59 „ Water tests applied 46 „ Smoke tests applied 19 „ Cleansed or repaired 60 „ relaid 16 „ reconstructed 2 Inspection Chambers repaired 4 „ „ new provided 19 Interceptors—caps fixed 2 Soil Pipes renewed 1 „ „ new provided 5 Ventilating Shafts repaired 4 Fresh air inlets repaired or new provided 19 Rain water pipes disconnected from drains 4 Water Closets. Pans and traps provided 36 Waste water preventers repaired 27 „ ,, „ new provided 6 „ „ „ Water supplied 21 Apartments repaired 82 „ lighted and ventilated 10 Sinks and Baths. Repaired or newly fixed 26 Waste pipes repaired 12 „ „ newly fixed 1 „ „ trapped 2 Cesspools. Abolished 1 Urinals. Repaired or cleansed 3 Flushing apparatus provided 1 Structurally improved 1 Sanitary Administration. 49 Water Supply. Cisterns repaired or renewed 31 Taps off main provided 7 Dustbins. Provided 102 Ashpits abolished 3 Yards. Paving repaired 65 Newly paved 42 Dampness. Roofs repaired 93 Gutters and rain water pipes repaired 51 Damp proof courses provided 31 External wall repointed 107 Floor spaces ventilated 12 Dangerous structures repaired or rebuilt ... 6 General. Food larders ventilated or new provision provided 59 Windows repaired 152 „ made to open 37 Stairs repaired or handrails provided 19 Grates repaired or renewed 71 Smoky chimneys remedied 17 Washing coppers repaired 23 Walls and ceilings—plaster repaired 205 „ „ stripped and redecorated 645 Verminous premises fumigated and cleansed 10 „ bedding cleansed and destroyed 4 Offensive accumulations removed 20 Miscellaneous defects remedied 68 Animals improperly kept 1 Stables. Manure receptacles provided or repaired 1 Floors and yards properly paved and drained 2 50 Sanitary Administration. In Connection with Infectious Disease. Rooms disinfected 348 „ stripped and cleaned 99 Lots of bedding disinfected 258 „ ,, destroyed 3 The following Schools were also disinfected during the year:— Public Elementary Schools. Westflelds Infants. East Sheen Mixed and Infants. National Schools. Private Schools. Castelnau College (twice). S.W. London College (twice). Convent School, Barnes. Legal Proceedings. It became necessary to institute legal proceedings in one instance only during the year. An application was made to the magistrates for an Order for the ejectment of the tenant of a house in respect of which a Closing Order had been made by the Council. The Order for Ejectment was granted. FOOD SUPPLY AND PLACES WHERE FOOD IS STORED OR PREPARED. Milk Supply. No milk is produced in the District, the source of the whole of the milk supplied to inhabitants is from outside. It is of the utmost importance that milk, especially as it enters so largely into the dietary of young children, should be produced as pure as possible, and safeguarded subsequently from every kind of contamination and adulteration. There is no indication that the milk supplied has been below the average. Sanitary Administration. 51 With regard to adulteration, 59 formal samples of milk were taken by the County Inspector under the Sale of food and Drugs Act (the Surrey County Council being the authority responsible for the administration of the Sale of Food and Drugs Act within the District). Of these 59 samples of milk, only 2 were found to be adulterated; a prosecution followed in respect of one of these but a conviction was not secured. With regard to contamination, much greater care is required in the storage and handling of milk. With the additional powers conferred under the Milk and Dairies (Amendment) Act, 1922, which came into operation (with the exception of Section 3) on 1st September, 1922, and under the Milk (Special Designations) Order, 1922, made under Section 3 of the Milk and Dairies (Amendment) Act, 1922, and coming into operation on 1st January, 1923, it should be possible to secure much greater freedom from contamination, both as regards contamination arising during milk production and during its distribution. Dairies, Cowsheds, and Milk-shops Reg-ulations. The number of milk-shops and milk-stores on the Register at the end of the year was 24. There are also three firms registered as retailers of milk in the District, but whose premises, from which their milk is retailed, are situated outside the District. There is no cow-shed in the District. All the milk-shops and milk-stores have been kept under close supervision by the Sanitary Inspector: in instances where the conditions were found not to be satisfactory action was taken under the newly-enacted Milk and Dairies (Amendment) Act, 1922, Milk and Dairies (Amendment) Act, 1922. Action was taken under Section 2 of this Act in the case of two retail purveyors of milk. The Council being satisfied that the public health was or was likely to be endangered on account of the unsatisfactory conditions of the premises in use (and on account of want of cleanliness on the part of one of the retailers), both of these retailers were removed from the Register. 52 Sanitary Administration. Meat. The source of the great bulk of the meat sold in the District is from outside. Meat from outside the District comes in mainly from the Smithfield and Islington Markets, and such meat is inspected at the place of slaughter. In spite of inspection, diseased meat may get through, and meat may also deteriorate before it reaches the purchaser. Regular and frequent inspections of meat exposed for sale in all butcher's shops have been carried out by the Sanitary Inspector to detect diseased or unsound meat. Meat killed in the District receives efficient inspection; slaughtering takes place at one slaughter-house only, and the Sanitary Inspector inspects the carcases and viscera of all animals killed there, an arrangement being in force whereby he is notified beforehand, by the Owner, of each occasion on which slaughtering, takes place. One carcase of a heifer was found to be tuberculous; the carcase and offals were surrendered voluntarily and destroyed. The Ministry of Health issued in March, 1922, a Memorandum on a System of Meat Inspection recommended by the Ministry, together with a Circular thereon, with the object of securing uniformity in meat inspection throughout the country. The methods recommended by the Ministry were in the main already in operation in this District, having been adopted and carried out by the Sanitary Inspector, who is a Certified Inspector of Meat, during the past two years or more. Slaughter-houses. The slaughter-house above referred tois the only licensed slaughter-house used in the District, and the Sanitary Inspector reports that it is kept in excellent condition. Visits of inspection during the year numbered 97. Other Foods and Places where Food is Prepared. In addition to the above-mentioned food premises, other places where food is sold, stored, or prepared for sale or consumption, have been periodically visited by the Sanitary Inspector. Sanitary Administration. 53 Such premises have included fishmongers, poulterers, greengrocers, restaurants and eating-houses, and cooked-provision shops (for list of unsound articles of food discovered, see below). Bakehouses. There are 13 bakehouses in the District; four of these are underground bakehouses. These premises have been inspected, and, apart from some minor defects in four instances, which have been remedied, were found by the Sanitary Inspector to be in good condition. There is also one large chocolate factory in the District; this has been inspected by the Sanitary Inspector in the course of his routine work, and conditions found satisfactory. Unsound Food. As a result of inspection, a number of articles of food in an unsound condition were detected by the Sanitary Inspector, and the following articles were surrendered voluntarily and destroyed:— Meat (tuberculous) 1 carcase of heifer and offals. Fish—Skate wings 6 stone. „ Codling 6 stone. „ Kippered Herrings 3 boxes. Sale of Food and Drugs Act. This Act is administered by the Surrey County Council; the County Medical Officer has supplied me with the following table, setting out the work undertaken in the District by the County Inspectors. Return of Samples Analysed during the Year ended 31st December, 1922. Articles. Analysed. Adulterated or deteriorated Prosecutions. Convictions Formal. Informal. Total. Formal. Informal. Total. Milk 59 — 59 2 — 2 1 — Spirits 12 — 12 4 — 4 4 3 Totals 71 — 71 6 — 6 5 3 54 Sanitary Administration. WATER SUPPLY. The water supply is that of the Metropolitan Water Board, and is sufficient and of good quality. The supply is constant. Almost entirely throughout the District the supply is through a storage cistern. Where this system is in use it is desirable, from a health point of view, to have a direct supply from a tap on the service pipe, available for water used for drinking purposes. In only a relatively small number of houses is this provision made. Water in cisterns not only tends to become flat and insipid, but is liable to contamination whilst in the cistern; such cisterns require to be subjected to periodical inspection, especially in poorer class property. During the year 31 cisterns were found by the Sanitary Inspector to be defective, and were remedied. In 7 instances a newdirect supply from a tap on the service pipe was provided. RIVER AND STREAM POLLUTION. No case has come to my notice of pollution of streams by effluents, solid refuse or filth. SEWAGE DISPOSAL. The water carriage system of sewage disposal is in use throughout the whole District, with the exception of 3 earth closets and 16 cesspools in positions where connection with a sewer is difficult or impossible ; the condition of these has been found to be satisfactory. One cesspool was abolished during the year. The purification of the sewage and the maintenance of the intercepting sewers is undertaken by the Richmond Main Sewage Board. DRAINAGE, WATER CLOSETS, &c. Numerous defects in connection with water-closets and drains were discovered by the Sanitary Inspector, and remedy of the defects obtained; these will be found referred to in detail in the table of Sanitary Defects given above. 55 Sanitary Administration. PUBLIC CONVENIENCES. The public conveniences in the District (both those maintained by the Council, and the public house urinals which are entered from the street and available to the public) have been regularly inspected during the year by the Sanitary Inspectors, and defective conditions found have been remedied. The urinal at the Bridge Hotel has been structurally improved. The public conveniences maintained by the Council number 5. These 5 public conveniences are for the use of men only, and water-closet accommodation is provided in only two of them. There are no public conveniences providing accommodation for women. The number of public-house urinals entered from the street and available to the public is 12. There are conveniences, both urinals and water-closet accommodation, at 3 Railway Stations in the District; water-closet accommodation is provided at each of the Stations for both sexes. All are entered from the Station premises. I do not consider that the requirements of the District as to public conveniences are met by the above-mentioned facilities ; the public conveniences are too few in number, the water-closet accommodation especially is insufficient, and the entire absence of women's lavatories for the use of the public (except those situated at the Railway Stations, needs remedying. The subject has been given careful consideration by the Council, and it is anticipated that improved facilities will shortly be provided. SCAVENGING AND REFUSE DISPOSAL. The scavenging and the disposal of the refuse from the District is undertaken by the Surveyor's Department. Collection of house Refuse. House refuse is collected at least once a week ; during the summer months it is removed twice weekly from flat-dwellings and large establishments. All house refuse is removed to the Council's 56 Sanitary Administration. Destructor for incineration, motor-driven vehicles being very largely used in its removal. Almost entirely throughout the District movable ash-bins of galvanised iron are in use. A small number of fixed receptacles, about 10 in number, still exist in West Road, Mortlake. In compliance with notices served by the Sanitary Inspector, 102 new movable ash-bins have been provided and 3 ash-pits abolished during the year. Cleansing: and Scavenging of Streets. The scavenging and cleansing of the streets have been undertaken at frequent intervals, the frequency depending upon the character of particular localities. Those streets which are liable to greater pollution or fouling, receive more frequent attention. Mechanical sweepers are largely used, and the road sweepings are removed by motor-vehicles. Watering of the street in association with scavenging has been resorted to as far as necessary. Difficulty arises in connection with passages at the rear of premises, such premises being very liable to get into an insanitary condition, and the securing of the cleansing of them not an easy matter. Such passages are much more easily kept in a sanitary condition if they are suitably paved. During the past year some of the passages have been so paved, and it is desirable they should be dealt with generally throughout the District in a similar way: they could then be easily and regularly scavenged. Disposal of Refuse. The house refuse removed is incinerated at the Council's Destructor. The refuse so removed from the Barnes Urban District aud destroyed during the year amounted to 9,691 tons. In addition to the refuse from Barnes, that from the Borough of Richmond is also destroyed at the Council's Destructor, the amount dealt with from the latter District during the year being 10,387 tons. Road sweepings from both Barnes and Richmond District are tipped ou a site adjacent to the Destructor. 57 Sanitary Administration. RATS AND MICE DESTRUCTION ACT, 1919. A whole-time Rat Catcher has continued to be employed by the Council during the year to assist in the work of rat destruction, under the supervision of the Sanitary Inspector. The Sanitary Inspectors make inspections in the District for the purpose of discovering rat-infested premises. The Sanitary Inspector reports that 4,956 rats' tails were brought to the Office by the Rat Catcher during the year, contrasted with 5,102 during the year 1921; poisoned bait was laid at 87 premises. 234 complaints were received of the presence of rats on premises. The Rat Catcher paid 634 visits to premises, in addition to periodical visits to such open places as Barnes and Sheen Commons, the Beverley Brook, Tow path, &c. DISINFECTION AND DISINFESTATION. The following is an account of the work carried out during the year in connection with :— (1) The disinfection and disinfestation of (a) Premises; (b) Bedding and other articles. (2) The cleansing of persons infested with vermin. The Disinfecting Station attached to the Isolation Hospital, and the Cleansing Station situated at the Council's Depot, have been used for these purposes. In premises, disinfection of rooms vacated by persons suffering from infectious disease has been by formaldehyde vapour, disinfestation of verminous premises has been by fumigation with sulphur dioxide and other means. The number of rooms disinfected after the occurrence of infectious disease was 348; and 99 rooms were stripped and cleansed on this account. Verminous premises fumigated and otherwise treated to rid them of vermin numbered 10. Lots of bedding disinfected after infectious diseases numbered 258 ; 4 lots of verminous bedding were destroyed. Cleansing Station. Arrangements are in force whereby the Council's Cleansing Station is available for the purpose of cleansing children attending the Public Elementary Schools, who, on account 58 Sanitary Administration. of being found persistently in a verminous condition, are removed there from the Schools under the powers conferred by Sectfon 122 of the Children Act, 1908. The number of children cleansed at the Cleansing Station on account of the verminous condition of their hair was 64 ; one child was dealt with on account of body vermin. In addition, the Cleansing Station is available for the treatment of children affected with Scabies, but no children were treated on this account during the year. No adult person infested with vermin applied during the year for cleansing of person or clothing, PUBLIC MORTUARY. At the Public Mortuary, adjacent to the Isolation Hospital, 33 bodies, on which post-mortem examinations were conducted and inquests held, were received. Of this number, 10 were bodies of persons resident in the District; 17 were bodies of non-residents whose death occurred in the District, and 6 were bodies of persons unknown. In addition, 5 bodies were received into the Mortuary for reasons other than inquest or post-mortem examination. The Public Mortuary and Post-mortem Room and the rooms used as a Coroner's Court were re-painted and renovated during the year. For the better preservation of bodies received at the Mortuary an additional air-tight shell, in which to retain corpses the burial of which is delayed for purposes of identification, has been provided. NUISANCES. The various nuisances dealt with during the year are included in the tabular summary, already given, of defects remedied. Nuisances arising from the keeping of animals, including fowls, duck, rabbits, pigeons, &c., at the rear of houses having very small yards are of frequent occurrence; in most of such cases it is extremely difficult, often impossible, to obtain a remedy under the Nuisance Section of the Public Health Act, 1875. Nuisances arising from this source would be far less frequent, and existing, nuisances more easily dealt with, if Bye-laws for the prevention of the keeping of such animals on any premises so as to be a nuisance or dangerous to health were adopted. 59 Sanitary Administration. OFFENSIVE TRADES. The only offensive trade carried on in the District is that of Fish Frying, which has been declared to be an " offensive trade " within the Urban District, and is controlled by Bye-laws. There were on the Register during the year five premises on which fish frying was permitted; these premises having been periodically inspected by the Sanitary Inspector and have been found by him to be conducted in a satisfactory manner. FACTORY AND WORKSHOPS ACT. The work carried out in connection with the inspection of Factories, Workshops, and Home-workers is summarised below : — Number of Factories on the Council's Register 33 Number of Workshops and Workplaces on the Council's Register 100 Number of Home-workers on the Council's Register 29 Factories have been visited by the Sanitary Inspector as occasions required. Workshops and Workplaces have been routinely inspected by him, and Home-workers have been kept under observation, especially in connection with the prevention of spread of infectious diseases. 1. Inspection of Factories, Workshops and Workplaces. Premises. Number of Inspections. Written Notices Factories (Including Factory Laundries) 8 2 Workshops (Including Workshop Laundries) 86 0 Workplaces (Other than Outworkers' premises) 14 0 Total 108 2 60 Sanitary Administration. 2. Defects found in Factories, Workshops and Workplaces. Particulars. Number of Defects. Found. Remedied. Nuisances under Public Health Acts :— Want of cleanliness 2 2 Other nuisances 5 4 Sanitary accommodation insufficient 0 0 unsuitable or defective 2 2 not separate for sexes 0 0 Breach of special sanitary requirements for bakehouses (ss. 97 to 100) 6 6 Total 15 14 Registered Workshops. Motor and Cycle Works 9 Blind Maker 1 Boot Repairers 15 Metal Workers 1 Furrier 1 Upholsterers 4 Dressmakers 15 Tailors 10 Workshop Laundries 3 Workshop Bakehouses 11 Others 16 86 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Acts (s. 5, 1901):— Notified by H.M. Inspector 2 Reports (of action taken) sent to H.M. Inspector 1 Underground Bakehouses (s. 101) in use at end of the year, 4 REGISTRIES FOR FEMALE DOMESTIC SERVANTS. The above-mentioned premises are controlled by bye-laws in force in the District: there are 4 such premises on the Register. Inspection during the year disclosed no breach of the Bye-laws. Housing. 6r II. HOUSING. The general situation with regard to housing in this District was reviewed in my Annual Report for 1921. Though the positionhas somewhat improved there is still a marked shortage of houses, particularly of houses for the working classes: difficulties in dealing with unfit houses and defective housing conditions necessarily continue. Houses Unfit for Human Habitation. Closing Orders were made under Section 17 of the Housing and Town Planning Act, 1909, in the case of 2 houses. In one case it became necessary to make application to the Magistrates for an Ejectment Order. The Order was granted and the tenants ejected. The premises which were in a very insanitary condition were thoroughly overhauled and improved; the Closing Order was then determined. In the second case a Closing Order having been made in respect of premises not originally constructed for human habitation, the premises were converted into a lock-up shop. A Closing Order made in 1920 in respect of certain premises was determined during the year 1922, the premises having been rendered fit for human habitation. One house, in respect of which a Demolition Order was made in 1921, has continued to be occupied owing to the difficulty of finding accomodation for the tenants. With regard to many houses which are incapable of being made fully fit and in normal times would be closed at the earliest opportunity, the procedure has to been require such hcnses to be so repaired as to be passibly habitable for the time being. Remedying of Defective Houses. A very large amount of work has been undertaken during the year in securing improvement in housing conditions aud has resulted in the remedying of a high percentage of the defective 62 Housing. conditions discovered in the course of inspection by the Sanitary Staff. Of 609 houses inspected, defective conditions were discovered in 454: the number of these dwelling houses rendered fit by informal action was 359. It became necessary to take action under Statutory Powers in respect of 48 houses, action being taken under the Public Health Acts in respect of 15 of them, and under Section 28 of the Housing and Town Planning Act, 1919, in the case of 33 : of the former all, and of the latter 25, were rendered fit. As many as 4250 visits of inspection were made by the Sanitary Inspectors in connection with this work. Increase of Rent, etc. (Restriction), Act, 1920. The Sanitary Inspector reports that 5 applications for certificates under the above Act were received, and in each case a certificate was granted. Overcrowding. Owing to the almost entire cessation of building in this District for four years during the War, overcrowding became very much increased. During the past two and-a-half years, however, much has been done to reduce this evil. There still remains a good deal of overcrowding in certain areas, aad some serious overcrowding in many of the houses occupied by the working-classes. A large number of houses originally intended for occupation by one family became, during the War, occupied by two or three families, and many of these are still so occupied. A large number of families formerly so housed, are now living under quite suitable conditions in the 142 houses erected by the Council under their Housing Scheme. During the past year 20 of the more serious cases of overcrowding were relieved by the families being allotted Council Houses, these being families with two or more children, who, most of them, previously occupied one room only. Three other serious cases of overcrowding were abated by the families themselves obtaining accommodation elsewhere. There is still a considerable shortage of houses, and necessarily overcrowding must continue until more houses are erected. Housing. 63 The number of dwelling-houses erected during the years since the commencement of the War have been as follows:— 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 190 108 55 3 0 10 95 160 103 Forty of the houses completed during 1920, and 102 of those completed during 1921, were erected by the Council under their Housing Scheme; the erection of these houses assisted very materially in reducing the amount of overcrowding which existed. The houses erected by private builders during 1920, 1921, and 1922, respectively, numbered 55, 58, and 103, a satisfactory increase, considering the very abnormal conditions of the building trade. There is every indication that there will be a very large increase in the number of houses erected during the year 1923. Reliable data in regard to the housing accommodation of the inhabitants are available from the Registrar-General's Census Returns. The opportunity has been taken of including in this Report some Tables giving interesting particulars as to the number and type of buildings in the District; the number of structurally separate dwellings; the number of rooms in the dwellings; the number of private families occupying them, and the number of persons in these families. Comparison between 1911 and 1921 of the number of persons living under the "overcrowded" conditions of more than two persons per room shows that, although the number of persons so living has increased slightly (1,525 persons in 1921; 1,427 persons in 1911), the proportion living under these conditions expressed as a percentage of the total population has diminished (4.5 % in 1921; 4.7% in 1911). 64 I. Buildings, Dwellings, Rooms and Population. type of building. Total Buildings. Buildings. Dwellings occupied by Non-Private Families. Structurally separate Dwellings occupied by Private Families. Population. Total Rooms occupied. Not containing Dwellings. Containing Dwellings. Undivided Private Houses 6,283 — 6,283 5 6,278 28,233 39,622 Housing. Structurally divided Private Houses 10 — 10 — 31 113 100 Blocks of Flats, Tenements 400 — 400 — 1,113 3,546 4,879 Shops 510 37 473 1 472 2,047 2,415 Other Buildingsº 146 88 58 13 54 360 170 Total 7,349 125 7,224 19 7,939 34,299 47,186 * Other Buildings include Offices, Factories, Warehouses, Workshops, Hotels, Institutions, Places of Worship, and Places of Amusement, 65 (2) Structurally Separate Dwellings occupied by Private Families or Vacant on Census Night. Dwellings containing Total Dwellings. Total Rooms. 1-3 Rooms. 4-5 Rooms. 6-8 Rooms. 9 or more Rooms. Total Structurally Separate Dwellings 369 3,193 3,716 661 7,939 47,186 Housing. Dwellings Vacant on Census Night 20 150 180 30 380 2,210 Dwellings occupied by 1 Private Family 337 2,742 2,965 546 6,590 38,876 2 ,, Families 11 287 502 52 852 5,203 3 or more Private Families 1 14 69 33 117 897 Total Dwellings occupied by Private Families Number % 349 3,043 3,536 631 7,559 44,976 5% 40% 47% 8% 100% — Total Private Families therein 362 3,358 4,180 754 8,654 – 66 (3) Private Families Classified by Size of Family, Rooms Occupied, and Density of Occupation. Number of Persons in Family. Number of Private Families occupying the following Number of Rooms. Total Private Families Population in Private Families. Rooms Occupied. Population living morethan 2 Persons per Room. 1 2 3 4 5 6—7 8—9 10 and over. 1 157 91 68 63 48 64 13 4 508 508 1,590 – Housing. 2 85 224 255 343 276 401 78 28 1,690 3,380 7,563 – 3 37 155 213 321 344 635 141 41 1,887 5,661 9,700 111 4 15 64 168 351 376 592 142 56 1,764 7,056 9,530 60 5 2 28 101 216 271 417 91 64 1,190 5,950 6,752 150 6 1 18 57 140 153 236 76 52 733 4,398 4,315 114 7 1 9 26 101 107 126 44 33 447 3,129 2,599 252 8 – 7 16 47 57 59 18 22 226 1,808 1,351 184 9 – 1 6 22 31 26 8 15 109 981 677 261 10 – 1 – 15 16 16 5 5 58 580 355 160 11 – – 1 7 5 8 4 2 27 297 163 143 12 – – – – 3 1 1 2 7 84 52 36 13 – – 1 – – 1 1 3 39 20 26 14 – – – – 2 – – – 2 28 10 28 15 and over – – – – – – – 3 3 50 67 – Total Private Families 298 598 912 1,626 1,689 2,582 621 328 8,654 – – – Population in Private Families 521 1,646 3,124 6,544 7,172 10,501 2,701 1,740 – 33,949 – – Rooms Occupied 297 1,195 2,732 6,502 8,445 16,524 5,186 3,883 – – 44,744 – Percentage of Families living in various units of occupation 1921 3.4 6.9 10.5 18.8 19.5 29.9 7.2 3.8 100 – – – 1911 2.7 5.9 9.6 17.5 19.0 30.5 9.0 3.8 100 – – – Families living more than 2 persons per room 56 64 50 44 10 1 0 0 225 1,525 637 1,525 67 Housing. Houses Let in Lodgings. The effect of registration of these houses is to render the premises subject to the requirements of the Council's Bye-laws with respect to houses let in lodgings or occupied by members of more than one family. New Bye-laws made under Section 26 of the Housing and Town Planning Act, 1919, were adopted by the Council in July, 1922. The Bye-laws previously in force applied only where the rent payable by each lodger did not exceed a certain amount fixed by the Bye-laws; the new Bye-laws, however, apply to any house used for occupation by the working classes, and let in lodgings or occupied by members of more than one family irrespective of the amount of rent paid. The previous Bye-laws had become inapplicable in the case of many houses, at one time subject to the Bye-laws, owing to increase in the amount of rent paid. The number of premises on the Register will now, no doubt, increase. At present the number of houses on the Register is 48. Such houses are situated mainly in West Road, Stanton Road, and Hampton Square, and these premises have been inspected routinely by the Sanitary Inspector during the year. Numerous defects found have been remedied either by action taken under the Bye-laws or by action under the Public Health Acts or Housing Acts. Common Lodging Houses. There are no Common LodgingHouses in the District. Housing Statistics for 1921 (Ministry of Health Table). Number of new houses erected during the year:— (a) Total 103 (b) As part of a municipal housing scheme 0 1. Unfit dwelling houses. Inspection—(1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 609 68 Housing. (2) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910. 185 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects " reasonably fit for human habitation" 454 2. Remedy of Defects without Service of formal Notices. Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their Officers 359 3. Action under Statutory Powers. A.—Proceedings under section 28 of the Housing, Town Planning, etc., Act, 1919. (1) Number of dwelling houses in respect of which notices were served requiring repairs 33 (2) Number of dwelling houses which were rendered fit:— (a) by owners 25 (b) by Local Authority in default of owners 0 (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close 0 B.— Proceedings under Public Health Acts. (1) Number of dwelling houses in respect of which notices were served, requiring defects to be remedied 15 (2) Number of dwelling houses in which defects were remedied (a) by owners 15 (b) by Local Authority, in default of owners 0 Housing. 69 C.—Proceedings under sections 17 and 18 of the Housing, Town Planning, etc., Act, 1909. (1) Number of representations made with a view to making of Closing Orders 1 (2) Number of dwelling houses in respect of which Closing Orders were made 1 (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit 2 (4) Number of dwelling houses in respect of which Demolition Orders were made 0 (5) Number of dwelling houses demolished in suance of Demolition Orders 0 I have the honour to be, Mr. Chairman and Gentlemen, Your obedient Servant, E. A. FREEAR WILKES, Medical Officer of Health. INDEX. PAGE Adoptive Acts 46 Ambulance Provision 44 Anthrax 15 Bacteriological Work 44 Bakehouses 53 Births 4 Birth Rate 5 Bye-laws and Regulations 46 Cancer 9 Cerebro-spinal Fever 15 Cleansing Station 57 Common Lodging Houses 67 Dairies, Cowsheds and Milkshops Regulations 51 Day Nurseries 36 Deaths 6 Death Rate 7 Death, Causes of 8 Death, Causes of. at age periods, Table Facing 9 Deaths in Public Institutions 10 Density of Population 4 Diphtheria 18 Disinfection 57 Drainage Work 48,54 Encephalitis Lethargica 15 Enteric Fever 23 Epidemic Diarrhoea 9, 11 Erysipelas 26 Factories and Workshops 59 Fishmongers 53 Food Supply 50 Fried Fish Shops 59 Health Visitors, Duties and Work of 38 Homes for Unmarried Mothers and their Children 44 PAGE Hospitals, Children's 42 ,, General 43 Isolation (Fever) 43 ,, Maternity 42 , Small-pox 43 ,, Tuberculosis 41 Houses Let in Lodgings 67 Housing 61-79 ,, Unfit Houses 61 ,, Remedy of Defects 61 ,, Statistics, 1921 67 Illegitimate Children, Births and Deaths of 14 Increase of Rent (Restriction) Act 62 Infantile Mortality 10-14 ,, ,, Rate of 11 ,, ,, Causes of 12 Table, 1921 13 Infectious Diseases, Notifiable 15 ,, ,, Tables 16 ,, ,, Non-notifiable 31 Influenza 32 Inquests 10 Laboratory Work 44 Legal Proceedings 50 Maternity and Child Welfare 32-37 do. Home Visiting 33 do. Centre 34 do. Other Services 35 Maternity Hospitals 42 Measles 24 Meat 52 Midwives 40 Milk Supply 50 Milk Dried, Supply of 34 Milk-shops and Milk-stores 63 Mortuary 58 72 INDEX (continued). PAGE Notification of Births Act 5 Notifiable Infectious Diseases 15-21 Nursing Arrangements, Home Nursing, &c. 40 Nuisances 58 Offensive Trades 59 Ophthalmia Neonatorum 26 Overcrowding 62 Persons per Inhabited House 66 Pneumonia 26 Population, Census 4 Public Conveniences 55 Puerperal Fever 26 Poor Law Medical Relief 32 Rats and Mice Destruction Act 57 Refuse, Collection of House Refuse 55 Refuse Disposal 56 Registries for Female Domestic Servants 60 Sale of Food and Drugs Act 53 Sanitary Administration 46-60 Sanitary Inspectors, Summary of Work of 47 Scarlet Fever 20 PAGE Scavenging of Streets 56 Schools and School Clinics 37. 41 Sewage Disposal 54 Slaughter Houses 52 Small-pox 23 Staff of Public Health Department 45 Statistics, Summary of Facing 1 Tuberculosis Deaths 9, 31 ,, Incidence 27 ,, Notification of 27 ,, Preventive Measures 28 ,, Treatment, sary and Institutional 28, 41 Unsound Food 53 Vaccination 24 Venereal Diseases Clinics 41 Verminous Persons and Premises 57 Vital Statistics 2-14 ,, ,, Tables 2 Water Supply 54 Whooping Cough 31 Zymotic Diseases 8