FUL 20 Council of the Borough of Fulham. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH J. CHARLES JACKSON. FOR THE YEAR 1919. FUL 20 Town Hall, Fulham, S.W. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Fulham. Sir, Ladies and Gentlemen, In their circular letter of January, 1920, the Ministry of Health requested the Council to consider the important question of taking special steps, now that the war is over to inform themselves as to the general condition of the health of their area, and of the various health services for which the Council are responsible under the Public Health Acts, the Maternity and Child Welfare Act, and other statutes and regulations through which the prevention of disease, diminution of sickness and the general physical welfare of the people are intended to be promoted. In a memorandum accompanying their letter the Ministry of Health indicated the lines upon which they wished the Medical Officer of Health to compile his report, and the subjects therein specified are dealt with here as far as possible in the order given, though owing to my absence through ill health, in some respects not so fully as could be wished. Natural and Social Conditions of the Borough. Population.—The population of Fulham as enumerated at the Census of 1911 was 153,284. For 1919, the Registrar-General adopted for the calculation of the death-rate and birth-rate of the borough the following estimates of the population :— For the death-rate 152,543 ,, birth-rate 158,904 The death-rate population excludes all non-civilian males, whether serving at home or abroad. This a 2 4 mate is based mainly upon the rationing returns furnished by the Ministry of Food. The birth-rate (and marriage-rate) population is intended to include all the elements of the population contributing to the birth and marriage-rates, and consists, therefore, of the death-rate or civilian population plus all non-civilians enlisted from this country, whether serving at home or abroad, who have been distributed over all the districts in the country in proportion to their estimated civilian population. It is difficult to reconcile the figures obtained from the food cards with the overcrowding which appears to exist in the borough, and as, in addition, there were at the Census of 1911 672 empty houses, nearly all of which are now occupied, it is probable that the population is under-estimated. The following table shows the increase of the population of the borough since 1851 :— TABLE I. Year. Population. Increase per cent, during previous intercensal period. Persons to the Acre. Rateable Value. £ 1851 Census 11,166 - 7.0 47,492 1861 „ 15,539 30.9 9.1 55,916 1871 „ 23,378 50.5 13.7 96,661 1881 „ 42,900 83.5 25.2 149,899 1891 „ 91,640 113.6 53.8 385,407 1896 „ 113,781 24.4 66.8 560,965 1901 „ 137,289 20.6 80.6 677,332 1911 „ 153,284 11.7 90.1 902,640 1919 (estimated) 158,904 ― 93.4 916,509 Physical Features and General Character of the Borough.—Placed within a loop of the Thames, Fulham consists of low-lying land surrounded on three sides by the river. Beneath nearly the whole area lies a bed of sand and ballast, varying in depth from 10 to 30 ft., 5 under which is the great bed of London clay. The low natural level is a drawback to the efficient drainage of the district, and the basements of many houses are flooded after heavy rain, especially when occurring at high tide, owing to the surcharging of the main County Council sewers. It is hoped that the improvements in their main drainage system, now proposed by the London County Council, may have some effect in remedying this serious evil. The advantages of the admirable subsoil have been reduced by the removal by builders and others from some localities of the sand and gravel and the substitution of more or less objectionable matter. With the exception of some 70 acres belonging to the Hurlingham Club, the grounds of the Bishop of London's Palace, Earl's Court Exhibition and Queen's Club, practically the whole of Fulham is now built over. Open Spaces.—Excluding two cemeteries, there are 68 acres of open spaces dedicated to the public—51 acres belonging to the borough and 17 to the County Council. The southern part of the borough is well provided with open spaces, but a recreation ground is badly needed in the north-east. The only land available is that formerly occupied by the Earl's Court Exhibition, and the Council should make all possible efforts to obtain this for an open space. Social Conditions.—Fulham is, in the main, a working class residential district. During the period of its most active growth from 1881 to 1891 some seven thousand working-class houses were erected, and active building of houses largely of the same type continued until about 1913, while many houses originally intended to be occupied by one family are now let out in tenements without, in many cases, any steps having been taken to adapt them for that purpose. The local industries, the number of which has considerably increased during the last few years, are of a varied character, the chief being gas works, motor works, laundries, distilleries, breweries, and biscuit, margarine, glucose and wallpaper manufactories. 6 Poor Law Relief.-—Though, no doubt, there is a good deal of poverty; in only two London boroughs, viz., Hampstead and Wandsworth, is the proportion of the population in receipt of relief lower than in Fulham. On July 1st, 1913, the number of persons in receipt of relief per 1,000 of the population ranged from 42.3 in Poplar to 12.1 in Fulham, 12.0 in Wandsworth and 8.0 in Hampstead. During the war there was, as will be seen from the subjoined table, a steady diminution in the number of persons in receipt of Poor Law relief :— TABLE II. Number of Persons in receipt of Poor Law Relief on the dates specified. Date. Number receiving Relief. Number in receipt of Outdoor Medical Relief only not included in Column 1. January 1st, 1914 1,920 90 ,, 1915 1,915 64 ,, 1916 1,572 86 ,, 1917 1,554 69 ,, 1918 1,527 64 ,, 1919 1,341 46 ,, 1920 1,430 46 Vital Statistics.—The statistics of births, deaths, etc., relate to the 53 weeks ended January 3rd, 1920. In Table III., the form originally prescribed by the Local Government Board, will be found the vital statistics for 1919 and previous years. TABLE III Vital Statistics of Whole District during 1919 and previous Years. Year. Population Estimated to Middle of each Year. Births. Total Deaths Registered in the District. Transferable Deaths,† Nett Deaths belonging to the District. 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 1913 157,117 4,234 4,302 26.9 1,833 11.3 212 407 412 96 2,028 12.7 1914 157,303 4,065 4,154 26.4 1,878 12.3 137 391 469 113 2,132 13.6 1915 al53,161 3,736 3,870 c24.3 1,787 11.7 130 677 446 115 2,334 15.2 1916 al49,428 6162,580 3,600 3,754 c23.l 1,324 8.9 131 789 330 88 1,982 13.3 1917 a145,186 6161,841 2,852 2,971 c18.4 1,251 8.6 139 882 323 109 1,994 13.7 1918 a143,211 6160,463 2,593 2,672 c16.7 1,704 11.9 186 973 286 107 2,491 17.4 1919 al 52,543 6155,904 2,947 3,000 cl8.6 1,510 9.7 242 634 250 83 1,902 12.2 (a) Estimated civil population. (b) Estimated total population. (c) Birth-rate calculated on estimated total population. Notes.—This Table is arranged to show the gross births and deaths registered in the district during the year, and the births and deaths properly belonging to it with the corresponding rates. The death-rates from 1915-1919 are calculated per 1,000 of the estimated civil population, and the other rates per 1,000 of the estimated gross population. *In Column 6 are included the whole of the deaths registered during the calendar year as having actually occurred within the district, but excluding the deaths of Soldiers and Sailors that have occurred in hospitals and institutions in the district. In Column 12 is entered the number in Column 6, corrected by subtraction of the number in Column 8 and by addition of the number in Column 9. Deaths in Column 10 are similarly corrected by subtraction of the deaths under 1, included in the number given in Column 8, and by addition of the deaths under 1 included in the number given in Column 9. † "Transferable Deaths" are deaths of persons who, having a fixed or usual residence in England or Wales, die in a district other than that in which they resided. The deaths of persons without fixed or usual residence, e.g., casuals, are not included in Columns 8 or 9, except in certain instances under 3 (6) below. In Column 8 the number of transferable deaths of "non-residents" which are deducted is stated, and in Column 9 the number of deaths of "residents" registered outside the district which are added in calculating the nett death-rate of the Borough. The following special cases arise as to Transferable Deaths :— (1) Persons dying in Institutions for the sick or infirm, such as hospitals, lunatic asylums, workhouses and nursing homes (but not almshouses) are regarded as residents of the district in which they had a fixed oru sual residence at the time of admission. If the person dying in an Institution had no fixed residence at the time of admission, the death is not transferable. If the patient has been directly transferred from one such Institution to another, the death is transferable to the district of residence at the time of admission to the first institution. (2) The deaths of infants born and dying within a year of birth in an Institution to which the mother was admitted for her confinement are referred to the district of fixed or usual residence of the parent. (3) Deaths from Violence are referred (a) to the district of residence, under the general rule; (6) if this district is unknown, or the deceased had no fixed abode, to the district where the accident occurred, if known; (c) failing this, to the districtwhere death occurred, if known; and (d) failing this, to the district where the body was found. Total population at all ages 153,284 At Census of 1911. Area of District in acres (land and inland water), 1701. Total families or separate occupiers 36,430 8 Marriages.—The number of marriages registered was 1,659, and the marriage-rate, i.e., the number of persons married per 1,000 of the population was 20.5. In the three preceding years the numbers were 1,918. 1,408 and 1,471. Births.—The births, corrected by the distribution of those occurring in lying-in institutions in the borough, to the districts in which the mothers resided, and the inclusion of children born to Fulham mothers in lyingin institutions outside the borough, numbered 3,000 against 2,671 in 1918, and the birth-rate was 18.6 per 1,000 of the estimated total population, or 1.9 per 1,000 above that of 1918; but 3.2 below the average rate of the preceding five years. There was a marked increase in the number of births during the fourth quarter, the figures for the four quarters being :— 1st Quarter 586 2nd „ 598 3rd „ 757 4th ,, 1,059 The birth-rate of the County of London was 18.3, and in the metropolitan boroughs the rates ranged from 24.8 in Poplar to 12.7 in Hampstead, and 10.3 in the City of London. Illegitimacy.—The illegitimates numbered 195, or 6.5% of the total births, against 5.4, 7.5 and 8.4% in the three preceding years. Natural Increase of Population.—The natural increase of the population of the borough during the year by excess of births over deaths was 1,098 against 1,772, 927 and 181 in the three preceding years. Deaths.—During the 53 weeks ended January 3rd, 1920, 1,510 deaths of civilians were registered in the borough. Of these 242 were of persons not belonging to the borough, while 634 inhabitants of Fulham died outside the borough, chiefly in various public institutions. There were therefore 1,902 deaths of persons (952 males and 950 females) having their usual residence in Fulham, corresponding to an annual rate per 10 TABLE IV. Causes of, and Ages at Death during Year 1919. Nett Deaths at the subjoined ages of "Residents," whether occurring within or without the District (a). Nett Deaths at all ages of "Residents" in the Wards of the Borough, whether occurring in or beyond the Wards. Causes of Death. All ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 y ars. 15 and under 25 years. 25 and under 45 ye ars 45 and under 65 years. 65 and upwards. Total Deaths whether of "Residents" or" Nonresidents " in Institutions in the District (b). Barons Court Ward. Lillie • d. Walham Ward. Margravine Ward. Munster Ward. Hurlingbam Ward. Sands End Ward. Town Ward. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11 12 13 14 15 16 17 18 19 A11 Causes Certified (c) 1,899 248 42 72 85 109 282 464 599 367 166 320 178 231 396 120 295 192 Uncertified 3 2 ... ... ... ... ... ... 1 ... ... 1 ... ... 1 ... 1 ... 1—Enteric Fever 2 ... ... ... ... 1 1 ... ... ... ... ... ... ... ... 1 ... 1 2—Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3—Measles 14 2 2 8 2 ... ... ... ... 16 ... 3 1 4 2 3 1 4—Scarlet Fever 5 ... ... 2 2 1 ... ... ... 12 ... 1 ... 1 2 ... 1 ... 5—Whooping Cough 4 2 1 ... 1 ... ... ... ... 7 ... ... 1 ... 2 ... 1 ... 6—Diphtheria and Croup 32 2 2 13 15 ... ... ... ... 103 ... 6 5 1 1 2 14 3 7—Influenza 147 2 2 8 5 13 46 47 24 3 i3 27 9 17 33 6 27 15 8—Erysipelas 4 ... ... ... ... ... 1 2 1 2 ... 2 ... ... ... ... 1 1 9—Phthisis (Pulmonary Tuberculosis) 168 1 ... 4 7 39 63 42 12 48 6 26 12 15 47 15 30 17 10—Tuberculous Meningitis 22 2 5 5 6 3 1 ... ... 8 4 3 2 1 4 1 4 3 11 —Other Tuberculous Diseases 20 ... 1 2 5 4 3 4 1 2 3 3 1 4 4 2 3 12—Cancer, malignant disease 182 ... ... ... ... 1 19 87 75 16 12 30 14 20 39 15 34 18 13—Rheumatic Fever 7 ... ... 1 1 3 1 ... 1 2 2 ... ... 1 3 ... ... 1 14—Meningitis. See note (d) 11 2 2 3 ... 2 ... ... 2 9 1 2 2 ... 2 ... 3 1 15—Organic Heart Disease 200 1 ... ... 2 5 18 66 108 16 21 25 18 25 37 12 34 28 16—Bronchitis 144 8 3 2 ... 2 8 34 87 3 14 25 15 21 29 4 19 17 17—Pneumonia (all forms) 167 34 14 10 10 8 37 24 30 19 13 29 19 23 39 12 21 11 18—Other Diseases of Respiratory Organs 23 2 1 2 2 ... 2 5 9 2 2 3 2 4 5 2 4 1 19—Diarrhoea and Enteritis 44 39 5 ... ... ... ... ... ... 8 2 11 3 12 8 2 3 3 20—Appendicitis and Typhlitis 16 ... ... 1 6 ... 4 4 1 1 2 2 ... 3 4 ... 2 3 21—Cirrhosis of Liver 7 ... ... ... ... ... ... 3 4 2 3 1 1 ... 1 ... ... 1 21 a-Alcoholism ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 22—Nephritis and Bright's Disease 52 1 ... ... 1 2 7 22 19 5 6 12 5 3 15 4 2 5 23—Puerperal Fever 10 ... ... ... ... 2 8 ... ... 6 ... 4 1 1 3 ... ... 1 24—Other accidents and diseases of Pregnancy and Parturition 6 ... ... ... ... 2 4 ... ... ... ... 1 2 ... 2 ... ... 1 25—Congenital Debility and Malformation, including Premature Birth 112 111 ... ... ... 1 ... ... ... 20 7 21 13 25 21 3 16 6 26—Violent Deaths, excluding Suicide 56 6 1 5 11 6 10 7 10 8 4 9 6 9 11 7 8 2 27—Suicide 11 ... ... ... ... 2 3 5 1 1 3 1 1 2 3 ... 1 ... 28—Other defined diseases 436 35 3 6 9 12 46 112 213 48 48 74 45 43 79 32 66 49 29—Diseases ill-defined or unknown ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1,902 250 42 72 85 109 282 464 598 367 166 321 178 231 398 120 296 192 SubEntries included in above figures. 14 (a) Cerebro-Spinal Meningitis 5 1 ... 1 ... 2 ... ... 1 7 ... 1 1 ... 1 ... 2 ... (a) All Transferable Deaths of residents, i.e., of persons resident in the District who have died outside (b) All deaths occurring in institutions for the sick and infirm situated within he district, whether of residents it, are included with the other deaths in columns 2-10. and columns 12-19. Transferable deaths of or of non-residents are entered in column 11 of Table IV non-residents, i.e., of persons resident elsewhere in England and Wales who have died in the District, (e) All deaths certified by registered Medical Practitioners and all Inquest cases are classed as "Certified," are in like manner excluded from these columns. For the precise meaning of the term "transferable all other deaths are regarded as "Uncertified." deaths see footnote to table. (d) Exclusive of "Tuberculous Meningitis (10), but inclusive of Cerebro-Spinal Meningitis. Deaths of soldiers and sailors occurring in hospitals and institutions in the district are excluded from the total number of deaths registered in the district, and such deaths in like manner are excluded from column 11. 11 1,000 of the estimated civilian population of 12.2. This is the lowest death-rate recorded in Fulham, being 5.2 per 1,000 below that of 1918 and 2.6 below the average rate of the preceding five years. The death-rate of the County of London was 13.4, and of the metropolitan boroughs only three, viz., Hampstead, 11.2; Wandsworth, 11.3; and Lewisham, 11.4; had lower rates than Fulham. Seasonal Mortality.—The mortality in the four quarters of the year was as under :— Deaths. Death-rate. First Quarter 676 17.5 Second ,, 414 10.6 Third „ 321 8.4 Fourth „ (14 weeks) 491 12.0 1,902 12.2 Distribution of Deaths.—The number and the causes of the deaths in the several wards of the borough are given in Table IV. The death rates in the wards, calculated on the assumption that the ratio of the estimated civilian population to the Census population was the same in each ward as in the whole of the borough, were as under :— TABLE V. Death-rates in Wards of Borough. Ward. Deathrate, 1919. Mean Deathrate, 1914-18. Ward. Deathrate, 1919. Mean Deathrate, 1914-18. Baron'sCourt 13.2 13.8 Munster 10.4 12.9 Lillie 13.3 16.3 Hurlingham 12.6 12.3 Walham 14.1 17.4 Sands End 11.2 13.8 Margravine 12.6 16.8 Town 14.4 14.2 12 Compared with 1918 the chief decline was in the mortality from influenza, which caused 147 deaths, against 489 in that year, but it was much more fatal than in any year prior to 1918. The mortality from zymotic diseases was the lowest recorded, 101 deaths being ascribed to the seven principal epidemic diseases, corresponding to a death-rate 0.66 per 1,000 against a quinquennial average of 1.5. There was a notable drop in the deaths from tuberculous diseases, and the deaths from respiratory diseases were also below the average, while there was an increase in the deaths from cancer. Certification of the Causes of Death.—Of the 1,902 deaths registered, 1,758, or 92.4 %, were certified by registered medical practitioners, and 141 by coroners after inquest, while 3 were uncertified. Deaths in Public Institutions. Fulham Infirmary.—This institution, which had been used since 1915 as a military hospital, was re-opened by the Guardians on October 1st, 1919. The deaths of 152 persons occurred in the Infirmary, of whom 102 lived in Fulham and 50 in other districts. Western Fever Hospital.—In the Western Fever Hospital there were 38 deaths of residents in Fulham, and 165 of residents in other boroughs. 14 TABLE VI. Infant Mortality during the year 1919. Nett Deaths from stated causes at various ages under One Year of Age. Nett Deaths under One Year of Residents in the Wards of the Borough, whether occurring in or beyond the Wards. CAUSE OF DEATH. Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3—4 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under One Year. Barons Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. All Causes { Certified 69 7 15 9 102 47 50 26 25 248 17 31 27 48 48 8 35 14 {Uncertified 2 ... ... ... ... ... ... ... ... 2 ... 1 ... ... 1 ... ... ... {Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... {Chicken Pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... {Measles ... ... ... ... ... ... 1 ... 1 2 ... 1 ... ... ... ... 1 ... {Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... {Whooping Cough ... ... ... ... ... ... ... 1 1 2 ... ... ... ... 1 ... ... ... { Diphtheria and Croup ... ... ... ... ... ... ... 1 1 2 ... 1 ... ... ... ... ... 1 {Erysipelas. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... {Tuberculous Meningitis ... ... ... ... ... ... ... 2 ... 2 1 1 ... ... ... ... ... ... {Abdominal Tuberculosis (a) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... {Other Tuberculous Diseases ... ... ... ... ... ... ... 1 ... 1 ... ... ... ... ... ... ... ... {Meningitis (not Tuberculous) ... ... ... ... ... ... 2 ... ... 2 1 ... ... ... 1 ... ... ... Convulsions 1 ... 2 ... 31 ... ... 1 1 5 ... 1 2 ... 1 ... 1 ... Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... 4 1 1 2 8 ... ... ... 3 4 ... ... 1 Pneumonia (all forms) ... ... ... 1 1 7 11 9 6 34 2 9 5 4 7 ... ... 2 Diarrhœa ... ... ... ... ... 2 2 3 3 10 ... 1 ... 4 2 1 1 1 Enteritis ... ... ... ... 1 7 13 4 4 29 2 9 2 7 6 1 1 1 Gastritis ... ... ... ... ... 1 1 ... ... 2 ... ... ... ... 1 ... 1 ... Syphilis ... ... 1 ... 1 4 4 ... ... 9 ... 4 1 1 1 1 1 ... Rickets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Suffocation, overlying 1 ... ... ... 1 1 1 ... ... 3 1 1 ... ... ... ... 1 ... Injury at Birth 4 ... ... ... 4 ... ... ... ... 4 1 ... 1 ... ... 1 1 ... Atelectasis 7 ... ... ... 9 ... ... ... ... 9 ... 2 1 1 2 ... 1 2 CongenitalMalformations (c) 3 ... ... 3 6 4 2 ... ... 12 1 2 2 1 3 ... 3 ... Premature Birth 47 4 5 3 59 2 3 ... ... 64 2 9 9 16 11 2 11 5 Arophy, Debility and Marasmus 6 2 5 2 15 10 7 ... 3 35 4 11 2 8 5 ... 4 1 Other Causes 2 ... ... ... 2 5 2 3 3 15 2 1 2 3 3 2 2 ... 71 7 15 9 102 47 50 26 25 250 17 53 27 48 49 8 35 14 Nett Births in the year—Legitimate, 2,805 ; Illegitimate, 195. (a) Under Abdominal Tuberculosis are included deaths from Tuberculous Nett Deaths in the year of—Legitimate infants, 212 ; Peritonitis and Enteritis and from Tabes Mesenterica. Illegitimate infants, 38. Want of Breast Milk is included under Atrophy and Debility. 15 Deaths occurring outside the borough among persons belonging thereto.—The deaths of Fulham residents outside the borough numbered 634, and occurred in the following institutions :— St. George's Hospital 48 West London Hospital 34 Other General Hospitals46 Children's Hospitals 20 Other Special Hospitals 25 Homes for advanced cases 17 Hospitals of Metropolitan Asylums Board 15 Poor Law Infirmaries 308 Lunatic Asylums 71 In Nursing Homes, Private Houses and elsewhere 50 634 Of the deaths registered, 736 or 38.7 per cent. took place either in Poor Law Institutions, in hospitals or in public lunatic asylums, the percentages in the various classes of institutions being as under :— Deaths in Workhouses or Workhouse Infirmaries 21.6 ,, Metropolitan Asylums Board Hospitals 2.8 ,, other Hospitals 10.6 ,, Public Lunatic and Imbecile Asylums 3.7 38.7 In the County of London, 44.7 per cent. of the deaths occurred in public institutions. Infantile Mortality.—Of the 1,902 deaths registered, 250 or 13.2 per cent. were of infants under one year of age, and the rate of infant mortality measured by the proportion of deaths under one year to registered births was 83 per 1,000, which is the lowest rate recorded in Fulham. The infantile death-rate of the County of London was 85 per 1,000 and in the metropolitan boroughs the rates ranged from 60 in Lewisham, 64 in Stoke Newington and 72 in Wandsworth to 102 in Kensington, 104 in Shoreditch and 105 in the City of London. 16 The decline in infant mortality during recent years; in Fulham is shown in the following table :— TABLE VII. Infant Mortality in Fulham. Deaths of Infants under one year of age per 1,000 births. Average of five years, 1886-1890 170 1891-1895 168 1896-1900 167 1901-1905 144 1906-1910 117 1911-1915 109 1916 88 1917 109 1918 107 1919 83 The infantile death-rates of the several wards of the borough were as under :— TABLE VIII. Infantile Death-rates in Wards of Borough. Ward. Deaths under one year per 1,000 Births. Ward. Deaths under one year per 1,000 Births. Barons Court 107 Munster 62 Lillie 109 Hurlingham 72 Walham 116 Sands End 62 Margravine 123 Town. 53 71 or 28.9 per cent. of the deaths of infants under one year of age occurred in the first seven days of life and 102 or 41 per cent. in the first four weeks, the mortality of infants under the age of four weeks being 34 per 1,000 births. Causes of Infantile Mortality.—Table VI. gives the causes of the deaths at various periods under one year, and in the following table the mortality from certain groups of diseases is given :— 17 TABLE IX. Death-rates of Infants under One Year of Age from certain Groups of Diseases. Diseases. Deaths per 1000 Births. 1919. Average of 5 years 1914-18. Infectious Diseases 20 10.3 Tuberculous „ 1.0 3.5 Respiratory „ 14.7 21.9 Diarrhoeal ,, 13.7 21.7 Developmental ,, 40.0 33.0 Other „ 11.6 15.6 83 106 It will be noticed that there was a notable decline in all the groups except that of developmental diseases, which was 20 per cent. above the quinquennial average. Of the deaths in this group 75 per cent. occurred in the first month of life or what is known as the neonatal period, and, as has been previously pointed out, the reduction in infant mortality in recent years has been almost entirely confined to children over a month old, and there has been little or no reduction in the mortality of infants under four weeks old, whose deaths are mainly due to antenatal causes which have as yet been but little affected by existing preventive methods. Deaths of Illegitimate Infants.—Of the 250 infants who died before attaining the age of one year, 38 were illegitimate, the mortality among them being at the rate of 195 deaths per 1,000 births against 76 per 1,000 among children born in wedlock. 18 SANITARY CIRCUMSTANCES OF THE DISTRICT. Sanitary Inspection of District.—The following inspections of dwelling-houses were made during the year by the Sanitary Inspectors :— Premises inspected *In consequence of complaints 1,976 In consequence of infectious disease 815 House-to-house inspection 310 3,101 * Inclusive of houses reported as insanitary by Tuberculosis Nurses, Health Visitors, etc. The following notices requiring the abatement of nuisances found were served :— Intimation Notices. Statutory Notices. Number served. Number complied with. Number served. Number complied with. 2,265 1,736 604 557 The following is a summary of the work carried out in compliance with the notices served :— Drains relaid 97 Drains repaired 309 Soilpipes renewed 36 Soilpipes repaired 135 Stackpipes repaired 398 Sinks renewed or repaired 240 W.C.'s repaired 547 Cisterns cleansed and covered 102 Water supply from main provided 51 Yards and forecourts paved 240 Dustbins provided 435 Dampness of rooms remedied 362 Rooms cleansed 3,855 Other nuisances abated 1,016 19 Proceedings for failing to comply with the Council's notices were instituted in the following cases :— Defendant. Offence. Result. Costs Owner of 54, Edith Road. Failing to abate nuisance at No. 54, Edith Road Order to abate nuisance made s. d. 2 0 Occupier of 5, Albert Mews. Overcrowding Order to abate within 21 days made 4 0 Owner of 153, Greyhound Rd. Failing to abate nuisance at 153,Greyhound Road Summons withdrawn on payment of costs. Work done 3 0 Owner of 67, Comeragh Road Dwelling-house without water supply at 67, Comeragh Road Fined 5s. and costs or 14 days in default 3 0 Owner of 36, Epple Road. Failing to abate a nuisance at 36, Epple Road Order for work to be done within 21 days 5 0 Owner of 2, Crondace Road. Failing to abate nuisance at 2, Crondace Road Summons withdrawn. Work done 2 0 Owner of 9, Crondace Road. Failing to abate nuisance at No. 9, Crondace road do. 2 0 Owner of 63, Waterford Rd. Failing to abate nuisance at 63, Waterford Road do. 3 0 Owner of 604, King's Rd. Failing to abate nuisance at 604,King's Road do. 3 0 Certificates under the Revenue Acts. Applications were received for certificates under the Revenue Acts for exemption from or reduction of inhabited house duty in respect of 254 tenements, of which 10 were granted, and 244 were given after certain specified work had been completed. 20 ficates for 480 tenements in Sands End Ward, which had been granted for a limited period, were withdrawn, as they had not been kept in a satisfactory condition. The owners have since the withdrawal of the certificates commenced to do the necessary repairs and the work is proceeding very satisfactorily. Premises and Occupations which can be controlled by Bye-laws or Regulations. Houses let in lodgings.—No action has been taken under the existing bye-laws in respect of houses let in lodgings or occupied by members of more than one family, as the exemption clause rendered them practically useless. New bye-laws were drafted in 1914, but owing to the war no further steps were taken, and now Section 26 of the Housing and Town Planning Act, 1919, provides that the London County Council shall make bye-laws in respect of houses let in lodgings for the whole of the County of London. When these are made and become operative, the registration of the houses and the enforcement of suitable bye-laws should materially facilitate efforts to keep the poorer class of tenement houses in decent condition. Underground Rooms.—Regulations in respect of underground rooms habitually used as sleeping places under Section 17 of the Housing, Town Planning Act, 1909, were made by the Council and approved by the Local Government Board in 1912. 3 notices were served in respect of underground rooms illegally occupied, which were complied with. Offensive Trades.—No trade defined as offensive by the Public Health (London) Act is carried on in Fulham. Nuisance from Skin Factory.—Complaints were received of the nuisance caused by offensive effluvia from a skin-drying business in Farm Lane. Plans for providing more efficient ventilation, as suggested, have been prepared by the owners, and are awaiting the approval of the Building Act Committee of the London County Council. 21 Nuisance from Margarine Factory.—Much trouble has been caused by the discharge of fat into the sewers from the Margarine Factory in Townmead Road, which caused the partial blockage of the sewer and the drains of some adjoining houses. Additional fat interceptors are being put in under the supervision of your Drainage Inspector which should prevent the continuance of the nuisance. Scavenging.—Removal of House Refuse.—Owing to labour troubles, and the difficulty of disposing of the refuse consequent on the repair and partial disuse of the destructor, the service for the removal of house refuse was during the greater part of the year most unsatisfactory, and great numbers of complaints were received of refuse not having been removed for some weeks. Towards the end of the year, however, there was a distinct improvement and this is being maintained, but a more frequent collection in the summer months and from " flats " where the storage accommodation is often inadequate, is needed. A more liberal interpretation of what constitutes "house refuse" is, as has been before pointed out, also needed, as we not infrequently have complaints of such things as old mattresses, often offensive and verminous, being left in the yards of houses owing to the refusal of the dustmen to remove them except on payment, on the ground that they are not "house refuse." It would appear that such things are covered by the definition of house refuse in the Public Health (London) Act, where it is said to mean ashes, "rubbish" and filth, but be that as it may, it seems hardly worth while for the sanitary authority to strain the point, and, for the sake of a few pence, haggle over the question of the responsibility for the removal of filthy rubbish. Destruction of Rats. Rat Week.—Efforts were made to organize, in accordance with the request of the Board of Agriculture, concerted measures for the destruction of rats during the week ended October 25th. The Sanitary Inspectors gave all the assistance they could to the occupiers and owners of premises known B 22 to be infested with the vermin, and the rat poisons recommended by the Board were supplied by the Council. No reliable estimate can be formed of the numbers of rats destroyed, but there is evidence that some diminution in their numbers resulted. It is, however, clear that continuous efforts are needed to produce really successful results, and this has been impressed upon the occupiers of the premises, and the Sanitary Inspectors are still, so far as their time will allow, engaged in the work. Inspection of Factories, Workshops and Workplaces. The following is a summary of the work of the Inspectors under the Factory and Workshops Act. Inspections. Premises. Number of Inspections. Written Notices. Prosecutions. Factories 265 8 ... (Including Workshop Laundries) Workshops 349 32 ... (Including Factory Laundries) Workplaces 164 8 ... Total 778 48 ... 23 Defects Found. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts:—* Want of cleanliness 32 ... ... ... Want of ventilation 2 2 ... ... Overcrowding ... ... ... ... Want of drainage of floors ... ... ... ... Other nuisances 2 ... ... ... Sanitary accommodation- Insufficient 6 6 ... ... Unsuitable or defective 4 4 ... ... Not separate for sexes 2 2 ... ... Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouses (s. 101) ... ... ... ... Breach of special sanitary requirements for bakehouses (ss. 97 to 100) 8 ... ... ... Other offences ... ... ... ... (Excluding offences relating to outwork which are included in Part 3 of this Report) Total 56 14 * Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act as remediable under the Public Health Acts. Outworkers' Premises. No. of Inspections. Notices Served. 912 32 FOOD. Milk.—There are, including 4 added during the year, 117 dairies and milkshops on the register which were kept under observation by your Food Inspector. B 2 24 592 samples of milk were purchased for analysis, of which 64 or 10.8 per cent. were certified to be adulterated against 9.6, 14.3 and 13 per cent. in the three preceding years. The average composition of the samples of milk taken in the four quarters of the year was as under:— Samples. Fat. Non-fatty Solids. Total Solids. 1st Quarter 150 3.57 8.77 12.34 2nd „ 134 3.25 8.50 11.75 3rd „ 133 3.51 8.70 12.21 4th „ 175 3.82 8.72 12.54 No preservative was found in any of the samples examined. Warranties.—In 13 of the 24 cases in which proceedings were instituted by the Council the summonses were dismissed on the ground that the vendors had purchased the milk under warranties that it was of genuine quality and had sold it in the same condition as they received it. Two summonses against farmers who supplied adulterated milk, for having given false warranties, were also dismissed on the ground that they had no reason to believe that the milk was other than as warranted. The need for the alteration of the law with regard to warranties has been repeatedly pressed upon the Local Government Board by the Council and other local authorities. Milk and Cream Regulations, 1912 and 1917.-—No samples of Cream under the above were taken during the year. 25 Milk (Mothers and Children) Orders, 1918.—Arrangements were made for the supply of milk under the above to nursing and expectant mothers and children under five years of age. During the year, 476 lbs. of dried milk and 315 quarts of milk were supplied free in cases which were recommended by the Assistant Medical Officer of Health and the Health Visitors. The Maternity and Child Welfare Committee have recently decided to call the attention of the inhabitants by means of advertisements in the local press, and posters, to the provision of the Order of 1919, empowering the Council to supply milk free or at a reduced price to nursing and expectant mothers, and to children under five in cases in which it is considered necessary owing to the high retail price of milk, and the following scale has been adopted for the guidance of the Sub-Committee dealing with the applications. " That milk, free or at a reduced price, shall be granted when the net family income, i.e., the income after payment of rent, insurance, travelling expenses and hire purchase of furniture does not exceed the undermentioned amounts " :— Family. Net Weekly Income. s. d. Husband and wife after 6th month of pregnancy 30 0 Husband, wife and one child 35 0 „ „ two children 45 0 „ „ three „ 55 0 „ „ four „ 62 6 „ „ five „ 70 0 21,140 lbs. of dried milk were sold at cost price at the Town Hall and the Welfare Centres to families with young children when recommended by the Assistant Medical Officer or Health Visitors. Other Food. Slaughterhouses.—The licences of the undermentioned slaughterhouses were renewed by the London County Council in October, no objection to their renewal being offered by the Borough Council. 26 Premises. Licences. 611, Fulham Road T. S. Payne. 640, King's Road E. Vaughan. There was no killing at 611, Fulham Road during the year. Bakehouses.—There are 68 bakehouses on the register of which 47 are underground. They were systematically inspected and 8 notices served in respect of breaches of the special requirements of bakehouses were complied with. Restaurant Kitchens, etc.—132 inspections of the kitchens were made by your Inspector, Mrs. Davies, and seven notices were served on account of defects observed. Food Inspection.—The stalls in North End Road were kept under careful observation by the Inspector of the District, and 311 special inspections of places where food is sold or stored were made by the other District Inspectors. Unsound Food.—The following articles examined at the request of the owners were condemned and destroyed :— 183 lbs. rabbits. 50 lbs. apple rings. 18 cases rabbits. 7½ bushels black currants. 310 rabbits. 151 tins condensed milk. 11 boxes herrings. 10 boxes mackerel. 203 boxes dates. 78½ lbs. cheese. 55 lbs. corned beef. 7 boxes kippers. 12 tins „ 30½ lbs. bacon. 45 sacks potatoes. 1 bushel plums. 42 bundles tomatoes. 6 boxes raisins. 2 sacks „ 56 lbs. „ 56 boxes „ 3 barrels grapes. 3 boxes apples. 214 lbs. melon and ginger jam. 27 Action under the Sale of Food and Drugs Acts. The undermentioned samples were purchased for analysis in 1919 :— Articles. No. of Samples taken Officially No. Adulterated. No. of Samples taken Unofficially. No. Adulterated. Total Samples. Total Adulterated. Percentage of Adulteration. Milk 584 60 8 4 592 64 10.8 Milk, skimmed 2 ... ... ... 2 ... ... Dried Milk ... ... 3 ... 3 ... ... Butter ... ... 77 1 77 1 1.3 Margarine ... ... 67 ... 67 ... ... Dripping ... ... 6 ... 6 ... ... Lard ... ... 34 ... 34 ... ... Sausage ... ... 29 3 29 3 10.4 Sausage (pork) ... ... 2 ... 2 ... ... Sausage (beef) ... ... 5 ... 5 ... ... Whiskey 5 ... ... ... 5 ... ... Bitter Ale 5 ... ... ... 5 ... ... Malt Vinegar ... ... 20 ... 20 ... ... Self-raising Flour ... ... 24 2 24 2 8.3 Coffee ... ... 28 ... 28 ... ... Cocoa ... ... 38 ... 38 ... ... Calomel Ointment ... ... 1 ... 1 ... ... White Pepper ... ... 10 ... 10 ... ... Cayenne Pepper ... ... 9 ... 9 ... ... Tinned Salmon ... ... 1 ... 1 ... ... Camphorated Oil ... ... 14 6 14 6 42.9 Pickled Onions ... ... 1 1 1 1 ... Mustard ... ... 6 ... 6 ... ... Baking Powder ... ... 5 ... 5 ... ... Malt Extract ... ... 1 ... 1 ... ... Dried Milk ... ... 3 ... 3 ... ... Salad Oil ... ... 9 ... 9 ... ... 596 60 398 17 994 77 7.8 Prosecutions in respect of adulterated samples were instituted in the following cases :— Defendant. Offence. Result. Penalty. Costs. Defendant. Joseph Hickman, 359, Fulham Palace Road Offence. Selling milk adulterated with 10% of added water Result. Dismissed. (Warranty proved) £ s. d. £ s. d. Penalty. Costs. — — Ditto Selling milk adulterated with 3% of added water and from which 23% of original fat had been abstracted Dismissed under Probation of Offenders Act — 2 2 0 Ditto Selling milk adulterated with 10% of added water Dismissed. (Warranty proved) — — 28 Defendant. Offence. Result. Penalty. Costs. James Hedges, 59, Langthorne Street Selling milk adulterated with 7% of added water Dismissed. (Warranty proved) £ s. d. £ s. d. — — Frederick Sadler, 59, Brecon road Selling milk adulterated with 4% of added water Convicted 8 0 0 1 1 0 Ditto Selling milk adulterated with 12% of added water Convicted 8 0 0 2 2 0 R. Eavis, Beechingstoke, Pewsey, Wilts. Giving a false warranty in respect to a consignment of milk to Mr. J. Hickman, 350, Fulham Palace Road Dismissed — — Frederick Sadler, 59, Brecon Road Selling milk adulterated with 4% of added water Convicted 4 0 0 2 2 0 C. Reakes, Southwick Court, Trowbridge, Wilts. Giving a false warranty in respect to a consignment of milk to J. Hedges, 59, Langthorne Dismissed — — Edward Charles Gardner, 18, Sherbrooke Road Selling milk adulterated with 7% of added water Dismissed. (Warranty proved) — — William Henry Porter, 68, Wards Avenue Selling milk from which 18% of its original fat had been abstracted Dismissed. (Warranty proved) — — Evan David Morgan, 5, Hartismere Road Selling milk from which 8% of the original fat had been abstracted Dismissed. (Warranty proved) — — Glovers Farm Co., Ltd., 15, Brook Green, Hammersmith Selling milk adulterated with 4% of added water Dismissed. (Warranty proved) — — George Harris, 42, Southerton Road, Hammersmith Selling milk adulterated with 3% of added water No conviction. Defendant ordered to pay costs — — 3 0 0 Richard Oliver Davies, 67, Aspenlea Road Selling milk from which 15% of the original fat had been abstracted Dismissed. (Warranty proved) — — Evan Evans, 66, Colehill Lane Selling milk from which 32% of the original fat had been abstracted Dismissed. (Warranty proved) — — John Bowen Walters, 797, Fulham Road Selling milk from which 22% of the original fat had been abstracted Dismissed. (Warranty proved) — — 29 Defendant. Offence. Result. Penalty. Costs. Richard Stanley Norrish, 25, Tamworth Street Selling milk from which 26% of the original fat had been abstracted No conviction. Defendant ordered to pay costs. £ s. d. £ s. d. — 4 4 0 Walter Cousens, 233, Munster Road Selling milk from which 14% of the original fat had been abstracted Dismissed. (Warranty proved) — — Richard Oliver Davies, 67, Aspenlea Road Selling milk from which 12% of the original fat had been abstracted No conviction. Defendant ordered to pay costs — 3 0 0 Richard Norrish, 25, Tamworth Street Selling milk from which 12% of the original fat had been abstracted Convicted 3 0 0 2 0 0 Philip Jenkins, 245, Munster Road Selling milk from which 23% of the original fat had been abstracted Dismissed. (Warranty proved) — — Sarah Anne Lloyd, 73, Moore Park Road Selling milk adulterated with 11% of added water Dismissed. (Warranty proved) — — John Jenkins, 49, Bayonne Road Selling milk adulterated with 19% of added water Convicted 2 0 0 2 2 0 Ditto Ditto Not dealt with — — Charles Spencer, 2, Everington Street Selling milk adulterated with 11% of added water Convicted 2 0 0 2 2 0 £ 27 0 0 23 15 0 Proceedings under the Defence of the Realm Act. William Graham, 469, Fulham Road Exposing for sale milk to which water had been added Convicted. 28 days imprisonment, subsequently reduced on appeal fo a fine of £10 10s. & costs. — — Prevalence of and Control over Infectious Disease. Table X. gives the number of cases of infectious diseases notified to the Medical Officer of Health during the 53 weeks ended January 3rd, 1920. TABLE X. Cases of Infectious Diseases notified during the Year 1919. Notifiable Disease. Number of Cases Notified. Total Cases Notified in each Ward of the Borough. At all Ages. At Ages—Years. Barons Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. Total cases removed to Hospital. Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to 65. 65 and upwards. Smallpox — — — — — — — — — — — — — — — — — Cholera (C), Plague (P) — — — — — — — — — — — — — — — — — Diphtheria (including Membranous Croup) 336 13 81 204 22 14 2 — 17 47 27 32 79 14 95 25 305 Erysipelas 75 — 1 8 8 24 25 9 5 13 7 9 18 2 13 8 32 Scarlet Fever 371 3 54 275 29 9 1 — 9 50 23 47 122 10 80 30 327 Typhus Fever — — — — — — — — — — — — — — — — — Enteric Fever 6 — — — 2 4 — — — — 2 1 1 — 2 — 4 Relapsing Fever (R) Continued Fever (C) 1 — — — — — 1 — — — — — 1 — — — — Puerperal Fever 35 — — — 11 24 — — 3 5 5 3 7 2 6 4 31 Cere0bro-Spinal Meningitis 9 1 2 4 1 — — 1 — 1 2 — 2 1 3 — 8 Polio-myelitis 2 — 2 — — — — — — 2 — — — — — — 2 Ophthalmia Neonatorum 47 47 — — — — — — 2 6 2 7 14 2 9 5 10 Pulmonary Tuberculosis 442 1 6 62 90 195 82 6 26 74 42 51 119 20 75 35 — Other forms of Tuberculosis 127 — 24 70 14 13 5 1 10 19 13 18 35 3 16 13 — Measles 615 18 228 347 11 11 — — 33 18 50 88 115 58 209 44 45 German Measles 121 4 34 60 14 8 1 — 12 13 2 22 48 2 14 8 3 Encephalitis Lethargica 6 1 — 2 1 1 1 — — — — 1 1 — 1 3 3 Pneumonia 199 6 26 30 25 62 33 17 20 36 14 35 53 6 24 11 50 Diarrhcea 83 44 39 — — — — — 3 12 14 10 12 4 17 11 25 Malaria 104 — — — 23 76 5 — 5 19 8 13 42 2 6 9 3 Dysentery 9 — — — 4 5 — — 1 1 1 2 3 — — 1 2 Trench Fever 1 — — — 1 — — — — — — — 1 — — — — Totals 2,589 138 497 1,062 256 446 156 34 146 316 212 339 673 126 570 207 850 30 31 Smallpox.—No case of smallpox has been notified in Fulham since 1916. Five suspicious cases were reported in 1919, but they were found not to be cases of smallpox. Vaccination.—The following table, furnished by the Vaccination Officer, Mr. H. Davies, gives the vaccination returns for the four years 1915-18, those for 1919 not being yet completed. TABLE XI. Vaccination Returns. Year. Births Successfully vaccinated. Insus. of Vaccination. Had Smallpox. Declarations of Conscientious Objections. Dead (unvac cinated.) Postponed by Medical Certificate. Removal to Districts & Vaccination Officer notified. Removal to Places unknown No. of Births not accounted for in other columns. 1915 3,741 2,136 4 — 749 269 95 72 363 53 1916 3,610 2,054 9 — 775 218 79 88 332 55 1917 2,852 1,549 7 — 623 166 105 93 254 55 1918 2,594 1,423 15 — 546 171 75 59 270 35 Of the children born during the four years 21 per cent. were exempted by declaration of conscientious objection, and of the surviving children, 40 per cent. remain unvaccinated. No vaccinations were performed by the Medical Officer of Health under the Public Health (Smallpox Prevention) Regulations, 1917. Scarlet Fever.—371 cases of Scarlet Fever were notified, against 228 in 1918, and there were five deaths, giving a case mortality of 1.4 per cent. 32 Diphtheria.—336 cases were notified, against 206 in the previous year, there being a sharp rise in the last three months, the figures for the four quarters being : — Cases. Deaths. 1st quarter 62 6 2nd „ 70 7 3rd „ 51 4 4th „ 153 15 During the last months of the year there was often difficulty in securing the prompt removal of cases, owing to the want of accommodation in the hospitals of the managers of the Metropolitan Asylums Board, consequent on several of their hospitals having been taken over by the War Office. In view of the necessity for the administration of anti-toxic serum in as early stage of the disease as possible, the attention of the doctors practising in Fulham was drawn to the probability that there would be delay in the removal of their patients suffering from diphtheria, and the advisability of giving in all cases an injection of anti-toxic serum, which could be obtained free of cost from the Public Health Department at the Town Hall. As this suggestion was in many instances not acted upon, a further letter, to the same effect, was written to them, and the need for the injection of a dose of at least 8,000-12,000 units in all definite cases pointed out. After this the practice was more generally adopted, and 648,000 units of anti-toxic serum were supplied by the Council for the purpose. In addition to the notified cases of Diphtheria, a number of bacteriological, or carrier cases, were found, i.e., cases from which the diphtheria bacillus was isolated, though they showed no clinical symptoms. In view of the shortage of accommodation even for acute cases, unless it was suspected that they had infected others, these carriers were not isolated in hospital, but were kept at home under observation. Errors in Diagnosis.—Of the patients notified, 20 or 6 per cent. were subsequently found not to be suffering from Diphtheria. 33 Enteric Fever.—Six cases were notified, against 15 in 1918, and there were two deaths. Cerebro-Spinal Fever.—There were nine notified cases, against eight in 1918, but in four the diagnosis was not confirmed, and there were five deaths. No contacts with the notified cases were bacteriologically examined. Polio-myelitis.—Two cases were reported. Both recovered with slight permanent paralysis. Encephalitis Lethargica.—Six cases were notified and two deaths were ascribed to the disease, one being an unnotified case. In three cases the diagnosis was not confirmed. Tuberculosis.—The notifications received during the year numbered 1,269. Under Form A.—Cases not previously notified 763 „ ,, B.—By School Medical Officers 30 „ „ C.—Cases admitted to Poor Law stitutions and Sanatoria 270 „ „ D.—Cases discharged from Poor Law Institutions and Sanatoria 206 Of the above, 588 were notifications of new cases, 433 being of pulmonary and 145 of other forms of tuberculosis. The following table gives the sex and ages of the persons notified :— TABLE XII. PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Summary of notifications during the 53 weeks ended January 3rd, 1920. Age Periods. Number of Notifications on Form A. Number of Notifications on Form B. (by School Medical Officers) Number of Notifications oc Form C. of admission to Primary Notifications. Total Notifications on Form A. Primary Notifiations. Total Notifications on Form B. Poor Law Institutions. Sanatoria. 0 to 1. 1 to 5. 5 to 10. 10 to 15. 15 to 20. 20 to 25. 25 to 35. 35 to 35. 45 to 55. 55 to 65. 65 and upwards Total. Under 5. 5 to 10. 10 to 15. Total. Pulmonary. Males 1 2 15 6 19 33 72 45 37 23 2 255 363 — 1 1 2 5 26 112 Females — 4 12 20 18 20 49 26 18 7 4 178 272 — 4 3 7 7 29 76 Non-pulmonary Males — 14 21 10 1 2 5 4 2 — — 59 66 — 3 3 6 6 8 5 Females — 10 12 11 7 4 1 2 1 2 1 51 62 — 7 4 11 14 6 8 34 35 Mortality from Tuberculosis.—168 deaths (102 of males and 66 of females) were registered from pulmonary tuberculosis, corresponding to a death-rate of 1.08 per 1,000, which is the lowest recorded in Fulham, and 0.28 per 1,000 below the average of the preceding five years. To other tuberculous diseases 42 deaths were asscribed, the mortality being at the rate of 0.27 per 1,000. Of the 168 persons certified as having died from pulmonary tuberculosis, 36 had not been notified as suffering from the disease. Of these 10 were inmates of Lunatic Asylums, eight died in hospitals or infirmaries and in three cases the cause of death was ascertained after inquest. The following table gives the time that elapsed in notified cases of pulmonary tuberculosis between the first notification and the date of death. TABLE XIII. Period, between date of Primary Notification and Death. Cases. Under 1 month 34 1 to 3 months 21 3 to 6 „ 19 6 to 12,, 18 1 to 2 years 26 Over 2 years 14 It is obvious that a large proportion of the fatal cases was not notified in the early stages of the disease. Prevention and Treatment of Tuberculosis.—The Fulham Dispensary for the Prevention of Consumption, founded by the Central Fund for the Promotion of the Voluntary System, was opened under the management of a voluntary Committee on November 1st, 1911, at 632, Fulham Road. In May, 1913, the Borough Council, with the approval of the Local Government Board, entered into an agreement with the Committee of Management of the Fulham Tuberculosis Dispensary, under which the Council agreed to contribute for the financial year 36 ending 31st March, 1914, the sum of £300 towards the maintenance of the Dispensary, and the Committee undertook : (1) To provide for the proper medical treatment at the Dispensary of all or any residents in the borough suffering from tuberculosis whose means are in the opinion of the Council insufficient to enable them to pay for such medical treatment. (2) To make suitable arrangements in co-operation with the Medical Officer of Health of the borough for the free medical examination of all contracts and suspects in connection with such patients. (3) To arrange that the place of residence of each patient shall be visited as often as may be necessary by one of the Medical Officers of the Dispensary, and also by one of the Nurses appointed by the Dispensary, and that all reports regarding any patient and the conditions existing at the place of residence of such patient shall be forwarded in duplicate to the Medical Officer of Health. (4) To provide and maintain in efficient condition to the satisfaction of the Council and the Local Government Board the said Dispensary at 632, Fulham Road, and also to provide all proper medical attendance and medicines required as aforesaid, and for such purposes to engage and retain the services of an experienced staff. (5) That the Medical Officer of the Dispensary shall under the administrative directions of the Medical Officer of Health act as "Tuberculosis Officer of the Borough" and assist in the carrying out of any necessary measures for the prevention of tuberculosis in the Borough, but that the Tuberculosis Officer shall be independent of any control by the Medical Officer of Health in all matters relating to diagnosis and the treatment of patients, contracts and suspects. (6) That the Tuberculosis Officer shall furnish to the Medical Officer of Health full information regarding the sanitary condition of all dwelling- 37 houses within the Borough in which cases of tuberculosis have been diagnosed or treated by him or his assistants. (7) That the Council shall be entitled to appoint three persons, to act upon and be members of the Dispensary Committee, and that such persons shall have and exercise all the rights and powers appertaining to membership of the said Committee. In 1914 the Dispensary was moved from 632, Fulham Road to 114, New King's Road, which was leased to the Committee by the Council, and a further agreement was made, under which the Council agreed to contribute £700 a year towards the maintenance of the Dispensary and to pay £50 a year to the Brompton Hospital for Consumption in respect of patients sent by the Tuberculosis Officer to the hospital for diagnosis or treatment as out-patients. As very few patients were sent from the Dispensary to Brompton the latter contribution has been, with the consent of the Governors of the hospital and the approval of the Local Government Board, reduced to £10 10s. Od. The Council also pay over to the Dispensary Committee the amount they receive, viz., £387 a year, from the London Insurance Committee, in respect of insured patients treated at the Dispensary. Of the net amount paid by the Council one half is refunded by the Ministry of Health and one quarter by the London County Council. The staff of the Dispensary at present consists of :— Tuberculosis Officer, Dr. J. Sullivan. Assistant Tuberculosis Officer, Dr. W. Murphy. Three Nurses. Dispenser and Laboratory Assistant. Clerk. During the past year 1,853 patients attended the dispensary, 478 being insured persons (including 193 ex-soldiers and sailors), 368 uninsured adults, and 1,007 children under 16. 797 (426 males and 371 females) were new patients, and of these 265 were notified as suffering from c 38 culosis (33.2 per cent.); the notification of old patients who were under observation, brought the number up to 320. The attendances at the dispensary numbered 9,226, consisting of 1,397 attendances of insured persons, 1,714 of uninsured adults, and 6,115 of children under 16. The following table gives the diagnosis at various age periods. TABLE XIV. Diagnosis at various Age Periods. Pulmonary Tuberculosis. Other Forms. Suspects. NonTuber cular. Percentage Tuberculous. Under 5 1 6 19 31 12.2 „ 10 17 21 88 91 16.3 „ 15 15 8 41 41 21.1 „ 25 49 8 21 33 50.9 „ 35 59 5 38 35 45.9 „ 45 46 1 26 26 47.4 45 and over 35 1 18 24 46.1 All ages 221 50 251 281 33.2 Institutional Treatment.—The following patients were sent to Institution :— Adults. Children Male. Female. under 16. To Sanatoria (early cases)— By London Insurance Committee 46 14 — By London County Council — 10 25 To Hospitals (acute and advanced cases)— By London Insurance Committee 37 7 — By London County Council — 7 10 To Infirmaries 6 18 27 To Convalescent Homes — 14 35 79 90 97 39 Home Supervision.—1,664 visits were made by the Medical Officers of the Dispensary and 4,043 by the nurses, who visit at the request of the Medical Officer of Health all notified cases in the Borough, in addition to those attending the Dispensary. The Tuberculosis Officer states that his colleague, Dr. Murphy, has devoted a large part of his time to visiting, and has done most valuable work in keeping in touch with tuberculous families, recording the progress of all notified cases and generally systematising the methods. A great deal has been done by the nurses to bring about improvements in home conditions and enable treatment to be carried out on hygienic lines and a number of insanitary houses were reported to the Medical Officer of Health, with the result that the necessary alterations were made in 88 houses during 1919. Advanced cases which had to be treated in their homes were referred to the Fulham District Nursing Association. Examination of Contacts.—When a case is notified as tuberculous, arrangements are made for the examination, if possible, of the other members of the family. Of 381 contacts examined seven, or 1.8 per cent., were notified as tuberculous, and 47 were placed under observation. The Tuberculosis Officer points out "that this percentage gives no indication of the actual prevalence of the disease among contacts because the examinations are made immediately after notification, that is, when tuberculosis is first discovered and is in many cases early and not infectious." As illustrating this he states that 30 of the 265 new tuberculous patients were contacts with old dispensary patients and that many others gave a history of having lived with a near relative suffering from consumption, and he points out the necessity for the following up and supervision of the entire family and not being satisfied with a single examination of contacts. Interim Tuberculosis Care Committee.—It was intended that in connection with Tuberculosis Dispensaries voluntary Care Committees should be c 2 40 ised, formed of representatives from the local authorities, boards of guardians, insurance committees and from all charitable and social organisations in the district, so that all available agencies can be linked up and any extra assistance, such as additional food, change of air, clothing, better home conditions, more suitable occupation, etc., that may be needed to enable patients to benefit to the fullest extent from the treatment provided, may be more readily secured. In consequence of the difficulty experienced in establishing a permanent Committee, owing to the war, an Interim Care Committee was set up by the London County Council, composed of representatives of all agencies whose work brings them in contact with tuberculous patients. The Interim Committee meets, as a rule, weekly, and has, in the opinion of the Tuberculosis Officer, been of great value in supplementing the medical work of the Dispensary and in preventing the overlapping resulting from several independent bodies dealing with the same problem. When considering the cases, reports on their medical aspect and on the home conditions and social circumstances are submitted to the Committee to enable them to deal effectively with them and decide, when institutional treatment is recommended, whether the patient shall be referred for this purpose to the London County Council, the Poor Law Guardians or a voluntary association. During last year, in addition to those dealt with by official bodies, 47 patients were referred to the Charity Organization Society, of whom ten were sent to Convalescent Homes, four were boarded out in the country, nine were assisted financially or with extra nourishment, clothing or bedding, and in 10 cases arrangements were made for the care of the children while the mother or father was in a Sanatorium. 43 children were referred to the Invalid Children's Aid Association, of whom 35 were sent to Convalescent Homes, or boarded out in the country, and in three cases physical exercises were arranged for. 41 Among the questions to be considered by the Council in the near future is that of their relation with the Tuberculosis Dispensary. The Central Fund for the Promotion of the Dispensary System unquestionably did valuable work in promoting in certain London boroughs Tuberculosis Dispensaries on the lines subsequently approved by the Departmental Committee, and Fulham profited by the early establishment, through voluntary efforts, of a dispensary. The dispensary has undoubtedly gained the confidence of the public and of the members of the medical profession in Fulham, who have, ever since its opening, most cordially co-operated with it, and last year upwards of a third of the new patients were sent to the dispensary by their doctors. It has also worked in intimate relation and cordial harmony with the Public Health Department, but it must be remembered that the Council are wholly responsible for all matters relating to the prevention of tuberculosis and that with an independent Committee undertaking an important side of the work there must be a certain want of control on the part of the Council, which is undesirable and difficulties in securing com plete co-ordination will at times arise. The Dispensary Committee have recently applied to the Council for an increase of the grant in aid, on the ground of the unavoidable increase in their expenditure, and the Public Health Committee have recommended the Council to increase their grant for the year ending March 31st, 1921, to £1,200, and to take steps to take over the management and control of the dispensary as from April 1st, 1921. The expenditure for the year 1919 was £2,637, and for the current year will probably amount to about £3,200. Should the Council take over the dispensary the net cost to them, after deducting the contributions of the Insurance Committee, the Ministry of Health and the London County Council, will be about £730, against £310 if their contribution is limited to a grant of £1,200. 42 Measles.—615 cases of measles were notified, 452 by medical practitioners and 163 by other persons. Fatality.—Measles was the cause of 14 deaths, giving a case mortality of 2.3 per cent., against 2.9 per cent. in 1918 and 3.7 per cent, in 1917. All the notified cases were visited by the Health Visitors, who give printed and verbal instructions regarding the precautions that should be taken. Cases requiring nursing assistance are reported to the Fulham District Nursing Association, who undertake the necessary nursing under an arrangement made with the Council, who pay the Association 8d. a visit for all cases of measles or other diseases nursed by them on behalf of the Council. Notification of Measles.—The order of the Local Government Board requiring the notification of Measles and German Measles, which came into force on January 1st, 1916, was rescinded by the Ministry of Health on January 1st, 1920. In their Order the Ministry stated that they were prepared to consider applications from Local Authorities who desired that the notification of Measles or German Measles should be continued in their district, and, at the request of the Borough Council, the Ministry have made an Order which comes into force on April 1st, 1920, requiring the notification of all cases of measles in the borough. Influenza.—At the beginning of February there was a recurrence of the Influenza epidemic which prevailed in the early summer and again in the autumn of 1918; and during the seven weeks of its maximum intensity the following deaths were attributed to it:— Week ended Feb. 15th 8 „ „ „ 22nd 23 „ „ Mar. 1st 26 „ „ „ 8th 16 „ „ „ 15th 12 „ „ „ 22nd 12 „ „ „ 29th 2 The total number of deaths from Influenza during the year was 147, representing a death-rate of 0.96 43 per 1,000 against 3.4 in 1918. Nursing assistance was, as in 1918, provided by the Council in all cases reported to the Medical Officers of Health as requiring it. Leaflets and posters containing precautionary advice were distributed throughout the boroughs. Proceedings under the Public Health (Influenza) Regulations were taken by the Council against the manager of the Fulham Theatre Cinema for not complying with the regulations "that a public entertainment shall not be carried on consecutively for more than four hours and that there shall be an interval of not less than thirty minutes between any two entertainments, during which interval the premises shall be effectively ventilated," and a penalty of £30 with £5 5s. costs was imposed. The Public Health (Pneumonia, Malaria, Dysentery, etc.) Regulations, 1919. An Order made on January 7th, 1919, by the Local Government Board requiring the notification of all cases of Malaria, Dysentery, Trench Fever, Acute Primary Pneumonia and Acute Influenzal Pneumonia came into operation on March 1st. Malaria.—104 cases of malaria were reported, in all of which the disease had been contracted abroad. Quinine treatment was provided in two cases. Dysentery.—Nine cases were notified, but no special measures under the regulations were required in any of them. Trench Fever.—One case was notified. Pneumonia.—199 cases were notified as suffering from pneumonia, 131 from acute primary pneumonia and 68 from acute influenzal pneumonia. As during the 10 months notification was in force 120 deaths were ascribed to pneumonia and 47 to influenzal pneumonia, it is evident that a considerable proportion of the cases was not notified. Of the cases notified 50 were treated in hospital. Nursing assistance was provided by the Council when needed. 44 MATERNITY AND CHILD WELFARE. The Scheme for the co-ordination and extension of maternity and child welfare work carried on in the borough, which was adopted by the Council in January, 1919, has been brought into operation. The scheme aimed at controlling the work of the voluntary organizations and co-ordinating it with that of the Council, and provided for:— (1) Notification of Births to the Medical Officer of Health. (2) Visitation of mothers and babies by Health Visitors. (3) Attendance of children from infancy up to school age at Consultations held by the Assistant Medical Officer of Health. (4) Home supervision of the children attending the Consultations by the Health Visitors and Nurses, to ensure the carrying out of the doctor's instructions and improvement of home conditions. (5) Operative treatment of children under school age suffering from dental defects, and enlarged tonsils and adenoids. (6) Treatment of children under school age suffering from minor ailments requiring continuous treatment and the assistance of a nurse. (7) Treatment in hospital of infants requiring special nursing or feeding. (8) Day Nursery for the care of children whose mothers are compelled to go out to work. (9) Nursing of children suffering from measles and ophthalmia. (10) Ante-natal Clinic for expectant mothers. (11) Dental Clinic for expectant and nursing mothers. (12) Maternity Home for women with inadequate home accommodation. (13) A system of "home helps" for services in the home when the mothers are absent. 45 (14) Provision of milk at a reduced price for necessitous mothers and their children. 1. Notification of Births.—2,808 notifications of living and 89 of still-born children were received under the Notification of Births Act, 97 per cent. of the births registered in Fulham being notified. Of these 2,220, or 77 per cent. were notified by midwives, 614 by medical practitioners and 63 by relatives. In addition to the above 147 births were notified from outlying institutions. The births which have been registered but not notified are reported by the Registrars, and the attention of the doctors or others is drawn to their neglect to notify; but as there is[a divided responsibility with regard to notification, no prosecutions have been instituted. 2. Visitation of Mothers and Babies by Health Visitors.—The Scheme provided for the appointment of two additional Health Visitors, making four in all, and Miss Becket and Miss Perrett were appointed and commenced their duties on May 12th, 1919. The following is a summary of the work of the Health Visitors in connection with notified births. First visits to Infants 2647 Re-visits 5839 Visits to children—aged 1-5 years 620 3. Attendance of children from infancy up to school age at Consultations held by the Assistant Medical Officer of Health. In April, 1919, Dr. Flora Murray, Assistant Medical Officer of Health for Bethnal Green, was appointed Assistant Medical Officer, to take charge, under the direction of the Medical Officer of Health, of the Maternity and Child Welfare work of the Council. Dr. Murray commenced her duties in May, but was, unforfortunately, owing to the breakdown of her health, compelled, a few weeks afterwards, to resign the appointment, and Dr. Ruby Thomson, who had been employed in a similar capacity at Willesden, was appointed to succeed her. Under an arrangement made with the Committee of the Fulham Maternity 46 and Infant Welfare Centre, the Infant Consultations, formerly held by four part-time doctors employed by the Committee, are now held by the Assistant Medical Officer of Health. These are held on Tuesday in each week at Melmoth Hall, on Wednesday and Thursday at 92, Greyhound Road, and on Friday at 170; Wandsworth Bridge Road, these premises being provided for the purpose by the Committee of the Welfare Centre. During the year 175 consultations were held, to which 834 babies were brought, who made 5,778 attendances. In addition 316 children, of 1 to 5 years, who attended on 720 occasions, were seen by the Medical Officer. 4. Home Supervision of Children attending the Consultations.—A Health Visitor is present at each Consultation and the homes of the babies attending are visited by her or by the Superintendent of the Welfare Centre, in order to secure, as far as practicable, the carrying out of the doctor's instructions and to report to the Medical Officer of Health any defects found in the home. In addition to those of the Health Visitors, 2,302 visits were paid by the Superintendent of the Welfare Centre and her Assistant. 5. Treatment of Children under School Age suffering from minor ailments.—Arrangements have been made at 92, Greyhound Road for the treatment of children under school ages suffering from so-called minor ailments requiring the services of a nurse. During the year 190 children attended the surgery for this purpose and there were 1,580 attendances. Many of the children brought to the surgery are referred by hospitals to the Centre, as the necessary dressings can be undertaken there instead of at the hospital, and the mothers are thus saved much time and trouble. 6. Operative Treatment of Children under school age.— An arrangement has been made with the Fulham School Treatment Centre, 18 and 20, Bagley Lane, which is under the direction of the Medical Officer of Health, for the operative treatment by the members 47 of the staff of children attending the Consultations who have been found to be suffering from dental defects, or enlarged tonsils and adenoids. Babies requiring circumcision are also operated on there by the Assistant Medical Officer of Health, with the assistance of the anaesthetist attached to the Treatment Centre. In all 30 children were operated on at the Treatment Centre. 7. Treatment in Hospital of Children requiring special nursing and feeding.— Fulham Babies Hospital.—This institution opened in March, 1916, at 706, Fulham Road, was moved to more commodious premises at 23, Broomhouse Road, in July, 1919. The Committee of management were enabled to do this through the generosity of Mr. Leslie, who purchased the freehold, and of Mrs. Power, who defrayed the entire cost of the necessary alterations amounting to upwards of £4,000. The hospital will now accommodate 20 patients and is admirably equipped in all respects. The Council contribute £1,000 a year towards its maintenance and nominate two members to serve on the Committee of Management, of which the Medical Officer of Health is Chairman. The Assistant Medical Officer of Health acts as Medical Officer, and in this way there is intimate cooperation between the Hospital and the Welfare Centre, as babies seen at the Consultations who require special nursing and feeding, unobtainable at home, can be at once admitted. Between January 1st and July, 1919, 32 children were treated in the old hospital, of whom four died, and from August 1st, when the new hospital was opened for patients, to the end of the year, 57 cases were admitted. It had been decided to reserve the hospital during August and September entirely for cases of diarrhoea, as experience had shown that there is great risk of the spread of infection, when cases of epidemic diarrhoea are treated in the same ward as the premature or marasmic children of the type generally sent as patients. 48 Diarrhoea was, however, so much less prevalent last summer than usual, that it was only found necessary to reserve one ward for it during the late summer months. In all, 34 babies were admitted with diarrhoea, of whom five died. The other cases admitted were mainly cases of broncho-pneumonia, or infants suffering from the direct result of improper feeding, and in the latter connection the hospital is a valuable adjunct to the infant clinic. The work during the last two months of the year was interfered with by the occurrence of some cases of nasal diphtheria, which, though showing few or no clinical symptoms, were removed to the Isolation Hospital and new cases were not admitted until it was ascertained by repeated bacteriological examinations that no other children were infected. It is to be regretted that the hospital is not more used by the medical practitioners of the borough, although their attention has been called several times to the facilities provided, and that they can, if they desire, undertake the treatment of their own patients while they are in the hospital. Dr. Arthur Saunders, Honorary Physician to the West London Hospital, has been good enough to act as Honorary Consulting Physician, and has rendered most valuable assistance in seeing patients with the Medical Officer and in procuring the admission to the West London Hospital of children who needed operations. 8. Day Nursery.—The Council give a grant of £300 a year to the Fulham Day Nursery at Eridge House, and the Assistant Medical Officer acts as Medical Officer. Every child on admission undergoes a complete physical examination, and this is repeated every three months. Any ailment is at once brought under the notice of the Medical Officer and several children have undergone minor operations, such as the removal of adenoids and circumcision. The nursery has the advantage of a large garden, in which children are kept as much as possible, and the progress they make is 49 most satisfactory. During the year there were 7,763 attendances, giving an average of attendance of 23 children on each day the nursery was open. Maternity Welfare. Ante-natal Clinic.—An ante-natal clinic for expectant mothers is held once a fortnight at 92, Greyhound Road, by the Assistant Medical Officer of Health. During the year there were 211 attendances of 84 women. Dental Clinic.—A dental clinic for nursing and expectant mothers attending the Welfare Centres is held weekly at the School Treatment Centre, 18, Bagley's Lane, by Mr. T. Vernon, the School Dentist, the expenses being defrayed by the Committee of the Welfare Centre. A nominal fee, ranging from 2d. to 9d., is paid by the women for extraction and fillings, and dentures are paid for by small instalments extending over from six to twelve months. During 1919, 72 women were treated, of whom 56 were supplied with dentures. Errors of Refraction.—Arrangements have recently been made with Mr. Hope Gunning, one of the Ophthalmic Surgeons at the School Treatment Centre, to undertake the examination for and correction of errors of refraction in women attending the Centre. Maternity Home.—The Council last year purchased 706, Fulham Road, formerly used as a Babies Hospital, for the purpose of a Maternity Home, for the reception during their confinement of women resident in Fulham who have no proper accommodation in their own homes. The Home, after the necessary alterations, was opened for the reception of cases in January of this year, and has beds for nine patients. The following rules for the admission of patients have been made by the Council:— "The Home shall be open for the reception during their confinement of women resident in Fulham, who have no proper accommodation in their own homes for their confinement. 50 Applications for admission shall be made to the Medical Officer of Health on the prescribed form, three months before the date of the expected confinement, and he shall be responsible for the selection of patients. Before a case is accepted for admission the applicant shall, when required, consult the Assistant Medical Officer of Health at the ante-natal clinic. The charge for attendance during the confinement and the maintenance in the home for 14 days shall be 30s., which must be paid before admission. In the event of the patient remaining in the Home by the permission of the Medical Officer of Health more than 14 days, the charge shall be 15s. for each week, or part of a week. Patients may, if they so desire, make arrangements (to be approved by the Medical Officer of Health) to be attended by their own doctor, but in such cases the doctor's fee, in addition to the charge for maintenance in the Home, must be paid by the patient, and the Council will not accept any responsibility for the payment. Applicants shall undertake, if admitted, to obey all regulations which may be made by the Council for the conduct of the institution." Home Helps.—No arrangements have yet been made for the provision of "home helps," to do the work of the house and attend to the other children of the family during the mother's absence from home. It is very questionable if an official "help" would be always acceptable, and it will probably be advisable, in many cases, to allow the patient to arrange with a friend or relative to undertake the care of her household, and for the Council, if satisfied as regards the suitability of the help, to bear a proportion of the cost. Stillborn Children.—Orders were given for the burial in the Fulham Cemeteries of 102 stillborn children, being in the proportion of one stillborn child to every 29-5 living. Of these 89 were notified. No 51 gations of still births were undertaken, but most of the mothers were visited with the view of securing their attendance at the Ante-natal Clinic in the event of subsequent pregnancy. Illegitimacy.—No special steps have been taken to deal with unmarried mothers or illegitimate children. The home for unmarried mothers and their children which was opened in 1917 at 56, Harwood Road, has been closed. The object of the home was to keep the mother and child together, to enable the mother to go out to work, and to contribute to the support of herself and the child. Under the Children Act the London County Council are the authority for the registration and supervision of foster mothers, and it is to be regretted that in this connection there is little or no co-operation with the infant welfare work of the Borough Council. It seems obvious that it would be beneficial if these powers were transferred to the Borough Council, who not only have the necessary local knowledge, a most important point, but would be able to utilise their various health services in dealing with the children. As it is, although the Borough Council are supposed to be responsible for infant welfare in their district, the children who need special attention and who show the highest rate of sickness and mortality are removed from their protection. Incidence of Infectious Diseases of Parturient Women and Infants and Young Children. Puerperal Fever.—35 cases of puerperal septicaemia were notified, or 11.3 per 1,000 births, of which 10 or 3.2 per 1,000 births' proved fatal. As was the case in several recent years, more cases were notified in Fulham in proportion to the population than in any metropolitan borough. In addition to the deaths from septicaemia, 6 deaths were attributed to other accidents and diseases of pregnancy and 7 to pneumonia or influenza within ten days of confinement. Ophthalmia Neonatorum.—47 infants were notified by doctors or midwives as suffering from ophthalmia. 52 Ten were treated in hospital or infirmary, and those kept at home who required special attention were referred to the Fulham District Nursing Association. The results of the notified cases were as under:— Recovered with unimpaired sight 34 Right eye, sight injured (corneal opacity) 1 Still under treatment 1 Slight conjunctivitis still present. Cornea undamaged 4 Left district (said to have recovered) 4 Died since notification 3 47 Whooping Cough.—The borough was exceptionally free from whooping cough during 1919, and there were only four deaths from it against a quinquennial average of 44. Arrangements have been made with the Nursing Association for the nursing of cases of the disease. Diarrhoea.—On the recommendation of the Maternity and Infant Welfare Committee, the Council made an order in July last requiring the notification of all cases of the disease known as epidemic diarrhoea or zymotic enteritis occurring in children under 5 years of age, for the period ended November 30th, 1919; and on its expiration, made, with the sanction of the Ministry of Health, a further Order making the disease permanently notifiable. All the notified cases were visited by the Health Visitors, and arrangements were made, as has been stated above, for the treatment in the Babies' Hospital of those which could not be satisfactorily nursed at home. There was, however, much less diarrhoea in Fulham last year than has ever been the case, and only 83 cases were notified—44 of infants under 12 months and 39 of children between 1 and 5 years ; and the deaths numbered 44, the numbers for the four quarters being :— 1st quarter 14 2nd „ 4 3rd „ 19 4th 7 44 53 Fulham has always been conspicuous by a high diarrhoeal mortality, and last year was the first in which the diarrhoeal death-rate has been lower in the borough than in the County of London, the respective rates being 14 deaths per 1,000 births in Fulham and 16 per 1,000 in London. The decline in diarrhoeal mortality last year was remarkable, as weather conditions were, if anything, more favourable to a high diarrhoeal death-rate than in any year since 1911, as although the mean temperature of the summer quarter was not above the normal, there was a long spell of hot, dry weather during the second half of August and the first half of September, the usual period of the maximum intensity of the disease, while the conditions resulting, from the breakdown of the service for refuse removal, were certainly most favourable to its prevalence. It is possible that the extensive use of dried milk for feeding infants, in place of the more or less dirty milk too often given to them, may have had some influence in preventing the disease. Reviewing the Maternity and Child Welfare scheme as a whole, it may be claimed that the attempt to link up the work of the voluntary societies with that of the Council has been fairly successful. With workers dealing with the same problem, but serving under different bodies, some friction will at times arise, and there must be a certain waste of energy in securing the necessary co-ordination; but the importance of retaining the cordial co-operation of voluntary social workers in so vital a matter is so great that a continuance of present methods is, at any rate for a time, advisable, and progress should be attempted on existing lines. The chief points calling for attention at present are 1. The Appointment of additional Health Visitors.— In their memorandum of August, 1918, the Local Government Board said "that if the various duties of a Health Visitor are to be fully performed, a district with about 400 births a year will be as much as one Health Visitor can undertake." If the increase of births shown in the last quarter of 1919 is maintained, d 54 and it probably will be, upwards of 4,000 births may be expected this year, so that the present staff of four Health Visitors will be very inadequate, and at least two additional Health Visitors should be appointed. 2. Infant Consultations—Additional consultations are needed, as it is not always possible to deal with all the babies now attending, and many have to be sent away without having been seen by the doctor. Arrangements should be made for an additional weekly consultation at 92, Greyhound Road, and also at 170, Wandsworth Bridge Road, and for these it will be necessary to secure the services of part time lady medical practitioners, as the time of the Assistant Medical Officer of Health is already fully occupied. Another Welfare Centre situated near Munster Road is also desirable. 3. Ante-natal Clinic.—Further development of the Ante-natal Clinic is much wanted, and although this will, no doubt, be promoted by the opening of the Council's Maternity Home, a more sympathetic attitude on the part of the midwives in the borough is desirable. There is little chance of securing this so long as the Council have no official relation with the practising midwives. The substitution of the Borough Council for the London County Council as the supervising authority under the Midwives Acts, 1912 and 1918, is essential to the complete success of a maternity welfare scheme. Sanitary Administration. Staff.—The staff of the Public Health Department, in addition to the Medical Officer of Health, consists of:— Assistant Medical Officer of Health, Dr. R. Thomson. Public Analyst, Mr. C. H. Cribb. 10 Sanitary Inspectors—Messrs. Jones, Grigg, Manning, Lloyd, Parsons, Clutterbuck, Gentry, Canton, Drake, and Mrs. Davies. 55 Mr. Jones acts as Inspector under the sale of Food and Drugs Acts and supervises the dairies, milkshops and slaughterhouses. Mr. Parsons supervises the construction of new drains and the reconstruction of systems of combined drainage for which the Council are responsible. Messrs. Grigg, Manning, Lloyd, Clutterbuck, Gentry, and Canton have districts assigned to them, and, in addition to their routine work of attending to complaints, securing the abatement of nuisances, inspection of workshops, etc., are now carrying out the continuous survey of their districts required by the Housing Acts. Mr. Drake makes enquiries into cases of infectious diseases occurring throughout the borough. Mrs. Davies is responsible for the condition of the factories and workshops where women are employed, the inspection of the homes of outworkers. Four Health Visitors : Mrs. Bryning, Misses Durnford, Becket and Perrot. Clerical Staff.—Chief Clerk, Mr. A. T. Hurford and 3 Junior Clerks. Bacteriological Work.—The following bacteriological examinations were made either by Dr. Burnet or at the laboratory of the Tuberculosis Dispensary:— Number of Specimens. Material from Cases of Suspected Diphtheria. Diphtheria bacillus isolated 81 Negative results 458 539 Blood from cases of Suspected Enteric Fever. Vidal or typhoid reaction obtained 6 Negative result 18 24 Sputa from cases of Suspected Tuberculosis. Tubercle bacillus found 230 Not found 887 1,117 Examinations for other organisms 26 Wasserman tests. 4 Blood examinations 19 56 Disinfection.—23,920 articles of bedding, clothing, etc., were disinfected at the Council's Disinfecting Station in Townmead Road. 2,189 rooms were disinfected and cleansed after infectious illness. Extension of Laundry.—Owing to the high cost of washing and the difficulty of getting the articles returned within a reasonable time, the Council have decided to do the washing of their Maternity Home and of the two institutions subsidised by them, viz., the Babies' Hospital and the Day Nursery, at the laundry of their Disinfecting Station. For this purpose additional machinery has been purchased, and a contract for installing it accepted, and it is hoped that the laundry will be ready early in the year. Public Mortuary:-190 bodies were removed to the Mortuary during the year and were admitted as follows:— By order of the Coroner 106 Brought by Police 9 At request of the Medical Officer of Health 3 For convenience till funeral 72 190 OTHER SERVICES. Co-operation with Poor Law Medical Service.— By the kindness of Dr. Parsons, Medical Superintendent of Fulham Infirmary, a weekly return of the children under 16 who are discharged from the Infirmary, together with suggestions for their after care, is forwarded to the Medical Officer of Health. The children under five are dealt with at the Infant Clinic or by the Health Visitors, and the older children are referred to the Tuberculosis Dispensary, the Children's Aid Society or the School Care Committee as the nature of the case may indicate. It is intended to make, if possible, similar arrangements with the almoners of the Victoria, West London and St. George's Hospitals. 57 HOUSING. 1. General Housing Conditions in the District. Number of Houses.—At the census of 1911 there were in Fulham 17,324 ordinary dwelling-houses, 1,102 shops with dwelling-rooms above, and 716 blocks of flats containing 4,330 flats, and since the census about 360 houses have been built. Number of Houses for the Working Classes.—There are 22,212 houses or tenements of a rateable value not exceeding £30, and, in addition, there are 2,248 houses assessed as a whole, but let out to two or more tenants. Assuming that in each of these houses there is an average of 2.5 tenements below the £30 rateable limit, the number of working-class houses and tenements may be estimated at 27,822. No houses for the working classes were erected during the year, but drainage plans of 28 houses to be commenced shortly have been approved. 2. Population.—Particulars have been given on page 3 of the Report. 3. (a) Extent of Shortage or Excess of Houses, and (b) Measures taken or contemplated to meet any shortage. (a) The housing needs of the borough really depend on the needs of the metropolis as a whole. Fulham has ample accommodation for those actually employed in it, but there is, on account of its accessibility, a practically unlimited demand for houses of the working-class type; and this was also the case before the war. (b) As regards measures to meet the shortage, it must be recognised that but little actual increase of housing accommodation can be provided in the borough itself, unless the whole of the ground occupied by the Hurlingham Club can be secured. Failing this, the best that can be hoped for is that sufficient new E 58 houses can be built to compensate for the diminished accommodation which will result if the congested and insanitary areas are to be effectively dealt with, and to this end the policy of the Council should be directed. All the vacant sites in the borough have been surveyed and enquiries made as to the possibility of obtaining them for housing purposes, but the majority were either considered unsuitable by the representative of the Housing Board who viewed them, or were ruled out by the excessive cost of the land. The only land in the borough available for a building scheme of any size is that belonging to the Hurlingham Club, and that which was occupied by the Earls Court Exhibition Co. With regard to the latter, the Council approached the owners, the District Railway Co., with a view to its acquisition, but were informed that the land is required for railway purposes, and even if it could be acquired, it is more adapted for an open space, which, as has been pointed out above, is badly needed in that part of the borough, than for housing purposes. As to Hurlingham, the Council resolved to acquire by compulsory purchase for building purposes 15 acres of land, bought by the Hurlingham Club in 1910 and used as a second polo ground; but the Housing Board refused to sanction the proposal on the ground that as compensation for severance would have to be paid to the owners, the cost of the land would be excessive. II. Overcrowding. At the census of 1911 there were in Fulham 3,199 tenements with more than two occupants per room, having a population at all ages of 21,784, of whom 8,554 were under 10, and the percentage of the population in "private families" living more than two in a room was 14.6. The following table gives the number of persons living in 1891, 1901, and 1911, in tenements of less than five rooms, to which the inquiry in 1891 and 1901 was limited. 59 TABLE V. Number of Persons living in Tenements of less than 5 rooms in 1891, 1901 and 1911. Number of Persons per Room. 1911. 1901. 1891. Total, Persons. Percentage of Total Population. Total Persons. Percentage of Total Population. Total Persons. Percentage of Total Population. Four or more persons to a room 1,706 1.1 943 0.7 1,579 1.7 Three and under four persons to a room 6,210 4.0 3,747 2.8 4,261 4.6 Over two and under three persons to a room 12,979 8.5 10,202 7.4 7,265 8.0 Two persons to a room 13,906 9.1 12,230 8.9 8,818 9.9 One and under two persons to a room 52,762 34.4 45,037 32.8 24,718 26.9 Less than one person to a room 12,463 8.1 9,305 6.7 4,497 4.9 100,026 65.2 81,464 59.3 51,138 55 .7 It will be seen from the above that the number of persons living under overcrowded conditions, i.e., more than two to a room, increased from 10.9 per cent, of the population in 1901 to 13.6 per cent. in 1911. In all but eight London boroughs there was a similar increase in the proportions of the population living more than two in a room, and as suggested by the Registrar-General, it may be partly accounted for by the limitation of the inquiry in 1891 and 1901 to tenements of less than five rooms, and the absence of any definition of the word "room" having led to some amount of understatement in these years of the families occupying tenements of four rooms or less, and also to a tendency to stretch the term "room" to cover a scullery, a lobby, closet, or any other more or less distinct space 60 within a building. This is rendered more probable by the fact that the number of inhabited buildings in London increased between 1901 and 1911, while the population diminished. The relative position of Fulham, compared with other metropolitan boroughs, as regards overcrowding, was, however, less satisfactory in 1911 than in 1901, as in the latter year in only nine boroughs was the proportion of overcrowding lower than in Fulham, while in 1911 fourteen boroughs had less. Judging from the complaints received and the observations of the Inspectors in the course of their duties, it is probable that there is much more overcrowding in the borough than there was nine years ago, though, as pointed out above, this is not confirmed by the returns of the Ministry of Food. No reliable figures, however, as to the amount of overcrowding can be given until the results of the census to be taken in April, 1921, are forthcoming. 2. Measures taken to deal with Overcrowding.— With the existing shortage of houses, but little could be done to deal with overcrowding. In five cases in which there was gross overcrowding, notices requiring its abatement were served under the Public Health Act, and in one case in which the notice was not complied with, a summons was issued and an abatement order made. In other cases endeavours were made to secure cleanliness of the overcrowded rooms and proper use of all means of ventilation. III. Fitness of Houses. 1. (a) General Standard of Houses in the Borough:— The working-class houses in Fulham consist largely of two-storey houses, most of which were constructed to house two families, and the remainder have been adapted to that purpose with varying degrees of completeness. The average accommodation provided consists of three or four rooms, scullery and w.c. In the larger proportion there is a common entrance to the two 61 tenements. Except in the areas mentioned below they are fairly well situated as regards light and air. The general character of the building must be described as inferior; for during the time when building was most active in Fulham there was. very inadequate supervision, and it was not uncommon to find serious defects, due to the bad quality of the material used and faulty workmanship in houses which had been quite recently erected. The other working-class houses comprise threestoried houses, some with basement rooms, situated in the older parts of the borough, which are let to three or more families, and have not been adapted for the purpose, and three-storied houses constructed for three families in which the lowest tenement is "underground," i.e., 3 ft. below the level of the street. (b) General Character of the Defects found to exist in unfit Houses.—Speaking broadly, the chief defects in the two-storey houses are general dilapidation and dirt. The drainage is, as a rule, satisfactory, and the sanitary appliances are adequate and in fair order. In some the roofs require attention, the paving of many yards is defective, the rooms are damp and dirty, and more or less dilapidated walls and ceilings are very common. These defects are all remediable without closing the premises, and will not entail any great expense on the owners. In the three-story houses occupied by several families, in addition to general repairs, structural alterations will in most cases be required to render them reasonably fit in all respects for habitation, since, as a rule, water will have to be laid on to the upper floors and additional sanitary conveniences will often be needed. The basement houses afford a difficult problem, as many of them, owing to insufficient light and ventilation, are really unfit for habitation, but until the house shortage in Greater London is relieved the disuse of them cannot be enforced. 2. Action taken as regards unfit Houses under (a) the Public Health Acts, (b) the Housing Acts.—Action 62 ing to unfit houses was confined during 1919 to proceedings under the Public Health (London) Act, and as regards verminous rooms under the London County Council General Powers Act, 1909. No action was taken under the Housing Acts, but the survey of housing needs required by the Act of 1919 was completed and forwarded to the Housing Commission on October 31st. The time, however, given was, as recognised by the Ministry, too short to permit of an accurate or detailed survey ; but it should give a fairly accurate idea of the housing conditions of the borough, and steps are now being taken to supplement it by a systematic and continuous inspection of defective houses with the view of putting into force, as far as practicable, the provisions of the Act relating to unfit houses. 4. Difficulties in remedying unfitness.—During the past three or four years difficulty has been experienced in getting work done in consequence of the scarcity of labour and materials, and the attention of the Inspectors has been mainly confined to securing the abatement of the more acute nuisances, and works of a less urgent character have been postponed until more normal times. The procedure, too, formerly practised by the Council, of referring to the Law and Parliamentary Committee all cases in which prosecutions were advised by the Public Health Committee, led in the past always to unnecessary delay and occasionally resulted in no action being taken to enforce the requirements of the Council. Under the Standing Orders of the Council the Public Health Committee are responsible for the execution of the provisions of the Public Health and kindred Acts, and it certainly does not promote efficiency when their decisions, based upon the reports of their officers, are overridden by another Committee who have, as a rule, but an imperfect knowledge of the facts, and whose true function should be to advise on any point of law that may be referred to them. 63 IV. Unhealthy Areas. No official or other representations have been made of unhealthy areas under Part I. or Part II. of the Housing Act of 1890; action under that Act and the Act of 1909 having been confined to the representation of individual houses. In the Survey the following six areas were specified as areas which may have to be dealt with under Part I. or II. of the Act of 1890:— Area. Acreage (approximate). Number of Houses. Population (approximate). 1. Heckfield Place, Wallham Lodge and Rock Avenues 5.0 202 2,400 2. Field Road Area,comprising Chelmsford Street, Field Road and 8 Cul-de-sacs opening into it 6.25 189 2,000 3. Church Path 0.68 43 350 4. Caroline Place 0.50 17 170 5. Welford Terrace and Aintree Street 20 67 590 6. Hartopp and Werley Avenues 1.5 68 580 In all the above, and especially in the first four, reconstruction schemes are desirable, but under existing conditions no houses should be closed unless additional accommodation has been provided to house at least as many persons as are displaced, and as there is very little hope that sufficient new houses to justify any extensive demolition can be built within a reasonable time, the only course practicable at present is to deal with the individual houses in these areas and endeavour to render them more habitable. In the event of any new houses being built either by the Council or by private enterprise, partial 64 struction schemes embracing a few houses could gradually be proceeded with. V. Bye-laws relating to Houses, to Houses Let in Lodgings, etc. (1) Working of existing bye-laws. (2) Need for new bye-laws or revision of existing bye-laws. The urgent need for bye-laws in respect of houses let in lodgings is dealt with on page 20. Although rather late in the day so far as Fulham is concerned, there is need, in order to strengthen the hands of the sanitary authority and enable them to exercise proper control over new houses, of a bye-law to the effect "That a person shall not let or occupy any new dwelling-house until such dwelling-house shall, after examination, have been certified by an officer of the Sanitary authority authorised to give such certificate, to be, in his opinion, in every respect fit for human habitation." This was advocated 25 years ago, and the necessity for it was urged upon the London County Council without effect. If a bye-law of this character had been made at that time some of the evils from which the borough is now suffering would have been prevented. In concluding this summary of the work of the Public Health Department, I must tender my thanks to all the members of the staff for the faithful and willing assistance they have at all times given me. I am, Sir, Ladies and Gentlemen, Your Obedient Servant, J. CHARLES JACKSON, April, 1920. Medical Officer of Health,