FUL 21 Metropolitan Borough of Fulham. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1922. A. MIDDLETON HEWAT, M.D., D.P.H., Medical Officer of Health. 3 PUBLIC HEALTH COMMITTEE. Chairman: Councillor H. Booth.. Vice-Chairman: Councillor G. L. Hodge. His Worship The Mayor (Councillor Major G. F. Clark, J.P.), Ex-officio. Alderman R. M. Gentry. Councillor W. Fowell. Councillor A. Andrews. ,, V. L. Franzini. „ Capt. W. S. Brooks. „ A. Gantlett. ,, W. R. Corbin. ,, C. Harwood. „ A. G. Everard. „ T. A. Speed. ,, S. Farley. „ H. J. Todd. Councillor W. Wilcox. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman : Councillor F. J. Bellenger. Vice-Chairman: †Miss P. Plater. His Worship The Mayor (Councillor Major G. F. Clark, J. P.), Ex-officio. Alderman R. M. Gentry. Councillor F. J. Shaw. Councillor Capt. W. S. Brooks. ,, W. A. White. „ A. G. Everard. †Mrs. Lewis. „ S. Farley. †Mrs. Warmington. „ W. Fowell. †Miss C. M. L. Wickham. † Co-opted members. 4 STAFF OF THE PUBLIC HEALTH DEPARTMENT. Medical Officer of Health:— *A. Middleton Hewat, M.D., Ch.B., D.P.H. (Edin.). Assistant Medical Officers:— *John Sullivan, M.B., Ch.B. (Edin.) [Tuberculosis Officer]. *Ruby Thomson, M.B., Ch.B. (Edin.). *G. F. Hardy, M.C., M.R.C.S., L.R.C.P. (Lond.). *Florence Wilson, M.B., Ch.B. (Glas.) [part-time]. Public Analyst:— Cecil H. Cribb, B.Sc. (Lond.), F.I.C. [part-time]. Clerical Staff:— Mr. A. T. Hurford, Chief Clerk. Mr. J. Castley, Mr. A. W. Gammack, *Miss B. Baron, *Miss M. Wacksmith, Mr. F. Walsh. Senior Sanitary Inspector:— *Charles Bristow Jones (Food and Drugs). Sanitary Inspectors:— *Frederick H. Manning. *Charles B. Lloyd. *Alfred J. Parsons. *Albert E. Clutterbuck. *Mark Canton. *Edgar Drake. *Thomas H. Robey. *William French. *Woman Sanitary Inspector :—Mrs. M. E. Davies. Health Visitors:— *Miss M. L. Durnford. *Mrs. J. Bryning. *Miss E. Beckett. *Miss A. Perrett. *Miss M. Jones. Tuberculosis Dispensary Staff:— *Miss A. B. Myers, *Miss K. Sewell and *Miss H. M. Turner, Nurses. *Miss M. C. Robinson, Dispenser and Laboratory Attendant. *Miss M. E. Sargent, Clerk. *Mr. and Mrs. Snell, Caretakers. Matron of Maternity Home : *Miss M. Bustard. Superintendent of Disinfecting Station : H. Toy. Chief Disinfector: Edward Eyles. Mortuary Keeper: H. Goulden. Rat Officer: H. W. Harvey [part-time]. *The Council receives a contribution from the Ministry of Health towards the salaries of these Officers. 5 Town Hall, Fulham, S.W.6. April, 1923. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Fulham. Gentlemen, I have the honour to submit herewith the Annual Report on the Health and Sanitary Condition of the Borough for the year 1922, this being my first annual report as your Medical Officer of Health. I should like to take this opportunity to place on record my great appreciation of the help which I have received from your late Medical Officer of Health, Dr. J. C. Jackson. His advice in many instances has been invaluable, and I feel that the satisfactory state of the work to which I have succeeded is due in no small measure to his foresight and sagacity. To my brother officials and to the members of the staff of the Public Health Department I also owe a debt of gratitude for much help always willingly given. I am grateful to members of the Council, and particularly to the Chairmen of the Public Health and Maternity and Child Welfare Committees, for sympathetic consideration of public health matters. A prologue such as this would be incomplete without reference to the kind welcome which I have received from the members of the different Voluntary Committees who do so much to augment the work of the Council, particularly in respect to Maternity and Child Welfare. Fulham is extraordinarily fortunate in its voluntary workers, and their efforts have done much to benefit the people of the Borough. I am, Mr. Mayor and Gentlemen, Your obedient Servant, A. MIDDLETON HEWAT, Medical Officer of Health. 6 I give below certain general statistics for the Borough as required by the Ministry of Health:— 1.—General Statistics. Area (acres) 1,706 Population (1921) 159,400 No. of inhabited houses (1921 Census) 25,979 No. of families or separate occupiers (1921 Census) 40,436 Rateable value £980,015 Sum represented by a penny rate £3,972 2.—Extracts from Vital Statistics of the Year. Births— Total. Males. Females.  Legitimate 3,088 1,611 1,477 Birth-rate 20•3. Illegitimate 154 65 89 Deaths 1,935 982 953 Death-rate 12•1. No. of Women dying in, or in consequence of childbirth— From sepsis 8 „ other causes 4 Deaths of Infants under one year of age per 1,000 births:— Legitimate 67 Illegitimate 103 Total 69 Deaths from Measles (all ages) 41 „ „ Whooping Cough (all ages) 26 „ „ Diarrhœa (under 2 years of age) 27 Population.—The Registrar-General has estimated the population of the borough at the middle of 1922 to be 159,500. (Males, 73,972; females, 85,528.) The population at the*Census, 1921, was 157,944, to which had to be added those persons who were on holiday out of the borough at the time of the Census (19th June), making a total estimated population of 159,400 for 1921. In his annual report for 1921 my predecessor, Dr. Jackson, gave figures dealing with the increase of population during the intercensal periods, with overcrowding and with the numbers of families occupying houses of different sizes, as revealed by the Census, 1921. Marriages.—The number of marriages registered was 1,320, and the marriage rate, i.e., the number of persons married per 1,000 of the population, was 8•2. 7 In the three preceding years the marriages numbered 1,477, 1,471, 1,659, thus showing a drop of 157 for 1922. 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 institutions outside the borough, numbered 3,242, of whom 1,676 were boys and 1,566 were girls. The birth-rate was 20•3 per 1,000 inhabitants, being 1•8 per 1,000 below that of 1921. The birth-rate for the whole of London was 21·0, and for England and Wales 20·6. Illegitimacy.—The illegitimate births numbered 154 (65 males, 89 females), or 4·7 per cent. of the total births, against 6·5, 4·8 and 4·5 per cent. in the three preceding years. Natural Increase of the Population.—The natural increase of the population by excess of births over deaths was 1,307, against 1,098, 2,501, and 1,662 in the three preceding years. Deaths.—During the 52 weeks ended 30th December, 1922, 1,897 deaths were registered in the borough. Of these, 362 were of persons not belonging to the borough, while 400 inhabitants of Fulham died outside the borough chiefly in various public institutions. There were, therefore, 1,935 deaths of persons—982 males and 953 females—having their usual residence in Fulham, representing an annual rate of 12·13 per 1,000 of the estimated population, being 0·4 per 1,000 above that of 1921. The death-rate of males was 13·2, of females 11·1. The following comparative death-rates are of interest :— Death-rates, 1922— England and Wales 12 ·9 London 13·4 105 large towns 13·0 Fulham 12·1 8 Zymotic Deaths.—The mortality from zymotic diseases was lower than in 1921, 144 deaths being due to the seven principal epidemic diseases, against 162. The zymotic death-rate was 0·93 per 1,000 population. Seasonal Mortality.—The mortality in the four quarters of the year was as under :— Deaths. Death-rate.  First Quarter 644 16·3 Second Quarter 472 11·8 Third Quarter 389 9·7 Fourth Quarter 430 10·7 1,935 12·1 9 Table 1.—Vital Statistics of Whole District during 1922 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. Number. * Rate per 1,000 Nett Births. Number. * Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13  1911 153,284 4,012 4,122 26·9 2,019 13·2 169 378 517 125 2,228 14·5 1912 155,402 4,079 4,213 27·1 1,830 11·8 173 366 395 94 2,023 13·0 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 a153,161 3,736 3,870 c24·3 1,787 11·7 130 677 446 115 2,334 15·2 1916 a149,428 3,600 3,754 c23·1 1,324 8·9 131 789 330 88 1,982 13·3 b162,580 1917 al45,186 2,852 2,971 c18·4 1,251 8·6 139 882 323 109 1,994 13·7 b161,841 1918 a143,211 2,593 2,672 16·7 1,704 11·9 186 973 286 107 2,491 17·4 b160,463 1919 a152,543 2,947 3,000 c18·6 1,510 9·7 242 634 250 83 1,902 12·2 b155,904 1920 a158,621 4,383 4,327 c27·2 1,888 11·9 457 396 320 74 1,827 11·5 b158,989 1921 159,400 3,546 3,528 22·1 1,865 11·7 381 382 291 83 1,866 11·7 1922 159,500 3,210 3,242 20·3 1,897 11·9 362 400 224 69 1,935 12·1 (a) Estimated civil population. (6) 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 (b) 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" 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 or usual 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 ; (b) 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 district where death occurred, if known; and (d) failing this, to the district where the body was found. Total population at all ages 157,938 at Census of 1921. Area of district in acres (land and inland water), 1,706. 10 Distribution of Deaths.—The number and the causes of the deaths in the several wards of the borough are given in Table II. Certification of the Causes of Death.—Of the 1,935 deaths registered, 1,752, or 90·5 per cent., were certified by registered medical practitioners, and 183 by coroners after inquest, no death being uncertified. Deaths in Public Institutions. Fulham Infirmary.—The deaths of 641 persons occurred in the Fulham Infirmary, of whom 486 lived in Fulham and 155 in other districts. Western Fever Hospital.—In this institution there were 38 deaths of residents in Fulham and 185 of residents in other districts. Deaths occurring outside the Borough among Persons belonging thereto.—The deaths of Fulham residents outside the borough numbered 400, and occurred in the following places :— St. George's Hospital 47 West London Hospital 32 Other General Hospitals 40 Children's Hospitals 38 Hospitals for Women 6 Other Special Hospitals 44 Homes for advanced cases 10 Hospitals of Metropolitan Asylums Board 16 Poor Law Infirmaries 16 Lunatic Asylums 63 Sanatoria 19 Nursing Homes, private houses and elsewhere 69 400 Of the deaths registered, 855, or 44·1 per cent., took place either in poor law institutions, in hospitals or in public lunatic asylums, the percentages in the various classes of institutions beings as under:— Per cent.  Deaths in Workhouses or Workhouse Infirmaries 25·9 „ Metropolitan Asylums Board Hospitals 2·7 „ other Hospitals 12·3 „ Public Lunatic and Imbecile Asylums 3·2 44·1 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 3 years. 3 and under 4 years. 4 and under 5 years. 5 and under 10 years. 10 and tinder 20 years. 20 and under 35 years. 35 and under 45 years. 45 and under 65 years. 65 years and upwards. Total Deaths, whether of "Residents" or" Nonresidents" in Institutions in the District (b). Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham 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 20 21 22  All Causes Certified (c) 1,935 224 99 40 14 17 44 61 139 163 499 635 892 188 326 180 217 407 125 314 178 Uncertified — — — — — — — — — — — — — — — — — — — — — 1. Enteric Fever 4 — 1 2 1 — — 4 3 — — — — 1 2. Small-pox 1 — — — — — — — — 1 — — — — — — — — 1 — — 3. Measles 41 6 16 11 2 4 2 — — — — — 25 1 5 7 7 12 — 8 1 4. Scarlet Fever 12 2 2 2 1 2 2 1 33 2 5 1 1 1 — 1 1 5. Whooping Cough 26 9 12 4 1 — — — — — — — 8 1 7 1 5 7 2 3 6. Diphtheria 33 1 7 5 1 5 10 4 — — — — 152 1 8 1 3 8 10 2 7. Influenza 76 1 5 5 — — — 2 7 12 23 21 26 6 12 2 5 22 8 14 7 8. Encephalitis Lethargica 3 — — — — — — — 1 2 — 2 1 — 1 — — — 1 — 9. Meningococcal Meningitis — — — — — — — — — — — — 2 — — — — — — — — 10. Tuberculosis of Respiratory System 163 1 2 - 17 44 45 47 7 63 8 28 13 24 40 11 26 13 11. Disseminated Tuberculosis 12 2 — 3 3 2 2 9 1 2 1 1 2 1 4 — 12. Other Tuberculous Diseases 21 1 3 3 1 — 5 5 2 1 6 3 2 1 3 6 — 5 1 13. Cancer, malignant disease 204 1 2 11 106 84 71 23 28 16 23 37 15 36 26 14. Rheumatic Fever 11 — — — — — 1 2 3 1 3 1 3 2 — 2 2 — 3 2 15. Diabetes 15 — — — — — — — 2 1 8 4 5 4 3 1 1 2 — 2 2 16. Cerebral Haemorrhage, etc. 80 — — — — — — 1 2 2 31 44 23 10 11 10 9 10 5 14 11 17. Heart Disease 199 — — — — — 3 15 15 70 96 47 18 23 21 25 46 13 30 23 18. Arterio-sclerosis 44 — — — 8 36 40 9 8 6 4 7 1 4 5 19. Bronchitis 155 9 5 — 1 — 2 — 2 3 32 101 52 12 31 12 18 43 14 15 10 20. Pneumonia (all forms) 195 49 34 8 1 4 4 2 11 17 33 32 64 14 34 25 28 40 12 26 16 21. Other Respiratory Diseases 22 — 1 — — — 1 1 1 4 7 7 4 3 3 1 1 5 — 8 1 22. Ulcer of Stomach or Duodenum . 12 — — — — — 2 1 5 4 2 2 1 1 1 2 3 1 1 23. Diarrhoea, etc. (under 2 years) 27 23 4 — — — — — — — — — 13 3 3 2 5 6 1 3 4 24. Appendicitis and Typhlitis 10 — 1 — 1 3 1 3 1 8 1 — 1 4 2 — 1 1 25. Cirrhosis of Liver 9 — — — — — — — — 1 7 1 4 2 3 — 1 1 1 1 — 26. Nephritis and Bright's Disease 60 — — — 1 2 6 27 24 32 8 11 6 7 10 3 10 5 27. Puerperal Sepsis 8 — — — — — — — 7 1 — — 9 2 — — 3 — 1 2 28. Other accidents and diseases of pregnancy and parturition 4 — — — — — — — 1 2 1 — 1 — — _ 1 _ 2 1 29. Congenital Debility and malformation, premature birth 94 93 — 1 — — — — — — — — 24 11 17 10 7 19 4 19 7 30. Suicide 24 — 1 7 6 9 1 5 2 3 3 5 6 — 4 1 31. Other deaths from violence 68 3 3 1 3 2 7 2 9 6 10 22. 44 7 12 6 3 18 5 14 3 32. Other defined diseases 302 26 3 — 2 1 6 9 15 26 65 149 111 35 62 28 23 50 27 49 28 33. Causes ill-defined or unknown — — — — — — — — — — — — — — — — — — — — — Total 1,935 224 99 40 14 17 44 61 139 163 499 635 892 188 326 180 217 407 125 314 178 (a) All " Transferable Deaths " of residents, i.e., of persons resident in the District who have died outside it, are included with the other deaths in columns 2—13, and columns 15—22. Transferable deaths of non-residents, i.e., of persons resident elsewhere in England and Wales who have died in the District, are in like manner excluded from these columns. For the precise meaning of the term transferable deaths " see footnote to Table I. (b) All deaths occurring in institutions for the sick and infirm situated within the district, whether of residents or of non-residents, are entered in column 14 of Table II. (c) All deaths certified by registered Medical Practitioners and all Inquest cases are classed as Certified , all other deaths are regarded as " Uncertified." 11 Causes of Death.—The causes of the deaths occurring in the borough during 1922 will be found in Table II. From this it will be seen that the principal causes were cancer (204 deaths), heart disease (199 deaths), tuberculosis (196 deaths), pneumonia (195 deaths), and bronchitis (155 deaths). The age distribution of these causes is worthy of note. Whereas cancer, heart disease and bronchitis are confined with a few exceptions to persons over 45 years of age, tuberculosis and pneumonia take a heavy toll of the younger portion of the population. About two-thirds of the deaths from tuberculosis and pneumonia occurred in persons under 45 years of age. The large number of deaths from cancer (204 this year and 210 last year) is a matter of serious concern. The deaths from this disease have shown a distinct tendency to increase throughout the country during recent years. The cancer death-rate in Fulham for 1922 was 1·27 per 1,000 population, in 1921 it was 1·31, whereas for 1900 and 1901 the rates were 0·82 and 0·85 respectively. The average rate for the five years 1900-1904 was 0·80, while for the last five years, 1918-1922, the average rate was 1·21 per 1,000, an increase of approximately 50 per cent. Despite much research, no certain cure for this disease has yet been found, and the best hope at the present time lies in early diagnosis and early surgical treatment. With this in view, the Public Health Committee during 1922 issued, free of charge, leaflets on the early signs and symptoms of cancer for the information of the public. These were distributed through the Health Visitors, the Infant Welfare Centres and other institutions. Several doctors in general practice in the borough were also good enough to keep a supply of these leaflets at their surgeries. With regard to tuberculosis, although the number of deaths is still disturbingly high, the tendency is for the death-rate to fall. Taking tuberculosis of the lungs 12 which from an infective point of view is the most important form of the disease as a standard, we find that the average death-rate for the past five years, 1918 to 1922, is 1·08, as compared with a rate of 1·41 for the five years 1900 to 1904, thus showing a fall of approximately 25 per cent, in 18 years. In Fulham this fall really began in the year 1919, although the year 1910 showed a low rate among many high ones. It is hoped that the comprehensive tuberculosis scheme now in operation in London may lead to a gradual decline in this death-rate, although at present the scheme is handicapped, as pointed out later in this report by the tuberculosis officer, by insufficient institutional accommodation for advanced and therefore infective cases. Infantile Mortality.—Of the 1,935 deaths, 224, or 11·5 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 of age to registered births, was 69 per 1,000, being 14 per 1,000 below that of 1921. This rate of 69 per 1,000 births is the lowest rate ever recorded in the borough and compares very favourably with other Metropolitan Boroughs, and with London as a whole. The rate for London was 74, and for England and Wales as a whole 77. The causes of the deaths of infants during 1922 are set out in Table III, and classified according to age and ward. The infantile mortality rate in Fulham since 1886 is given in the subjoined table, which shows very clearly the great advance made in this important matter. If the infantile mortality rate of 1886-1890 had persisted until this year, no less than 551 infants would have died during 1922, as compared with the actual number of deaths, 224. This shows a saving of 327 infant lives for the year. 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. Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward.  All Causes Certified 61 11 14 8 94 36 43 27 24 224 16 47 26 27 45 7 39 17 Uncertified - - - - - - - - - - - - - - - - - - 1. Small-pox - - - - - - - - - - - - - - - - - - 2. Chicken-pox - - - - - - - - - - - - - - - - - 3. Measles - - - - - - - 3 3 6 — 1 1 1 2 - 1 - 4. Scarlet Fever - - - - - - - - - - - - - - - - - - 5. Whooping Cough - - - - - 2 3 3 1 9 - 3 — 2 2 - 1 1 6. Diphtheria and Croup — — — — — — — 1 — 1 - — — — — - 1 7. Erysipelas - - - - - - - - - - - - - - - - - - 8. Tuberculous Meningitis - - - - - - - - - - - - - - - - - - 9. Abdominal Tuberculosis (a) — — — — — 1 — — — 1 - — - — 1 - — - 10. Disseminated Tuberculosis — — — — — — 1 1 — 2 - 1 — — — - 1 - 11. Other Tuberculous Diseases — — — — — — 1 — — 1 - — 1 — — - — - 12. Meningitis (not Tuberculous) — — 1 — 1 — — — — 1 - — — — - - - 1 13. Convulsions - - - - - 2 1 1 — 4 - 1 — 1 1 - 1 - 14. Laryngitis — — — — — — — — — — - — — — — - — - 15. Bronchitis — — 1 — 1 3 1 2 2 9 - 5 1 2 1 - — - 16. Pneumonia (all forms) 1 2 1 5 9 7 12 8 13 49 1 8 6 8 9 2 12 3 17. Influenza — — — — — — — 1 — 1 - — — — — — — 1 18. Diarrhoea - - - - - - 1 1 2 4 1 1 — 2 — — — — 19. Enteritis — 1 2 — 3 5 7 3 1 19 2 1 1 2 6 1 2 4 20. Gastritis — — — — 1 — 1 2 — — — 1 — — 1 — 21. Syphilis — 2 — — 2 1 4 — — 7 — 2 3 — 1 — 1 — 22. Rickets — — — — — — 1 — —- 1 — 1 — — — — — — 23. Suffocation, overlaying 1 — — — 1 — — — — 1 — — 1 — — — — — 24. Injury by Birth 1 — — — 1 — — — — 1 — 1 — — — — — — 25. Atelectasis 6 2 1 — 9 — — — — 9 1 2 2 — 1 — 2 1 26. Congenital Malformations 3 2 5 7 2 3 — 17 3 2 2 2 2 1 4 1 27. Premature Birth 34 2 4 2 42 3 — — — 45 1 10 3 3 15 2 7 4 28. Atrophy, Debility and Marasmus 12 — 3 — 15 4 2 — — 21 5 3 4 2 2 — 4 1 29. Other causes 3 — 1 1 5 1 6 — 1 13 2 5 1 1 2 1 1 — Total 61 11 14 8 94 36 43 27 24 224 16 47 26 27 45 7 39 17 Nett Births in the Year— Legitimate 3,088 Illegitimate 154 Nett Deaths in the Year of— Legitimate infants 207 Illegitimate infants 17 (a) Under Abdominal Tuberculosis are included deaths from Tuberculous Peritonitis and Enteritis, and from Tabes Mesenterica. Want of breast milk is included under Atrophy and Debility. 13 Infant Mortality in Fulham. Dealths 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 1920 74 1921 83 1922 69 Deaths of Illegitimate Children.—Of the 224 infants who died before attaining the age of one year, 17 were illegitimate, the mortality among them being in the proportion of 103 deaths per 1,000 births, against 67 per 1,000 among children born in wedlock. Maternity and Child Walfare. The work in connection with the Council's Maternity and Child Welfare scheme has been carried out during the year on practically the same lines as were very fully detailed in the Report by the late Medical Officer of Health, Dr. Jackson, for the year 1919, and it will only be necessary for me in this report to give an account of the work undertaken during the year. Notification of Births.—Notifications of the births of 2,921 living children and 97 stillborn children were received during the year under the Notification of Births Act, 93·09 per cent. of births registered being notified. Of these, 2,281 or 75·58 per cent. were notified by Midwives, 529 by doctors, and 208 by the parents or other persons present at the birth. Visitation of Mothers and Babies.—The visits paid during the year by the Health Visitors were as follows;— 14 First visits to infants 3,044 Revisits to infants 5,329 Revisits to children aged 1 to 5 years 5,733 Visits to cases of Ophthalmia Neonatorum 40 „ „ Measles 2,511 „ „ Pneumonia 8 „ „ Diarrhoea 2 „ „ Puerperal Fever 5 Other visits 904 Infant Welfare Centres.—The Infant Welfare Centres have been carried on throughout the year by the Voluntary Infant Welfare Committee, the staff consisting partly of municipal officers and partly of officers paid by the Voluntary Committee. The Medical Officers concerned in this work (Dr. Ruby Thomson, Dr. G. F. Hardy and Dr. Florence Wilson) are all provided by the Borough Council as also are the Health Visitors. The Voluntary Committee provide a Superintendent for the Centres and an Assistant Superintendent. Three Centres are in operation, viz. : at 92, Greyhound Road, at 170, Wandsworth Bridge Road and at Melmoth Hall, Eustace Road, thus dividing the Borough into three districts with a Centre within reasonable reach of the mothers residing in each district. The Consultations held at these Centres are divided into two classes; (1) Ante-natal and (2) Post-natal. The Ante-natal Consultations are held by Dr. Ruby Thomson, the Assistant Medical Officer of Health, on one morning and one afternoon each week. The Postnatal Consultations, or, as they are generally known, the Infant Welfare Clinics are held on three afternoons each week at Greyhound Road, two afternoons each week at Wandsworth Bridge Road and two afternoons each week at Melmoth Hall, thus making a total of seven such clinics per week. These Clinics are conducted by Dr. Thomson on three occasions, Dr. Hardy on two occasions and Dr. Wilson on two occasions. I give below particulars of the attendances at these Clinics during the year :— Ante-natal Clinic. No. of women who attended 326 No. of attendances 1,151 15 Infant Welfare Clinics. - Number of Consultations. First Attendances of Babies. Total Attendances. ge Attendances. 92, Greyhound Road 130 479 5,445 42 170, Wandsworth Bridge Rd. 92 281 3,489 38 Melmoth Hall 87 268 2,875 33 In connection with these Clinics the following are particulars of children who attended for special treatments :— At 92, Greyhound Road. No. of children who attended for massage or treatment of minor ailments 292 No. of attendances 1,403 At The School Treatment Centre, 18, Bagleys Lane. For operative treatment for enlarged tonsils and adenoids— No. of children 7 For dental treatment (No. of children) 7 For dental treatment (No. of women) 90 Total attendances of women for dental treatment Of these 90 women, 25 were provided with dentures. 301 For Visual defects— No. of mothers treated 5 No. of children treated 6 Fulham Babies' Hospital, Lindsay House, BroomHouse Road.—This Hospital, conducted by a Voluntary Committee and containing 21 cots, receives a grant of £1,000 per annum from the Borough Council. Its primary function is the treatment of nutritional and dietetic disorders in infants. The Medical Officer of Health is Medical Superintendent of the Hospital and during the year 1922, the clinical work of the hospital has been in charge of Dr. Thomson and Dr. Hardy, two of the Assistant Medical Officers of Health. 16 It is satisfactory that during the year the hospital had not to be entirely closed for any period owing to infectious disease, although on two or three occasions wards had to be individually closed on this account. The small ward had to be closed owing to a burst pipe from January 3rd to January 22nd, but otherwise the wards were only closed for odd days in order to enable disinfection to be carried out. The following is a summary of the work of the Hospital during 1922 :— In Hospital, January 1st, 1922 14 Number of babies admitted during the year 140 Average duration of stay (days) 37·7 Number of cases discharged : (a) In good health 56 (b) Improvement 44 (c) No improvement 12 (d) On account of the development of infectious disease 13 Viz.— Measles 6 Pertussis 4 Scarlet fever 1 Chicken pox 2 No. of deaths 11 No. in hospital, 31st December, 1922 18 The average daily number in the wards during the year was approximately 16 as compared with the average during 1921 of 12. Fulham Day Nursery, Eridge House, Fulham Park Gardens.—The Fulham Day Nursery is conducted by a Voluntary Committee of which the late Medical Officer of Health, Dr. J. Charles Jackson, is Chairman. This Committee receives a grant of £300 per annum from the Borough Council and the Medical Officer of Health is a member of the Committee. The Medical work is in charge of Dr. Ruby Thomson, Assistant Medical Officer of Health. The attendances during the year were as follows :— Individual children attended— Under three years of age 136 Over three years and under five 28 17 The total attendances made by the above children were :— Under three years— Whole day 6,793 Half day 292 Over three years- 782 Whole day Half day 5 Total- Whole day 7,575 Half day 297 The Borough Maternity Home, 706, Fulham Road.— This Institution is entirely under the control of the Borough Council, the medical work of the home being in the hands of Dr. Ruby Thomson, Assistant Medical Officer of Health. The following is a record of the cases admitted to the home during 1922 :— Cases admitted 169 Average duration of stay (days) 14 No. of cases delivered by— (a) Midwives 164 (b) Doctors 5 No. of cases notified as puerperal sepsis 2 No. of cases in which the temperature was above 100·4 for 24 hours 4 No. of cases notified as ophthalmia neonatorum nil No. of cases of " inflammation of eyes " however slight 3 No; of infants not entirely breast-fed while in the Institution nil No. of maternal deaths 1 No. of foetal deaths (stillborn or within ten days of birth) 3 No. of cases in which medical advice was sought by the midwife— During labour 7 After labour 6 For the infant 6 I should like to record my appreciation of the way in which the Matron and the staff of the Maternity Home have carried out their duties during the year. The work 18 is hard and the hours irregular, but every one in the Institution takes a real interest in the work and there is a spirit of mutual helpfulness. During the year 1922, the Council decided that owing to the large number of applicants for admission, it was necessary to increase the accommodation of the home. Accordingly, three additional rooms and a bathroom were built on to the house, which has enabled the Matron's former sitting room to be converted into a ward for three additional beds, and one member of the nursing staff who formerly had to sleep outside the Institution has now been provided with a bedroom. There will now be accommodation for ten cases under normal circumstances instead of seven as formerly, but owing to the irregularity with which confinements occur, it is not always possible to limit our numbers strictly, and on many occasions additional beds have to be put up for temporary emergencies. Provision of Milk.—Under the Maternity and Child Welfare Act, 1918, milk is provided free, or at less than cost price to necessitous cases under the Council's scheme. During the year grants of milk were made to expectant mothers and to children under five years in 449 cases. The amount expended was:- £ s. d. For dried milk 304 7 5 For fresh milk 33 10 8 Total £337 18 1 This compares with the sum of £1,041 15s. expended in 1921 and £1,169 14s. 1920. It will be seen, therefore, that there has been considerable economy effected in this distribution of milk. All applications are considered by a sub-committee of the Maternity and Child Welfare Committee, who institute the necessary inquiries as to the circumstances of the applicants, and each case is considered in 19 nection with the scale of income which has been approved by the Ministry of Health. In addition to the milk given free or at a reduced price, 25,764 lbs. of dried milk, value £2,556 19s. nd., were sold at cost price to persons recommended by the Health Visitors or Welfare Centres. Incidence of Infectious Disease among Parturient Women and Infants. Puerperal Fever.—Thirty-one cases of puerperal fever, equal to 9·56 per 1,000 births, were notified, and of these cases 8 died. Twenty-nine of the 31 cases were removed to hospital. The number of cases of this disease notified during 1921 was 27 with 6 deaths, so that there has been an increase of 4 cases and 2 deaths during the year. In addition to these, 4 deaths were due to accidents of pregnancy and parturition as compared with 7 during 1921. In the report of my predecessor for 1921, it was stated that the number of notified cases of puerperal fever was higher in Fulham than in any other metropolitan borough. For 1922, Fulham still has a much larger number of cases than the average for the London boroughs, and only one borough shows a larger number. Arrangements were made during the year with the Fulham Guardians, whereby medical practitioners can send into the Fulham Infirmary suspected cases of puerperal fever without waiting till the diagnosis is absolutely certain. This enables such cases to be brought under effective treatment at the earliest possible moment, thus giving the patient the best chance of recovery. It is a recognised fact that the earlier such cases are thoroughly treated, which in many instances is impossible in working-class houses, the better the prognosis for the patient. It is hoped that medical practitioners will avail themselves of this arrangement, and that our mortality from puerperal fever may be accordingly diminished. 20 Ophthalmia Neonatorum.—Thirty-three infants were notified as suffering from ophthalmia neonatorum, of whom 8 were removed to hospital. This total compares with 30 notifications during 1921, of whom 5 were removed to hospital. The result of the cases was as under :— Cases notified. Treated at home. In hospital. Vision unimpaired. Vision imparied. Total blindness. Deaths Left the district. 33 25 8 25 1 — 4 3 Measles.—Of the total of 2,438 cases of measles notified during 1922, 1,353 occurred in children under the age of five years. Diarrhœa.—Seventeen cases of diarrhœa were notified during 1922 compared with 140 during 1921. All of these cases were under the age of five years. No doubt the marked difference between the climatic conditions during the two summers accounts for this difference in figures. Home Nursing. Arrangements are in operation whereby home nursing is provided in the borough for :— (a) Cases of infectious disease, particularly influenza and pneumonia, in persons over five years of age. (b) For any case of serious illness in children under five and occasionally for pregnant and nursing mothers. This nursing is only available for persons who are in such a financial position as to be unable to pay for the services of a nurse. The arrangements are made by the Public Health Committee and the Maternity and Child 21 Welfare Committee with the Borough of Fulham District Nursing Association, which is affiliated to Queen Victoria's Jubilee Institute. The work carried out by these district nurses is most valuable, and the Borough Council were fortunate in being able to come to satisfactory arrangements with the association. The fee for each visit paid by the district nurses, and chargeable to the Borough Council, is one shilling. During 1922 these fees amounted to the sum of £68 14s., payable by the Public Health Committee, and £80 14s. payable by the Maternity and Child Welfare Committee. In the latter case one-half of this amount is recoverable from the Ministry of Health by way of grant. Infectious Diseases. The total number of cases of infectious diseases notified during the year was 4,388, compared with 2,834 for the year 1921. Towards this total of 4,388, measles contributed 2,438 cases, as compared with 369 during 1921. It will be seen, therefore, that the epidemic of measles accounted for practically the whole of the difference in the number of notifications between the two years. Full particulars of these notifications arranged according to disease, ward and age, will be found in Table IV, page 28. Scarlet fever was less prevalent than in the previous year, 626 cases compared with 921, while diphtheria was reduced in numbers by approximately one-fifth, there being 438 cases compared with 579 in 1921. There were three outbreaks of infectious disease during the year which require special note. (1) Measles.—This disease was epidemic in the borough during February, March and April. In one week in March no fewer than 158 cases were notified, while the average notifications during the latter part of March and early April were approximately 130 per week. The outbreak was fairly well distributed throughout the borough, with the exception that Munster Ward 22 had nearly double the number of any other ward. There were 700 cases during the year in Munster Ward, while Barons Court Ward had the least incidence with only 86 cases during the year. This outbreak rapidly tailed off during the latter part of April, May and June. In July the average weekly notifications had fallen to 25, and in the latter part of August to 5. From August until the end of the year the maximum number of cases of measles notified in any week was 6. Fortunately, the majority of the cases were mild, but 41 deaths were attributed to this disease, whereas diphtheria and scarlet fever added together accounted for 45 deaths. (2) Typhoid Fever.—A sharp and fatal outbreak of typhoid fever occurred in one house in Walham Avenue during July. There were 6 cases involved, of whom 2 died. The outbreak was very carefully investigated, and the following is the result of our inquiries:— "R. C., a female aged 13, commenced to be ill about the 3rd July. She was removed to the Fulham Infirmary, where she died on 22nd July. A post mortem examination was performed, and considerable typhoid ulceration of the last 4 feet of the small intestine was found. The spleen was large and congested. Clinically this patient suffered from typical typhoid fever. Mrs. M. R., a female aged 19, commenced to be ill on the 11th July. Mrs. F. C., a female aged 41, mother of the above two patients, also complained of symptoms about the 15th July, but on careful inquiry it was found that she had been feeling ill since about the 21st June. A. C., a male aged 8, took ill about the 1st July, 1922. W. C., a male aged 9, took ill about the 14th July, while D. C., a baby, began to suffer on the 27th July. All the above patients gave positive Widal reactions to B. Typhosus up to a high degree of dilution. "Careful inquiry and examination of the house, including the drains, revealed no obvious source of infection, either in food or dwelling-house. It is worthy of note that the husband of Mrs. F. C. (and the father of the children) suffered twice while in the army from P.U.O. Since his discharge in 1918, he has been a chronic neurasthenic and is never in good health. Two specimens of stools were examined from this man, and in both cases with negative results. Against the possibility of his being a carrier, and the source of infection, must be placed the fact that he had been at home on and off since 1918 with no previous ill effects on his family, and he had recently been in a convalescent home and did not infect anybody there, I am inclined to think that the first case, and the 23 infecting agent in the others, was in reality Mrs. F. C., who, as will be seen from the dates of onset, had been out of sorts since about the middle of June. It is impossible, however, to say from what source she derived her infection. In this connection, it should be mentioned that living in the same house were a man and his wife and two children, none of whom contracted the disease, although using the same water supply and the same W.C. This latter family, however, provided and cooked their own food separately, whereas Mrs. F. C. prepared and cooked the food for the rest of the household. All the cases were isolated, either in the Fulham Infirmary or in the South Western Fever Hospital. The house was thoroughly disinfected, the drains were tested, and the house was done up throughout by the owner. There was no spread of the disease from this one infected house. (3) Smallpox.—During the prevalence of smallpox in London in the autumn of 1922, Fulham was fortunate in escaping with only two cases, both in the same house. I give below a copy of the special report which I presented to the Council on this matter in November, 1922:— "A woman and her daughter, aged 12, who were living in domestic service in the Borough of Westminster, visited a relative on 23rd September at Dartford. At the time of the visit it was not known that this relative was suffering from smallpox. The woman and her daughter left Dartford on 24th September and returned to Westminster. On 25th September they were notified that the relative in Dartford was suffering from smallpox. Unfortunately, the woman and her daughter delayed their vaccination until 27th September. On 28th September they both left Westminster, stating that they were returning to Dartford, but as a matter of fact they came to Fulham, and thus escaped the vigilance of the Sanitary Authorities, both in Westminster and Dartford. "On the 5th October, I was asked by a doctor in the Borough to see this woman, as he thought she was suffering from smallpox. I was able to confirm the doctor's diagnosis, and as we were both very suspicious that the daughter was also suffering from a mild attack of smallpox, we decided to call into consultation Dr. Wanklyn, the London County Council's smallpox specialist. Dr. Wanklyn confirmed our suspicions with regard to the daughter, and both cases were at once removed by river ambulance to the Metropolitan Asylums Board's Smallpox Hospital at Dartford. The room in which the patients had lived, and in fact the whole house, was thoroughly disinfected, and all articles used by the patients were removed to the disinfecting station. "I at once took every step to find out all persons who had been in contact with the patients during the time they had been ill, i.e., from 3rd October to 5th October. They were lodgers in a house in Fulham. This house contained ten other occupants, of whom no 24 ess than six went out to work, one girl being employed in a laundry, two men in delivering laundry, and two men as motor drivers. In addition a small boy attended a private school in the Borough. All these persons had been more or less in contact with the patients between 3rd October, when they first took ill, and 5th October. Further contacts were a sister who had visited her on one occasion and a daughter of the householder. Both these contacts lived in another part of Fulham. Fortunately, the patients knowing that they had been exposed to infection did not go outside the house from the time they first felt ill. This was a very considerable help in enabling us to check the spread of the disease. It was obvious, however, that with so many workers engaged in such occupations as motor driving and delivering laundry, the risk of spread was very considerable. Under the circumstances, it was absolutely essential that these people should be prohibited from going to work until the quarantine period was over, and after consultation with the late chairman of the Public Health Committee, we decided to pay the workers full compensation for loss of wages during this period. All the contacts were most helpful in every way, agreed to be vaccinated at once, and were so vaccinated, and agreed to abide by all the restrictions which I put upon their movements. "I made arrangements that Inspector Grigg should visit the house every morning, take any messages and do any shopping required. Foodstuffs, etc., were left next door and taken in by Inspector Grigg later in the day. I visited the house personally every morning during the latter part of the quarantine period, and upon satisfying myself that the contacts were in good health, they were allowed to go for walks, but prohibited from entering shops, public vehicles, or places of entertainment. I visited the school attended by the boy, and circularised the parents of all children of that school, advising them to be vaccinated. I further communicated with the persons in charge of the various laundries and motor garage concerned, advising vaccination of contacts. "I am glad to be able to state that we can look upon this outbreak as finished, no secondary cases having occurred. "Unfortunately, the adult patient died in hospital." Tuberculosis.—Three hundred and eighty-five new cases of tuberculosis were notified during the year. Of these, 272 were cases of tuberculosis of the respiratory system, 5 were cases of disseminated tuberculosis, and 108 cases of tuberculosis of other organs. This total of 385 compares with a total of 360 during 1921, so that there is a slight increase, which is accounted for entirely by an increased number of notifications from tuberculosis of other organs (108 as against 74 in 1921). In Table IV, page 28, the notifications of tuberculosis 25 will be found classified according to age and ward. The question of the notification of tuberculosis occupied considerable attention during the year, and it was felt by some members of the Council that general practitioners were not notifying cases of this disease as early and as carefully as they might do. Below I give the result of an inquiry made into the figures for notifications and deaths from this disease during the year:- Mortality from Tuberculosis. Respiratory System— 163 deaths 90 males, 73 females. Death rate 1.02 per 1,000, being 0.6 higher than 1921. 137 notified (84-0 per cent.), 26 not notified (16 per cent.) of whom 10, or 38.4 per cent, died in institutions. Other Tuberculous Diseases— 33 deaths 11 males. 22 females (including 12 deaths from disseminated tuberculosis). Death Rate 0.2 per 1,000. 22 notified (66.6 per cent.), 11 not notified (33.3 per cent.) of whom 5, or 45.4 per cent, died in institutions. Period between Primary Notification and Death. Respiratory System— Under 1 month 21 (15.3 per cent.). 1-3 months 14 (10.2 per cent.). 3-6 „ 24 (17.5 per cent.). 6-12 „ 29 (21.2 per cent.). 1-2 years 20 (14.6 per cent.). Over 2 years 29 (21.2 per cent.). Other Tuberculous Diseases— Under 1 month 17 (77.4 per cent.), including 4 disseminated tuberculosis. 1-3 months 1 (4.5 per cent.), including 1 disseminated tuberculosis. 3-6 „ Nil. 6-12 „ 1 (4.5 per cent.), including 1 disseminated tuberculosis. 1-2 years 1 (4.5 per cent.), including 1 disseminated tuberculosis. Over 2 years 2 (9.1 per cent.), including 2 disseminated tuberculosis. 26 From this it will be seen that of the deaths from tuberculosis of the respiratory system 16.6 per cent, had not previously been notified as suffering from tuberculosis while for other tuberculous diseases 32 per cent, of the deaths had not been previously notified. It is rather a noteworthy fact that of these failures to notify no less than 42.8 per cent. of the respiratory type and 62.5 per cent. of other types were cases dying in Institutions. It would appear, therefore, that the blame for failure to notify may be fairly evenly divided between the general practitioners and the Institutions. Perhaps a more important point arises in connection with the period between the date of primary notification and the death of the patient. It will be seen from the above table that 16.4 per cent. of the respiratory cases and 88.2 per cent, of the non-respiratory cases were only notified within a month of their death. It will be quite obvious that it is almost impossible for the Public Health Authority to be of much assistance to cases which are only brought to their notice within a few weeks of the patient's death and it is reasonable to conclude that many of these cases might, with considerable advantage, have been notified earlier. Venereal Diseases. The treatment of venereal diseases in Fulham is in the hands of the London County Council and arrangements are made whereby persons may receive treatment for venereal diseases at special clinics held at certain hospitals, those most convenient for Fulham being the West London Hospital and St. George's Hospital. Educational work is carried out on this subject in the Borough by a local voluntary Committee under the National Council for combating Venereal Diseases. This Committee is a very efficient and representative body, and during 1922 much work was done towards educating public opinion on the important subject of venereal diseases. These diseases lend themselves 27 essentially to preventative treatment as the inculcation of a higher moral standard, and the knowledge of the possible results of indiscriminate sexual intercourse can, if thoroughly realised and acted upon, do much to reduce the incidence of these diseases. I give below a list of lectures and film displays given by the Committee during 1922:— List of Lectures and Film Displays. Where held. Date. Subject. Lecturer. Sherbrooke Road School 15.2.22 Lecture. Dr. Gordon Clark. Women's Co-operative Guild 16.2.22 ,, Dr. Logan. Labour Party 16.2.22 „ Dr. Frazer Nash. New King's Road School 8.3.22 „ Dr. Frazer Nash. Queensmill Road School 22.3.22 „ Dr. Sloan Chesser. Central Library 30.5.22 Film. Dr. Sloan Chesser. „ „ 31.5.22 „ Dr. Feldman. Langford Road School 7.6.22 Lecture. Dr. Douie. Mothers' Union 12.6.22 ,, Dr. Douie. Trades and Labour Councils 16.6.22 „ Mr. Elliott. Women's Co-operation Guild 5.7.22 ,, Dr. Frazer Nash. Mothers' Meeting 17.7.22 „ Dr. Frazer Nash. Social Workers 3.10.22 Film. Miss Dugdale. St. Dunstan's Road School 21.11.22 „ Dr. Douie. „ „ „ „ 21.11.22 " Dr. Douie. 28 Table IV.—Cases of Infectious Diseases notified during the Year 1922. Notifiable Diseases. Number of cases notified.. Total cases notified in each Ward of the Borough. Total Cases removed to hospital. Deaths. At all ages. At ages—Years. Barons Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. 0-1 1-2 2-3 3-4 4-5 5-10 10-20 20-35 35-45 45-65 65 and upwards. Smallpox 2 — — — — — — 1 — 1 — — — — — — — 2 — — 2 1 Cholera, Plague — — — — — — — — — — — — — — — Diphtheria (including Membranous Croup) 438 12 46 49 39 26 130 74 49 4 8 1 18 85 22 72 103 20 100 18 416 33 Erysipelas 94 — 1 — 1 3 — 10 15 11 25 28 3 17 6 22 23 2 19 2 54 7 Scarlet Fever 626 4 23 33 42 31 240 196 42 12 2 1 22 103 46 81 148 21 149 56 586 12 Typhus Fever — — — — — — — — — — — — — — Enteric Fever 16 — 2 — — — 3 5 2 3 1 2 3 7 1 — 1 2 16 4 Relapsing Fever, Continued Fever — — _ _ — _ _ — — — — — — — — — — — — — — — Puerperal Fever 31 — — — — — — — 22 8 1 — 3 6 2 3 8 2 5 2 29 8 Cerebro-Spinal Meningitis 1 —. — — — — — 1 1 — — — — — — — — — Poliomyelitis 2 — 1 — — — — 1 — — — — — — — — — — 1 1 2 — Ophthalmia Neonatorum. . 33 33 — — — — — — — — — — 1 8 2 6 4 — 6 6 8 — Tuberculosis of Respiratory System 272 — 1 1 — 1 8 37 100 44 75 5 13 39 21 41 64 18 47 29 — 163 Disseminated Tuberculosis 5 2 — — — — 1 — 1 — 1 — 1 1 1 1 1 — 12 Other Tuberculous Diseases 108 1 5 5 1 5 20 33 26 5 5 2 4 24 9 5 29 5 24 8 — 21 Measles 2,438 117 316 358 232 330 1,001 62 15 3 3 1 86 452 173 376 700 107 274 270 109 41 Encephalitis Lethargica 3 — — — — — — — 1 1 1 — 1 2 — — — — — 3 3* Pneumonia 300 9 36 20 13 5 27 32 49 42 46 21 15 44 26 61 108 5 24 17 187 195 Diarrhoea 17 15 1 1 — — — — — — — — 4 2 6 2 — 3 — 14 27 Malaria 1 — — — — — — — 1 — — — — — — 1 — — — Dysentery — — — — — — — — — — — — — — — — — — — 1 1 — Trench Fever — — — — — — — — — — — — — — — — — — — — — — Total 4,388 193 432 467 328 401 1,430 451 323 134 169 60 168 786 319 674 1,192 182 654 413 1,427 527 *1 Patient notified as suffering from Cerebro-Spinal Meningitis. 29 Treatment of Tuberculosis. The Tuberculosis Dispensary, which acts as the centre for the co-ordination of the treatment of tuberculosis in the Borough, is situated at 114, New King's Road. The premises are excellently adapted for the purpose and were taken over on 1st April, 1921, from the Voluntary Committee which from November, 1911, till that date, had carried out this important work. The administration of the Dispensary is now in the hands of the Borough Council Public Health Committee, subject to the approval of the arrangements by the London County Council and the Ministry of Health. The Ministry of Health contribute 50 per cent. and the London County Council 25 per cent, of the net expenditure, the balance being found by the Borough Council. The staff consists of one whole-time tuberculosis officer (Dr. J. Sullivan), one part-time assistant tuberculosis officer (Dr. G. F. Hardy), three nurses, one dispenser and laboratory assistant, one clerk and the caretakers. I append a short account by Dr. Sullivan of some of the features of the work during 1922, which he considers worthy of note. Report by the Tuberculosis Officer on the Work of the Tuberculosis Dispensary.—The care of persons suffering from tuberculosis is undertaken by a number of authorities under the general supervision of the Ministry of Health, and in London two schemes exist, one under the London County Council and the other under the Poor Law Authorities. Under the London County Council scheme the central co-ordinating authority is the London County Council and the local centres are the Borough Councils. Residential treatment is provided by the London County Council in Institutions belonging to the Metropolitan Asylums Board, and in voluntary hospitals and sanatoria, and by the Guardians in the tuberculosis wards of Infirmaries, while surgical cases are sent to special hospitals both by the London 30 County Council and by the Guardians. Patients living at home are under the care of private doctors, outpatient departments of hospitals or dispensaries. The co-ordinated measures of the London County Council and Borough Councils have been fairly successful and there is now a definite scheme of cooperation between the different bodies dealing with tuberculosis. It is the duty of the dispensary to see that all patients are kept under supervision or treatment and that no case is lost sight of. The system at present, however, is complicated and much time is occupied in correspondence, form filling, and administrative work generally, which could more usefully be spent on clinical work. There is a good deal of overlapping between the central and local arrangements which, no doubt, will be eliminated in the course of time and as the result of experience. There is, moreover, great need to simplify procedure. The fact that the London County Council and Poor Law schemes are under separate control is also a difficulty. Note on the want of accommodation for cases in the second and third stages.—These may be looked upon as more or less advanced cases. On account of the lack of accommodation in institutions for these cases, they have to be treated at home during the greater part of the course of the disease. Although it is a difficult matter in many instances to ascertain the source of infection in a case of tuberculosis, the disease is certainly caused in many cases by the patient living in contact for a prolonged period with another person suffering from tuberculosis, and it is impossible to take adequate precautions against infection in the average home. It has been estimated that approximately 94 per cent, of cases are due to infection from a human source and 6 per cent, from a bovine source. On investigation of the histories of the 190 new cases notified for tuberculosis during the year, 60 were traced to infection from other members of the family, equivalent to a percentage of 31•5. It is, of course, impracticable to compel all patients in the later stages to go to institutions, firstly, on account of the expense involved, and secondly, on 31 account of the harshness of such a proceeding. A rapid decline in the tuberculosis death rate is not, however, to be expected until the most obvious cause of the spread has been removed. The chief difficulty at present is that most of the accommodation available for advanced cases is in infirmaries, and many persons refuse to go to a Poor Law Institution. Alternative accommodation, near enough for friends to visit frequently and sufficiently attractive to induce patients to remain, is much needed. Home visiting and examination of contacts.—5,447 home visits were made by the nurses during the year under review. The chief objects of the visits are to keep the home under supervision and to see that curative and preventive measures are carried out. A general idea of the economic, social and financial circumstances is obtained by the nurse, so that if help is necessary the case can be reported to the Care Committee. A knowledge of the home circumstances is of great assistance in the treatment of the case and also from the public health point of view. During 1922, 73 houses were dealt with by the Medical Officer of Health on the recommendation of the Dispensary staff. The visiting ensures that the Dispensary keeps in touch, not only with the patient but with other members of the family, or contacts. This is especially important if the case is one discharging tubercle bacilli in the sputum and such cases are visited more frequently than those which are not infectious. As regards the routine examination of contacts, 409 examinations were made and 34 contacts were advised to attend as patients. The number of contacts found to be tuberculous on first examination is very small, as prolonged and intimate contact is necessary unless there is a diminution of specific resistance such as is probably the case in certain families. Active signs may not develop until some years after the original exposure to infection, and it is advisable in many cases to re-examine contacts at intervals. The Care Committee.—The Dispensary is fortunate in having so many experienced workers on the Care 32 Committee and there is no doubt of the great value of this work. Social work in Fulham is very well organised and the overlapping and over-visiting which existed some years ago have been practically abolished. The duties of the Committee come under the following heads:— 1. Obtaining financial assistance, clothing, bedding, food and extra nourishment in necessitous cases. This is not done by the Care Committee itself but indirectly by the Charity Organisation Society, the Soldiers' and Sailors' Families' Association, the British Red Cross Association, the Guardians, and the Fulham Borough Council. 2. Friendly visiting. 3. Arranging for children and other dependants while the father or mother is in sanatorium. 4. Obtaining institutional treatment in a few instances for advanced cases for whom the London County Council are unable to provide accommodation. 5. Obtaining convalescent treatment for persons not coming under the London County Council scheme, e.g., persons debilitated after nursing a patient. 6. Assessing each case receiving institutional treat- ment under the London County Council's scheme, and collecting the weekly assessment. Extra nourishment.—During the year, extra nourishment was granted by the Borough Council to 26 patients, and the amount expended was £29 os. 11d. As an example of the work of the Care Committee I give below some typical cases dealt with during the past year:— Typical Cases dealt with by the Interim Tuberculosis Care Committee. A, a girl of 13, not strong, who was rapidly deteriorating both physically and morally in bad home surroundings. Her mother, who was recommended for sanatorium treatment, refused to leave 33 home until this child was arranged for, and through the C.O.S. she was placed in a small private training home, where a point was stretched to admit her although under the usual age limit. She has settled down very happily and has improved in every way. B was a married man with two young children who, on first coming to the Dispensary, was found to be in need of sanatorium treatment. An ex-Service man, he was not at the time in receipt of a pension and was unable to go away until his family were arranged for financially. He was referred to the C.O.S., who made him an allowance for some weeks, and, when his appeal for a pension went in, obtained help for him from the British Red Cross, thus enabling him to accept treatment with an easy mind. The appeal for pension was ultimately successful and the family are now comfortably off. C was a child of 12, who after some time at the open-air school was pronounced fit to attend ordinary council school. She flagged a good deal in the late spring and was referred to the Invalid Children's Aid Association, who sent her to Yarmouth for six weeks. She came back at the end of September looking very well, has attended school regularly since and when seen at the Dispensary in February of this year was complaining of nothing. D was the mother of a patient, a young girl of 17, whom she nursed devotedly for many months. When the daughter died, the mother was quite worn out and a change was essential. The spare money of the family, however, had all been swallowed up in the illness and the wished-for change seemed out of the question. Again the C.O.S. was asked to help and she was sent to Wales to stay with her sister, her fares being paid by the Society. She was away several weeks and returned very much better for the change and rest. E came to the Dispensary one Thursday evening so ill that she had to be sent into the Infirmary the next morning. A visit to the home disclosed the fact that there were five small children and the problem was what to do with them. The case was referred to the C.O.S. and until arrangements could be made for the children, a neighbour was found who did all she could. Finally the two tiniest were sent to St. Margaret's Guest House, the C.O.S. helping very largely with the cost; one was admitted to the Infirmary, and the neighbour looked after the two eldest, who were of school age, a friendly eye being kept on them by the C.O.S. The patient was away five months and made %ood progress. She has now been home for nine weeks, but the three children are still away as it is felt the care of them would be too much for her. F was a young man living alone. When he became ill his income consisted solely of his National Health Insurance money, hardly enough to provide entirely for an invalid. As he was appealing for a pension, the British Red Cross were asked to help and during 34 the time he had to wait before being admitted to a Sanatorium, that Association gave him a grant of milk and eggs which was of verv great benefit to him. Summary of Dispensary Statistics for 1922. Number of new patients— Insured 227. Uninsured 364 (151 adults and 213 children). Total 591 Number of patients who attended (old and new), 1,454. Number of attendances— Insured 2,507. Uninsured 3,703. Total 6,210. Number of cases notified to M.O.H.— Pulmonary 176. Non-pulmonary 46. Total 222 (of these, 190 were notifications of new patients). Number of physical examinations 2,993 Number of reports sent to public bodies 945 Number of reports sent to doctors 214 Number of home visits paid by doctors 1,264 Number of home visits paid by nurses 5,447 Patients sent to institutions bv the L.C.C.— Hospital. Sanatoria. Men 29 56 Women 5 29 Children 2 7 13 children have been sent to Convalescent Homes through the Invalid Children's Care Committee. 5 girls were placed in Training Homes by the Charity Organisation Committee. 2 women were sent to Convalescent Homes by the Charity Organisation Committee. 5 patients were admitted to institutions privately. 73 homes were reported as insanitary and have been done up. 35 Contacts— Number of examinations of contacts 409 Number of contacts made patients 34 Ex-service men— 310 ex-service men attended during the year, and of these 214 were notified cases of tuberculosis. Table A.—Showing who recommended the patients. 236 were recommended by private doctors. 20 „ „ the Medical Officer of Health. 22 „ „ the School Medical Officers. 15 „ „ the school authorities. 9 „ „ hospitals. 2 „ „ sanatoria. 8 „ ,, other dispensaries. 2 ,, ,, the Fulham Infirmary. 47 „ „ the army authorities. 63 „ „ the dispensary staff. 10 „ „ the London County Council. 41 „ „ friends. 36 „ ,, other patients. 38 „ „ the door plate. 15 ,, „ the Invalid Children's Aid Association. 4 „ „ the Charity Organisation Society. 1 was recommended by the Children's County Holiday Fund. 1 „ „ the Soldier's and Sailors' Families Association. 1 „ „ the district nurse. 20 were contacts. 591 Table B.—Sex and age of new patients for 1922. Under 5 yrs. 5-10 yrs. 10-15 yrs. 15-25 yrs. 25-35 yrs. 35-45 yrs. 45 yrs. & over All ages. Males 27 69 24 44 65 42 44 315 Females 12 51 30 47 66 46 24 276 Total 39 120 54 91 131 88 68 591 36 Table C.—Diagnosis in males and females. Total Cases. Pulmonary Tuberculosis. Other forms. Suspects NonTuber cular. Percentage Tuberculous. 315 males 100 17 10 188 36•5 276 females 55 18 3 200 26•4 591 both sexes 155 35 13 388 32•1 Table D.—Diagnosis at various age periods. Pulmonary Tuberculosis. Other forms. Suspects. Non Tubercular. Percentage Tuberculous. Under 5 years 1 6 2 30 17•9 „ 10 „ 5 11 1 103 13•3 ,, 15 ,, 3 9 2 40 22•2 ,, 25 ,, 41 3 3 44 48•3 „ 35 „ 53 3 1 74 42•5 „ 45 „ 21 2 4 61 26•1 45 years and over 31 1 — 36 47•0 Total 155 35 13 388 32•1 Table E.—Housing conditions. Of 175 of the 190 tuberculous patients found in 1922— 3 lived in the basement. 49 „ on the ground floor. 49 „ „ first floor. 4 „ ,, second floor. 8 „ „ third floor. 5 „ „ top floor. 36 „ on more than one floor. 21 „ in the whole house. 175 37 Table F.—Housing accommodation. Number of Families occupying 1 room. 2 rooms. 3 rooms. 4 rooms. 5 rooms. 6 rooms or over. Patient living alone 5 — 1 Patient living with 1 other 8 12 4 1 1 — „ „ 2 others 2 9 16 7 3 3 „ „ 3 „ — 5 14 8 6 2 „ „ 4 „ 1 3 9 7 2 3 „ „ 5 „ — 1 7 4 5 2 „ „ 6 „ — 2 2 6 — — „ „ 7 „ — — 4 5 — — „ „ 8 „ — — — 1 — — „ „ 9 „ — — — — — 1 „ „ 10 „ — — 1 — — — „ „ 11 „ — — — — 1 — „ „ 14 „ — — — — — 1 Total 16 32 58 39 18 12 Table G.—Sleeping accommodation of 175 tuberculous patients. The patient slept— In a separate room In 65 cases. Alone in bed with one other in room „ 13 „ „ „ two others in room „ 11 „ „ „ three others in room „ 4 „ „ „ four others in room „ 1 case. „ „ five others in room „ 1 „ „ „ six others in room „ 1 „ In bed with one person and no others in room In 52 cases. „ „ one other in room „11 „ „ „ two others in room „ 5 „ „ „ three others in room „ 2 „ „ „ four others in room „ 1 case. In bed with two persons and no others in room „ 6 cases. „ „ two others in room „ 1 case. In bed with three persons and two others in room „1 „ 38 Table H.—Occupations of 99 tuberculous men in 1922. 2 bakers. 6 painters. 1 basket maker. 1 photographer. 1 bookkeeper. 1 piano regulator. 2 bus conductors. 1 plumber. 2 carmen. 7 porters. 1 cabinet maker. 1 postman. 10 clerks. 1 public house manager. 2 commercial travellers. 1 Red Cross worker. 2 compositors. 1 saddler. 1 cook. 1 scaffolder. 1 draughtsman. 1 sheet metal worker. 1 electrician. 4 shop assistants. 8 engineers. 1 shop manager. 1 gardener. 1 stoker. 2 gas fitters. 1 student. 1 groundsman. 1 tailor. 1 handyman. 1 ticket collector. 1 hot water fitter. 1 upholsterer. 2 inspectors. 1 van salesman. 1 ironmoulder. 1 warehouseman. 8 labourers. 1 window cleaner. 7 motor drivers. 1 wood machinist. 1 packer. 2 no occupation. Occupations of 56 tuberculous women in 1922. 1 biscuit packer. 1 ironer. 1 boarding house keeper. 2 machinists. 1 book folder. 1 milliner. 2 cashiers. 2 shop assistants. 5 clerks. 1 solderer. 7 domestics. 1 tailoress. 1 dressmaker. 1 ticket sorter. 4 factory hands. 3 no occupation. 22 housewives. Children under 15 years. 18 boys. 17 girls. 39 TABLE V.—PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Summary of notifications during the period from lst January, 1922, to 31st December, 1922. Age Periods. Number of Notifications on Form A. Number of Notifications on Form B. (by School Medical Officers). Number of Notifications on Form C. of admission to Primary Notifications. Total Notifications on Form A. Primary Notifications. Total Notifications on Form B. Poor Law Institu tions. Sanatoria. 0-1. 1-5. 5-10. 10-15. 15-20. 20-25. 25-35. 35-45. 45-55. 55-65. 65 and upwards. Total Primary Notifications. Under 5. 5-10. 10-15. Total Primary Notifications. Pulmonary— Males — 3 3 3 11 15 40 24 35 13 2 149 243 — — — — — 7 112 Females — — 5 8 15 17 28 20 15 12 3 123 196 — — — — — 4 63 N on-Pulmonary— Males 1 9 12 7 7 5 4 2 1 — 1 49 59 — — — — — 2 17 Females 2 7 9 13 6 6 12 3 4 1 1 64 77 — — — — — 1 12 40 Food. Considerable attention has been directed during 1922 to the question of purity of food-stuffs and the conditions under which they are manufactured or kept. It is satisfactory to note that the percentage of adulterated milk samples, viz., 2•9 per cent., is the lowest ever recorded in any year in the borough. This is probably the result of the persistent efforts made by Inspector Jones during past years to impress upon the milk sellers in the borough that all milk sold must come up to the standard laid down by the Board of Agriculture. Inspector Jones has also paid particular attention to the bakehouses in the borough and an endeavour is being made to raise the general standard of cleanliness of these places. Another matter which received attention during the year was the adulteration of various prepared food-stuffs with preservatives such as boric acid, salicylic acid, etc. The use of these preservatives appears to be becoming more and more prevalent and they are now eaten in so many articles of diet without their presence being declared that it is possible for anyone in the course of a day's eating to take into his system a very considerable amount of these preservatives. Special action was taken by the Public Health Committee in connection with the presence of boric acid in sponge cakes, sponge fingers and sponge biscuits, these being articles which are eaten to a considerable extent by invalids and young children. The source of the boric acid in these articles is preserved liquid egg shipped from China and elsewhere. Protracted negotiations have taken place with the Liquid Egg Trade on this subject, and it is satisfactory to relate that in the early part of 1923 an agreement was reached between the trade and the Ministry of Health that liquid eggs preserved with boric acid should not be used in the preparation of the abovementioned articles. This, however, is only one of many problems connected with preservatives in foodstuffs, and the attention of the Ministry of Health has been directed to this matter by many Municipalities and by several organisations dealing with public health. It is hoped, therefore, that the Ministry will go into this 41 question very carefully and as soon as possible issue to the respective trades and to local authorities, regulations as to what preservatives may be used and in what amounts, and above all, specify that the presence of preservatives in any food-stuff must be declared to the purchaser. This latter proviso would, at any rate, enable people to know what they were actually eating in the way of preservatives, whereas, at present, they are in ignorance in the matter. Milk.—During the year 642 samples of milk were purchased for analysis; 19, or 2.9 per cent., were reported below the standard adopted by the Board of Agriculture. Proceedings were instituted by the Council in two cases. One summons was dismissed on a warranty that the milk was sold in the same condition as when received, and one vendor was fined 20s. and 20s. costs for selling milk adulterated with 8 per cent, of added water. Six samples of milk were certified by the Analyst to contain Anatto (a vegetable colouring matter), and in each case the milk vendors were ordered to be cautioned. One hundred and four applications have been received for Registration as Dairymen or Purveyors of Milk in the borough for the new register under the Milk and Dairies (Amendment) Act, 1922. Cream (Milk and Cream Regulations, 1912 and 1917). —Twenty-six samples of cream were purchased for analysis. One vendor was prosecuted and fined 20s. and £2 2s. costs for selling preserved cream not properly labelled, and one retailer was ordered by the Public Health Committee to be cautioned for selling cream containing "14 per cent, of boric acid and not having the receptacle properly labelled. The following particulars of proceedings taken in 1922 under the above regulations, made in pursuance of the Public Health (Regulation of Food) Act, 1907, are given in the form suggested by the Local Government Board in their circular letter of October 27th, 1913:- 42 1. Milk and Cream not Sold as Preserved Cream. Articles. (a) (b) Number of samples examined for the presence of a preservative. Number in which a preservative was found to be present. Milk and separated milk 642 none Cream 13 6 2. Cream Sold as Preserved Cream. (a) Instances in which samples have been, submitted for analysis to ascertain if the statements on the label as to preservatives were correct— (1) Correct statements made 13 (2) Statements incorrect — Total 13 (b) The examination made of milk fat in cream sold as preserved cream— (1) Above 35 per cent. 26 (2) Below 35 per cent. — Total 26 (c) Instances where (apart from analysis) the requirements as to labelling of preserved cream in Article 5(1) and the proviso in Article 5 (2) of the Regulations have not been observed 2 (d) Particulars of each case in which the Regulations have not been complied with and action taken. Proceedings taken in one case. Defendant fined 20s. and £2 2s. costs. The other retailer cautioned. 3. Thickening substances. Evidence of their addition to cream or preserved cream None. 4. Other observations None. Bakehouses.—The 68 Registered Bakehouses have all been throughly inspected during the year. Of this number, 10 only were found to be in a completely satisfactory condition. Verbal notices were given to the occupiers of the remaining 58 to carry out the necessary cleansing or repairs. 43 One hundred and forty-five re-inspections were made and the work ordered was completed within a reasonable time of inspection, with one exception, and written notice has been served on the owner of this bakehouse to remedy the defect complained of. Out of the 68 Bakehouses in the Borough, 43 are situate underground. Slaughterhouses.—There are two licensed slaughterhouses in the Borough:— No. 611, Fulham Road. No. 640, King's Road. Sixty visits have been made to these slaughterhouses during the year. At No. 611, Fulham Road, no animals have been slaughtered for over 12 months. The slaughterhouse is periodically cleansed and limewashed. A contravention of the by-laws for slaughterhouses for the County of London, by permitting blood from an animal slaughtered at 640, King's Road, to. flow directly into the drain, was reported, and this being the first occasion on which a complaint was made, the slaughterman was reprimanded and cautioned. This slaughterhouse is periodically cleansed and limewashed. The London County Council Inspectors also visit these slaughterhouses. Food-preparing Places.—Special attention has been paid during the year to the sanitary condition of the various food-preparing places in the Borough. The number of visits paid to ice-cream premises, bakehouses, milkshops, slaughterhouses, etc., are detailed elsewhere. In addition to these, your female Inspector, Mrs. Davies, has made 117 inspections of restaurant kitchens and eating-houses. In connection with these, 28 notices to improve the premises were served. We have a record of 73 such kitchens in the borough. In the latter part of the year arrangements were made whereby the Sanitary Inspectors, acting on a rota of two per week, inspect all the food barrows, market stalls and food shops in North End Road and other special localities on Friday and Saturday evenings. 44 Unsound Food.—The following articles examined at the request of the owners, were condemned and destroyed :— Fish 9 cases. Broccoli 4 bags. Rabbits 42. Apples 16 boxes. Grapes 50 boxes. Prunes 2 boxes. Winkles 1 bag. Bananas 1 box. Melons 1 case. Lemons 33 cases. Pears 50 bushels. Tomatoes 2 boxes. Samples Purchased for Analysis during 1922:— Article. Number of samples taken officially. Number Adulterated. Number of samples taken unofficially. Number Adulterated. Total Samples. Total Adulterated. Percentage of Adulteration. Milk 613 28 12 _ 625 28 4•4 Separated milk 6 1 1 — 7 1 14•2 Condensed milk — — 2 — 2 — — Cream 8 2 5 4 13 6 46•1 Preserved cream 7 2 7 — 14 2 14•2 Butter 1 — 143 1 144 1 0•6 Cheese — — 20 — 20 — — Olive oil — — 4 — 4 — — Lard — — 15 — 15 — — Beef dripping — — 10 1 10 1 10•0 Malt and cod liver oil emulsion — 1 1 1 1 100•0 Self-raising flour — — 9 — 9 — — Cocoa — — 17 1 17 1 5•7 Chocolates — — 4 — 4 — — Grape nuts — — 4 — 4 — — Malt vinegar 11 3 7 — 18 3 16•6 Wood vinegar 1 — — — 1 — — Vinegar 1 — — — 1 — — Mustard — — 3 — 3 — — Cake 1 1 3 2 4 3 75•0 Sponge cake 3 — 24 6 27 6 22•2 Sponge fingers — — 3 — 3 — Sausages 12 10 3 1 15 11 73•3 Liquorice powder — — 8 — 8 — — Purified borax — — 6 — 6 — — Coffee — — 6 — 6 —- — Jam — — 3 — 3 — — Fish paste — — 6 — 6 — — Chicken and ham paste — — 2 — 2 — — Dried milk — — 1 — 1 — — Humanised milk — — 1 — 1 — — Pear drops — — 1 — 1 — — Gull's eyes 1 — 1 — 2 — — Sweets 1 — 1 — 2 — — Whipped cream bon-bon — — 1 — 1 — — 666 47 334 17 1,000 64 6•4 45 Proceedings were instituted in the undermentioned cases:— Defendant. Offence. Result. Penalty. Costs. Frederick Edwards, 355, Fulham Palace Road, S.W. Selling tinned peas containing 2.59 grains of copper Summons dismissed, warranty proved £ s. d. £ s. d. - - Messes. Nathan, Mack & Shimberg, 77-78, Chiswell Street, E.C. Selling tinned peas containing 0.44 grains of copper Dismissed - - Albert E. Jupe, 22, St. John's Road, Putney Selling tinned peas containing 0.7 grains of copper Dismissed — — Alexander Dunnett, 44, Bolingbroke Road, Wandsworth Common Selling tinned peas containing 0.42 grains of copper Dismissed - James Dunnett, 23, Churchfield Mansions, New King's Road Selling tinned peas containing 0.42 grains Dismissed - - William Joseph Charman, 184, Munster Road, S.W. 6 Selling tinned peas containing 0.34 grains of copper Withdrawn in view of above decisions - - Messrs. Gapps, Ltd., 88, Lillie Road Selling tinned peas containing 0.55 grains of copper Withdrawn in view of above decisions - - Fredk. Willgross, 9, Hugon Road, Fulham, S.W. 6 Selling milk adulterated with 8 per cent. of added water Convicted 1 0 0 l 0 0 Robert Record, 33, New King's Road Selling milk 8 per cent. deficient in fat Dismissed. Warranty proved - - John Best, Ltd., 119-120, London Wall, E.C. 2 Selling beef sausages adulterated with 47.6 grains of boric acid per lb. Convicted . 5 0 0 2 2 0 Alfred Bernard Hemmings, 200, Fulham Road Selling sponge cakes adulterated with 35 grains of boric acid per lb. Withdrawn on undertaking by defendant not to use liquid eggs in future - - David Owen, 797, Fulham Road Selling preserved cream in a receptacle not properly labelled Convicted . 1 0 0 2 2 0 Henry Charles Whitehall, 90, Railway Street, Barnes Unlawfully carrying on the trade of a Purveyor of Milk Convicted . 2 0 0 - Adrian Harley Gold, 92, May St., W.14 without being registered Delivering to purchaser preserved cream in a receptacle Convicted . 2 0 0 2 0 0 Adrian Harley Gold, 92, May St., W.14 not properly labelled Depositing for sale preserved cream not properly labelled Not dealt with on account of above conviction - - Albert Victor March, 14, Hugon Road, S.W. 6 Selling milk containing 14 per cent. of added water Convicted . 10 0 0 - 46 General Sanitary Administration. Bacteriological Work.—The following bacteriological examinations were made during 1922 either at the Borough Bacteriological Laboratory or by Dr. Burnet at his laboratory in Harley Street. The bulk of the work is done at the Borough Laboratory, but specimens may be sent by doctors to Dr. Burnet when the Borough Laboratory is closed, e.g., on Sundays and public holidays:— Material from cases of suspected diphtheria— Diphtheria bacillus isolated 153 Negative result 752 - 905 Blood from cases of suspected Enteric Fever— Widal or typhoid reaction obtained 8 Negative result 7 15 Pathological specimens for enteric organisms— Positive result — Negative result 11 11 Sputa from cases of suspected tuberculosis— Tubercle bacillus found 286 „ ,, not found 1,220 1,506 Examinations of urine 45 Blood counts 12 Other examinations 58 2,552 Disinfection.—The following rooms were disinfected and cleansed after infectious disease:— Rooms fumigated after Scarlet Fever 602 „ „ Diphtheria 362 „ „ Phthisis 254 „ „ Measles 539 „ „ Erysipelas 55 „ „ Encephalitis Lethargica 3 „ „ Influenza 4 „ „ Scabies 48 „ „ Pneumonia 2 „ „ Puerperal Fever 25 „ „ Cancer 30 Carried forward 1924 47 Brought forward 1924 Rooms fumigated after Whooping Cough 1 „ „ Enteric Fever 8 „ „ Venereal Disease 1 „ „ Cerebro Spinal Meningitis 2 „ „ Chickenpox 1 „ „ Smallpox 13 „ „ Polio Myelitis 1 „ „ for Vermin 19 Rooms sprayed 185 „ fumigated by request 18 2,173 The following articles were disinfected at the Council's Disinfecting Station :— From Private Houses. From Institutions. Total. Beds 1,162 11 1,173 Palliasses 283 — 283 Mattresses 1,257 201 1,458 Spring beds 57 — 57 Pillows 2,661 272 2,933 Cushions 778 3 781 Bolsters 1,081 5 1,086 Blankets 3,006 550 3,556 Sheets 2,015 176 2,191 Covers 1,244 32 1,276 Eiderdowns 312 — 312 Counterpanes 1,119 17 1,136 Curtains 1,946 27 1,973 Hearth rugs and carpets 816 5 821 Articles of clothing 5,354 433 5,787 Sundries 3,915 179 4,094 27,006 1,911 28,917 Public Mortuary.—One hundred and seventy-two bodies were removed to the Mortuary during the year and were admitted as follows :— By order of the Coroner 146 Brought by Police 14 For convenience till funeral 12 172 48 Ninety-four post-mortem examinations were made, and inquests were held in 145 cases. Sanitary Inspection of the District.—The following inspections of dwelling-houses were made during 1922 by the District Sanitary Inspectors:— Cause. Premises Inspected. *In consequence of complaint 1,823 In consequence of infectious disease 395 House-to-house inspections 444 Re-inspections 15,558 * This number includes 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 up to Dec. 31st, 1922. Number served. Number complied with up to Dec. 31st, 1922. 2,734 2,292 392 367 The following works were carried out and repairs effected as a result of the action of the Sanitary Inspectors:— Drains relaid 118 Drains repaired 522 Soil pipes renewed 69 Soil pipes repaired 86 Eaves and downspouting repaired 555 Sinks renewed or repaired 257 W.c.'s and flushing apparatus repaired 672 Cisterns cleansed and covered 323 Water supply provided from main 61 Yards and forecourts paved 652 Roofs, chimneys and walls repaired 1,492 Dustbins provided 473 Dampness of walls remedied 671 Internal house repairs done 5,047 Rooms cleansed 6,619 Overcrowding abated 9 Other nuisances abated 1,256 49 The following additional matters were dealt with by the District Inspectors:— Ice-cream premises— No. of inspections 138 Other food places— No. of inspections 201 Smoke nuisances— Complaints 10 Observations 73 Notices 10 No. abated 6 Factory and Workshops Acts.—The following inspections were made under the provisions of the above Acts during 1922:— Premises. Number of inspections. Number of notices served. Factories 116 5 Workshops 193 31 Workplaces 48 7 Outworkers 775 26 Result of Notices for Factories and Workshops. Work done. Walls and ceilings cleansed 22 Foul w.c. pans cleansed 3 W.c. seats repaired 1 W.c. doors repaired 2 Flushing apparatus repaired 5 Vent of w.c. repaired 1 Work of Female Inspector.—The greater part of the work under the Factory and Workshops Acts is carried out by the Female Sanitary Inspector, Mrs. Davies, who also inspects regularly all restaurant kitchens, particulars of which have already been given. She also carried out the following work:— Visits. Notices served. To verminous cases 26 7 To infectious disease 62 7 To dirty tenants 5 4 50 Drainage of Buildings.—The following drainage plans were submitted to and approved by the Public Health Committee during 1922:— Plans for drainage of new buildings [inclusive of Block of Dwellings (10 tenements), Shops (lock-up) 59, Church, War Memorial Hall, Cinemas, Studios, Garages, Petrol-filling Station, Stables, Wharf] 80 Additions to existing buildings 24 Reconstruction of the drains of existing buildings 77 The supervision of the above work, with the exception of reconstructions, is in the hands of Inspector Parsons, the Drainage Inspector. In connection therewith he paid 1,420 visits to works under construction. Legal Proceedings.—Proceedings under the Public Health (London) Act, the Metropolis Management Act, and the Housing and Town Planning Act, were instituted by the Council in the following cases:— Defendant. Offence. Result. Penalty. Costs. Edward Doggett, 63, Kensington Park Road, Notting Hill, W. 11 Claim of £61 19s. 9d. for repairs at 69, Brookville Road Order forthwith, with 5 per cent. interest from 7 th November, 1921 £ S. d. £ s. d. - 0 12 0 James Clarke, 5, Salisbury Mews Failing to abate a nuisance Withdrawn (nuisance abated) - - Mrs. Eliza Schofield, 10, Britannia Road, Fulham Failing to abate nuisances at Nos. 1 to 7, Sotheron Road, respectively Order to abate nuisances - l 1 0 George Rutter, 115, Hammersmith Road Failing to abate a nuisance at 117, Hammersmith Road Order to abate - l 1 0 Manbre Sugar and Malt, Ltd.,Winslow Road, Hammersmith Failing to abate a nuisance from black smoke Order to abate - 2 2 0 Miss Rosa Ardin, 27, Pellant Road Failing to abate a nuisance at 627, King's Road Withdrawn (nuisance abated) - - 51 Defendant. Offence. Result. Penalty. Costs. Manbre Sugar and Malt, Ltd., Winslow Road, W. 6 Failing to comply with nuisance order respecting black smoke on 29th March, 1922 Convicted £ s. d. £ S. d. 5 0 0 5 5 0 Do. do. Failing to comply with nuisance order respecting black smoke on 18th April, 1922 Convicted 0 5 0 - Do. do. Failing to comply with nuisance order re black smoke on 19th April, 1922 Convicted 0 5 0 - Do. do. Failing to comply with nuisance order re black smoke on 20th April, 1922 Convicted 0 5 0 - Do. do. Failing to comply with nuisance order re black smoke on 24 th April, 1922 Convicted 0 5 0 - Do. do. Failing to comply with nuisance order re black smoke on 27th April, 1922 Convicted 0 5 0 - Do. do. Failing to comply with nuisance order re black smoke on 8th May, 1922 Convicted 0 5 0 - Charles Edward Parker, 2a, Tasso Road Failing to notify Council of alteration to drains Ordered to pay costs — 1 1 0 Emma P. Cripps and Edith Cripps, 61, Santos Road, Wandsworth, S.W. Recovery of cost of making Nos. 7, 8 and 9, Novello Street fit for habitation (£43 1s. 2d. and interest) Claim reduced to £35, and order made for payment by consent - - F. Mann, 42, Radipole Road, Fulham, S.W. Recovery of cost of making 31 and 37, Tilton Street fit for habitation (£14 12s. and interest) Account and costs paid, summons withdrawn - - H. Brown, Bradwell Holt, 29, Beulah Hill, Upper Norwood Recovery of cost of making 36, Aintree Street fit for habitation (£164 10s. 7d. and interest) Withdrawn. Order made by Council for payment by instalments - - Do. do. Recovery of cost of making 28, Aintree Street fit for habitation (£10 14s. 1d. and interest) Summons withdrawn, account and costs paid - - 52 Defendant. Offence. Result. Penalty. Costs. £ s. d. £ s. d. Victoria A. Sharpe, 23, Netherton Road, Twickenham Recovery of cost of making 2a, Britannia Road fit for habitation (£70 19s. 2d. and interest) Summons withdrawn, account paid - - W. Byford, 41, Balverine Grove, Merton Park Recovery of cost of making 15, Varna Road fit for habitation (£26 17s. and interest) Adjourned sine die, defendant undertaking to pay by monthly instalments - - F. Mann, 42, Radipole Road, Fulham Cost of relaying drains at 33, Querrin Street (£35 16s. 6d.) Adjourned, defendant agreed to pay debt and costs by instalments - - Christian Groebel, 63, St. Martin's Lane Recovery of cost of making 45, Fernhurst Road fit for habitation (£29 10s. 3d. and interest) Order for payment of £10 - - James S. Harman, 35, Earl's Court Road, S.W. Recovery of cost of making 22, Broomhouse Road fit for human habitation (£157 19s. 10d. and interest) Order for payment of amount claimed and costs - 1 1 0 Mrs. Isabel Coleman, 18, Cavendish Road, Brondesbury Cost of repairing 40, Broomhouse Road, as found by Ministry of Health on appeal (£129 2s. 3d) Order for payment - 2 2 0 Henry Brown, 21, Wellington Square, S.W. 3 Failing to abate a nuisance at 167, North End Road Summons withdrawn, defendant not owner - - Do. do. Failing to provide dustbin at 167, North End Road Summons withdrawn defendant not owner - - Rat Destruction.—The Council retain the services of a part-time Rat Officer, who is available for property owners to enable them to rid their premises of rats, and who also inspects the Borough as to the presence of rats and deals with rats in the sewers. 53 Poison was laid as follows by the Rat Officer during the year:— Private houses 345 Factories 3 Other premises 8 Sewers and drains 151 £65 2s. 6d. was paid by property owners to the Council for the services of the Rat Officer in connection with the destruction of rats at the above premises. Housing. Houses Let in Lodgings.—The proposed by-laws under Section 26 of the Housing and Town Planning Act, in respect of houses let in lodgings, have not yet been issued. No action has been taken during the year under the old by-laws, but such houses have been dealt with as required under the Public Health (London) Act and Section 28 of the Housing, Town Planning, etc., Act. Certificates under the Revenue Acts.—Certificates for exemption from or reduction of inhabited house duty were granted in respect of 561 tenements. Certificates of Water Supply.—Certificates of water supply were given in respect of 7 new premises. Increase of Rent and Mortgage Interest (Restriction) Act, 1920.—Under Section 2 of this Act, 29 applications for certificates that "the house is not in all respects reasonably fit for human habitation or is otherwise not in a reasonable state of repair" were received. Certificates were granted in 22 of these cases. Section 28 of the Housing, Town Planning, etc., Act, 1919.—During the year 1922 the Borough Council made considerable use of this Section, 686 notices being issued under these statutory powers. This Section gives the sanitary authority power to require repairs, and applies to any working-class dwelling regardless of the rent or the date at which it was let. The repairs which may be required under this Section 54 are somewhat wider than those enforceable under the Public Health Act and are such as are necessary to render a dwelling-house "in all respects reasonably fit for human habitation." If after the expiration of the time given in the notice for the execution of the repairs, the works have not been carried out and due measures are not being taken to have them carried out, the local authority may themselves carry out the repairs, charging the owner with the expenses, which, until paid, constitute a charge on the property. An owner has a certain amount of redress in that it is possible for him to declare his intention to close the house rather than carry out the necessary repairs, if these repairs constitute " reconstruction " of the premises. During 1922 the Borough Council themselves carried out repairs in default of the owner to 20 premises at a cost of approximately £531. During 1921 the amount expended under this Act by the Borough Council was £1,573 13s. 10d. Although the work in connection with these 1921 figures was commenced during that year, a considerable amount was not finished until during 1922, and, in addition, a large amount of work had to be completed during 1922 in connection with the recovery of the costs from the owners of the property dealt with during 1921. We have now had two years' experience of the work of Section 28 of the Housing Act, 1919, involving a total outlay by the Council of £2,105 15. in property repairs. It may be well, therefore, to give in some detail our experiences and the difficulties which we have met with in working this Section. For purposes of convenience we may look at these matters as they affect:— Firstly, the carrying out of the work, and, secondly, the recovery of the expenses. During 1922 we had the experience of two Ministry of Health Inquiries and ten summonses in the Policecourt for the recovery of expenses, and I have, so far as possible, embodied the various questions which have arisen during these Inquiries in the following remarks:— 55 (1) It would appear that notices served under Section 28 must be very definite. They must specify exactly what work is to be done. They must be carefully issued, and in the notice plenty of time must be allowed the owners in which to do the necessary repairs, e.g., in view of subsequent criticisms it is much better to allow an owner two or three months to do the repairs rather than try and force him to do them within three weeks, as, in the latter alternative, the owner may be able to plead that the time allowed was insufficient. (2) Apart from the statutory obligations under the Act, viz., the service of the notice, it is wise to write at least one, and preferably more, letters to the owner pointing out that, if he fails to do the work before a certain date, the matter will be placed before the Public Health Committee with a view to the Council carrying out the repairs themselves and charging him with the costs. It is advisable that a further letter should be written, when the Council has decided to do the work, informing the owner of the exact date on which the Council's workmen propose to enter the premises. (3) During the progress of the repairs the Sanitary Inspector should visit the premises regularly and keep detailed notes of the progress of the work on each occasion. The greatest care must be exercised by the contractor, be he municipal or outside tenderer, to avoid doing any work which is not specified in the notice, as, in the event of an appeal, the owner will certainly do his best to escape this extra charge. Careful account must be kept of each item of the work. This might appear quite superfluous, but it came out very markedly in our Inquiries that the referee wished to know the exact cost of various items of the work, not merely the total cost. (4) One of the most difficult situations under this Act arises where the owner, having done part of the work demanded by the notice, leaves undone some items which the .Council eventually do for him. In 56 Such cases it is very necessary that the Sanitary Inspector should make most detailed notes of exactly what the owner has already done and that, however badly the owner may have done the work, none of what he has already done shall be done over again by the Council. At the conclusion of the first Ministry of Health Inquiry which arose out of the appeal of the owner against the charges made by the Council for work done, I issued the following among other instructions to the Sanitary Inspectors, in order to avoid difficulties which had arisen at the Inquiry :— (1) Inspectors must make a note in their diaries whenever they see an owner or a builder either at the property or at the office. (2) Where a limited amount of the work specified in the notice is already being carried out by the owner, Inspectors must keep full notes of the exact amount of the work done each time they visit the premises, particularly where work is being badly done. (3) If Inspectors take exception to the way work is being done and consider that it is scamped or unsatisfactory, definite reasons and examples must be given. (4) Inspectors should, if at all possible, see builders on the job and should make an effort to do so. (5) On completion of all the work an owner intends to do, a report should be made out, setting out what has been left undone. (6) Where work is being done by the Council under Section 28 in default of the owner, Inspectors should visit the property from time to time and satisfy themselves that nothing is being done which is not included in the original notice served on the owner. There are one or two difficulties which have arisen in practice and which are worth noting. In many cases, after the Council has got out estimates for the work and has notified the owner that the Council's workmen will enter the premises on a certain date, the owner himself makes a desperate effort and arrives with his workmen on the premises a day or two before the Council are due to commence. In such cases it would appear to be wise to allow the owner to carry out the repairs himself. Where an 57 outside contractor has tendered for this work there may naturally be difficulties when he is suddenly deprived of the job at the last moment, after all his trouble of tendering and preparing for the work. In Fulham, during 1922, work was carried out by the direct labour of the Council's own employees, and therefore this difficulty did not arise except that it made considerable unnecessary work in the Surveyor's Department. Where an outside contractor, however, is employed, I am of opinion that he might have good cause to claim compensation from the Council for the loss of the job. Another point which arose at one of the Inquiries had reference to the time taken by the Council to complete the repairs. An owner was served with notice to complete certain repairs within 21 days. Eventually, in default of the owner, the Council entered the premises and carried out the work, but the Council took considerably longer than 21 days to do the work. The owner pleaded that this showed that the time allowed him was unreasonable. This contention, however, was not upheld, but it would seem advisable that in such cases the Council should endeavour to carry out the repairs in the time allowed to the owner in order to avoid this criticism. Recovery of Expenses.—After the work has been completed, it is often a matter of difficulty to extract the costs from the owner. The legal position does not appear to be too clear. In the first place, the owner has the right to appeal to the Ministry against the charges and the Minister may direct an Inquiry to be held at which the whole case is gone into in detail and an award made. In one of the appeal cases at Fulham it became necessary subsequently to proceed in the Police-court for the recovery of the amount due. At the Police-court the Stipendiary Magistrate who heard the case held that he had the right to go into the whole question de novo. The Council took exception to this, but, as the ultimate decision of the Magistrate was in their favour, there was no need to 58 take the matter further. In other cases, where there had been no appeal to the Ministry either against the notice to repair or the demand for expenses, the defendants challenged in the Police-court the requirements in the notice as well as the amount of the expenses. Objection to this was taken by the Council's Solicitor on the ground that the defendants, having neglected to appeal to the Minister of Health, were stopped from raising these questions before the Magistrate. The Magistrate over-ruled the objection of the Council's Solicitor, and in one case deducted almost two-thirds of the Council's claim. The Council did not appeal, as the sum involved was not a large amount, but a letter upon the subject was addressed to the Ministry of Health. I append a copy of this letter. From these remarks, however, it will be seen that the owner would appear to have the right to appeal to two tribunals, in both of which the Council must be successful in order to recoup themselves for the ratepayers' money which they have laid out on these housing repairs. This is a most unsatisfactory state of affairs, and, as a result partly of this and partly of the initial difficulty of carrying out the work, the Borough Council has decided only to use Section 28 in most exceptional cases and as a general rule to deal with all housing repairs under the Public Health Act. The Police-court summonses for the recovery of costs, with the results thereof, will be found among the summonses on pages 51, 52 and 53. While this report was in the press the result of the appeal in the case of Ryall (Bermondsey Borough Council) v. Hart, was decided. In this case the magistrate held that the question of the unreasonableness of the time specified in the notice was a matter for his jurisdiction. He found that the respondent could not by any reasonable effort or diligence have complied with the notice, and that the period of 21 days specified in the notice 59 was not in all the circumstances a reasonable time, and that the notice was therefore invalid. He accordingly dismissed the complaint. On appeal the Court (Lord Hewart C.J., Shearman and Branson J.J.) dismissed the appeal. Their judgment was as follows:— "It was true that an owner might appeal under s. 15, sub-s. 6, of the Act of 1909 to the Minister of Health against a notice of a local authority requiring him to execute certain works or against a demand for the recovery of expenses incurred by the local authority in doing the work, but that section did not make the decision of the Minister final or say that if the owner did not appeal to the Minister and the local authority did the work their claim for the expenses of the work could not afterwards be questioned. When the local authority sought to recover the expenses before a Court of summary jurisdiction under s. 28 of the Act of 1919, the magistrate was entitled to see whether the conditions laid down by s. 28 had been complied with, including the condition that the notice served upon the owner specified a reasonable time within which he was to execute the work. The decisions in Ryall v. Cubitt Heath (1922) 1 K.B. 275, and Rex v. Minister of Health. Ex parte Rush (1922) 2 K.B. 28, were not inconsistent." This decision would appear more than ever to support our contentions as to the unworkable nature of Section 28 as it at present stands. I append hereto a short note of the two appeals by owners to the Ministry of Health during 1922. Appeals to Ministry of Health, 1922. (1) Re 40, Broomhouse Road. £ s. d. Claim 155 5 0 Appeal against demand. Inquiry 30th June, 1922. Order of Ministry, dated 9th October, 1922, reducing claim to £129 3s. 3d., and ordering appellant to pay expenses of Inquiry, £8 13s. 10d., and each party to bear their own costs. Deduction of £26 1s. 9d. from claim:— £ s. d. Unnecessary painting 19 1 6 Work not covered by notices 7 0 3 £26 1 9 60 (2) Re 18-23, Novello Street. £ s. d. Claim 78 7 5 Appeal against demand. Inquiry 21st September, 1922. Order of Ministry, 6th January, 1923, reduced claim to £85 17s., and ordered Council and Appellant to pay expenses of Inquiry, £7 9s 10d., equally, and to bear their own costs. Deduction of £19 10s. 5a. from claim:— £ s. d. Works not comprised in notices 4 4 0 Works executed by Council after being carried out by owner 8 4 0 Establishment charges 7 2 5 £19 10 5 Copy of letter sent to the Ministry of Health re Section 28 of the Housing, Town Planning, etc., Act, 1919. Sir, Recovery of Expenses under Section 28 of the Housing, etc., Act, 1919. I am directed by the Borough Council to inform you that they have experienced considerable difficulty in recovering through the Local Police-court expenses incurred in default of compliance by the owners with Notices served under Section 28 of the Housing, Town Planning, etc., Act, 1919. In a recent case the expenses amounted to £29 10s. 3d., but only £10 was awarded by the Magistrate. At the hearing of the summons the Defendant challenged several of the requirements of the Notice, and he also challenged the demand for expenses on the ground that they were excessive. The Council's Solicitor took objection to any enquiry being made by the Magistrate either as to the requirements of the Notice or as to the expenses, the view of the Council being that, had the Defendant felt aggrieved either by the Notice or the demand, his proper procedure was to appeal to the Minister of Health, and that, having failed to do so, he could not complain before the Magistrate of the Notice or the Demand. In support of this contention the Solicitor pointed out how inconvenient the procedure would be, because, apart altogether from the unsuitability of a Court of Summary Jurisdiction for cases of this kind, unless an appeal was made it would not be possible to ascertain whether the requirements of the Notice or the expenses were in order until the hearing before the Magistrate, and if the Magistrate then decided that the requirements and expenses were ultra vires or excessive, by the hypothesis the Council would have done all the work, incurred all the expense, and would not be able to recover, whereas, if proceedings could be taken earlier to test the validity of the requirements and the expenses, these matters could be put right and the burden placed upon the proper shoulders. As a matter of fact, in 61 the present case the Defendant had not appealed against the Notice to repair; he had, however, attempted to appeal against the demand for expenses, but his notice being out of time, the Minister had refused to entertain it. The Magistrate, as in previous cases, overruled the objection of the Council's Solicitor and proceeded to hear the evidence, finding as stated above. In view of the small amount involved, the Council decided not to ask for a Case to be stated, but to bring the facts to the notice of the Minister with a view to the matter being remedied in future legislation. In these circumstances, I am instructed to ask if the Minister will kindly consider the advisability of inserting provisions in the next Housing Bill, setting out clearly the right of Appeal against Notice for repairs and Demands for expenses as established in the case of Rex v. Minister of Health ex-parte Rush, and preventing any enquiry by the Magistrate (except, of course, as to the approval by the Council of and service of the Notice to repair and the Demand for expenses) in summary proceedings for recovery of expenses. The Council's view is that expenses incurred by them under the Section in question should be as unquestionable in a Court of Summary Jurisdiction as of a wage-earner's assessment to income tax. I am, Sir, Your obedient Servant, (Signed) J. Percy Shuter, 1th February, 1923. Town Clerk. The Secretary, Ministry of Health, Whitehall, S.W. 1. Closing Orders. Closing Orders were made during the year in connection with the following properties:— (i) 61 and 63, Aspenlea Road.—These premises, which comprised a number of tenements, with a large common yard in the centre, were found in a very bad sanitary condition and much dilapidated. The inhabitants of this yard were mainly Italians, who made ice-cream in small lock-up premises under the tenements in which they lived. Notices were served upon the owner in September, 1922, under Section 28 of the Housing, Town Planning, etc., Act. The owner served a counter-notice that the premises were incapable, without reconstruction, of being made fit for human habitation, and declaring his intention of closing the premises for human habitation, which the Council accepted on the 29th November, 1922. The District Surveyor, who had previously inspected 62 the premises, then served notices under the London Building Act, certifying the structure as dangerous, and the whole yard was consequently demolished about the end of the year. Eleven families were turned out. Nine succeeded in findingother accommodation, while two families went into the Workhouse. (2) Nos. 1, 2, 3, 4, 5, 6 and 7, Sotheron Road.— This row of dwelling-houses had for many years received attention from the Local Sanitary Authority, but, through neglect on the part of the owner, the houses had been allowed to become exceedingly insanitary and out of repair. Statutory notices were served in November, 1921, under the Public Health Act, and, failing compliance on the part of the owner, summonses were issued on February 9th, 1922. After many adjournments, owing to promises on the part of the owner, the Court finally made orders on July 20th, 1922, that the notices should be obeyed. These orders were not complied with, however, and on nth October the Council made Closing Orders under Section 17 of the Housing, Town Planning, etc., Act, 1909. Owing to the difficulty in obtaining other accommodation for the tenants, it was decided that, although formal notices to quit should be served on the tenants, the houses should only be closed as and when they became vacant. Up to the time of writing, No. 7 has become vacant and been closed; the other houses are still occupied. 63 Housing Conditions. Year ending 31st Dec., 1922. Number of new houses erected during the year:— (a) Total 405 tenements. (b) As part of a Municipal housing scheme — Unfit Dwelling-houses. (I) Inspections:— (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 2,673 (2) Number of dwelling-houses which were in- spected and recorded under the Housing (Inspection of District) Regulations, 1910 444 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwelling-houses (exclusive of those referred to under the preceding subheading) found not to be in all respects reasonably fit for human habitation 928 II.—Remedy of defects without Service of Formal Notice:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 15 III.—Action under Statutory Powers:— A.—Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 686 (2) Number of dwelling-houses which were rendered fit:— (a) By owners 655 (b) By Local Authority in default of owners 28 (3) Number of dwelling-houses in respect of which Closing Orders become operative in pursuance of declaration of owners of intention to close 2 B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 1,280 (2) Number of dwelling-houses in which defects were remedied:— (a) By owners 1,163 (b) By Local Authority in default of owners — C.—Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc., Act, 1909:— (i) Number of representations made with a view to the making of Closing Orders - (2) Number of dwelling-houses in respect of which Closing Orders were made 7 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit - (4) Number of dwelling-houses in respect of which Demolition Orders were made - (5) Number of dwelling-houses demolished in pursuance of Demolition Orders 64