Full 22 Metropolitan Borough of Fulham. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH * FOR THE YEAR 1923. A. MIDDLETON HEWAT, M.D., D.P.H., Medical Officer of Health. 3 Metropolitan Borough of Fulham. PUBLIC HEALTH COMMITTEE. Chairman : Councillor H. Booth. Vice-Chairman: Councillor A. G. Everard. His Worship The Mayor (W. J. Waldron, Esq., J.P.), Ex-officio. Uderman R. M. Gentry. Councillor A. Gantlett. Councillor Capt. W. S. Brooks. „ C. Harwood. „ W. R. Corbin. „ G. L. Hodge. „ S. Farley. „ Miss H. A. Packer. „ W. Fowell. „ T. A. Speed. „ V. L. Franzini „ H. J. Todd. Councillor W. Wilcox. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman : Councillor W. Fowell. Vice-Chairman : † Miss P. Plater. His Worship The Mayor (W. J. Waldron, Esq., J.P.), Ex-officio. Alderman J. Palmer. Councillor F. J. Shaw. Councillor F. J. Bellenger. „ W. A. White. „ Capt. W. S. Brooks. †Mrs. Corbin. „ S. Farley. †Mrs. Pritchard. „ G. L. Hodge. †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.), D.P.H. (Lond.) (Tuberculosis Officer). *Ruby Thomson, M.B., Ch.B., D.P.H. (Edin.). *G. F. Hardy, M.C., M.R.C.S., L.R.C.P. *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. 1Mr. J. Castley, Mr. A. W. Gammack, *Miss B. Baron, *Miss M. Wacksmith, Mr. F. Walsh. Senior Sanitary Inspector :— 1*Charles Bristow Jones (Food and Drugs). Sanitary Inspectors :— 1*Frederick H. Manning. 12*Charles B. Lloyd. 12*Alfred J. Parsons. 1*Albert E. Clutterbuck. 12*Mark Canton. 1*Edgar Drake. 1*Thomas H. Robey. 123*William French. Woman Sanitary Inspector :—1*Mrs. M. E. Davies. Health Visitors 166*Miss M. L. Durnford. 466*Mrs. J. Bryning. 450*Miss E. Beckett. 146*Miss A. Perrett. 456*Miss M. Jones. Tuberculosis Dispensary Staff :— 4*Miss A. B. Myers, 4*Miss K. Sewell and 4*Miss H. M. Turner (Nurses). 4*Mrs. D. F. Douglas (Temporary Nurse). *Miss M. C. Robinson, Dispenser and Laboratory Assistant. *Miss M. E. Sargent, Clerk and Secretary of the Care Committee. *Mr. and Mrs. Snell, Caretakers. Matron of Maternity Home : 46*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 Exchequer Grant towards the salaries of these officers. 1 Certificated Sanitary Inspector. 2 Food Inspector's Certificate. 3 Registered Plumber. 4 Trained Nurse. 6 Health Visitor's Certificate. 6 Certificate of Central Midwives' Board. 5 Town Hall, Fulham, S.W. 6. April, 1924. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Fulham. Mr. Mayor, Lady and Gentlemen, I have the honour to submit herewith the Annual Report on the health and sanitary condition of the Borough for the year 1923, this being my second Annual Report as your Medical Officer of Health. The year 1923 has been a noteworthy one in connection with the public health work of the Borough and, amongst other things, I should desire to draw your attention to the following :— (1) We had during 1923 the lowest death-rate ever recorded in the history of the Borough, viz. : 10-5 per thousand population. (2) 1923 also showed the lowest infantile mortality rate ever recorded in the Borough, viz. : 64 deaths under one year of age per thousand births. (3) We had during this year also the lowest birthrate (19-3) ever recorded in the Borough, with the exception of the three war years, 1917, 1918 and 1919, when, of course, unusual factors were at work to influence the birth-rate. (4) The estimated population of 161,600 for 1923 is the largest number of persons ever estimated to live in the Borough, and as this is based on a census taken so recently as 1921, its accuracy may reasonably be accepted. (5) Despite our record low general death-rate, the death-rate from Cancer is the highest ever recorded in the history of the Borough, being 1-3 per thousand of the population. 6 (6) The Council has entered into new agreements with the Infant Welfare Centres Committee and the Fulham Babies' Hospital Committee, ensuring the continuance of these valuable institutions on satisfactory lines. (7) The end of the year 1923 saw the commencement of a serious epidemic of measles. (8) The Milk (Special Designations) Order, 1922, subsequently revoked by the Milk (Special Designations) Order, 1923, came into force on January 1st, 1923. The latter order came into force on July 1st, 1923. Fuller details of all these matters will be found in the body of the Report. It was with great regret that we heard during the year of the death of your late Medical Officer of Health, Dr. J. C. Jackson. His services to the Borough were fully dealt with at the time of his retirement in 1922, but even after his retirement he continued to take an active part in many of the voluntary medical activities of the Borough, and his sudden death was a great blow to us all. In accordance with the wishes of the Ministry of Health I have, on page 4, given particulars of the qualifications of each member of the Public Health Staff. I should like to take this opportunity of thanking all those who have assisted during the year in any way in their various capacities, whether as Councillors, Voluntary Workers or Officers, in helping to carry on the work of Preventive Medicine in the Borough. I am, Mr. Mayor, Lady and Gentlemen, Your obedient Servant, A. MIDDLETON HEWAT, Medical Officer of Health. 7 I give below certain general statistics for the Borough as required by the Ministry of Health: 1.—General Statistics. Area (acres) 1,706 Population (1923) 161,600 No. of inhabited houses (1921 census) 25,979 No. of families or separate occupiers (1921 Census) 40,436 Rateable value £983,398 Sum represented by a penny rate £4,037 2.—Extracts from Vital Statistics of the Year. Births— Total. Males. Females. Legitimate 2,975 1,544 1.431 Birth rate 19.3 Illegitimate 148 82 66 Deaths 1,708 871 837 Death-rate 10.5 No. of women dying in, or in consequence of, childbirth— From sepsis 9 „ other causes 9 Deaths of Infants under one year of age per 1,000 births— Legitimate 59 Illegitimate 155 Total 64 Deaths from Measles (all ages) 23 „ „ Whooping Cough (all ages) 14 „ „ Diarrhoea (under 2 years of age) 25 Population.—The Registiar-General has estimated the population of the borough at the middle of 1923 to be 161,600. (Males, 74,812 ; Females, 86,788.) Marriages.—The number of marriages registered was 1,284, and the marriage rate, i.e., the number of persons married per 1,000 of the population, was 7-9. In the three preceding years the marriages numbered 1,471 ; 1,659 ; 1,320 ; thus showing a decrease of 36 for 1923. 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 3,123, of whom 1,626 were boys and 1,497 were girls. The birth rate was 19.3 per 1,000 inhabitants, being 1.0 per 1,000 below that of 1922. The birth rate for the whole of London was 20.2, and for England and Wales 19.7. 8 Illegitimacy.—The illegitimate births numbered 148 (82 males, 66 females), or 4*7 pel cent, of the total births, against 4-8, 4-5 and 4-7 pei cent, in the three preceding years. Natural Increase of the Population.—The natural increase of the population by excess of births over deaths was 1,415, against 2,501 ; 1,662 ; and 1,307 in the three preceding years. Deaths.—During the 52 weeks ended 31st December, 1923, 1,632 deaths were registered in the borough. Of these, 252 were of persons not belonging to the borough, while 328 inhabitants of Fulham died outside the borough, chiefly in various public institutions. There were, therefore, 1,708 deaths of persons—871 males and 837 females—having their usual residence in Fulham, representing an annual rate of 10-5 per 1,000 of the estimated population, being 1 -6 per 1,000 below that of 1922, and the lowest on record. The death rate of males was 11-6, of females 9 • 5. The following comparative death rates are of interest:— Death-rates, 1923— England and Wales 11·6 London 11·2 105 large towns 11·6 Fulham 10·5 Zymotic Deaths.—The mortality from zymotic diseases was lower than in 1922, 87 deaths being due to the seven principal epidemic diseases, against 144 in 1922. The zymotic death rate was 0-53 per 1,000 population, as compared with 0-93 for 1922. Seasonal Mortality.—The mortality in the four quarters of the year was as follows:— Deaths. Death-rate. First Quarter 462 11·4 Second Quarter 425 10·5 Third Quarter 328 8·1 Fourth Quarter 493 12·2 1,708 10·5 9 TABLE I.—Vital Statistics of Whole District during 1923 and previous Years. Year. Population Estimated to Middle of each Year. Births. Total Deaths Registered is the District. Transferable Deaths. † Nett Deaths Belonging to the District. Uncorrected Number. Nett. Of NooResideots registered in the District. Of Residents not registered in the District. Under 1 Year of Age. At all Ages. Number. * Rate. Number. * Rate per 1.000 Nett Births. Number. * Rate. Number. Rate. 1 2 3 4 5 6 7 8 9 10 ii 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 a l53,161 3,736 3,870 c 24·3 1,787 11·7 130 677 446 115 2,334 15·2 1916 a 149,428 b162,580 3,600 3,754 c 23·1 1,324 8·9 131 789 330 88 1,982 13·3 1917 a l45,186 b 161,841 2,852 2,971 c l8·4 1,251 8·6 139 882 323 109 1,994 13·7 1918 a 143,211 b 160,463 2,593 2,672 c l6·7 1,704 11·9 186 973 286 107 2,491 17·4 1919 a l52,543 b155,904 2,947 3,000 c l8·6 1,510 9·7 242 634 250 83 1,902 12·2 1920 a 158,621 b158,989 4,383 4,327 c 27·2 1,888 11·9 457 396 320 74 1,827 11·5 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 1923 161,600 3,312 3,123 19·3 1,632 10·0 252 328 199 64 1,708 10·5 (a) Estimated civil population. (b) Estimated total population. (c) Birth-rate calculated on estimated total population. Notes.—This Table is arranged to show the gross births and deaths registered in the district during the year, and the births and deaths properly belonging to it with the corresponding rates. The death-rates from 1915-1919 are calculated per 1,000 of the estimated civil population, and the other rates per 1,000 of the estimated gross population. • In Column 6 are included the whole of the deaths registered during the calendar year as having actually occurred within the district, but excluding the deaths of Soldiers and Sailors that have occurred in hospitals and institutions in the district. In Column 12 is entered the number in Column 6, corrected by subtraction of the number in Column 8 and by addition of the number in Column 9. Deaths in Column 10 are similarly corrected by subtraction of the deaths under 1, included in the number given in Column 8, and by addition of the deaths under 1 included in the number given in Column 9. t *' 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 at the Census of 1921 157,938 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 1,708 deaths registered, 1,565, or 91.6 per cent., were certified by registered medical practitioners, and 143 by coroners after inquest, no death being uncertified. Deaths in Public Institutions. Fulham Infirmary.—The deaths of 616 persons occurred in the Fulham Infirmary, of whom 483 lived in Fulham and 133 in other districts. Western Fever Hospital.—In this institution there were 24 deaths of residents in Fulham and 94 of residents in other districts. Deaths occurring outside the Borough among Persons belonging thereto .—The deaths of Fulham residents outside the borough numbered 328, and occurred in the following places :— St. George's Hospital 40 West London Hospital 24 Other General Hospitals 32 Children's Hospitals 25 Hospitals for Women 6 Other Special Hospitals 32 Homes for advanced cases 9 Hospitals of Metropolitan Asylums Board 7 Poor Law Infirmaries 10 Lunatic Asylums 51 Sanatoria 21 Nursing Homes, private houses, and elsewhere 71 328 Of the deaths registered, 764 or 44.7 per cent, took place either in poor law institutions, in hospitals, or in public lunatic asylums, the percentages in the various classes of institutions being as under :— Per cent. Death in Workhouses or Workhouse Infirmaries 28.8 „ Metropolitan Asylums Board Hospitals 1.8 ,, other Hospitals 11.1 Public Lunatic and Imbecile Asylums 3.0 . 44.7 11 12 TABLE II. Causes of and Ages at Death during the Year 1923. Nett Deaths at the subjoined ages of "Residents," whether occurring within or without the District (a). Total Deaths whether of "Residents" or "Nonresidents" in Institutions in the District (b). 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 under 20 years. 20 and under 35 years. 35 and under 45 years. 45 and under 65 years. 65 and upwards. Barons 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) 1,708 199 57 15 16 13 26 56 113 119 467 627 770 180 295 162 180 368 106 279 138 Uncertified ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1. Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... 3 ... ... ... ... ... ... ... ... 2. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Measles 23 5 11 3 1 2 1 ... ... ... ... ... 22 1 1 5 1 4 2 9 ... 4. Scarlet Fever 5 1 ... 1 1 ... 2 ... ... ... ... ... 12 ... 1 ... 1 2 ... 1 ... 5. Whooping Cough 14 9 2 ... 1 1 1 ... ... ... ... ... 6 ... 2 1 4 1 ... 6 ... 6. Diphtheria 20 ... 3 3 1 2 6 4 ... ... 1 ... 72 ... 4 2 1 5 2 4 2 7. Influenza 27 1 ... ... ... ... 1 1 ... 1 9 14 1 3 1 1 5 3 1 7 6 8. Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 9. Meningococcal Meningitis 2 1 ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... ... 1 ... ... 10. Tuberculosis of Respiratory System 149 ... 1 1 1 ... ... 16 43 28 49 10 64 9 33 10 21 33 8 27 8 11. Disseminated Tuberculosis 8 1 1 ... 1 1 ... 1 3 ... ... ... 6 ... 1 ... 1 2 1 3 ... 12. Other Tuberculous Diseases 24 5 5 ... 1 1 1 5 1 1 3 1 12 1 3 1 4 8 1 4 2 13. Cancer, malignant disease 212 ... ... ... ... ... ... 2 4 15 105 86 75 26 29 20 22 38 18 41 18 14. Rheumatic Fever 1 ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 15. Diabetes 15 ... ... ... ... ... ... ... 1 2 7 5 9 1 1 3 2 4 2 2 ... 16. Cerebral Haemorrhage, etc. 92 ... ... ... ... ... ... ... 1 8 22 61 41 13 12 6 4 23 5 13 16 17. Heart Disease 202 ... ... ... ... ... 3 7 16 12 67 97 50 20 48 21 9 43 18 24 19 18. Arterio-sclerosis 51 ... ... ... ... ... ... ... ... ... 4 47 47 3 9 4 5 10 3 9 8 19. Bronchitis 114 9 3 ... ... ... ... ... 1 3 30 68 34 11 32 11 16 19 5 12 8 20. Pneumonia (all forms) 174 31 20 2 2 2 4 4 11 13 48 37 81 16 29 23 20 41 9 29 7 21. Other Respiratory Diseases 21 2 ... ... ... ... ... ... 1 2 3 13 3 2 4 1 2 3 2 6 1 22. Ulcer of Stomach or Duodenum 19 ... ... ... ... ... ... 2 2 1 11 3 12 2 3 1 ... 4 1 3 5 23. Diarrhoea, etc. (under 2 years) 25 21 4 ... ... ... ... ... ... ... ... ... 19 4 3 2 6 6 1 2 1 24. Appendicitis and Typhlitis 10 ... ... ... 1 ... 1 1 3 ... 2 2 6 2 ... 1 1 4 1 1 ... 25. Cirrhosis of Liver 8 ... ... ... ... ... ... ... ... ... 1 7 3 2 1 1 1 1 ... 2 ... 26. Nephritis and Bright's Disease 45 ... ... ... ... ... ... 1 2 6 17 19 16 4 7 4 2 10 2 6 10 27. Puerperal Sepsis 9 ... ... ... ... ... ... ... 5 4 ... ... 9 1 2 1 1 4 ... ... ... 28. Other accidents and diseases of pregnancy and parturition 6 ... ... ... ... ... ... ... 1 5 ... ... 3 ... ... ... 2 1 1 2 ... 29. Congenital Debility and malformation, premature birth 89 89 ... ... ... ... ... ... ... ... ... ... 22 9 15 11 9 16 2 20 7 30. Suicide 24 ... ... ... ... ... ... ... 1 3 14 6 2 6 3 1 3 6 2 2 1 31. Other deaths from violence 55 4 2 4 4 3 4 3 2 2 13 14 27 7 9 9 6 12 1 8 3 32. Other defined diseases 264 20 5 1 2 1 1 9 14 13 61 137 113 37 41 22 31 65 17 36 15 33. Causes ill-defined or unknown ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Total 1,708 199 57 15 16 13 26 56 113 119 467 627 770 180 295 162 180 368 106 279 138 (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 2.18 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 1. (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." ' ' 13 Causes of death.—The causes of death occurring in the borough during 1923 will be found in Table II. From this it will be seen that the principal causes were: Cancer (212 deaths), heart disease (202 deaths), tuberculosis (181 deaths), pneumonia (174 deaths), and bronchitis (114 deaths). It is a very interesting fact that these causes of death appear this year in exactly the same order in which they appeared last year, but there are certain differences in the actual figures. Cancer still heads the list of causes of death and, in fact, the actual number of deaths caused by this disease has increased during the past year by 8 as compared with 1922. Heart disease shows an increase of 3 deaths, tuberculosis a decrease of 15, pneumonia a decrease of 21 and bronchitis a decrease of 41. I devoted some considerable space in my report last year to the problem of cancer. This year the number of deaths from this cause is the greatest ever recorded in the history of the borough, the nearest being the figure of 210 deaths in 1921. The cancer death-rate in Fulham for 1923 was 1 -3 per thousand of the population. The leaflets on this disease first issued in 1922 by the Public Health Committee have continued to be distributed during the past year, and, in so far as they tend to persuade persons suffering from suspicious symptoms of this disease to obtain the earliest possible medical attention they undoubtedly are of considerable benefit. At the present time the Ministry of Health is conducting, with the aid of various local authorities, an investigation into the subject of cancer of the breast, and I hope that I may be able to give some interesting facts i my next Annual Report. It is satisfactory that the death-rate from tuberculosis continues to fall. As I pointed out in my Annual Report for 1922, there has been a gradual fall, amounting to over 25 per cent, in the past 19 years. Undoubtedly much of this fall is due to the steady work being done by the Tuberculosis Dispensary and to the gradual improvement in the standard of living of the working-classes during recent years. 14 The death rate from tuberculosis of the lungs for 1923 was 0.9 per thousand of the population. For disseminated tuberculosis it was 0.04, and for tuberculosis of other organs it was 0.14. Infantile Mortality.—Of 1,708 deaths during 1923, 199 or 11.6 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 64 per thousand, being 5 per thousand below that of 1922, and 19 per thousand below that of 1921. This rate of 64 per thousand births is the lowest rate ever recorded in the borough, but in this year of almost phenomenally low infant mortality rates Fulham stands none too well as compared with other Metropolitan boroughs. Out of 25 London boroughs, for which I have been able to obtain the pro infantile mortality rate, Fulham stands tenth, and amongst the boroughs with a lower infantile mortality rate than Fulham are such populous workingclass boroughs as Deptford (62), Poplar (62), Stepney (61), Greenwich (57), Battersea (49) and Woolwich (43). While, undoubtedly, we are making distinct progress in the reduction of our infantile mortality rate, it is clear, from the figures which I have quoted, that we must not yet be satisfied with the results of our work. During 1923 the infantile mortality rate for London was 61, and for England and Wales, as a whole, 69. The causes of deaths of infants during 1923 are set out in Table No. III., and classified according to age and ward. In this regard it is worthy of note that 51 or approximately 25 per cent, of the total deaths occurred as a result of premature birth. There should be a reasonable chance of preventing a considerable amount of this form of infant mortality when we are able to get a larger proportion of our mothers to attend the Ante-Natal Clinic, and come under medical attention prior to the birth of the child. The other principal causes of infant mortality during the year were pneumonia 31 deaths, atrophy and debility 21 deaths, and diarrhoea and enteritis 21 deaths. 15 16 TABLE III. Infant Mortality during Year 1923. Nett Deaths from slated causes at various ages under One Year of Age. Nett Deaths under One Year of Residents in the Wards of the Borough, whether occurring in or beyond the Wards. CAUSE OF DEATH. Under 1 Week. 1—2 Weeks. 2 -3 Weeks. 3—4 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under One Year. Barons Court Ward. Lillie Ward. Walham Ward Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward All Causes Certified 62 9 3 7 81 36 34 24 24 199 19 32 24 26 39 6 43 10 Uncertified ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2. Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Measles ... ... ... ... ... ... 1 ... 4 5 1 ... ... ... 1 ... 3 ... 4. Scarlet Fever ... ... ... ... ... ... ... 1 ... 1 ... 1 ... 1 ... ... ... ... 5. Whooping Cough ... ... ... ... ... 4 3 ... 2 9 ... 2 ... ... 1 ... 5 ... 6. Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 7. Erysipelas ... ... ... ... ... ... ... ... ••• ... ... ... ... 1 ... ... ... ... 8. Tuberculous Meningitis ... ... ... ... ... ... ... 2 ... 4 1 2 ... 1 ... ... ... ... 9. Abdominal Tuberculosis (a) ... ... ... ... ... ... 1 ... ... 1 ... ... ... 1 ... ... ... ... 10. Disseminated Tuberculosis ... ... ... ... ... ... 1 ... ... 1 ... ... ... ... ... ... ... ... 11. Other Tuberculous Diseases ... ... ... ... ... ... ... ... ... ••• ... ... ... ... ... ... ... 12. Meningitis (not Tuberculous) ... ... ... ... ... 1 1 2 ... 4 ... ... 2 ... ••• 1 1 ... 13. Convulsions ... ... 1 ... ... 1 ... ... ... 1 2 ... ... 1 ... i ... ... ... 14. Laryngitis ... ... ... ... ... ... ... 1 l 2 1 ... 1 ... 2 ... 1 ... 15. Bronchitis 1 1 ... ... 2 1 4 2 ... 9 ... 2 4 1 10 ... 3 ... 16. Pneumonia (all forms) 1 ... ... 1 2 6 10 6 7 31 1 3 1 6 ... ... 7 ... 17. Influenza ... ... ... ... ... ... ... 1 ... 1 ... ... 1 ... 3 ... ... ... 18. Diarrhoea ... ... ... ... ... 3 4 ... 1 10 ... 2 1 2 1 1 ... 1 19. Enteritis ... ... 1 ... 1 3 2 3 2 11 2 3 1 2 ... ... 2 ... 20. Gastritis ... ... ... ... ... ... 1 ... ... 1 ... ... ... ... ... ... ... ... 21. Syphilis ... ... 1 ... 1 ... 1 ... ... 2 1 ... ... 1 ... ... ... ... 22. Rickets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 23. Suffocation, overlaying ... ... ... ... ... 1 ... ... ... 1 ... *•* ... ... 1 ... ... ... 24. Injury by Birth 3 1 ... ... 4 ... ... ... ... 4 ... 1 ... ... 1 1 ... 1 25. Atelectasis 8 ... ... ... 8 ... ... ... ... 8 1 ... ... 2 4 ... 1 ... 26. Congenital Malformations ... 4 1 1 6 2 ... ... ... 8 1 ... 1 1 ... 1 4 ... 27. Premature Birth 36 4 1 3 44 6 1 ... ... 51 3 9 7 4 11 ... 11 6 28. Atrophy, Debility and Marasmus ... 9 ... ... 1 10 6 3 2 ... 21 5 5 3 2 1 1 4 ... 29. Other causes... ... 1 ... 1 2 3 1 2 4 12 2 2 1 1 2 1 1 2 Total 62 9 3 7 81 36 34 24 24 199 19 32 24 26 39 6 43 10 Nett Births in the Year- Legitimate ... ... ... ... ... ••• ••• 2,975 Illegitimate ... ... ... ... ... 148 Nett Deaths in the Year of— Legitimate infants ••• 176 Illegitimate infants ... ••• 23 (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. 17 The infantile mortality rates for Fulham since 1866 are given in the subjoined table. If the infantile mortality rate of the years 1886-1890 had persisted to this year no less than 530 infants would have died as compared with the actual number of deaths, 199, thus showing a saving of 331 infant lives for the year. Infant Mortality in Fulham. Deaths of Infants under one year of age per thousand births. Average for five years :— 1886-1890 170 1891-1895 168 1896-1900 167 1901-1905 144 1906-1910 117 1911-1915 109 1916-1920 92 1921 83 1922 69 1923 64 Deaths of Illegitimate Children.—Of the 199 infants who died before attaining the age of one year, 23 were illegitimate, the mortality amongst them being in the proportion of 155 deaths per thousand births, against 59 per thousand among children born in wedlock. This illegitimate infantile mortality rate of 155 is an increase of 52 over that for 1922, when the rate was 103. It is, of course, an acknowledged fact that the average illegitimate child does not get the same care and attention that the legitimate child receives, and in addition, undoubtedly in some cases deliberate inattention is paid to the child in the hope that it may succumb. This, however, is very difficult to prove. It is interesting to look at the causes of these illegitimate deaths, and during 1923 they were as follows : Prematurity 10, wasting and malnutrition 3, want of attention at birth 2, bronchitis 1, pneumonia 1, congenital syphilis 1, enteritis 2, meningitis 2, lack of vitality 1. Here we see that prematurity again accounts for a large number of the deaths, over 43 per cent, of the total. 18 Maternity and Child Welfare. The work in connection with the Council's Maternity and Child Welfare scheme has been carried out during the year on the lines very fully detailed in the report by your late Medical Officer of Health for the year 1919 and in my report for 1922. I shall, therefore, in this year's report only deal briefly with the subject. Notification of Births.—Notifications of the births of 2,862 living children and 75 stillborn children were received during the year under the Notification of Births Act, 91.6 per cent, of births registered being notified. Of these 2,145 or 75 per cent, were notified by midwives, 591 by doctors and 201 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 : First visits to infants 2,836 Revisits to infants 8,442 Revisits to children 1 to 5 years 6,084 Visits to cases of Ophthalmia Neonatorum 22 „ ,, Measles 1,873 „ „ Pneumonia 49 „ ,, Diarrhoea 74 „ „ Puerperal Fever 33 Other visits 508 Infant Welfare Centres.—The Infant Welfare Centres have been carried on as before by the Voluntary Infant Welfare Committee. Owing to a reduction in the voluntary subscriptions, it was necessary for the Borough Council to increase its grant to this Committee to £500 per annum, instead of £250, as before. The work performed by these centres is a very valuable part of the Borough's infant welfare campaign, and much of its success is due to the energy and enthusiasm of Miss Williams, the Superintendent of the Centres, who is ably backed up in her efforts by the Borough Health Visitors. A famous French physician has said that "an Infant Welfare Centre is worth just as much as the presiding physician." If this is indeed a fact, then the Borough Council are fortunate in that Dr. Ruby Thomson, Dr. G. F. Hardy and Dr. Florence 19 Wilson, all of whom have been engaged in this work for some considerable time, have been able to continue their work during the current year. The continuity of tenure of such offices is a very great asset, and one which in many boroughs, owing to the comparatively low salaries paid for such officers, appears to be impossible of attainment. In Fulham we are fortunate, in that our physicians at these centres do take a very real interest in the work and co-operate to the fullest extent with the various institutions, the officers of the voluntary % committee and with the Health Visitors. For particulars as to the various centres, etc., a reference should be made to my annual report for 1922. I give below particulars of the attendances at the centres during the year :— Ante-Natal Clinic. No. of women who attended 343 No. of attendances 1,366 Infant Welfare Clinics. Number of Clinics held. . First Attendances of Babies. Total Attendances. Average Attendances. 92, Greyhound Road 136 500 5,030 37 170, Wandsworth Bridge Road 94 358 3,740 39 Melmoth Hall 98 288 3,506 35 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 255 No. of attendances 1,207 20 At the School Treatment Centre, 18, Bagleys Lane. For operative treatment for enlarged tonsils and adenoids (No. of children) 5 For dental treatment (No. of children) 17 For dental treatment (No. of women) 85 Total attendances of women for dental treatment 248 For visual defects 16 Fulham Babies' Hospital, 23, Broomhouse Road— This hospital, conducted by a Voluntary Committee, and containing 21 cots, is subsidised by the Borough Council. During 1922 the previous annual grant of £1,000 per annum was reduced to £700 per annum, and in consideration of this reduction the Council altered their agreement with the Hospital Committee. Under the new agreement the Borough Council reserves for the use of Fulham residents 14 cots, while the other 7 cots are at the disposal of the Voluntary Committee for the reception of cases from outside the Borough. The Council were influenced in making these arrangements by the fact that cots in the hospital had not been fully occupied during 1922, and they felt that it was a pity to retain cots for which they had no use, while preventing children from other boroughs from using them. The Medical Officer of Health is Medical Superintendent of the Hospital, and during 1923 the clinical work of the hospital has been in charge of Dr. G. F. Hardy, one of the Assistant Medical Officers of Health. The hospital is fortunate in having had the continued services of the Matron (Miss Driver) and Sister (Mrs. Buckley) for some years now. Both of them are enthusiasts in the work and no trouble is spared to do the best for the infants in their care. The following is a summary of the work of the hospital during 1923 :— In Hospital, January 1st, 1923 17 Number of babies admitted during the year 159 Average duration of stay (days) 32.9 Number of cases discharged :— (a) In good health 76 (b) Improvement 41 (c) No improvement 17* 21 (d) On account of the development of infectious disease 9 Viz.— Measles 1 Pertussis 1 Scarlet Fever 3 Diphtheria 1 German Measles 3 Number of deaths 18 Number in Hospital, 31st December, 1923 15 * Of these, 6 were surgical cases transferred to other hospitals. The average daily number in the wards during the year was approximately 14, as compared with 16 in 1922, and 12 in 1921. In considering this average daily number in hospital it should be borne in mind that on 3 occasions during the year admissions to the hospital had to be stopped, owing to infectious disease. We were fortunate, however, in that at no time during 1923 had the hospital to be entirely closed owing to infectious disease. Fulharm Day Nursery, Eridge House, Fulham Park Road.—The Fulham Day Nursery is conducted by a Voluntary Committee, of which your Medical Officer of Health is Chairman. This Committee has continued to receive, during 1923, a grant of £300 per annum from the Borough Council. The primary object of the Day Nursery is to look after, during the day, the children of women who are obliged, through financial circumstances, to go out to work. The majority of these women are widows, or wives separated from their husbands, but in a few cases children of wives living with their husbands have been accepted when the husband is either out of work or earning a wage insufficient for the upkeep of his family, and necessitating the mother also working. The Day Nursery sustained a great loss through the death of the Matron, Mrs. Fitness. The Committee were, however, extremely fortunate in being able to obtain the services of Miss Carvick to succeed her. Miss Carvick had formerly been Matron of the Day Nursery, and was fully acquainted with the work, and is 22 tially the right person in the right place. The medical work of the Day Nursery has continued, as in the past, under the charge of Dr. Ruby Thomson, Assistant Medical Officer of Health. Attendances during the year were as follows :— Individual children attended— Under three years of age 104 Over three and under five years 12 The total attendances made by the above children were :— Under three years— Whole day 5,069 Half day 986 Over three years— Whole day 1,510 Half day 347 Total— Whole day 6,579 Half days 1,333 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. As stated in my annual report of 1922, the accommodation at the Maternity Home is now 10 beds, whereas formerly it was 7. The following is a record of cases admitted to the home during 1923 :— Cases admitted 189 Average duration of stay (days) 14 Number of cases delivered by— (a) Midwives 178 (b) Doctors 11 Number of cases notified as puerperal sepsis nil Number of cases in which the temperature was above 100-4 for 24 hours 1 Number of cases notified as ophthalmia neonatorum 1 Number of cases of " inflammation of eyes," however slight 3 Number of infants not entirely breast-fed while in the institution nil Number of maternal deaths nil Number of foetal deaths (stillborn or within 10 days of birth) 2 23 Dr. Thomson visits the Maternity Home every day and supervises generally the medical work of the home. We are again fortunate in this instance, in having continuity of tenure of office as both Dr. Thomson and the Matron, Miss Bustard, have held office since the opening of the institution in 1920. During 1923 the Council decided to raise the charges for admission to the Maternity Home ; the minimum fee, which used to be £2 0s. 0d., has now been raised to £3 0s. 0d., additional charges being made where the incomes of the patients warrant them. This fee includes all expenses incidental to the confinements and the residence of the patients in the home for 14 days, and is inclusive of medical attention if required. During the latter part of the year the applications for admission to the Maternity Home fell off very considerably, and a special Sub-Committee was appointed to investigate the possible causes. In their report they stated that " after careful consideration, we are of opinion that the reduction in the number of admissions is not generally due to the raising of the fees, nor to any particular reason, but is an occurrence incidental to the working of such institutions." 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 three years of age in 320 cases, compared with 449 cases during 1922. The amount expended was:— £ s. d. For dried milk 148 19 0 For fresh milk 20 11 9 Total £169 10 9 24 It will be seen, therefore, that there has been a gradual decline in the amount of money expended in this way during the past three years, the greatest drop being between 1921 and 1922. Very careful enquiries are made into the financial circumstances of applicants for free or reduced price milk, and the Maternity and Child Welfare Committee have been much helped in these enquiries by the assistance of the Charity Organisation Society. In addition to the milk given free or at reduced price, 15,079 lbs. of dried milk, value £1,339 2s. 4d., were sold at cost price to persons recommended by the Health Visitors or Infant Welfare Centres. During 1922 the amount of dried milk distributed was 25,764 lbs., value £2,556 19s. 1 1d. There has, therefore, been a considerable falling off in the amount of dried milk sold at cost price. Incidence of Infections Disease among Parturient Women and Infants. Puerperal Fever. Thirty-two cases of puerperal fever, equal to 10 per thousand births, were notified during 1923, compared with 31 during the previous year. There were nine deaths from this disease against eight during 1922. All the cases except three were removed to hospital. In my annual report for 1922 I outlined the arrangements which had been entered into with the Fulham Guardians whereby medical practitioners can now send into the Fulham Infirmary suspected cases of puerperal fever without waiting until the diagnosis is absolutely certain. This enables such cases to be brought under effective treatment at the earliest possible moment. On making an analysis of the cases of this disease during 1923, I find that no less than thirteen occurred subsequent to mis-carriages, many of them in the early months of pregnancy. When considering the high incidence of this disease in Fulham, viz. : 10 per thousand births, the fact should be borne in mind that the rate following actual labours (when the thirteen cases of mis-carriage are deducted) is only 6 per thousand births. It is 25 ally admitted that the risk of some septic infection following a mis-carriage is considerable, particularly when, as is no doubt the case, many of these miscarriages are brought about intentionally, either by drugs or instruments. All these cases of puerperal fever following mis-carriage were notified from the Fulham Infirmary, and as in many places it is unusual to notify such cases as puerperal fever, this may account for the relatively high figure which is shown in Fulham compared with the other Metropolitan boroughs. Ophthalmia Neonatorum.—Twenty-two infants were notified as suffering from ophthalmia neonatorum, of whom 7 were removed to hospital. This total compares with thirty-three notifications during 1922, of whom 8 were removed to hospital. The result of the cases was as under Cases notified. Treated at home. In hospital. Vision impaired. Vision unimpaired. Total blindness. Deaths. Left the district. 22 15 7 Nil 16 1 Nil 5 Measles.—Of the total of 1951 cases of measles notified during 1923, 1,037 occurred in children under the age of 5 years. A special report on this subject appears under the heading of Infectious Disease later in this Report. Diarrhoea.—Seventy-nine cases of diarrhoea were notified during 1923, compared with 17 during 1922. No doubt the hotter summer of 1923 had much to do with this increase. All of the cases of diarrhoea were under five years of age. All cases of " Epidemic Diarrhoea " or " Zymotic Enteritis," under the age of five years are compulsorily notifiable in Fulham by special order of the Borough Council made under 26 Section 55 of the Public Health (London) Act, 1891. This Order came into force on February 9th, 1920. Home Nursing.—Similar arrangements to those fully explained in my Annual report of 1922 continued in force in the borough during 1923, whereby Home Nursing is provided through the agency of the Fulham District Nursing Association, which is affiliated to Queen Victoria's Jubilee Institute. The fee paid by the Borough Council was as before, one shilling for each visit. During the year these fees amounted to the sum of £34 2s. 0d., payable by the Public Health Committee, and £60 15s. Od. 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. The number of visits paid during the year was as follows :— To persons over 5 years of age 1,338 visits. To persons under 5 years of age 559 ,, The great majority of visits paid to persons over the age of five were in respect of abscess of the breast occurring amongst nursing mothers. Vaccination. I am indebted to Mr. H. Davies, Vaccination Officer to the Fulham Guardians, for the following information with reference to vaccination. During the year 1923, 2,789 successful primary vaccinations were carried out, compared with 1,787 during 1922. I give in the following table fuller details of vaccinations carried out during the year ended 31st December, 1922, but these detailed figures are not yet available for 1923. No. of births registered from January 1st, 1922, to December 31st, 1922 3,191 Successfully vaccinated 1,787 Insusceptible of vaccination 6 Dead—unvaccinated 135 Postponed by medical certificate 50 Certificates granted under Clause 2 of Vaccination Act, 1898 916 Removed to districts in which Vaccination Officer has been notified 70 Removed to places unknown 204 Outstanding 23 27 Owing to the various outbreaks of Smallpox which have taken place in London during the past year or two, I thought it would be interesting to see what effects these outbreaks had had on the number of vaccinations performed by the public vaccinators. Mr. Davies, therefore, has kindly supplied me with information for the past three years from September, 1920, to September, 1923, and the figures are distinctly illuminating. I give these figures below :— September, 1920, to September, 1921 2,924 Vaccinations ,, 1921 „ 1922 1,309 ,, 1922 „ 1923 5,981 During the first period, September, 1920, to September, 1921, two or three cases of Smallpox occurred in London, but none in Fulham, and one gets the total of 2,924 vaccinations. During the next period, September, 1921, to September, 1922, no cases of Smallpox occurred either in London or Fulham, and apparently, as a result, one gets a distinct drop in vaccinations, the figure being 1,309, the most noticeable part of the drop being the figure for re-vaccinations, which fell from 1,475 in the first period to 42 in the second period. During the third period, September, 1922, to September, 1923, when two cases of Smallpox occurred in Fulham, and a considerable number in other parts of London, there is noticeable a very considerable increase in the number of vaccinations, the figure for the previous year being exceeded by more than five times, there being a total of 5,981 against 1,309. In this instance there is marked increase, both in primary vaccinations and in re-vaccinations, the primaries increasing from 1,267 in the second period to 2,996 in the third period, while re-vaccinations increased from 42 in the second period to 2,985 in the third period. It would appear, therefore, that there is a distinct relationship between the number of vaccinations performed and the presence or absence of Smallpox. Evidently some people have consciences which allow them to object when they fancy they are safe and to be willing when there is any danger of Smallpox. This is only another example of the futility 28 of the present vaccination legislation. As I have said repeatedly, the present law regarding vaccination should be amended so that vaccination is either entirely voluntary or strictly compulsory, with revaccination at a later date. Poor Law Relief. Through the courtesy of Mr. Mott, Clerk to the Fulham Guardians, I am able to give some figures as to the amount of relief dispensed by the Guardians during the past year. The close relationship between poverty and ill-health justifies some consideration of these figures. The subjoined table gives the number of persons receiving relief, both indoor and out-door, and the persons in 'receipt of out-door medical relief only, during each six-monthly period, from the six months ended January 1st, 1914, to the six months ended January 1st, 1924. It will be noticed that the number in receipt of poor law relief during 1923 was considerably below the number for 1922. One matter to which I think attention should be drawn is the comparatively small number of persons in receipt of out-door medical relief only. When one takes into consideration the large number of cases in which members of my staff are constantly being told that people, although not in need of general relief, cannot afford to call in a doctor, it seems extraordinary that the number shown in this table should be so small. One cannot help thinking that there is still in the popular mind a very considerable prejudice against calling in the poor-law doctor. The routine of application to the relieving officer prior to obtaining the poor-law doctor is, I believe, one of the great stumbling blocks. It is undoubtedly necessary that some check should be placed upon the financial position of persons who might choose to avail themselves of the services of the poor-law doctor, but I am strongly of the opinion that if some easier method could be evolved, whereby poor persons could be enabled to obtain the services of a doctor in their own homes a considerable number of deaths, particularly amongst young children and 29 infants, could be avoided. The old club system which existed in the north of England prior to the passing of the Insurance Act, under which system in many instances all the members of the family were able to obtain medical attention, although having many drawbacks, certainly enabled poor persons to obtain immediate medical attention for their children, and personally I should be very glad if the present Insurance Act could be extended, so far as medical benefit is concerned, to the dependents of insured persons. (1) (2) Number receiving re- Persons in receipt of lief. Indoor and out- out-door medical re- Date. door, but excluding lief only not included (Half-year Lunatics and figures in column 1. ending). in column 2. 1st Jan., 1914 1,920 90 1st July, 1914 1,804 88 1st Jan., 1915 1,915 64 1st July, 1915 1,553 66 1st Jan., 1916 1,572 86 1st July, 1916 1,511 77 1st Jan., 1917 1,554 69 1st July, 1917 1,546 65 1st Jan., 1918 1,527 64 1st July, 1918 1,439 * 73 1st Jan., 1919 1,341 46 1st July, 1919 1,376 43 1st Jan., 1920 1,430 46 1st July, 1920 • 1,426 44 1st Jan., 1921 2,465 75 1st July, 1921 2,486 70 1st Jan., 1922 4,074 58 1st July, 1922 3,520 56 1st Jan., 1923 3,120 64 1st July, 1923 2,659 92 1st Jan., 1924 2,793 70 Infectious Disease. The total number of cases of infectious disease notified during the year was 3,608, compared with 4,388 for the year 1922, and 2,834 for the year 1921. Towards this total of 3,608 measles contributed 1,951. 30 The fall in the total number of cases of infectious diseases is due to a considerable decline in the amount of diphtheria and scarlet fever, there being, roughly, 160 cases less of each disease, as compared with the previous year, but against this must be set an increase in the notifications of Infantile Diarrhoea, from 17 to 79. It is interesting, however, that whereas 27 deaths during 1922 were ascribed to this disease, only 25 deaths were attributed to it in 1923, so that we have a larger number of cases, but a smaller number of deaths. It is difficult to account for this marked disparity between the figures of the two years, and one can only surmise that the incidence of the disease during 1922 was not fully illustrated by the number of notifications. Full particulars of these notifications arranged according to disease, ward and age, will be found in Table IV., page 36. In the last quarter of the year measles gradually became epidemic, and I give below a special report on the outbreak. Apart from this there was no matter in connection with infectious diseases during the year calling for particular notice. In connection with diphtheria and scarlet fever, I have had special note made during the year as to whether the diagnoses as notified were confirmed in the fever hospitals to which the patients were admitted. As a result, we find that 45 notifications of diphtheria or 16.2 per cent. of the total cases, and 64 notifications of scarlet fever or 13.7 per cent. were not confirmed in hospital. There was no case of smallpox in the borough during the year. Measles. During the year 1923, 1,951 cases of measles were notified, as compared with 2,438 during the previous year. The deaths from this cause numbered 22, as com pared with 41 during 1922. During recent years 31 measles has appeared in epidemic form in Fulham and throughout London generally every alternate winter, so that although the figures of notifications for 1922 and 1923 are somewhat similar, the figures taken over the winter period of 1921-22 and 1922-23 are very different. Though the notifications during the two winter quarters, 1921-22, amount to 1,676, those for the two winter quarters, 1922-23, amount only to 153. At the time of writing we are in the midst of the epidemic period for winter 1923-24; and have, in fact, had 1,318 notifications during the last quarter of 1923. It will be of interest to look at the number of notifications received for the various quarters of the last two years when the gradual decline of the winter 1921-22 epidemic will be noticed, followed by the start of the winter 1923-24 epidemic. Number of cases notified for the quarter ending :— 1922. 1923. March 31st 1,315 March 31st 116 June 30th 954 June 30th 309 September 30th 132 September 30th 208 December 31st 37 December 31st 1,318 As stated above, there have been 22 deaths from measles during the year under review, and I have gone through these cases in an endeavour to ascertain, if possible, some of the underlying causes. The Council will be aware that hospital accommodation is provided by the Metropolitan Asylums Board for severe cases of measles where, in the opinion of the Borough Medical Officer of Health, the home conditions are unsatisfactory. The Poor Law Guardians also admit cases of measles into certain wards in the Infirmary. Further, home nursing is provided for cases of measles by the Council through the agency of the Queen Victoria Jubilee District Nurses. All cases of measles which are notified to the Public Health Department are at once visited by one of the Health Visitors, who, if necessary, points out to the parents the means available for dealing with the case by removal to hospital or by district nurse. 32 In our enquiry into the causes of deaths from this disease our first endeavour was to ascertain to what extent the means provided by the Council, the Metro politan Asylums Board and the Guardians had been utilised in these cases, and with what result. The following facts emerge :— (1) None of these deaths occurred in cases removed to the hospitals of the Metropolitan Asylums Board. (2) Five deaths occurred amongst cases removed to the Poor Law Infirmary, but in the majority of these the cases were only removed as a last resort, and when the child was severely ill with pneumonia. (3) No deaths occurred amongst cases nursed by the District Nurses. (4) Three cases who died were not notified to the Health Department previously, and were therefore not visited by the Health Visitors. (5) In five cases the notification was only received on the day before or on the day of the child's death, and therefore the Public Health Department was unable to take any steps to improve the conditions. (6) In six cases the parents did not choose to avail themselves of either hospital or District Nurse. (7) In three cases the patient was only slightly ill when visited by the Health Visitor, but developed lung complications from seven to ten days later, and no effort appears to have been made to obtain hospital or nursing assistance. Every death from measles was attended by a medical practitioner at some stage of the illness, but, unfortunately, in many cases the doctor is either called in too late, or is only called in to make a diagnosis, and thereafter the parents endeavour to carry on the treatment themselves. At the commencement of this year's epidemic I issued a letter to the general practitioners working in the borough, reminding them that measles was a notifiable disease in this borough, and acquainting them with the provisions made for dealing with severe cases. Unfortunately, our work in connection with 33 measles is handicapped by our limited staff of Health Visitors. Our five Health Visitors are in normal times fully employed in dealing with Maternity and Child Welfare work, and with the few cases of measles which occur. It follows therefore that in times of measles epidemics, even though the cases over 5 years of age are visited by the female sanitary inspector, a certain amount of the child welfare work has to be sacrificed in order that the health visitors may pay even one visit to each of the notified cases of measles. Any subsequent following up of cases, except those that are found on the first visit to be extremely ill, is out of the question, and undoubtedly it is badly required. It should be added that early in 1924 the Council appointed an additional temporary Health Visitor for measles purposes, and that this added greatly to the general efficiency of the work. It seems deplorable that a disease which causes so many deaths (there were 13 in Fulham in the month of December alone) should be regarded so lightly by the majority of parents. Not only does measles cause death, but it is also in many cases the starting point for various forms of subsequent ill-health. Tuberculosis, ear, nose and throat affections, sub-acute bronchitis, anaemia and general delicacy are only too often the aftermath of a neglected case of measles. Measles is in every respect at the present time a much more dangerous disease than either scarlet fever or diphtheria, both of which are regarded with apprehension, the greatest care being bestowed on children so suffering. Measles is looked upon as an every-day occurrence and worthy of as little attention as can reasonably be given to the sufferers. By making measles a notifiable disease, and therefore bringing to bear upon it the clauses of the Public Health (London) Act relating to infectious disease, a step has undoubtedly been taken towards making the man in the street realise that this disease is as serious and as worthy of care as the other diseases which are notifiable. I do not wish here to enter into a discussion as to the merits or demerits of the Notification of measles. 34 Suffice it to say that, although in my opinion the notification of measles can do little to limit its spread owing to the fact that the most infectious period of this disease is prior to the development of the rash, yet, undoubtedly notification, by making it practicable to have these cases visited by the Health Visitors and advice, nursing and other treatment provided, impresses upon parents the serious nature of the illness, and without doubt gives those affected a better chance of recovery, and enables them to avail themselves of the treatment provided. In this respect one must consider as gain, not only the lives which are saved, but also, as pointed out previously, the amount of subsequent sickness which may be prevented, owing to greater care being taken of the patients. Venereal Diseases. The educational work in connection with venereal diseases is carried out in the borough by a local voluntary committee under the auspices of the National Council for Combating Venereal Diseases. This Committee was officially recognised by the Borough Council during the year, a member of the Public Health Committee being appointed to serve upon it, and a small donation being made towards the expenses of the Committee. The Medical Officer of Health, one of the sanitary inspectors, and one of the Health Visitors, have for some years been members of this Committee. Much good work was done during the year, and real interest was apparent at the various lectures and film shows. I give below a list of such educational meetings held during the year 1923 :— 35 List of Lectures and Film Displays given by the N.C.C.V.D. Committee during 1923. Where held. Date. Subject. Lecturer. Women's Free Church Council 16.1.23 Lecture. Miss Dugdale. Fulham Palace Road School 20.2.23 Film. Mrs. N. Rolfe. Women's Co-operative Guild 21.2.23 Lecture. Miss Dugdale. Fulham Palace Road School 27.2.23 Film. Mr. E. B. Turner. All Saints 5.3.23 Lecture. Miss Dugdale. Bethel Chapel 5.3.23 ,, Dr. Mary Douic. Beaufort House School 6.3.23 Film. Mrs. Altentop. Assembly Hall, Wandsworth Bridge Road 8.3.23 Lecture. Miss Dugdale. Dawes Road Congregational Church 19.3.23 ,, Miss Clark. Beaufort House School 17.4.23 Film. Mrs. N. Rolfe. Wesleyan Schoolroom, Walham Green 25.4.23 Lecture. Miss Dugdale. Lecture Hall, Central Library 2.5.23 Film. Dr. Sloan Chesser. Women's Free Church Council 22.6.23 Lecture. Miss Dugdale. Bethel Chapel 16.7.23 ,, Miss Dugdale. Dawes Road Baptist Church 17.9.23 ,, Miss Dugdale. Assembly Hall, Wandsworth Bridge Road 18.10.23 Film. Miss Dugdale. Central Library 14.11.23 ,, Mrs. Clayton. Dawes Road Baptist Church 19.11.23 ,, Miss Dugdale. Lillie Road School 28.11.23 ,, Dr. Mary Douie. Congregational Church, Dawes Road 10.12.23 Lecture. Dr. Mary Douie. The free treatment of venereal diseases in Fulham is in the hands of the London County Council, and arrangements are made whereby persons may receive such treatment at special clinics held at certain hospitals, those most convenient for Fulham being the West London Hospital and St. George's Hospital. Particulars as to days and hours of attendance can be obtained at the Public Health Department, and notices giving these particulars are displayed in the public lavatories in the borough. Such treatment is entirely free, and the greatest care is taken to ensure secrecy. Early and efficient treatment is the only hope in these diseases, and there is now no reason why any person so afflicted should not avail himself or herself of these facilities. Table IV.—Cases of Infections Diseases notified during the Year 1923. Notifiable Diseases. Number of Cases Notified. Total Cases Notified in each Ward of the Borough. At all Ages. At Ages—Years. Barons Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Huriingham Ward. Sands End Ward. Town Ward. Total cases removed to Hospital. Deaths. 0-1. 1-2. 2-3. 3-4. 4-5. 5-10. 10-20. 20 35. 35-45. 45-65. 65 and upwards. Smallpox — — — — — — — — — — — — — — — — — — — — — — Cholera, Plague — — — — — — — — — — — — — — — — — — — — — — Diphtheria (including Membranous Croup) 277 7 21 27 29 13 83 51 38 6 o 16 47 45 37 54 20 46 12 271 20 Erysipelas 76 1 — 2 2 — 3 8 13 10 20 17 — 13 7 18 20 2 13 3 48 3 Scarlet Fever 466 11 15 26 41 32 195 103 33 6 4 — 16 111 44 63 100 24 87 21 448 Typhus Fever — — — — — — — — — — — — — — — — — — — Enteric Fever 3 — — — — — — 1 1 — 1 — — — — — 1 1 1 — 3 — Relapsing Fever, Continued Fever — — — — — — — — — — — — — — — — — — — — — — Puerperal Fever 32 — — — — — — — 21 11 — — 2 3 6 8 9 2 2 — 29 9 2 1 — — — — — 1 — — — — — — — 1 — 1 — — 1 1 Polio-myelitis 5 1 2 — — — 2 — — — — 1 — 1 1 — 1 —" 1 1 1 Ophthalmia Neonatoru m 22 22 — — — — — — — — — — 3 4 4 2 2 2 5 — 7 — Tuberculosis of Respiratory System 319 1 1 1 1 3 10 43 120 47 80 12 18 62 26 53 74 11 46 29 — 149 Disseminated Tuberculosis ... 4 2 1 — 1 — — — — — — — — 2 — — 1 — 1 — — 8 Other Tuberculous Diseases... 151 4 4 7 8 5 47 43 18 V 8 — 3 21 11 30 42 6 31 7 — 24 Measles 1,951 84 189 184 284 296 796 100 13 5 — — 68 311 342 100 347 102 560 121 106 23 Encephalitis Lethargica 2 — — — — — — — 1 — 1 — — — — — 1 — — 1 1 — Pneumonia 218 12 17 11 11 3 23 19 37 28 42 16 12 34 9 50 54 9 38 12 161 174 Diarrhoea 79 4a 17 12 2 3 — — — — — — 1 16 7 19 15 — 18 3 50 25 Malaria 1 — — — — — — — — — 1 — — — — — 1 — — — 1 — Dysentery — — — — — — — — — — — — — — — — — — — — — — Trench Fever — — — — — — — — — — — — — — — — — — — — — — Total 3,608 190 266 272 379 355 1,157 371 295 120 159 44 140 624 502 382 721 181 848 210 1,127 442 37 Tuberculosis. Four hundred and seventy-four new cases of tuberculosis were notified during the year. Of these, 319 were cases of tuberculosis of the respiratory system, 4 were cases of disseminated tuberculosis, and 151 cases of tuberculosis of other organs. In Table IV., page 36, the notifications of tuberculosis will be found classified according to age and ward. Below I give figures relative to the deaths from this disease, and the number of such deaths previously notified as suffering from tuberculosis. Mortality from Tuberculosis. Respiratory System— 149 deaths 87 males, 62 females. Death-rate 0.92 per 1,000, being 0.1 lower than 1922. 129 notified (86.6 per cent.), 20 not notified (13.4 per cent., of whom 6 or 30 per cent. died in institutions). Other Tuberculous Diseases— 32 deaths 17 males, 15 females (including 8 deaths from disseminated tuberculosis). Death-rate 0.19 per 1,000, compared with 0.2 for 1922. 20 notified (62.5 per cent.), 12 not notified (37.5 per cent., of whom 6 or 50 per cent, died in institutions). Period between Primary Notification and Death. Respiratory System— Under 1 month 21 (16.2 per cent.). 1-3 months 25 (19.4 per cent.). 3-6 ,, 17 (13.2 per cent.). 6-12 „ 20 (15.5 per cent.). 1-2 years 22 (17.1 per cent.). Over 2 years 24 (18.6 per cent.). Other Tuberculous Diseases— Under 1 month 11 (55 per cent.), including 3 disseminated tuberculosis. 1-3 months 2 (10 per cent.) including 1 disseminated tuberculosis. 3-6 ,, 1 (5 per cent.), disseminated tuberculosis. 6-12 „ Nil. 1-2 years 2 (10 per cent.). Over 2 years 4 (20 per cent.), including 1 ated tuberculosis. 38 The death-rate for tuberculosis of the lungs is this year 0.92 per 1,000, as compared with a rate of 1.02 per 1,000 for 1922. The total notifications of all forms of tuberculosis for this year are, however, 474 against 385 for 1922, showing an increase for the year 1923 of 89. From the figures given above, it will be seen that of the deaths from tuberculosis of the respiratory system, 13.4 per cent. had not previously been notified as suffering from this disease, while for other tuberculous diseases 37.5 had not previously been notified. It will further be noticed that 16.2 per cent. of respiratory cases and 55 per cent. of non-respiratory cases were only notified within a month of their death. Prevention and Treatment of Tuberculosis.—The Tuberculosis Dispensary is situated at 114, New King's Road. The administration of the Dispensary is 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, one part-time assistant tuberculosis officer, three nurses, one dispenser and laboratory assistant, one clerk and the caretakers. Report by the Tuberculosis Officer [Dr. Sullivan) on the Work of the Tuberculosis Dispensary.—The Fulham Dispensary is carried on as a part of the Public Health Department of the Borough Council under the admin. istration of the Medical Officer of Health. The first tuberculosis dispensary was opened in Edinburgh by Sir R. W. Philip, now Professor of Tuberculosis at Edinburgh University, and to his 39 initiative and arduous work in the face of immense odds and prejudice is due the fact that the dispensary has become a world-wide institution. The main features of the dispensary system are as follows The Dispensary is the centre of anti-tuberculosis operations in its own area, and in order to attain this object its work is co-ordinated with that of all agencies dealing with persons suffering from the disease. In London this includes the following :— The Health Ministry, the War Pensions Ministry and to some extent the Labour Ministry. The London County Council (Public Health and Education departments, and schools). The Poor Law Authorities and Infirmaries. Hospitals. Medical Practitioners. Approved Societies. Social Service Workers. The general practitioners and dispensary workers are the main forces occupying the front line in the operations against tuberculosis as they are in close touch with the disease at the chief source of infection the patient's home. The Dispensary work consists of :— (1) Detection and diagnosis.—This is important, because the disease is curable in its early stages, and generally incurable in its later manifestations. This aspect of the work involves among other duties the examination and re-examination of contacts, the observation of suspicious cases, and the home supervision of the patients' families. (2) Treatment.—The chief duty of the Tuberculosis Officer with regard to treatment is 40 to ensure that every person suffering from or suspected to be suffering from tuberculosis receives treatment. A certain number of cases are treated at the Dispensary, but the majority are referred to private doctors or sent to hospitals or sanatoria. (3) Prevention.—The primary responsibility of the Dispensary is the prevention of tuberculosis, and for this reason the Dispensary has become part of the Public Health Department of the Borough Council. The chief object of visiting the advanced cases in their homes is to prevent the spread of the disease; the treatment of these cases is carried out by private doctors. The Dispensary endeavours to keep in touch with all notified cases, and few cases are lost sight of; with this object the following-up system recommended by the Health Ministry and the London County Council is in operation. Undue interference with the rights of people in their homes is to be avoided, and compulsion in any form is unwarranted and, indeed, is bad policy. (4) The Dispensary acts as an information bureau in relation to tuberculosis, and careful records are kept of all work done. The Care Committee.—The economic and social aspect of dispensary work is the special province of the Care Committee. This Committee was taken over from the London County Council by the Borough Council during 1923 ; it is an essential part of dispensary organisation, and not a mere side issue. It consists of members of the Borough Council and coopted members having special experience of Welfare Work. Cases of tuberculosis notified to the Medical Officer of Health are visited by the Dispensary Nurses, and 41 those requiring financial or other assistance are reported to the Care Committee. In the early days of the Dispensary a good deal of overlapping took place between the visits paid by the nurses and those paid by the Care Committee Visitors, but the duties of each have now become clearly defined, and the overlapping has been almost entirely abolished. The Dispensary and its Care Committee are associated in their work with many official and voluntary bodies, including the following: London County Council, War Pensions Ministry, School Authorities and their Care Committees, Charity Organisation Society, Invalid Children's Aid Association, Children's Country Holiday Fund, Approved Societies, Almoners' departments of Hospitals, Benevolent Societies, including the Peterborough Benevolent Society in Fulham, Welfare Departments of large business houses, and last, but not least, the Guardians ; each of these is represented on the Care Committee. Committee meetings take place once a fortnight, and urgent cases are dealt with by the Chairman, Tuberculosis Officer and Secretary. Although the patient naturally receives first consideration, the family is taken as the unit and not the individual, as the Dispensary deals both with the treatment of the patient and prevention of infection of other members of the household. Tuberculosis care work falls under the following heads:— 1. Securing Financial Help or Help in Kind.—The Fulham Committee gives no help directly, but is responsible for seeing that help is given through other agencies. Financial help is obtained from the Charity Organisation Society, the United Services Fund, the British Red Cross Association or from the Guardians. The financial enquiries regarding income and expenditure are made and recorded by a visitor from 42 the Care Committee. It may be taken as a general rule that no financial enquiries are made by the Nurses, who, nevertheless, obtain, in the course of their home visits, a general idea of the economic and social position of the family without asking direct questions. 2. Securing Extra Nourishment for the Patient.— This is done through the Guardians, the Charity Organisation Society, the Borough Council, and the British Red Cross Association. During 1923 extra nourishment was granted by the Borough Council to 35 patients, at a cost of £27 9s. l0d. Last year the amount expended was £29 0s. 11d. 3. Lending of Beds and Bedding, in order to enable the patient to sleep alone. At the present time ten beds are on loan from the Dispensary, and the British Red Cross Association also provides beds in the cases of ex-service men. 4. Making Assessments and Collecting Weekly Payments.—When a patient is to be sent to an institution by the London County Council the Committee makes enquiries and verifies statements regarding income and expenditure, recommending the amount of the assessment to the London County Council. The weekly payments are collected by one of the Care Committee visitors, and in the course of these visits any change in the financial position of the family becomes known to the Committee. Parents and guardians are kept informed of the progress of their children while away in institutions, and in this way friendly relations are established with the Care Committee visitor. 5. Friendly Visiting and General Advice.—This is helpful, and is much appreciated by the patients. The visitor is sometimes instrumental in preventing premature discharge of patients from institutions. 6. Convalescent Treatment and Boarding Out in the country, either for the patient or a member of the 43 family, is arranged through the Charity Organisation Society, the Invalid Children's Aid Association, the Children's Country Holiday Fund, and the British Red Cross Association, or the cost of a holiday may be provided by the Charity Organisation Society. Many adults suffering from advanced tuberculosis have to be treated at home, either because the existing accommodation in institutions is insufficient, or because they refuse to go away from home. In these cases, if there are children living at home in close contact with the patient, an endeavour is made to have the children removed from the source of infection, and boarded out in the country, either through the Guardians, the Charity Organisation Society or the United Services Fund. The Invalid Children's Aid Association does not deal with healthy contacts, but sends a large number of non-pulmonary cases to convalescent homes and elsewhere, receiving a grant for the purpose from the London County Council. 7. Clothing.—The Care Committee refer to the Charity Organisation Society and the British Red Cross Association patients whose clothing or underclothing is deficient. This is very useful, particularly for patients going to sanatoria. 8. Employment.—One of the duties laid on the Committee by the Health Ministry is that of assisting to provide employment for patients on discharge from institutions. Our success in this has been limited. The few successful cases have been due to the effort of individual members of the Committee or of the Staff. The Charity Organisation Society, the Labour Exchange and the Society for securing employment for the Defective are now being asked to assist. 44 Typical Examples of Care Committee Cases. The Secretary of the Care Comm ittee (Miss Sargent) reports the following Cases as typical of many dealt with by the Committee during the year :— A was a maid in domestic service when she first came to the Dispensary. She was suffering from tuberculous glands, and was sent away to sanatorium where the treatment did her so much good that on her return she was able to take another place, which she kept for some months, and then broke down in health again. Operative treatment was obtained for her from the Infirmary, and then through the Care Committee she found a place as parlourmaid at Naylands Sanatorium. She is now getting on well, and is very happy, and there is every prospect that she will eventually be able to resume her ordinary work under normal conditions. B was a widow left with three delicate children, and was herself in need of prolonged institutional treatment. The one little boy who was suffering from spinal caries, was sent to Alton by the London County Council, and the same authority provided treatment at Carshalton for the younger girl, who was suffering from tuberculous glands. The elder girl was placed in a home in the country by the United Services Fund, and the mother was thus left free to accept hospital and then sanatorium treatment. When the time came for the little girl to be discharged from Carshalton, the mother was not fit to look after her, and so, through the Invalid Children's Aid Association, she obtained admittance to the Royal Patriotic Corporation Fund Home, where she was soon after joined by her elder sister, and in this way the two little girls will be brought up together. C was a discharged soldier, who came home from hospital with very little chance of recovery. The British Red Cross Association were asked to grant bed and bedding, so that he could sleep alone and thus lessen the risk of infection to his family. A nice single bed, mattress, sheets and blankets were supplied and everything done to make him as comfortable as possible. D was a widow with three sons, who had got into very low water through ill-health and unemployment. Everything that could be turned into money had gone, and the home was reduced to less than the barest necessaries, while any attempt at keeping up appearances had become a thing of the past. The Dispensary first lent blankets, and the patient was recommended for sanatorium treatment. When she came to go away the Charity Organisation Society were asked to supply clothing, and this they did so generously that, as she said, " she felt a different woman." The boys found work, and during the mother's absence they steadily saved up until they had bought blankets and quilts for the beds. In addition, they redecorated the home so as to have it 45 bright and clean for her return. There was constant visiting by one of the Dispensary Nurses, and her interest and encouragement had a great deal to do with the improved home conditions. E was a widow with three children who, after working hard to support them, broke down in health, and had to be sent to a sanatorium. The eldest girl looked after the two children of school age during the mother's absence, but, not strong herself, when the latter returned, and there was much nursing to do as well as the housework, nearly broke down. After much persuasion the mother consented to the Guardians taking charge of the two children, and the boy was sent to the " Exmouth," while the little girl was placed in one of the Guardians' Homes. The London County Council arranged a further supply of treatment for the mother, and thus freed from responsibility the elder girl was able to take advantage of the offer of the Charity Organisation to convalesce her. She was fitted out with clothes and sent to the seaside for a time, and on her return was able to start work. She is now employed as a waitress, and is getting on well. Fulham Dispensary, 1923 Number of New Patients— Insured 185 Uninsured 442 Total 627 Number of Attendances— Insured 2,288 Uninsured 3,261 Total 5,549 Number of patients who have attended both old and new, 1,398. Number of Notifications— Pulmonary 141 Non-pulmonary 88 Total 229 (Of these 202 were notifications of new patients). Number of physical examinations 2,755 Number of reports sent to public bodies (508 to Ministry of Pensions; 491 London County Council). 999 Number of reports sent to doctors 218 Number of contacts examined for first time 351 Number of home visits paid by doctors 552 Consultations 50 46 Number of home visits paid by the nurses 4,603 Number of ex-service men attending 276 Number of ex-service men notified as suffering from tuberculosis 213 Sputum examinations for tubercle bacilli 1,616 Urine examinations 69 Blood examinations 13 Bacteriological examinations of urine, pleural fluids, etc. 30 Patients sent into Institutions— (a) By the London County Council— Hospital. Sanatorium Men 44 49 Women 14 23 Children 2 14 (ib) By the Relieving Officer mostly to Infirmary— Men ... 7 Women 7 Children 19 13 children have been sent away by the Invalid Children's Aid Association. 2 Women were sent to Homes for the Dying by the Charity Organisation Society. 1 woman was sent to a convalescent home by the Charity isation Society. 2 children were boarded out by the Charity Organisation Society. 1 man was sent to a convalescent home by the Royal Red Cross Association. 2 children were placed in permanent homes by the United Services Fund. 2 patients went to sanatoria privately. Total number sent away during the year, 202. A great defect in the tuberculosis scheme in London is the lack of sufficient accommodation in institutions for advanced cases. It must be admitted that it is not necessary for all advanced cases to go to hospital, and that many will not go even if they are offered vacancies. Nevertheless, the accommodation available is quite inadequate, and until this defect is remedied the disease will go on spreading insidiously from one person to another living in contact with him. 47 Table A. Showing who recommended the Patients. 231 were recommended by private doctors. 25 the Medical Officer of Health. 15 „ „ the School Medical Officers. 15 „ „ the school authorities. 14 ,, „ hospitals. 4 ,, ,, sanatoria. 6 „ other dispensaries. 3 „ „ the Fulham Infirmary. 23 „ „ the army authorities. 64 ,, ,, the dispensary staff. 16 „ „ the London County Council. 73 „ „ friends. 53 „ ,, other patients. 39 „ ,, the door plate. 10 ,, „ the invalid Children's Aid Association 3 ,, the Charity Organisation Society. 2 „ ,, the district nurses. 1 „ ,, the Relieving Officer. 1 the Red Cross. 29 were contacts. 627 Table B. Sex and Age of New Patients for 1923. Under 5 yrs. 10 yrs. 15 yrs. 25 yrs. 35 yrs. 45 yrs. 45 & over All ages. Males 32 81 44 28 43 41 55 324 Females 31 49 37 42 77 31 36 303 Both Sexes 63 130 81 70 120 72 91 627 48 Table C. Diagnosis in Males and Females. Total Cases. Pulmonary Tuberculosis. Other forms. Suspects. NonTuber cular. Percentage Tuberculous. 324 males 75 36 11 202 34.25 303 females 57 34 13 199 30.03 627 all ages 132 70 24 401 32.21 Table D. Diagnosis at Various Age Periods. Pulmonary Tuberculosis. Other forms. Suspects. NonTuber cular. Percentage Tuberculous. Under 5 years 3 15 45 28.57 „ 10 — 26 2 102 20.00 „ 15 „ 5 15 3 58 24.69 „ 25 21 7 5 37 40.00 „ 35 40 1 10 69 34.18 ,, 45 „ 20 3 3 46 31.94 45 and over 43 3 1 44 50.54 All ages 132 70 24 401 32.21 Table E. Housing Conditions. Of 189 of the 202 tuberculous patients found in 1923— 9 lived in the basement. 42 „ on the ground floor. 60 „ ,, first floor. 14 „ ,, second floor. 4 „ third floor. 8 „ „ top floor. 35 „ on more than one floor. 17 „ in the whole house. 189 49 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 8 2 Patient living with 1 other 4 4 5 1 3 — „ „ 2 others 2 10 12 7 3 2 3 „ 5 7 22 6 3 2 ,, ,, 4 ,, 2 6 10 9 3 4 — 1 7 5 3 — ,, ,, 6 ,, 1 1 5 2 4 — ,, 7 ,, — — 1 2 1 3 ,, ,, 8 — — 1 4 2 — ,, ,, 9 ,, — — 1 1 — 1 ,, ,, 10 ,, 1 Total 22 31 64 37 23 12 Table G. Sleeping Accommodation of 189 Tuberculous Patients. The patients slept- In a separate room In 52 cases. Alone in bed with one other in room . „ two others in room ,, 13 ,, ,, „ three others in room ,,11 „ „ ,, six others in room „ 1 „ In bed with one person and no others in room ,, 54 „ ,, „ one other in room „ 14 „ „ „ two others in room „ 11 „ „ ,, three others in room ,, 6 „ In bed with two persons and no other in room „ 6 „ ,, „ one other in room „ 2 „ ,, ,, two others in room ,, 4 ,, 189 cases. 50 Table H. Occupations of 76 Tuberculous Men in 1923. 2 barmen. 1 gardener. 1 blindmaker. 1 jeweller. 1 book-packer. 9 labourers. 1 boot repairer. 1 lead-caster. 1 briar pipe-maker. 1 linotype operator. 1 bricklayer. 1 male nurse. 1 butler. 1 mechanic. 1 cab-washer. 1 milkman. 1 carman. 1 painter. 2 carpenters. 1 pie-maker. 1 chauffeur. 5 porters. 7 clerks. 1 post officer sorter. 1 club attendant. 2 postmen. 1 commissionaire. 1 railway gateman. 1 designer. 1 schoolkeeper. 1 dispenser. 1 shop assistant. 1 dustman. 3 shop-keepers. 1 dyer and cleaner. 1 store-keeper. 1 electrical core filer. 2 stage managers. 1 engineer. 2 street traders. 1 factory caretaker. 1 theatre attendant. 2 fishmongers. 1 tram conductor. 1 fitter's mate. 2 warehousemen. 3 no occupation. Occupations of 62 Tuberculous Women in 1923. 1 barmaid. 1 milliner. 2 clerks. 1 paper bag packer. 7 domestics. 1 printer. 2 dressmakers. 3 shop assistants 1 factory forewoman. 2 shorthand-typists. 1 Governess. 1 tailoress. 1 housekeeper. 1 waitress. 32 housewives. 5 no occupation. Children under 15. 35 boys. 29 girls. 51 TABLE V.—PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Summary of notifications during the period from 1st January, 1923, to 31st December, 1923. 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 U Primary Notifications. Total Notifications on Form A. Primary Notifications. Total Notifications on Form B. Poor Law Institutions. 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 1 5 6 8 14 19 26 35 36 14 7 171 277 _ _ _ _ _ 8 142 Females 2 3 3 4 7 14 43 9 15 7 4 111 197 _ 1 _ 1 1 20 70 Non-pulmonary Males 3 16 21 12 5 8 2 1 1 2 _ 71 88 _ _ _ _ 2 1 27 Females 1 8 22 11 4 5 1 6 3 2 _ 63 75 _ _ _ _ _ 3 29 52 Food. Much attention has been directed during 1923 to the many questions connected with the purity of our food supplies, and the conditions under which they . are manufactured and kept. The number of adulterated samples of milk has risen from 2.9 per cent. in 1922, to 4.5 per cent. in 1923, but the greater part of this increase was due to particular watch which was kept on a notorious milk sophisticator, from whom a large number of adulterated samples were obtained. This man was eventually convicted on nine samples, and was fined a total sum of 45 guineas and 9 guineas costs. He has now ceased to trade in this borough. This man was registered as a milk-seller in another London borough. We endeavoured to get the Borough Council concerned to strike him off their register of milksellers, but they declined to do so. In my annual report for 1922 I reported that, after protracted negotiations, an agreement had been reached between the Ministry of Health and the Liquid Egg Trade that liquid eggs should not be used in the preparation of small sponge cakes, sponge biscuits and sponge fingers. Samples of these articles have been taken during 1923, and it is satisfactory that the bakers in the borough appear generally to be observing this agreement. A special committee, appointed by the Minister of Health, has been sitting during this year in order to consider the whole question of preservatives in food-stuffs. This Committee has heard much evidence and gone very carefully into the difficult questions involved, but their report has not yet been issued. It is greatly to be hoped that their findings will place this subject on some definite basis, and enable local authorities to proceed on uniform lines, and with some certainty of obtaining convictions. Definite pronouncements will help the trade also, which, at present, is placed in great difficulties owing to conflicting views. 53 Another matter which should engage the attention of our legislators is the manner in which foodstuffs of all kinds are exposed for sale on open stalls and open shop fronts. One has only to consider the way foodstuffs are sold on the market stalls in the North End Road to realise the potential danger of such procedure. Under our present law it is impossible to deal effectively with such exposure. Again, attention should be directed to places where food is kept prior to sale or exposure for sale. I have, during the year, come across some bad instances of this kind. Costers have been found keeping food and even fruit in sculleries, stables and filthy stores. The Bill recently presented to Parliament, requiring the registration of costers, market stalls and food storage places, is badly required in the form of an Act of Parliament. Milk.—During the year 588 samples of milk were purchased for analysis; 27, or 4.5 per cent. were reported below the standard adopted by the Ministry of Agriculture. Proceedings were instituted by the Council in 20 cases. Particulars of these proceedings will be found in the table on page 61. There are at present 90 dairymen on the Register of Milk Sellers. The introduction of the Milk and Dairies (Amendment) Act, 1922, which came into force on January 1st, 1923, made it opportune to revise very thoroughly our register of milk sellers. Considerably more stringent requirements were demanded in the standard of cleanliness and general suitability of such places. As a result no less than 30 milk sellers voluntarily gave up their registration, and 2 were compulsorily removed from the register. Most of these were cases of small general stores, where articles were sold such as paraffin oil, meat, vegetables, etc., which are not desirable shop-mates for milk. The Public Health Committee drew up a list of prohibited articles, and any milk-shop selling such articles was given the option of giving up the sale of milk or the sale of the prohibited article. 54 Several cases where milk was sold from dwelling houses were also dealt with, and the milk vendors were informed that they must either give up the sale of milk or find more suitable premises. As a result of this action the general standard of milk-shop in the borough has been undoubtedly raised, and the number reduced, so that those remaining can be more adequately supervised and sampled. Cream (Milk and Cream Regulations, 1912 and 1917). 25 samples of cream were purchased for analysis. The following particulars of proceedings taken in 1923 under the above Regulations, made in pursuance of the Public Health (Regulation of Food) Act, 1907, are given in the form suggested by the late Local Government Hoard in their circular letter of October 27th, 1913: 1. Milk and Cream not Sold as Preserved Cream. Articles. (a) Number of samples examined for the presence of a preservative. (b) Number in which a preservative was found to be present. Milk and separated milk 610 nil Cream 12 4 2. Cream Soli) 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 55 (b) The examination made of milk fat in cream sold as preserved cream :— (1) Above 35 per cent. 25 (2) Below 35 per cent. Total 25 (r) 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 (</) Particulars of each case in which the Regulations have not been complied with and action taken. Proceedings taken against one vendor. Defendant ordered to pay .til Is. ()d. each on two summonses. 3. Thickening substances. Evidence of their addition to cream or preserved cream Nil 4. Other observations Nil The Milk [Special Designations) Order, 1923. This order, which requires that all sellers of graded milk shall be licensed by tin- local authority came into force on July 1st, 1923, and revoked the Milk (Special Designations) Order, 1922, which had previously been in force since January 1st, 1923. This order is a most important one, and it will not, therefore, be out of place if I give here a short summary of its main provisions so far as they concern this Council. The special designations under which milk may be sold or offered or exposed for sale in pursuance of this order are the following: "Certified," "Grade A (Tuberculin Tested)," " Grade A " and " Pasteurised." Licences to produce " Grade A " milk may be granted by County Councils and County Borough Councils, and every District Council is authorised to grant licences to any person to sell milk as " Pasteurised," and to any person to sell milk as " Certified," " Grade A (Tuberculin Tested) " or " Grade A " otherwise than from the establishment at which the milk 56 is produced. Every licence shall be valid for a period ending on the 31st day of December in the year in respect of which it is granted. Application for a licence shall be made in writing to the local authority. The licensing authority shall require every applicant to satisfy them that his arrangements for the production, storage, treatment and distribution of the milk are such as to comply with the conditions upon which the licence may be granted. The fee payable for a licence in respect of a shop or premises at or from which the milk is sold is five shillings per annum. The licensing authority has power to suspend or revoke the licence if they are satisfied that any of the conditions upon which the licence was granted are not being complied with. A licensing authority may delegate its powers to a committee of the authority. The order lays down certain definite conditions applying to all holders of licences to sell graded milk, and also definite bacteriological standards to which the various grades of milk must conform. These, however, are too lengthy to set out in extenso in this report. As an example, however, and as this is the " Graded " milk most generally sold in Fulham, the following conditions applying to the sale of " Certified " milk may be quoted :— (1) The milk shall not be removed from the bottles or the seals broken before delivery to the purchaser. (2) On a sample being taken at any time before delivery to the consumer the milk shall be found to contain :— (a) Not more than 30,000 bacteria per cubic centimetre ; and (b) No coliform bacillus in one-tenth of a cubic centimetre. 57 (3) The milk shall not at any stage be treated by heat. Further, in connection with "Certified" milk, the producer must arrange that the cows are free from tuberculosis as indicated by the tuberculin test, that the herd is kept apart from other cattle, that the milk is bottled at the farm immediately after production, and that the bottle shall be closed with a suitable tightly fitting disc and covered with a suitable outer cap overlapping the lip of the bottle, and so fastened as to form a-complete seal. The cap must bear the name and address of the producer, the day of production and the words " Certified Milk." This order ought, undoubtedly, to lead to the production and sale of a milk having a much higher standard of purity than we have previously been able to obtain, and, by showing that by a little care such a standard of purity is obtainable, will undoubtedly help to raise the standard of the cleanliness of milk production generally, but at present two criticisms have been directed against it which certainly have some foundation. It is said :— (1) That the higher price of graded milk places it outside the range of the purse of any but the well-to-do, particularly where it is required in any quantity for the feeding of infants and young children. (2) That the elimination from these selected herds of cows reacting to the tuberculin test, but having no actual signs of tuberculosis, and their transference to the ordinary herds make it more likely that the ordinary milk from these farms may contain tubercle bacilli. It is an unfortunate fact that so long as it costs more money to produce graded milk than ordinary milk, we will need to put up with the increased cost but whether there is any real justification in fact as apart from theory for the second criticism I am unable to say. 58 Samples of graded milks are taken and examined regularly as to their bacterial purity, and as to their chemical standard by the Public Health Department. Particulars are given below. No. of licenses granted to sell certified milk 20 No. of supplementary licenses granted to sell certified milk 2 No. of licenses granted to sell Grade A (Tuberculin Tested) milk 1 No. of samples taken in accordance with the instructions of the Ministry of Health 10 No. of samples not up to the standard as laid down by the Ministry of Health 1 Bakehouses.—Following on the very thorough inspection and the improvements thereafter carried out during 1922, it has not been found necessary to pay quite so much attention to bakehouses during the year under review. Nevertheless, Inspector Jones has paid 44 visits of inspection to the 68 registered bakehouses in the borough. A considerable improvement was found in the conditions of all those bakehouses where fault had to be found during the intensive period of inspection of 1922. Of the 68 bakehouses in the borough, 43 are situated underground. Slaughter-houses.—There are two licensed slaughterhouses in the borough :— No. 611, Fulham Road, No. 640, King's Road. Ninety-nine visits of inspection have been made to these slaughter-houses during the year, and the conditions have been found satisfactory on each occasion. Food-preparing places.—The usual care was bestowed during the year on all places where food is prepared, particularly to the various food kitchens, restaurants and eating places. These places are, as 59 a rule, systematically visited by the Female Sanitary Inspector, Mrs. Davies, and during 1923 she has made 384 inspections. In connection with these kitchens, 36 notices to improve the premises were served. We have a record of 85 such kitchens in the borough, but as there is no obligation on such kitchens to register with the Public Health Department, we have to depend on the observation of the inspectors to keep the department informed of the presence of these kitchens. During the latter part of 1922 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. This arrangement was continued during 1923, and has been found a useful method of dealing with the possibility of unsound food being foisted upon the public during the rush hours of the week-end evenings. Unsound Food.—The following articles, examined at the request of owners, were condemned and destroyed :— Tomatoes 106 boxes. Potatoes 3 boxes. Fish 13 ,, Apricots 75 „ Dates 2 „ Corned Beef 34 tins. Apples 32 „ Pears 24 baskets. Mutton 2 stones. Grapes 4 „ 60 Samples Purchased for Analysis during 1923:— Article. Number of samples taken officially. Number Adulterated. Number of samples taken unofficially. Number Adulterated. Total Samples. Total Adulterated. Percentage of Adulteration. Milk 588 27 6 — 594 27 4.5 Separated milk 6 1 — — 6 1 16.6 Butter 1 — 116 1 117 1 0.8 Cheese — — 20 — 20 — — Cream 4 1 8 3 12 4 33.3 Preserved cream 2 — 11 — 13 — Lemon curd 2 — 2 2 4 2 50.0 Lemon cheese — — 1 — 1 — — Lard — — 22 — 22 — Honey — — 3 — 3 — — Borax 2 — 15 4 17 4 23.5 Gelatine — — 2 1 2 1 50.0 Salts — — 4 — 4 — — Rice 1 — 5 0 6 2 33.3 Fish pastes 2 — 0 — 4 — — Meat pastes — — 3 — 3 — — Sweets 1 — — — 1 — — Jam 1 — 11 2 12 2 16.6 Meat pies 7 2 — — 7 2 28.5 Cocoa — — 22 — 22 — — Coffee 1 — 16 1 17 1 5.8 Pepper 1 — 8 — 9 — — Mustard — — 6 — 6 — — Malt vinegar 2 — 4 1 6 1 16.6 Sugar — — 1 — 1 — — Self-raising flour — — 12 — 12 — — Sponge cakes 2 — 28 3 30 3 10.0 Sponge fingers — — 4 4 — — Beef sausages — — 9 2 9 2 22.2 Pork sausages — — 3 2 3 2 66.6 Prescriptions — — 6 — 6 — — Shredded suet — — 1 — 1 — Margarine — — 5 5 — — Camphorated oil 5 — — — 5 — — Machine skimmed condensed milk — — 9 — 9 — — Full cream condensed milk — — 7 1 7 1 14.2 628 31 372 25 1,000 56 5.6 It is an interesting commentary on the state of our food supplies that, roughly, one in every twenty samples (5.6 per cent.) taken during the year was found to be adulterated in some way or another. This, however, is an improvement on the previous year, when 6.4 per cent, were adulterated. 61 Proceedings were instituted in the undermentioned cases Defendant. Offence. Result. Penalty. Costs. Messrs. Gapps, Ltd., 88, Lillie Road, S.W. Selling raspberry jam adulterated with salicylic acid to the prejudice of the purchaser Ordered to pay costs £ s. d. £ s. d. — o 2 0 Leonard Smith, 32, Pond Place, Chelsea, S.W. Selling milk 5 per cent, deficient in fat Convicted 0 10 0 2 2 0 Do. do. Selling milk 3 per cent, deficient in fat Not proceeded with — — Do. do. Selling milk 13 per cent, deficient in fat Not proceeded with — — Do. do. Selling milk adulterated with 4 per cent, of added water Convicted 2 0 0 5 5 0 Leonard Foulger, 14, Shawfield Street, Chelsea, S.W. Selling milk adulterated with 4 per cent, of added water Convicted. 1 0 0 — James Timms, 25, Ewald Road, S.W. 6 Carrying on trade of purveyor of milk without being registered Convicted 1 0 0 — Cornelius Moriarty, 24, Delorme Street, S.W. 6 Selling milk 6 per cent, deficient in fat Warranty pleaded. Summons dismissed — — John Miller, 246, Brondesbury Villas, Kilburn Selling sponge cake adulterated with 14 per cent, boric acid Convicted 0 5 0 1 1 0 Do. do. Selling sponge fingers adulterated with 16 per cent, boric acid Convicted 0 5 0 1 1 0 Arthur Floyd, 6, Charleville Road, W. 14 Selling certified milk 5 per cent, deficient in fat Dismissed — — George Green, alias Albert Rhodes, 12-15, Railey Mews, Kentish Town Selling milk 5 per cent, fat abstracted Convicted 5 5 0 1 1 0 Do. do. Selling milk 3 per cent, fat abstracted Convicted 5 5 0 1 1 0 Do. do. Selling milk 6 per cent, fat abstracted Convicted 5 5 0 1 1 0 Do. do. Selling milk 3 per cent, fat abstracted Convicted 5 5 0 1 1 0 Do. do. Selling milk 4 per cent, fat abstracted Convicted 5 5 0 1 1 0 Do. do. Selling milk 4 per cent, fat abstracted Convicted 5 5 0 1 1 0 George Rhodes, 220, Arlington Road, Camden Town Unlawfully carrying on the trade of a purveyor of milk without being registered Defendant absconded. Prosecution not ceeded with — — George Green, alias Albert Rhodes, 12-15, Railey Mews, Kentish Town Selling milk 5 per cent, fat abstracted Convicted 5 5 0 1 1 0 Do. do. Selling milk 9 per cent, fat abstracted Convicted 5 5 0 1 1 0 Do. do. Selling milk 14 per cent, fat abstracted Convicted 5 5 0 1 1 0 62 Defendant. Offence. Result. Penalty. Costs. Great Ponton Dairies, Ltd., 23, High Street, Grantham Selling milk adulterated with 7 per cent, of added water Ordered to pay costs. £ s. d. £ s. d. — 2 2 0 Do. do. Selling milk adulterated with 3 per cent, of added water Ordered to pay costs — 2 2 0 Edward Chipperfield, 44, Burmestcr Road, Tooting Selling milk adulterated with 7 per cent, of added water Withdrawn. Summons against employers dealt with — — Do. do. Selling milk adulterated with 3 per cent, of added water Withdrawn. Summons against employers dealt with. — — Mary Davies, 151, Fulham Palace Road, S.W. 6 Selling cream containing 20 grains boric acid per lb. of cream Withdrawn — — Do. do. Unlawfully delivering preserved cream in a receptacle not properly labelled Ordered to pay costs — 1 1 0 Do. do. Unlawfully depositing for sale preserved cream in a receptacle not properly labelled Ordered to pay costs — I 1 0 Great Ponton Dairies, Ltd., 23, High Street, Grantham Selling milk adulterated with 3 per cent, of added water Convicted 2 0 0 — Do. do. Selling milk adulterated with 3 per cent, of added water Dismissed on payment of costs — 2 0 0 Thomas Birkbeck, 16, Cardoza Road, Holloway Selling milk adulterated with 3 per cent, of added water Withdrawn — — Do. do. Selling milk adulterated with 3 per cent, of added water Withdrawn — — General Sanitary Administration. Bacteriological Work.—The following bacteriological examinations were made during 1923, either at the Borough Bacteriological Laboratory or by the Clinical Research Association of Watergate House, Adelphi. The bulk of the work is done at the Borough Laboratory, but specimens may be sent by doctors to the Clinical Research Association when the Borough Laboratory is closed, e.g., on Sundays and public holidays :— Material from cases of suspected diphtheria— Diphtheria bacillus isolated 78 Negative result 667 745 63 Blood, from cases of suspected Enteric Fever— Widal or typhoid reaction obtained 3 Negative result 22 25 Pathological specimens for enteric organisms— Positive result — Negative result 11 11 Sputa from cases of suspected tuberculosis— 1,629 Examinations of urine - 3 Blood counts 4 Other examinations 48 2,465 Disinfection.—The following rooms were disinfected and cleansed after infectious disease Rooms fumigated after Scarlet Fever 501 „ ,, Diphtheria 274 „ Phthisis 355 „ ,, Measles 363 Erysipelas 48 „ ,, Influenza 1 „ ,, Scabies 21 „ „ Pneumonia 5 „ „ Puerperal Fever 21 „ „ Cancer 33 „ ,, Enteric Fever 2 „ ,, Ophthalmia Neonatorum 4 Cerebro Spinal Meningitis 2 „ „ Poliomyelitis 2 „ „ for Vermin 38 „ ..by request 38 Rooms sprayed 23 1,731 64 The following articles were disinfected at the Council's Disinfecting Station :— Articles. From Private Houses. From Institutions. Total. Beds 997 11 1,008 Palliasses 218 — 218 Mattresses 986 289 1,275 Spring beds 26 — 26 Pillows 2,019 375 2,394 Cushions 481 62 543 Bolsters 837 — 837 Blankets 2,483 890 3,373 Sheets 1,522 340 1,862 Covers 806 193 999 Counterpanes 731 119 850 Curtains 269 — 269 Carpets 515 — 515 Hearth rugs 376 — 376 Articles of clothing 2,891 795 3,686 Eiderdowns 202 — 202 Sundries 1,033 334 1,367 16,392 3,408 19,800 Public Mortuary.—One hundred and thirty-three bodies were removed to the Mortuary during the year, and were admitted as follows:— By order of the Coroner 97 „ ,, Medical Officer of Health 2 By Police 19 For convenience till funeral 15 133 Seventy-seven post-mortem examinations were made, and inquests were held in 114 cases. Sanitary Inspection of the District.—The following inspections of dwelling-honses were made during 1923 by the District Sanitary Inspectors :— 65 Cause. Premises Inspected. *In consequence of complaint 2,153 In consequence of infectious disease 1,051 House-to-house inspections 97 Re-inspections 12,438 * 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, 1923. Number served. Number complied with up to Dec. 31st, 1923. 2,167 1,912 314 273 The following works were carried out and repairs effected as a result of the action of the Sanitary Inspectors:— Drains tested 1,207 Drains relaid 165 Drains repaired 424 Soil pipes renewed 95 Soil pipes repaired 70 Eaves and down-spouting repaired 352 Sinks renewed or repaired 214 W.C.s and flushing apparatus repaired 592 Cisterns cleansed and covered 273 Water supply provided from main 51 Yards and forecourts paved 377 Roofs, chimneys and walls repaired 857 Dustbins provided 359 Dampness of walls remedied 478 Internal house repairs done 1,475 Rooms cleansed 3,191 Overcrowding abated 16 Other nuisances abated 1,115 66 The following additional matters were dealt with by the District Inspectors:— Ice-cream premises— No. of inspections 393 Other food places— No. of inspections 1,033 Smoke nuisances— Complaints 9 Observations 122 Notices 7 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 268 75 Workshops 808 78 Workplaces 300 27 Outworkers 763 32 Result of Notices for Factories and Workshops. Work clone. Walls and ccilings cleanscd 77 Foul w.c. pans cleansed 38 W.c. seats repaired 11 W.c. doors repaired 12 Flushing apparatus repaired 59 Vent of w.c. repaired 5 Lavatory accommodation provided 3 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 all the restaurant kitchens, particulars of which have been given earlier in this report. She also carried out the following work during 1923:— Visits. Notices Served. To verminous cases 83 11 To infectious disease 75 2 To dirty tenants 28 2 Others 4 4 67 Drainage of Buildings.—The following drainage plans were submitted to and approved by the Public Health Committee during 1923 :— Plans for drainage of new buildings (inclusive of Block of Dwellings (16 tenements), Lock-up Shops, Flats, Garages, Pavilions, Parish Hall, Studio, Work-shops and Workrooms) 105 Additions to existing buildings 37 Reconstruction of the drains of existing buildings 72 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 1,974 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. Frederick Tofield, 24, Vera Road, Fulham Failing to deposit plans of alteration of drains of No. 236, Lillie Road Plans deposited. Summons withdrawn £ s. d. £ s. d. — — Mrs. Stephen-s, " Kington," Wern Road, Skewen, Glam. Failing to abate a nuisance at 68, Waterford Road Order to abate — — Do. do. Failing to cleanse room from vermin at 68, Waterford Road Convicted 0 5 0 — Do. do. Failing to amend drains at 68, Waterford Road Convicted 0 5 0 — Do. do. Failing to provide dustbin at 68, Waterford Road Convicted 0 5 0 2 2 0 Henry Brown, 21, Wellington Square, Chelsea Failing to abate a nuisance at 28, Aintree Street Order to abate within 21 days — 0 3 0 T. Pollard, 48, Richmond Road, Earls Court Recovery of balance of cost of making 18, Ancill Street, fit for habitation Order for payment of balance £30 with interest £1 10s. 9d. and costs — 2 2 0 Joseph Caira, 61 Aspenlea Road, Fulham Failing to obey closing order Order to quit within 6 weeks — — Matteo Pacitti, 61, Aspenlea Road, Fulham Failing to obey closing order Order to quit within 6 weeks — — David Siggens & Ruth Siggens, 61, Aspenlea Road, Fulham Failing to obey closing order Order to quit within 6 weeks — — George Coomer, Bradwell House, Bradwell-on-Sea Failing to abate nuisance at 93, Rylston Road Order to abate within 21 days — 0 3 0 F. J. Ockenden, 12, Shotley Street, Fulham Failing to abate nuisance from overcrowding Order to abate within 6 weeks. — — 68 Rat Destruction.— Poison was laid as follows by the Rat Officer during the year Private houses 310 Factories 3 Other premises 12 Sewers and drains 352 677 £11 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. Certificates under the Revenue Acts.—Certificates for exemption from or reduction of inhabited house duty were granted in respect of 114 tenements. Certificates of Water Supply.—No applications were received for certificates of water supply during the year. Rent and Mortgage Interest Restrictions Act, 1923.— 32 applications for certificates under the above Act, that "the house is not in a reasonable state of repair " were received. Certificates were granted to 16 of these cases. Houses Let in Lodgings.- The proposed bye-laws under Section 26 of the Housing and Town Planning Act, in respect of houses let in lodgings, are still, apparently, under the consideration of the Ministry of Health and the London County Council. These bye-laws were sent to the Borough Council for their consideration nearly two years ago, but so far nothing has materialised in legal form. I understand that these bye-laws will again shortly be submitted to the Metropolitan Borough Councils, after which, possibly, they may reach maturity. No action has been taken during 1923 under the old bye-laws. 69 House Repairs.—In my annual report for 1922 I gave a very full and detailed account of the Council's activities under Section 28 of the Housing, Town Planning, etc., Act, 1919. Following upon the legal difficulties of enforcing this Section the Public Health Committee decided to proceed as a general rule in regard to house repairs under the Public Health (London) Act, and only to use Section 28 of the Housing Act in exceptional cases. As a matter of fact, only two statutory notices were served under Section 28 during the year, and the local Authority did not proceed to carry out repairs in default of the owner in any case. It has been suggested that Section 10 (2) of the Housing, etc., Act, 1923, might remedy some of the difficulties which had previously been encountered, but in the opinion of the Borough Solicitor, this section would only partially help matters, and would still leave open several of the awkward results which we previously encountered in administering Section 28. For example, one of our great difficulties was that, despite the fact that the owner has the right of appeal to the Ministry of Health, and although he failed to avail himself of that right, when the Council took action against the owner in the police court for the recovery of expenses the Magistrate decided to hear the whole evidence, both as regards the terms of the Statutory Notice, the work done and the expenses charged. As a result, the Council on several occasions found themselves out of pocket, as the sum awarded by the Magistrate was lower than the actual expenditure by the Council. Section 10 (2) (b) of the Housing etc., Act, 1923, does not appear to touch the powers of a Magistrate in this regard, although it lays down very clearly the powers of the Ministry of Health in regard to an owner's appeal to that body. Apart altogether from any legal difficulties regarding expenses, there are all the other difficulties encountered in dealing with the practical application of Section 28, 70 which I fully explained in my report for 1922. The various quibbles which arose at Ministry of Health enqiuries, regarding such things as:— (1) Work partially and badly done by the owner, and therefore done over again by the Borough Council in order to make a satisfactory job. (2) The time to be allowed for the completion of the job by the owner. (3) All the trouble and expense gone to by a contractor or by the Borough Council itself in getting out estimates for work which at the last moment is undertaken by the owner himself. (4) The absolute necessity of adhering strictly to the letter of the statutory notice in carrying out the repairs by the Council. Anyone who has had practical experience of the class of house repair carried out under under this section will realise what this means. These are only quoted to illustrate a few of our original difficulties which still remain untouched by Section 10 of the 1923 Act. In all these matters differences of opinion arose between the Council and the Ministry of Health Inspector at Inquiries held during 1922. Despite the fact that we have confined our efforts to securing the remedy of those housing defects which can be dealt with under the Public Health (London) Act, the Metropolis Management Acts, and the London County Council (General Powers) Acts, we have been successful in getting considerable improvements to property effected and generally speaking housing repairs have been efficiently dealt with. The appointment of the Temporary Housing Inspector was terminated in June, 1923, and as a result the amount of house-to-house inspection has been considerably reduced. In my opinion, owing to the state which much of the property in Fulham has reached on account of lack of repairs during the war, and the ravages of age and sub-let tenancies, the practice of 71 house-to-house inspections should be increased, and this is only possible with our present staff of district inspectors at the risk of the neglect of other sections of their work. It would be a great advantage to have one or more special housing inspectors. Certainly, if and when the new Houses-let-in-Lodgings Bye-Laws come into force it will undoubtedly be necessary to appoint additional inspectors if the bye-laws are to be efficiently administered. Closing Orders.—No new Closing Orders were made during the year. Housing Accommodation.—The Fulham Borough Council has no housing scheme. During 1920 and 1921 much time was devoted by the Housing Committee to an attempt to secure suitable sites for possible housing schemes, but with no result. I think it is desirable that new members of the Council and the public in Fulham should be made aware that the Council only decided to abandon its attempt at a housing scheme after very long and mature consideration. Endeavours were made to secure land for building purposes in several parts of the Borough, but all attempts failed for one reason or another, generally as a result of the excessive price asked for the land. As a last blow, the Ministry of Health turned down the Council's application to secure the whole or part of the Hurlingham Polo Grounds. It should be borne in mind that the available building land in Fulham is now very limited, and in fact, the borough is already fully populated for its area. Despite the unfortunate failure of the Borough Council in this regard, considerable increase in the available housing accommodation in the borough has been made by public and private enterprise. I would refer particularly to the Lewis Trust Buildings in Walham Green and the War Seal Mansions in Fulham Road. The latter buildings are the result of an appeal made during the war on behalf of crippled ex-service men. The foundation was initiated by Sir Oswald Stoll in 1915, 72 the object being to provide self-contained residential flats wherein disabled ex-service men could live with their families and obtain for themselves on the spot the after-care and treatment necessary for their condition. All the costs of propaganda were borne by Sir Oswald Stoll, and in addition he gave to the Foundation the freehold of the whole of the valuable site upon which the War Seal Mansions now stand. The foundation stone was laid in August, 1917, and by the end of 1918, 72 flats and the treatment and administrative buildings had been erected. During 1923 a further block of 66 flats, fronting Fulham Road, has been added, and at the end of 1923 there were altogether 112 flats occupied, the remaining 23 being in process of completion. In November, 1923, there were a total of 222 adults and 118 children housed in the War Seal Mansions. Of this total, 38 families, or approximately 114 persons, had previously lived in Fulham. I give below some figures prepared by the Town Clerk, giving particulars of the accommodation at the Lewis Trust Dwellings and the previous habitat of the original tenants :— Locality of previous addresses of tenants. No. of flats. Fulham 183 Chelsea 53 Kensington 32 Hammersmith 19 Wandsworth 13 Battersea 8 Other London Boroughs 37 Outside London 23 368 The total number of flats is 377 ; one flat is used by the Superintendent and three by porters, and for various reasons the information was not obtained in five cases. 73 It will be seen, therefore, that almost exactly half the flats were first occupied by persons formerly residing in Fulham. At the end of October, 1923, there were 1,964 persons housed in these dwellings, made up as follows :— Adult Adult Male Female Males. Females. Children. Children. 464 481 528 487 As these dwellings house approximately 970 persons who formerly resided in other houses in Fulham, they constitute a valuable contribution to the "Housing Problem" in Fulham. I am much indebted to Mr. H. C. Sydney, Secretary of the Lewis Trust Dwellings, and to Mr. W. J. Roberts, Secretary of the War Seal Foundation, for so kindly supplying me with information regarding these housing schemes. Housing Conditions. Year ending 31st Dec., 1923. Number of new houses erected during the year :— (a) Total 108 (b) With State Assistance under the Housing Acts, 1919 or 1923— (i.) By the Local Authority (ii.) By other bodies or persons Unfit Dwelling-houses. (I.) Inspections :— (1) Total number of dwelling-houses inspected for housing defects- (under Public Health or Housing Acts) 3,113 (2) Number of dwelling-houses which were in- spected and recorded under the Housing (Inspection of District) Regulations, 1910 97 (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 2,288 74 II. Remedv 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 80 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 2 (2) Number of dwelling-houses which were rendered fit:— (a) By owners 1 (b) By Local Authority in default of owners — (3) Number of dwelling-houses in respect of which Closing Orders become operative in pursuance of declaration of owners of intention to close 1 B.—Proceedings under Public Health Acts :— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 314 (2) Number of dwelling-houses in which defects were remedied :— (a) By owners 273 (b) By Local Authority in default of owners C.—Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc., Act, 1909 :— (1) 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 — (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 — 75 CONTENTS. page Babies' Hospital 20 Bacteriological Work 62 Bakehouses 58 Day Nursery 21 Death, Causes of 13 Disinfection 63 Drainage of Buildings 67 Factory and Workshops Acts 66 Food 52 Food Preparing Places 58 General Sanitary Administration 62 Home Nursing 26 Housing 68 Housing Conditions 73 Infantile Mortality 14 Infant Welfare Centres 18 Infectious Diseases 29 Infectious Disease among Parturient Women and Infants 24 Introductory 5 Legal Proceedings 67 Maternity and Child Welfare 18 Maternity Home Milk " 53 Milk (Special Designations) Order, 1923 55 Notification of Births 18 Poor Law Relief 28 Proceedings under Food and Drugs Acts 61 Provision of Milk 23 Public Health (Tuberculosis) Regulations 51 Public Mortuary 64 Rat Destruction 68 Samples Purchased for Analysis 60 Sanitary Inspection of the District 64 Slaughterhouses 58 Staff—Public Health Department 4 Tuberculosis 37 Tuberculosis Dispensary 38 Unsound Food 59 Vaccination 26 Venereal Disease 34 Vital Statistics 7