FUL 23 Metropolitan Borough of Fulham. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1924. A. MIDDLETON HEWAT, M.D., Ch.B., D.P.H.. Medical Officer of Health. 3 PUBLIC HEALTH COMMITTEE. Chairman : Councillor A. G. Everard. Vice-Chairman: Councillor W. Wilcox. His Worship The Mayor (E.H. Pritchard, Esq., B.A., J.P.), Ex-officio. Alderman R. M. Gentry. Councillor H. Booth. „ H. M, Bowden. „ W. S. Brooks. „ W. R. Corbin. „ S. Farley. Councillor W. Fowell. „ V. L. Franzini. „ C. Harwood. „ G. L. Hodge. „ W. L. Leonard. Miss H. A. Packer. Councillor H. J. Todd. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman: Councillor W. Fowell. Vice-Chairman : *Miss C. M. L. Wickham. His Worship The Mayor (E. H. Pritchard, Esq., B.A., J.P.), Ex-officio. Alderman J. Palmer. Councillor F. J. Bellenger. „ S. Farley. „ A. Gantlett. „ G. L. Hodge. Councillor F. J. Shaw. ,, W. A. White. *Mrs. Corbin. *Mrs. Pritchard. *Mrs. Van den Bergh. * 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. 1 Mr. J. Castley, *Miss B. Baron. Mr. A. W. Gammack, *Miss M. Wacksmith, Mr. F. Walsh. Senior Sanitary Inspector:— 1 *Charles Bristow Jones (Food and Drugs). Sanitarv Inspectors:— 1 *Frederick H. Manning. 13 *Alfred J. Parsons. 12 * Mark Canton. 1 *Thomas H. Robey. 12 *Charles B. Lloyd. 1 *Albert E. Clutterbuck. 1 *Edgar Drake. 123 * Willi am French. Woman Sanitary Inspector: 1 *Mrs. M. E. Davies. Health Visitors:— 156 *Miss M. L. Durnford. 456 *Mrs. J. Bryning. 456 *Miss E. Beckett. 156 *Miss A. Perrett. 456 *Miss M. Jones. Tuberculosis Dispensary Staff:— (Nurses) 4*Miss H. M. Turner. 4 *Miss J. Tinnion. 46 *Miss M. A. Shepherd. *Miss M. C. Robinson, Dispenser and Laboratory Assistant. *Miss M. E. Sargent, Clerk ,and Secretary of the Care Committee. *Miss L. Adams, Clerk (part time). *Mr. and Mrs. Snell, Caretakers. Matron of Maternity Home: 46 *Miss M. Bustard. Superintendent of Disinfecting Station: Mr. H. Toy. Chief Disinfector: Edward Eyles. Mortuary Keeper : D. MacKay. Rat Officer : H. W. Harvey (part-time). *The Council receives Exchequer grant towards the salaries of these Officers. 1 Certificated Sanitary Inspector. 4 Trained Nurse. 2 Food Inspector's Certificate. 5 Health Visitor's Certificate. 3 Registered Plumber. 6 Certificate of Central Midwives' Board. 5 Town Hall, Fulham, S.W. 6, April, 1925. 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 1924, this being my third Annual Report as your Medical Officer of Health. The year 1924 has not been marked by the noteworthy happenings of 1923, nor can we show such satisfactory figures so far as vital statistics are concerned. I would, however, draw your attention to the following matters:— (1) The death-rate for 1924 was 11.1 per thousand, compared with 10.5 for the previous year. (2) The infantile mortality rate rose from 64 in 1923 to 72 in 1924. This was accompanied by a general rise in the infantile mortality rate throughout the country. (3) We have to record the lowest birth-rate, 18.2, ever recorded in the Borough with the exception of the one war year 1918. (4) The estimated population of 163,100 for 1924 is the largest number of persons ever estimated to live in the Borough. (5) The-death rate from cancer, viz., 1.35 per thousand, is the largest ever recorded in the history of the Borough. 6 Official circulars were issued during the year 1924 dealing with the following matters:— Nos. Public Health (Meat) Regulations, 1924 1432 Cancer 476, 496 and 516 Encephalitis Lethargica 509 Food-poisoning inquiries C.L.2 Poliomyelitis (Infantile Paralysis) 538 Maternal Mortality 517 Foot-and-Mouth Disease 502 Housing (Financial Provisions) Act, 1924 520 Public Health (Tuberculosis) Regulations, 1924 549 Fuller details of many of these official circulars will be found in the body of the Report. It is with regret that I have to refer to the death of Dr. Percy W. Spaull, which occurred during the year. Dr. Spaull acted for a considerable time during Dr. Jackson's period of office, as deputy Medical Officer of Health for the Borough, and always took a very great interest in the various voluntary medical institutions, particularly in the School Treatment Centre, of which he was treasurer for several years. 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 1.—General Statistics. Area (acres) 1,706 Population (1923) 163,100 No. of inhabited houses (1921 Census) 25,979 No. of families or separate occupiers (1921 Census) 40,436 Rateable value £990,358 Sum represented by penny rate £4,042 2.—Extracts from Vital Statistics of the Year. Births— Total. Males. Females. Legitimate 2,835 1,400 1,435 Birth-rate 18.2. Illegitimate 132 71 61 Deaths 1,820 946 874 Death-rate 11.1. No. of Women dying in, or in consequence of, child-birth— From sepsis 4 other causes 6 Deaths of Infants under one year of age per 1,000 births:— Legitimate 70 Illegitimate 106 Total 72 Deaths from— Measles (all ages) 29 Whooping cough (all ages) 14 Diarrhoea (under 2 years of age) 22 Population.—The Registrar-General has estimated the population of the Borough at the middle of 1924 to be 163,100. (Males, 75,512; females, 87,588.) Marriages.—The number of marriages registered was 1,288, and the marriage rate, i.e., the number of persons married per 1,000 of the population, was 7.8. In the two preceding years the marriages numbered 1,284 in 1923 and 1,320 in 1922, thus showing an increase of 4 for 1924. 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 2,967, 8 of whom 1,471 were boys and 1,496 were girls. The birth-rate was 18.2 per 1,000 inhabitants, being 1.1 per 1,000 below that of 1923. The birth-rate for the whole of London was 18.7, and for England and Wales 18.8. Illegitimacy.—The illegitimate births numbered 132 (71 males, 61 females), or 4.4 per cent. of the total births, against 4.7 in both 1923 and 1924. Natural Increase of the Population.—The natural increase of the population by excess of births over deaths was 1,147, against 1,415 in 1923 and 1,307 in 1922. Deaths.—During the year ended 31st December, 1924, 1,717 deaths were registered in the borough. Of these, 270 were of persons not belonging to the borough, while 373 inhabitants of Fulham died outside the borough chiefly in various public institutions. There were, therefore, 1,820 deaths of persons—946 males and 874 females—having their usual residence in Fulham, representing an annual rate of 11.1 per 1,000 of the estimated population, being 0.6 per 1,000 above that of 1923. The death-rate of males was 12.5, of females 9.9. The following comparative death-rates are of interest:— Death-rates, 1924— England and Wales 12.2 London 12.1 105 large towns (average) 12.3 Fulham 11.1 Zymotic Deaths.—The mortality from zymotic diseases was lower than in 1923, 82 deaths being due to the seven principal epidemic diseases, against 87 in 1923. The zymotic death-rate was 0.50 per 1,000 population, as compared with 0.53 for 1923. 9 Seasonal Mortality.—The mortality in the four quarters of the year was as under:— Deaths. Death-rate. First Quarter 623 15.2 Second Quarter 397 9.7 Third Quarter 347 8.5 Fourth Quarter 453 11.0 1,820 111 It is interesting to note that whereas during the year under review the worst seasonal mortality took place during the first quarter, in the preceding year the worst mortality was in the fourth quarter, when the death rate was 12.2. This is due, to some extent, to the fact that the measles epidemic developed during the last quarter of 1923 and the first quarter of 1924, whereas during the first quarter of 1923 and the last quarter of 1924 there was no measles epidemic in existence. 10 Table I.—Vital Statistics of Whole District during 1924 and previous Years. Year. Population Estimated to Middle of each Year. Births. Total Deaths Registered in the District. Transferable deaths.† Nett Deaths Belonging to the District. Uncorrected Number. Nett. Of NonResidents registered in the District. Of Residents not registered in the District. Under 1 Year of Age. At all Ages. Number. Rate. Number. * Rate. Number. * Rate per 1,000 Nett Births. Number. * Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1911 153,284 4,012 4,122 26.9 2,019 13.2 169 378 517 125 2,228 14.5 1912 155,402 4,079 4,213 27.1 1,830 11.8 173 366 395 94 2,023 13.0 1913 157,117 4,234 4,302 26.9 1,833 11.3 212 407 412 96 2,028 12.7 1914 157,303 4,065 4,154 26.4 1,878 12.3 137 391 469 113 2,132 13.6 1915 al53,161 3,736 3,870 c24.3 1,787 11.7 130 677 446 115 2,334 15.2 1916 al49,428 3,600 3,754 c23.1 1,324 8.9 131 789 330 88 1,982 13.3 6162,580 1917 al45,186 2,852 2,971 c18.4 1,251 8.6 139 882 323 109 1,994 13.7 b161,841 1918 al43,211 2,593 2,672 c16.7 1,704 11.9 186 973 286 107 2,491 17.4 6160,463 1919 a 152,543 2,947 3,000 cl8.6 1,510 9.7 242 634 250 83 1,902 12.2 b155,904 1920 al58,621 4,383 4,327 c27.2 1,888 11.9 457 396 320 74 1,827 11.5 b6158,989 1921 159,400 3,546 3,528 22.1 1,865 11.7 381 382 291 83 1,866 11.7 1922 159,500 3,210 3,242 20.3 1,897 11.9 362 400 224 69 1,935 12.1 1923 161,600 3,312 3,123 19.3 1,632 10.0 252 328 199 64 1,708 10.5 1924 163,100 2,975 2,967 18.2 1,717 10.5 270 373 214 72 1,820 11.1 (a) Estimated civil population. (b) Estimated total population. (c) Birth-rate calculated on estimated total population. Notes.—This Table is arranged to show the gross births and deaths registered in the district during the year, and the births and deaths properly belonging to it with the corresponding rates. The death-rates from 1915-1919 are calculated per 1,000 of the estimated civil population, and the other rates per 1,000 of the estimated gross population. *In Column 6 are included the whole of the deaths registered during the calendar year as having actually occurred within the district, but excluding the deaths of Soldiers and Sailors that have occurred in hospitals and institutions in the district. In Column 12 is entered the number in Column 6, corrected by subtraction of the number in Column 8 and by addition of the number in Column 9. Deaths in Column 10 are similarly corrected by subtraction of the deaths under 1, included in the number given in Column 8, and by addition of the deaths under 1 included in the number given in Column 9. † "Transferable Deaths" are deaths of persons who, having a fixed or usual residence in England or Wales, die in a district other than that in which they resided. The deaths of persons without fixed or usual residence, e.g., casuals, are not included in Columns 8 or 9, except in certain instances under 3 (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. 11 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 1,820 deaths registered, 1,658, or 91.1 per cent., were certified by registered medical practitioners, 161 by coroners after inquest, and one death being uncertified. Deaths in Public Institutions. Fulham Infirmary.—The deaths of 628 persons occurred in the Fulham Infirmary, of whom 526 lived in Fulham and 102 in other districts. Western Fever Hospital.—In this institution there were 18 deaths of residents in Fulham and 148 deaths of residents in other districts. Deaths occurring outside the Borough among Persons belonging thereto.—The deaths of Fulham residents outside the borough numbered 373, and occurred in the following places :— St. George's Hospital 60 West London Hospital 21 Other General Hospitals 48 Children's Hospitals 23 Hospitals for Women 6 Other Special Hospitals 42 Homes for advanced cases 9 Hospitals of Metropolitan Asylums Board 13 Poor Law Infirmaries 17 Mental Hospitals 62 Sanatoria 15 Nursing Homes, private houses and elsewhere 57 373 Of the deaths registered, 860, or 47.2 per cent., took place either in poor law institutions, in hospitals or in mental hospitals, the percentages in the various classes of institutions being as under :— Per cent. Deaths in Workhouses or Workhouse Infirmaries 29.8 „ Metropolitan Asylums Board Hospitals 1.7 „ Mental Hospitals 3.4 „ other Hospitals 12.3 47.2 12 Causes of Death.—The causes of deaths occurring in the Borough during 1924 will be found in Table II, pp. 13, 14. From this, it will be seen that the principal causes were cancer (221 deaths); pneumonia (189 deaths); tuberculosis (162 deaths); bronchitis (156 deaths). In my annual report for 1923 I stated that these causes of death Lad appeared in exactly the same order for two years. Again they appear in almost the same order, the only difference being that pneumonia takes precedence over tuberculosis as a cause of death. It will be noticed that cancer still heads the list, and in fact the actual number of deaths from this disease has increased during the past year by 9 as compared with 1923. As there was an increase of 8 as between 1922 and 1923, it would appear that cancer is still gaining ground as a cause of death. Heart disease shows an increase of 19 deaths; pneumonia an increase of 15 deaths; tuberculosis a decrease of 19 deaths; and bronchitis an increase of 42 deaths. I have dealt in my last two annual reports with the question of cancer as a cause of death, and it is again my unpleasant duty to record the fact that more deaths took place from this disease in Fulham during 1924 than have ever taken place in any single year since records have been kept. The cancer death rate for Fulham was 1.35 per thousand population as compared with a rate of 1.3 per 1,000 for the year 1923. The Ministry of Health has recently set up a Departmental Committee to enquire into this subject of cancer, and this Committee has published four valuable contributions to our knowledge of this disease. The first (Circular No. 426) deals with the characteristic features and natural course of cancer. It points out that in a population of 37,885,242 persons in England and Wales in 1921, a total number of 46,022 deaths were attributed to cancer. These figures imply that out of each average 1,000,000 persons, 1,215, and out of each 1,000, 1.21 died of cancer. The death rate per 1,000 of the population attributed to cancer in England and Wales has gradually increased from 0.32 in 1851-60 to 1.21 in 1921. 13 14 TABLE II. Causes of and Ages at Death during the Year 1924. 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 op 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 years and upwards. Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 All Causes Certified (c) 1,819 214 64 29 9 14 24 57 125 135 496 652 821 193 298 176 212 376 106 288 170 Uncertified 1 — — — — — — — — — — 1 — — — — — 1 — — — 1. Enteric Fever 1 — — — — — — — 1 — — — 1 — — — — 1 — — — 2. Small pox — — — — — — — — — — — — — —. — — — — — — 3. Measles 29 8 11 4 2 3 1 — — — — — 55 3 5 7 1 7 1 3 2 4. Scarlet Fever 5 — 1 — 1 — 3 — — — — — 12 — — 1 2 — — 1 1 5. Whooping Cough 14 4 6 2 1 1 — — — — — 7 — 4 4 — 2 — 3 1 6. Diphtheria 11 — 3 3 2 1 2 — — — — — 86 — 3 1 3 2 — 1 1 7. Influenza 60 4 7 — 1 1 — — 4 — 22 21 2 9 9 6 5 9 7 9 6 8. Encephalitis Lethargica 5 — — — — — — — 1 2 2 — 3 — — 1 1 2 1 — — 9. Meningococcal Meningitis — — — — — — — — — — — — — — — — — — — — — 10. Tuberculosis of Respiratory System 129 — — — — — 1 13 52 21 39 3 52 10 17 13 13 31 8 25 12 11. Disseminated Tuberculosis 9 4 1 2 — — — — 1 — 1 — 3 1 3 2 — — — 3 — 12. Other Tuberculous Diseases 24 — 5 2 — — 4 7 1 4 1 — 12 1 7 3 6 3 — 4 — 13. Cancer, malignant disease 221 — — — — — — 3 4 17 107 90 81 23 42 16 19 50 14 26 31 14. Rheumatic Fever 4 — — — — — — 1 1 1 1 — — — — 1 — 1 — 2 — 15. Diabetes 14 — — — — — — — 1 1 3 9 6 1 2 1 2 2 — 5 1 16. Cerebral Haemorrhage, etc. 84 — — — — — — — 3 1 27 53 23 15 13 3 13 12 9 9 10 17. Heart Disease 221 — — — — — 1 7 6 14 78 115 56 33 34 25 25 34 11 35 24 18. Arterio-sclerosis 48 — — — — — — — — — 3 45 41 4 7 7 4 9 5 7 5 19. Bronchitis 156 11 1 3 — — — — 1 3 38 99 56 10 24 8 15 43 9 29 18 20. Pneumonia (all forms) 189 43 22 10 2 3 3 2 6 14 32 52 74 22 37 20 26 50 6 22 6 21. Other Respiratory Diseases 16 — — — — — — 1 3 1 8 3 4 3 — 2 2 7 — — 2 22. Ulcer of Stomach or Duodenum 16 — — — — — — — 1 3 7 5 3 1 2 3 3 3 — 3 1 23. Diarrhœa, etc. (under 2 years) 22 18 4 — — — — — — — — — 12 — 7 6 4 1 1 2 1 24. Appendicitis and Typhlitis 11 — — — — 1 — 2 4 2 2 — 11 1 1 — 4 1 2 1 1 25. Cirrhosis of Liver 9 — — — — — — — 1 1 6 1 2 2 1 — — 2 1 1 2 26. Nephritis and Bright's Disease 47 — — — — — — 5 3 5 24 10 25 3 12 4 5 9 2 9 3 27. Puerperal Sepsis 4 — — — — — — — 1 3 — — 7 — 1 — 1 2 — — — 28. Other accidents and diseases of pregnancy and parturition 6 — — — — — — — 3 3 — — 5 2 — — 1 2 — 1 — 29. Congenital Debility and malformation, premature birth 80 80 — — — — — — — — — — 32 9 9 12 9 13 6 16 6 30. Suicide 18 — — — — — — — 1 2 14 1 6 3 2 1 2 3 1 4 2 31. Other deaths from violence 71 5 — 1 2 5 8 10 9 14 17 28 7 12 9 5 15 4 13 6 32. Other defined diseases 296 37 3 2 — 2 4 8 16 28 67 129 116 30 44 20 41 61 18 54 28 33. Causes ill-defined or unknown — — — — — — — — — — — — — — — — — — — — — Total 1,820 214 64 29 9 14 24 57 125 135 496 653 821 193 298 176 212 377 106 288 170 (a) All " Transferable Deaths " of residents, i.e., of persons resident in the District who have died outside it, are included with the other deaths in columns 2—13, and columns 15—22. Transferable deaths of non-residents, i.e., of persons resident elsewhere in England and Wales who have died in the District, are in like manner excluded from these columns. For the precise meaning of the term " transferable deaths " see footnote to Table I. (b) All deaths occurring in institutions for the sick and infirm situated within the district, whethei 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." 16 be obtained in all disorders of the stomach, bowels or womb." It is urged that early diagnosis is of paramount importance. "Cancer itself in its early stages is almost invariably unaccompanied by pain, and is sometimes painless throughout. This painlessness of cancer often leads the patient to delay seeking medical advice. Medical advice should be sought at once, particularly if a tumour or lump is found in the breast, if an ulcerated condition exists on the tongue, lip or skin, which does not heal in a few days, if there is persistent hoarseness, if a mole or wart shows a tendency to grow, if blood or mucus is passed with the stools, if there is a bloody or offensive discharge at other than the normal monthly periods, especially at the change of life or after it has passed." The subject of the treatment of cancer is next dealt with, and the Committee appear to be of the opinion that in cancer early operation affords the best chance to the patient, although they do not feel justified in stating that all risk of recurrence is necessarily removed even if undertaken in an early stage of the disease. "There is, however, indubitable evidence that removal by operation, though ultimately followed by recurrence, enables many people to live a natural life in comfort for considerable periods, while in advanced cases such removal may relieve or prevent prolonged suffering. There are many cases, moreover, in which cancerous growths have been removed once and for all, the patient has lived for years afterwards without recurrence, and has ultimately died from an entirely different cause, and lastly evidence has accumulated that in some varieties of cancer, and in some situations, radium or X-ray treatment, or diathermy, carried out by expert medical practitioners, offers at least as good a chance to the patient as surgery." It is particularly urged that "patients should not waste time or money by trying quack remedies which at best are useless, and at worst aggravate the disease." It is also urged in the memorandum that local health authorities should undertake propaganda and educational work in connection with cancer, but as this has already been done by the Fulham Council ever since I became their Medical Officer of Health, it is unnecessary for me to go further into this matter. 17 The second memorandum (Circular 476) issued by the Ministry of Health's Cancer Committee deals with the effects of radium and X-rays upon normal and cancerous tissues. This is almost entirely a scientific and technical exposition of the subject, and little good would be served by my quoting it in any detail in this report. Generally speaking, while it is recognised that radium and X-rays may have a most beneficial effect on many varieties of cancer, it is certainly not yet established that either of these radiations is by any means a panacea for all cases of cancer. Good results are frequently obtained when a complete surgical operation is undertaken followed by X-ray or radium treatment for some period afterwards. The third memorandum (Circular No. 496) deals with the subject of cancer of the breast with particular reference to results of treatment by operation. Dealing with, the actual operation mortality after this disease, it is pointed out that "under modern conditions deaths directly attributable to the operation, if performed by skilful surgeons and in well equipped institutions, have been reduced in the case of breast operations to a fraction of 1 per cent. Similarly, the convalescence of the patient after operation is nowadays in sharp contrast to that which obtained 50 years ago. Then, amputation of the breast, even if successful, meant weeks or possibly months of disability due to the suppuration which occurred. At the present time even more extensive operations heal without any suppuration and the patient is out of bed in about a fortnight." Dealing with the natural course of cancer of the breast, the memorandum continues, "The value of operation for cancer of the breast can best be appraised after a short consideration of the natural course of the disease. It occurs chiefly, though not exclusively, in women, and constitutes the largest portion of cancer mortality amongst women in England and Wales, with the single exception of cancer of the genital organs. It may occur at any period of adult life, and with increasing frequency as age advances. After the age of 45 it constitutes a very serious factor in the total 18 mortality. The disease occurs with approximately equal frequency in either of the breasts, but sometimes, if the case runs a slow course, the other organ becomes affected towards the end of the disease. The various portions of the breast show differences in their liability to attack, for there is reason to believe that the upper and outer quarter is the commonest situation in which cancer appears, while the nipple is the rarest. The other portions occupy intermediate positions in this respect, without noteworthy differences between them. The matter is important because the severity of the disease bears a relation to the portion of the breast affected. The growth itself consists in a localised hard mass or swelling which may, for a time, pass unrecognised owing to the fact that in its early stages, cancer is usually unattended by pain. This mass grows, leads to contraction of the tissues in its neighbourhood with coincident retraction of the nipple, and alteration of its position. The subsequent course of cases varies within wide limits. Usually but little time elapses between the recognition of the local mass and the discovery of enlarged glands in the armpit. After a longer or shorter period the skin over the mass in the breast may give way and an ulcer result. At the same time, extension from the primary mass may have taken place in other directions, by way of the lymphatics or of the blood stream, so that secondary nodules are formed in the chest, the liver and other internal organs, the skin and, in some cases, certain of the bones. These bring in their train other symptoms, amongst which pain is important, and ultimately the patient dies, death frequently being determined by some intercurrent disease, which, in the lowered condition of her vitality, she is no longer able to resist. There is no evidence that child bearing or suckling is a predisposing cause of cancer of the breast. Statistics show that after the change of life cancer of the breast causes relatively a larger number of deaths among the unmarried than among married women. For many reasons the natural duration of cancer of the breast is difficult to state with precision. Thus (1) the onset frequently cannot 19 be fixed with any degree of accuracy; (2) amongst cases of cancer, even in women of the same age and of the same habit of body, some run an acute, others a chronic, course; and (3) the age at which the patient becomes affected appears to exert an important influence upon the natural course of the disease; cancer takes on the whole, a more rapid course in the young person than in the old. It should also be added that if cancer of the breast supervenes during pregnancy or lactation, the course of the disease may be abnormally rapid. While subject to these variations, the average natural duration of a case of cancer of the breast appears to be a little over three years." That there is a close relationship between chronic inflammatory conditions of the breast and the onset of malignant disease is emphasised, and " there is no doubt that microscopical examination frequently shows a concomitant condition of cancer and chronic inflammation, or that breasts which are the seat of such chronic inflammation may pass into cancer by imperceptible stages." Turning next to treatment of cancer of the breast, the memorandum states, Whatever may be the result of future investigations and whatever may be the case with cancer in other regions, it is beyond question that, at the present time, early surgical operation affords the one chance for a patient suffering from cancer of the breast. Cases of cancer treated only with internal medicines, or external applications, or by dietetic methods are not being effectually treated. This does not mean that such agents as radium and X-rays cannot be usefully employed as aids to surgery, or in cases in which surgical operation is impossible. We now come to the most important point of all, viz., the measure of the success of surgical treatment. We have seen that the average duration of life in patients whose disease has followed a 'natural' course is little more than three years. This average figure has been obtained by noting the duration of life in a large number of women whose history is known from the time of coming under skilled observation until death. No precisely comparable figure for patients who have 20 been operated upon can be given, and for the best of reasons. Some patients—and under favourable conditions a large number of them—live for many years, and it is impossible for the surgeon to keep in touch with all of them for perhaps ten, fifteen or more years after operation. Even to secure exact information for so short a period as three or five years after operation is not easy. Hence a majority of surgeons have been obliged to content themselves with reporting the percentages of their patients who have survived three years from the date of operation. The aggregate results, based on the experience of many surgeons in different countries, are as follows. When the old and now generally superseded incomplete operation was performed, about 25 per cent. of the patients were known to be alive at the end of three years after operation. When the more complete operation of modern times was performed, twice as many, some 50 per cent., survived three years, and 33 per cent. survived five years after operation. These statistics, however, relate to patients who at the time of operation were in various stages of the disease, some in a condition such that, although the surgeon could be reasonably sure that operation would afford relief, and might eradicate the disease altogether, he could have little confidence that the disease would not recur. On the other hand, statistics exist of the results when the disease at the time the patient came to the surgeon appeared to be in an early stage and limited to the breast only. In this early condition, it is certain that 60 per cent., and highly probable that 75 per cent., of the patients were alive and well three years after operation. Indeed, some experienced surgeons, such as the late Professor Halsted, have thought that the percentage of cured patients might, in these circumstances, be stated to reach 75 per cent. In the special circumstances of operation at the most favourable—that is, the earliest —moment after recognition of a lump in the breast, there is an average prolongation of life amounting to many years. We have advisedly refrained from adopting the word ' cure,' and have only spoken of the prolongation of life. It is, however, certain that cure, in the widest popular sense of the word, has 21 frequently been effected by early operation—i.e., that patients have lived ten, fifteen, twenty or more years, and died ultimately of some other disease. The teaching of surgical statistics is clear. It is that the results of early and complete operation justify not a certain, but a highly favourable, prognosis." The fourth memorandum (Circular 516) deals with experimental cancer research, is of a highly technical nature, and is hardly suitable for popular consumption. Suffice it to say that, so far as experimental work has gone, according to this memorandum no definite conclusion has been come to as to the causal agent in malignant disease. It is most satisfactory that such an able Committee, consisting as it does of some of the leading authorities on cancer, and of several highly qualified members of the medical staff of the Ministry of Health, should be devoting attention to this problem and at the same time keeping the most recent work on this subject before the attention of those of us who are directly or indirectly engaged in fighting this scourge. Again, this year it is pleasing to record a fall in the death rate from tuberculosis. The death rate from tuberculosis of the respiratory system for 1924 was 0.80 per 1,000 population, for disseminated tuberculosis 0.05, and for tuberculosis of other organs 0.14. This subject is dealt with in detail under the heading of tuberculosis on page 43. Infantile Mortality.—Of 1,820 deaths during 1924, 214, or 1.2 per cent., were of infants under one year of age, and the rate of infantile mortality measured by the proportion of deaths under one year of age to registered births was 72 per thousand, being 8 per thousand above that for 1923 and 3 per thousand above that for 1922. This rise in the infantile mortality rate appears to have been general throughout the country during the year under review, and in my opinion a considerable amount of this mortality must be attributed to the extraordinarily long period of wet weather which we had during the year. With the exception of a short period about June there was 22 practically no summer, and the amount of sunshine must have been considerably below the general average. The infantile mortality rate for London as a whole was 69 and for England and Wales as a whole 75. It is interesting to note that last year our rate was 3 per thousand above that for London as a whole, while this year again we are exactly 3 per thousand above the average for London. Out of 29 London Boroughs (including the City), for which I have been able to obtain the infantile mortality rate, Fulham stands fourteenth, having an equal rate with Hammersmith and Poplar. In my report for last year I pointed out that certain populous working-class boroughs, particularly in the East End, had lower infantile mortality rates than Fulham, and amongst them I mentioned Deptford, Poplar, Stepney, Greenwich, Battersea and Woolwich. This year our rate is better than any of the above with the exception of Battersea and Woolwich, and in these latter cases the rates have risen in both those boroughs considerably more than they have done in Fulham. Whereas our rate rose this year by 8 per thousand, the Battersea rate has risen by 13 and Woolwich by 22 per thousand. There is therefore some satisfaction in that although our rate has risen it has not risen in the same proportion as has the rate in many other London Boroughs. The causes of deaths of infants during 1924 are set out in Table No. 111, and classified according to ward and age. Again, I must point out the large number of deaths of infants, viz., 50, which occurred as a result of premature birth. In my last Annual Report I pointed out that we might reasonably hope to prevent a considerable amount of this mortality when we were able to get a larger proportion of our mothers to attend the ante-natal clinics, or to attend their own general practitioners regularly during the ante-natal period. This is a purely educational matter and everything is being done by the Health Visitors and at the Infant Welfare Centres to inculcate the principles of ante-natal care. It will not be out of place to mention, therefore, that early in 1925 the Borough Council came to an arrangement with the voluntary infant welfare 23 24 Infant Mortality during Year 1924. Nett Deaths from stated causes at various Ages under One Year of Age. Nett Deaths under One Year of Residents in the Wards of the. Borough, whether occurring in or beyond the Wards. Cause of Death. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths Under One Year. Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. All Causes Certified 59 13 9 10 91 34 33 25 31 214 17 39 33 25 34 9 41 16 Uncertified — — — — — — — — — — — — — — — — — — 1. Small-pox — — — — — — — — — — — — — — — — — — 2. Chicken-pox — — — — — — — — — — — — — — — — — — 3. Measles — — — — — — — 1 7 8 1 1 2 — 2 — — 2 4. Scarlet Fever — — — — — — — — — — — — — — — — — — 5. Whooping Cough — — — — — 2 — 1 1 4 — 1 1 — 1 — — 1 6. Diphtheria and Croup — — — — — — — — — — — — — — — — — — 7. Erysipelas — — — — — — — — 2 2 1 — 1 — — — — — 8. Tuberculous Meningitis — — — — — — — — — — — — — 9. Abdominal Tuberculosis (a) — — — — — — — — — — — — — — — — — — 10. Disseminated Tuberculosis — — — — — 1 — 2 1 4 — — 1 — — — 1 — 11. Other Tuberculous Diseases — — — — — — — — — — — — — — — — — — 12. Meningitis (not Tuberculous) — — — 1 1 — 3 — 1 5 — 2 2 — — — — 1 13. Convulsions 2 2 1 — 5 — — — — 5 — — — — — 1 1 1 14. Laryngitis — — — — — — — — — — — — — — — — — — 15. Bronchitis — 1 1 1 3 1 4 1 2 11 — — — 1 2 — 3 1 16. Pneumonia (all forms) 1 — 1 1 3 9 15 8 8 43 1 9 4 8 11 — 10 — 17. Influenza — — — — — 1 1 2 — 4 — — 1 — — 1 — — 18. Diarrhoea — — — 2 — — 3 2 2 9 — 4 3 — — — 1 1 19. Enteritis — — — — — 4 — 3 2 9 — 2 — 4 1 1 1 — 20. Gastritis 1 — — — 1 — — 1 1 3 — — 1 — — — l 1 21. Syphilis 1 — — — 1 2 — 1 — 4 — 1 1 — — — l 1 22. Rickets — — — — — — — — — — — — — — — — — — 23. Suffocation, overlaying 1 1 — — 2 — 1 — — 3 2 — 1 — — — — — 24. Injury by Birth 6 2 1 — 9 1 — — — 10 1 1 — 1 3 — 4 — 25. Atelectasis 3 — — — 3 — — — — 3 — 1 — — 2 — — — 26. Congenital Malformations 2 1 2 — 5 2 — 1 — 8 3 — 1 2 1 1 — — 27. Premature Birth 37 3 2 3 45 4 1 — — 50 5 6 9 4 7 3 12 4 28. Atrophy, Debility and Marasmus 2 2 — 1 5 4 3 — — 12 — 2 1 3 1 1 3 1 29. Other causes 3 1 1 1 6 3 2 2 4 17 3 3 2 — 3 1 3 2 Total 59 13 9 10 91 34 33 25 31 214 17 39 33 25 34 9 41 16 Nett Births in the Year— Legitimate 2,835 Illegitimate 132 Nett Deaths in the Year of— Legitimate infants 200 Illegitimate infants 14 (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. 25 centres committee to provide an additional ante-natal session at the Wandsworth Bridge Road Centre. The other principal causes of infant mortality duirng the year were pneumonia 43 deaths as compared with 31 during 1923; atrophy and debility 12 deaths, bronchitis 11 deaths; diarrhœa and enteritis 18 deaths. The infantile mortality rates for Fulham since 1886 are given in the subjoined table :— Infant Mortality in Fulham. Deaths of Infants under one year of age per 1,000 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 1924 72 I give below a table showing the infantile mortality rates for the last two years (1923 and 1924) for the various wards in the Borough:— - Births and birth rates. Infantile deaths. Infantile mortality rate. 1923. 1924. 1923. 1924. 1923. 1924. Barons Court 148 (11.2) 151 (11.4) 19 17 128 112 Lillie 404 (15.8) 342 (13.3) 32 39 79 114 Walham 259 (20.6) 296 (23.1) 24 33 92 111 Margravine 502 (26.0) 504 (26.1) 26 25 52 50 Munster 755 (19.4) 643 (16.6) 39 34 51 53 Hurlingham 112 (11.5) 105 (10.8) 6 9 53 85 Sands End 537 (19.5) 528 (19.1) 43 41 80 77 Town 406 (27.7) 398 (27.2) 10 16 24 40 The Borough 3,123 (19.3) 2,967 (18.1) 199 214 64 72 26 It will be seen from this table that for the two years the highest infantile mortality rate is found in Barons Court Ward and the lowest in Town Ward. It is somewhat disturbing to find that a ward like Barons Court should have a higher infantile mortality rate than wards like Sands End and Walham. It will be noticed that the birth rate in Barons Court Ward is extremely low as compared with the other wards, with the exception of Hurlingham, and it would seem that under such circumstances the few children that are born should be better looked after than the many that are born in some of the other wards. This, unfortunately, does not appear to be the case. In Hurlingham Ward, where the birth rate for the two years approximates closely to that of Barons Court Ward, the average infantile mortality rate for the two years is 69 against an average rate of 120 for Barons Court Ward. Deaths of Illegitimate Children.—Of the 214 infants who died before attaining the age of one year, 14 were illegitimate, the mortality amongst them being in the proportion of 106 deaths per thousand births against 70 per thousand births amongst children born in wedlock. This illegitimate infantile mortality rate shows a decrease of 49 as compared with 1923, when the rate was 155. The difference between the legitimate and illegitimate death rate this year is therefore not so great as is usually the case. 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. It is only necessary, therefore, in this year's Report to refer briefly to the subject. Notification of Births.—Notifications of the births of 2,687 living children and 77 stillborn children were received during the year under the Notification of Births Act, 90.56 per cent. of births registered being 27 notified. Of these, 2,170 or 78.51 per cent. were notified by midwives, 425 by doctors, and 169 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 2,648 Re-visits to infants 8,361 Re-visits to children aged 1 to 5 years old 6,723 Visits to cases of ophthalmia neonatorum 36 „ „ measles 1,142 ,, ,, pneumonia 46 ,, ,, diarrhoea 38 „ „ puerperal Fever 21 Other visits 469 . Infant Welfare Centres.—The Infant Welfare Centres have been carried on as before by the Voluntary Infant Welfare Committee. This Committee is financed partly from voluntary funds, partly by a grant of £500 from the Borough Council, one half of which is repaid by the Ministry of Health. The staff and general arrangements have remained exactly as detailed in my Annual Report for 1922. I give below particulars of the attendances at the centres during the year:— Infant Welfare Clinics. Number of consultations. First attendances of babies. Total attendances. Average attendances. 92, Greyhound Road 129 480 6,C96 47 170, Wandsworth Bridge Rd. 96 320 4,310 45 Melmoth Hall 94 275 3,758 40 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 215 No. of attendances 1,005 28 At The School Treatment Centre, 18, Bagleys Lane. For operative treatment for enlarged tonsils and adenoids—No. of children 11 For dental treatment (No. of children) 15 For dental treatment (No. of women) 88 Total attendances of women for dental treatment 327 Of these 88 women, 24 were provided with dentures. For visual defects— No. of mothers treated 51 Ante-Natal Clinic. Number of women who attended 347 Number of attendances 1,371 Number of ante-natal visits 572 It is of interest to note that the average attendances at all the Infant Welfare Centres have increased considerably over those for 1923. At Greyhound Road the average attendance has increased from 37 per session to 47; at 172, Wandsworth Bridge Road from 39 to 45, and at Melmoth Hall from 35 to 40. The numbers attending the ante-natal clinic, however, have only increased very slightly, 347 women attending during 1924 as against 343 for 1923. It is most necessary that every effort should be made to increase the attendances at our ante-natal clinics, particularly if we are to deal with the infant mortality under one month of age. Fulham Babies Hospital, 23, Broomhouse Road.— This hospital is conducted by a voluntary committee subsidized to the amount of £700 per annum by the Borough Council. Half of this sum is repaid to the Borough Council by the Ministry of Health, so that only £350 is contributed from the rates. Under the agreement the Borough Council reserves for the use of Fulham residents 14 cots, while the other 7 cots in the hospital are at the disposal of the voluntary committee for the reception of cases from outside the Borough. The same arrangements exist in regard to the medical and nursing staff as outlined in my Report for 1923. 29 The following is a summary of the work of the hospital during 1924:— In hospital, January 1st, 1922 15 Number of babies admitted during the year 172 Average duration of stay (days) 34.12 Number of cases discharged: (a) In good health 90 (b) Improvement 36 (c) No improvement 29 (d) On account of the development of tious disease 4 Viz.— Pertussis 1 German Measles 2 Chicken-pox 1 No. of deaths 22 No. in hospital, 31st December, 1924 20 The average daily number in the wards during the year was approximately 16, as compared with 14 in 1923 and 16 in 1922. In considering this average daily number in hospital it should be borne in mind that on two occasions during the year admissions to one ward of the hospital had to be stopped for periods of 10 and 21 days owing to infectious disease. We were fortunate in that at no time during 1924 had the hospital to be entirely closed owing to infectious disease. The small ward was closed for 14 days in the spring for painting and cleaning. Fulham 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 1924 a grant of £300 per annum from the Borough Council, one half of which is repaid by the Ministry of Health. The work of the Day Nursery continued during the year on similar lines to those detailed in my Reports for 1922 and 1923. Unfortunately, towards the end of the year the health of Miss Carvick, the matron, began to cause the committee serious concern and eventually she was allowed a prolonged period of leave. We were 30 tunate, however, in being able to obtain the temporary services as matron of Miss Nelson, sister of the Borough Council's Maternity Home. She continued in the capacity of matron until the end of the year. Owing to circumstances which it is difficult to ascertain, the attendances at the day nursery show some falling-off from previous years. As compared with 1923 the total whole-day attendances have fallen from 6,579 to 4,967, but the half-dav attendances have increased by 5, being 1,338 as compared with 1,333 during 1923. The Committee of the day nursery are inclined to think that a considerable amount of this falling-off in attendance is due to the fact that fewer women with young children appear to be engaged in daily employment necessitating the placing of their children in the care of other people during the daytime. At the beginning of 1925 the numbers are, however, showing a tendency to increase again. The attendances during the year were as follows:— Individual children attended— Under three years of age 64 Over three years and under five 23 The total attendances made by the above children were:— Under three years— Whole day 3,177 Half day 900 Over three years— Whole day l,790 Half day 438 Total— Whole day 4,967 Half day 1,338 The Borough Maternity Home, 706, Fulham Road.— This institution is entirely under the control of the Borough Council, the medical work of the home being in the hands of Dr. Ruby Thomson, Assistant Medical Officer of Health. The accommodation at the maternity home is now 10 beds and the following is a record of cases admitted to the Home during 1924: — 31 Cases admitted 176 Average duration of stay (days) 14 No. of cases delivered by— (a) Midwives 168 (b) Doctors 8 No. of cases notified as puerperal sepsis No. of cases in which the temperature was above 100-4 for 24 hours 1 No. of cases notified as ophthalmia neonatorum 5 No. of cases of "inflammation of eyes" however slight 1 No. of infants not entirely breast-fed while in the institution No. of maternal deaths 1 No. of foetal deaths (stillborn or within ten days of birth) 8 The minimum fee charged for admission to the home is £3, which covers all expenses, including medical attention, for the fortnight. In exceptional cases the Maternity and Child Welfare Committee have the power to reduce this fee. Additional charges are, of course, made where the income of the patient warrants them. The number of cases admitted during 1924 shows a decrease of 13 as compared with 1923. Provision of Milk.—Under the Maternity and Child Welfare Act, 1918, milk is provided free or at less than cost price to necessitous cases under the Council's scheme. During the year grants of milk were made to expectant mothers and to children under five years in 245 cases. The amount expended was— £ s. d. For dried milk 119 4 0 For fresh milk 12 1 5 Total £131 5 7 This compares with the sum of £169 10s. 9d. expended during 1923, £337 18s. id. in 1922, £1,041 15s. in 1921, and £1,169 14S- in 1920. 32 It will be seen therefore that there has been a steady decline in the amount of money spent in this way during the past three years, the greatest drop being between 1921 and 1922. The usual careful enquiries have been 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, 13,481 lbs. of dried milk, value £1,028, were sold at cost price to persons recommended by the health visitors or Infant Welfare Centres. In 1923 the amount of dried milk distributed was 15,079 lbs., value £1,339 2s. 4d. Incidence of Infectious Disease amongst Parturient Women and Infants. Puerperal Fever.—26 cases of puerperal fever, equal to 8.7 per 1,000 births, were notified during 1924, compared with 32 cases the previous year. There were 4 deaths from this disease against 9 during 1923. All the cases except one were removed to hospital. Although the number of cases of this disease notified in the Borough is still high, it is some consolation to know that there is a decrease as compared with the previous year, and the marked drop in the number of deaths is most satisfactory. In my Annual Report for 1923 I stated that a considerable number of the notifications of puerperal fever received in this Borough are in respect of women who have suffered from miscarriages, many of them in the early months of pregnancy. Although it would appear that such cases should certainly be notified as puerperal fever, I can safely say that in many districts this rule is more honoured in the breach than the observance. I think that this undoubtedly accounts, to a considerable extent, for the fact that our number of cases of puerperal fever is generally in excess of that in many other districts. During 1924 I find that no less than seven of these notifications referred to cases of puerperal fever which occurred subsequent to miscarriages, so 33 that although the incidence rate of this disease in Fulham, viz., 8.7 per thousand births is still high, the rate omitting the cases following miscarriages would be only 6.7 per thousand births. The corresponding figure for 1923 was 6.0. Ophthalmia Neonatorum.—Twenty-seven infants were notified as suffering from ophthalmia neonatorum, of whom 11 were removed to hospital. This total compares with 22 notifications during 1923, and 33 during 1922. The result of the cases was as under:— Cases. Treated at home. Treated in hospital. Vision impaired. Vision unimpaired. Total blindness. Deaths. Left the district. 27 16 11 2 25 nil. nil. nil. Measles.—Of the total of 1,692 cases of measles notified during 1924, 1,029 occurred in children under the age of five years. Diarrhoea.—40 cases of infantile diarrhoea were notified during 1924 as compared with 79 during 1923. Undoubtedly the absence of hot summer weather had much to do with this decrease in the notifications of this disease. All these cases were under 5 years of age. Perhaps I may take this opportunity of reminding medical practitioners in the Borough that all cases of epidemic diarrhoea [zymotic enteritis] under the age of 5 years are compulsorily notifiable in Fulham by special order of the Borough Council made under 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 for 1922 continued in force in the Borough during 1924. By these 34 arrangements, 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 Council was, as before, one shilling for each visit. During the year these fees amounted to £21 3s., payable by the Public Health Committee, and £95 5s. 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 sum payable by the Maternity and Child Welfare Committee increased from £60 15s. in 1923. This increase was almost entirely due to the epidemic of measles, which necessitated a much greater amount of nursing of cases of post-measles pneumonia. This nursing undoubtedly saved many children's lives, and enabled many to make a complete recovery, where otherwise they might have been left with some chronic lung disease. The district nurses work in the closest possible association with the Public Health Department, and Miss Watson, the Superintendent, is always most willing to let us have reports as to the progress of cases, or any other information which we may require. Many of these visits to measles cases were the result of an investigation carried out in the first place by the Borough Council's health visitors. The number of visits paid during the year was as follows:— To persons over 5 years of age 423 To persons under 5 years of age 1,905 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 1924, 2,042 successful primary vaccinations were carried out compared with 2,789 during the year 1923, and 1,787 during 1922. I give in the following table fuller details of the vaccinations carried out during the year ended 31st December, 1923, but similar detailed figures are not yet available for 1924:— 35 Number of births registered from 1st January, 1923 to 31st December, 1923 3,103 Successfully vaccinated 1,958 Insusceptible of vaccination 1 Dead—un vaccinated 138 Postponed by medical certificate 35 Certificates granted under clause 2 of the Vaccination Act, 1898 637 Removed to districts in which Vaccination Officer has been notified 51 Removed to places unknown 244 Outstanding 39 In my Report for 1923 I dealt in considerable detail with the subject of vaccination, particularly in regard to the relationship existing between the number of vaccinations performed and the prevalence of smallpox in or around the district. In continuance of these remarks, I would point out that it is interesting that the number of successful vaccination certificates received during 1924 is less by 747 than in 1923. Undoubtedly part of this fall must be attributed to the fact that no case of smallpox occurred in Fulham during 1924, whereas two cases were notified during 1923. The case of smallpox which I have dealt with later in this report, although giving the Public Health Department considerable anxiety, was not generally known to the public and was, as previously stated, notified in Chelsea and not in Fulham. Poor Law Relief. Through the courtesy of Mr. Mott, Clerk to the Fulham Guardians, I am able to give below some figures as to the amount of relief dispensed by the guardians during the year as compared with previous years It will be noticed that the persons in receipt of outdoor medical relief only have fallen from 162 in 1923 to 114 in 1924; similarly there has been a decline in the number of persons receiving indoor and outdoor relief. 36 Date. (Half-year ending) (1) Number receiving relief. Indoor and outdoor, but excluding Lunatics and figures in column 2. (2) Persons in receipt of outdoor medical relief only not included in column 1. 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 1st July, 1924 2,328 63 1st Jan., 1925 2,366 51 Infectious Diseases. The total number of cases of infectious diseases notified during the year was 3,258, compared with 3,608 for the year 1923 and 4,388 for the year 1922. Towards this total of 3,258 measles contributed 1,692. It will be seen that there is a drop of 350 in the total numbers as compared with the previous year. There is a fall in the case of every disease except erysipelas, which increased from 76 to 92 cases; enteric fever, which increased from 3 to 7 cases; poliomyelitis (infantile paralysis), which increased from 5 to 7 cases; ophthalmia neonatorum, which increased from 22 to 37 27 cases; encephalitis lethargica, which increased from 2 to 21 cases, and pneumonia, which increased from 218 to 326 cases. The two most serious increases are those of encephalitis lethargica and pneumonia. Noticeable falls in the prevalence of infectious diseases are found in the case of scarlet fever, which has fallen from 466 to 360, tuberculosis of the respiratory system, which shows a fall from 319 to 270, and epidemic diarrhoea, which shows a fall from 79 to 40. Full particulars of these notifications, arranged according to disease, ward and age, will be found in Table IV, page 42. 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 the result we find that 63 notifications of diphtheria, or 24.3 per cent. of the total cases, and 29 notifications of scarlet fever, or 8.03 per cent., were not confirmed in hospital. The percentage of apparently erroneous notifications regarding diphtheria has increased from 16.2 per cent. in 1923 to 24.3 per cent. in 1924. I am of opinion that part of this was the result of a prosecution which took place in Gloucester during the year, when a medical man was prosecuted for neglecting a case of diphtheria. He was eventually acquitted, but undoubtedly it raised fears in the minds of many general practitioners and in my opinion led to them notifying diphtheria more readily than they might have done had that prosecution not taken place. It will be obvious that if a practitioner notifies a case as diphtheria and has it removed to hospital he can hardly afterwards be charged with neglect, and provided he has used reasonable care in arriving at his diagnosis he is apparently on safe ground. There are four matters in connection with infectious disease which it may be interesting to deal with in further detail. They are as follows:— Smallpox.—Although no case of this disease was notified in the Borough during the year, nevertheless 38 we had one alarm which fortunately did not result in any cases. This particular outbreak occurred in August, and although the person affected lived in Fulham while she was actually suffering from the disease, she moved into the Borough of Chelsea before calling in a doctor, and the notification was therefore sent to the Chelsea Council. Under the circumstances it was, of course, incumbent upon us to take all the necessary steps as if the case had been notified in Fulham. The infection in the case of the patient was probably acquired while she was on holiday in Brighton. All the usual steps were taken to prevent the spread of the disease and vaccination was offered to all the contacts, although several of them refused it. Owing to the fact that it was not until five days after the rash appeared that the correct diagnosis was arrived at, we were extremely fortunate in escaping without further cases, particularly as during the active stage of the disease the patient moved from Fulham to Chelsea, walking through the street and going by 'bus. Measles.—There were 1,692 cases of measles notified during the year 1924, as against 1,951 in 1923 and 2,438 in 1922. These notifications in 1924 constitute the latter half of an epidemic, the peak of which was reached just about the new year. The number of notifications received during the first week in Januarywas 153 and the number remained about 100 a week until the end of February, after which there was a steady decline through March and April. During May the numbers remained stationary again at about 25 notifications per week. There was again a fall in June, July and August, and in September the average number of notifications was only 2 per week, which average continued to the end of the year, there being, however, seven weeks during October, November and December when no cases were notified. The epidemic accounted for the lives of 29 children in 1924 as compared with 23 deaths during the previous year. It would seem, therefore, that this latter part of the epidemic was, on the average, more fatal than the previous months, but I think one should take into consideration the fact that the weather during the early months of the year is 39 always much more trying to children who have any tendency to suffer from lung troubles than are the months at the end of the year, and that the large majority of these measles deaths resulted from bronchial-pneumonia. Everything possible was done to provide suitable treatment for these cases. In my Annual Report for last year I detailed all the methods used and the results, and it is unnecessary to repeat this. I should mention, however, that the Council in February appointed a temporary health visitor for the purpose of visiting all the cases of measles over the age of five years, those under that age being dealt with by the permanent health visitors. Mrs. Davies, the woman sanitary inspector, also gave considerable help in visiting the cases of measles among older children. Encephalitis Lethargica.—As stated earlier in this Report there were 21 cases of this disease, which is commonly known as "sleepy sickness," notified during 1924. This is quite a considerable outbreak and is the largest number which has ever been notified in any one year in Fulham. The cases were scattered throughout the Borough, and in only one case was one able to trace with any reasonable certainty direct infection from one case to another. It would appear that either the infectivity in these cases is very low or else that the population as a whole has a considerable resistance to the infection. The disease is one which demands the greatest respect not only because of the serious nature of the acute stage, which probably has a case mortality of anything between 30 and 50 per cent., depending on the nature of the outbreak, but also because it is becoming more and more evident that the sufferer from this disease is not rid of his troubles when he has recovered from the acute stage, but that he may be left with various forms of mental disturbance, some being so bad as to alter the whole character of the patient. Many cases have come to light during the year in which children have developed bad and even criminal habits apparently as a result of an attack of this disease. Towards the end of the year I instituted 40 an enquiry into the past history of all the cases that had occurred during the first six months of the year and the following remarks from the notes are illuminating:— Case I.—The mother states that this child is now reported from school as being slow and irritable. Case II.—Apparently recovered but still attends hospital as an out-patient; has developed a pronounced stoop and suffers from sleeplessness. Case III.—Partially recovered but still gets drowsy periods. Case IV.—This patient appears to have made an almost complete recovery, but still finds any heavy work beyond his power. Case V.—Mother says the patient is still rather nervous and unable to sleep properly. Case VI.—Fairly complete recovery but not yet quite her normal self. Still receiving medical attention; has grown very stout since the illness and has developed studious habits. In this latter case the alteration in the habits seems to have been one for the child's good, which is rather unusual. A very noticeable fact which came out in this enquiry was that the great majority of these patients appear to be still either attending their own doctor or a hospital out-patients' department many months after their apparent recovery from the acute stage. The Ministry of Health at the present time is taking particular interest in this disease and local education authorities are also being encouraged to study it with a view to providing proper educational facilities for children who may be mentally affected by it. Venereal Diseases.—The education of the public on tne subject of venereal diseases is carried out in the borough by a local voluntary committee under the auspices of the National Council for Combating Venereal 41 Diseases. Much good work has been done during the year, and the attendances at the lectures in the majority of cases were surprisingly good. The free treatment of venereal diseases in Fulham is in the hands of the London County Council, and such treatment can be obtained at special clinics held at 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. Early, efficient and prolonged treatment is the only hope of cure in these diseases, and there is now no reason why any person, however poor, should not avail himself or herself of these facilities. I give below a list of lectures, etc., on this subject held in the borough during the year 1924:— Venereal Diseases—List of Lectures and Film Displays given by the N.C.C.V.D. Committee during 1924. Date. Where held. Subject. Lecturer. Number attending. 14.1.24 Town Hall, Fulham Film Dr. Feldman 160 20.2.24 Infant Welfare Centre Lecture Miss Dugdale 30 20.2.24 Library Hall Film Miss Dugdale 60 4.3.24 Town Hall, Fulham Film Mr. Turner 150 24.3.24 Assembly Hall, Wandsworth Bridge Road Film Miss Dugdale 50 28.5.24 St. Oswald's Hall Lecture .. Miss Dugdale 20 4.6.24 Halford Road School Film Mrs. Clayton 70 6.10.24 Library Hall Film Dr. Feldman 70 11.12.24 Star Road School Film Dr. Turner 85 12.12.24 Library Hall Slides Dr. Sloan Chesser 70 18.12.24 North End Road School Film Dr. Sloan Chesser 45 Total atten dances 810 42 Table IV.—Cases of Infectious Diseases notified during the Year 1924. Notifiable Diseases. Number of Cases Notified- Total Cases notified in each Ward of the Borough. Total Cases removed to hospital. Deaths. At Ages—Years. Barons Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. At all Ages. 0-1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-35 35-45 45-65 65 and upwards. Smallpox — — — — — — — — — — — — — — — — — — — — — — — Cholera, Plague — — — — — — — — — — — — — — — — — — — — — — — Diphtheria (including Membranous Croup) 259 8 13 23 25 28 72 35 15 32 6 2 — 9 53 31 37 77 15 25 12 258 11 Erysipelas 92 4 1 1 — — 2 3 2 6 19 39 15 4 17 11 15 21 3 17 4 61 9 Scarlet Fever 360 6 16 20 35 38 121 67 22 26 8 1 — 18 75 19 53 108 13 52 22 338 5 Typhus Fever — — — — — — — — — — — — — — — — — — — — — — — Enteric Fever 7 — — — — — — 1 — 2 2 2 — — — — — 2 2 1 2 6 1 Relapsing Fever, Continued Fever — — — — — — — — — — — — — — — — — — — — — — — Puerperal Fever 26 — — — — — — — — 18 8 — — 1 5 2 3 6 — 7 2 25 4 Cerebro-Spinal Meningitis 2 1 — — — — — — — — — — — — 1 — — 1 — — — 2 1 Polio-myelitis 7 2 2 — — — 1 — — 1 — 1 — — 3 3 — 1 — — — 7 — Ophthalmia Neonatorum 27 27 — — — — — — — — — — — — —4 3 1 9 1 7 2 11 — Tuberculosis of Respiratory System 270 — 2 — 1 1 16 7 28 117 44 50 4 17 32 34 45 59 14 47 22 — 129 Disseminated Tuberculosis 7 2 3 1 — — — — — 1 — — — 1 1 — 2 — 1 2 — — 9 Other Tuberculous Diseases 119 2 7 5 5 5 44 19 11 12 4 4 1 6 19 15 14 26 3 28 8 — 24 Measles 1,692 101 195 193 269 271 549 73 14 23 3 1 — 68 205 170 326 463 85 228 147 127 29 Encephalitis Lethargica 21 — — 1 — — 2 5 3 6 2 2 — — 5 1 2 5 2 2 4 18 5 Pneumonia 326 25 49 22 24 16 23 14 10 38 35 48 22 9 73 51 56 66 13 52 6 218 189 Diarrhoea 40 23 11 3 2 1 — — — — — — — — 14 10 3 6 2 4 1 32 9 Malaria 3 — — — — — — — — 3 — — — 1 — — 1 — — — 1 1 — Dysentery — — — — — — — — — — — — — — — — — — — — — — — Trench Fever — — — — — — — — — — — — — — — — — — — — — — — Total 3,258 201 299 269 361 360 831 224 105 285 131 150 42 134 507 350 558 890 154 472 233 1,104 424 43 Tuberculosis. Three hundred and ninety-six new cases of tuberculosis were notified during the year. Of these, 270 were cases of tuberculosis of the respiratory system, 7 were cases of disseminated tuberculosis, and 119 cases of, tuberculosis of other organs. In Table VI, page 61, 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— 129 deaths 80 males, 49 females. Death rate 0.80 per 1,000, being 0.12 lower than in 1923. 115 notified (89 0 percent.) 15 not notified (11.0 percent., of whom 4 or 26.6 per cent. died in institutions). Other Tuberculous diseases— 33 deaths 11 males, 22 females (including 9 deaths from disseminated tuberculosis). Death rate 0.2 per 1,000, compared with 0.19 for 1923. 25 notified (78.8 per cent)., 8 not notified (11.2 per cent., all dying in institutions). Period between Primary Notification and Death. Respiratory System— Under 1 month 15 (13.0 per cent.). 1.3 months 10 ( 8.7 per cent.). 3-6 months 19 (16.5 per cent.). 6-12 months 14 (12.2 per cent.). 1-2 years 23 (20.0 per cent.). Over 2 years 34 (29.6 per cent.). Other Tuberculous Diseases— Under 1 month 21 (84.0 per cent.), including 7 disseminated tuberculosis. 1-3 months 1 (4.0 per cent.). 3-6 months — 6-12 months — 1-2 years — Over 2 years 3 (12.0 per cent.). 44 I have caused enquiry to be made as to how many of the tuberculosis deaths during 1924 came under the notice of the Tuberculosis Dispensary at some period in their previous medical history. Out of 162 deaths, 85 were at some time or other patients at the Tuberculosis Dispensary. It should be remembered that in London there are various other facilities for dealing with tuberculosis such as general and special hospitals (e.g., Brompton Hospital) and infirmaries. Particularly is this the case with regard to patients suffering from tuberculosis of organs other than the lungs. If we deduct the 33 such deaths during the year we find that 83 out of 129 pulmonary cases had previously attended at the dispensary and I think this can be looked upon as a fairly satisfactory figure under present conditions. It should, moreover, be remembered that while these other patients may not have actually attended the dispensary their homes have been visited by the tuberculosis nurses and their general hygienic conditions and mode of life supervised. Of those deaths who did not come under the notice of the dispensary as patients, 15 were attended by private doctors, the remainder apparently having been in, or under the care of, hospitals or infirmaries. Of the 162 deaths which occurred during the year, 100 occurred in institutions and 62 at home. The death rate for tuberculosis of the lungs is this year 0.80 per thousand as compared with the rate of 0.92 for 1923 and 1.02 for 1922. This is a very noteworthy fall extending over the three-year period. From the figures given above it will be noticed that of the deaths from tuberculosis of the respiratory system, 11 per cent. had not previously been notified as suffering from this disease, while for other tuberculous diseases 11.2 per cent. had not previously been notified. These figures are a very great improvement upon the figures for 1923, particularly in regard to other tuberculous diseases, the unnotified percentage of which during 1923 was 37.5. It will further be noticed that 13.0 per cent. of respiratory cases and 84 per cent. of nonrespiratory cases were only notified within a month of their death. This figure for the non-respiratory cases is unsatisfactory and compares badly with the figure 45 of 55 per cent. for 1923. Of course it should be borne in mind that a large number of these cases are acute conditions such as tuberculous meningitis (of which there were 14), tuberculous enteritis, tuberculosis of the internal organs such as the kidney, etc., the total recognisable duration of the illness of which may not extend over more than a month. Prevention and, Treatment of Tuberculosis.—The Tuberculosis Dispensary is situated at 114, New King's Road. The working arrangements are exactly as detailed in my Report for 1923. I give in Table V, p. 46, an interesting summary of the whole position of the tuberculosis problem in Fulham. 46 TABLE V.—DISPENSARY STATISTICS, 1913-24. Year. New Patients. Attendances at Dispensary. Doctors' Home Visits. Nurses' Home Visits. Suffering from Pulmonary Tuberculosis. Suffering from other forms of Tuberculosis. Doubtful Cases. NonTuberculous Cases. Insured. Uninsured. 1913 324 86 323 429 2,361 11,967 2,175 1,517 1914 203 45 261 361 2,276 8,084 2,385 2,547 1915 174 28 260 323 1,171 5,568 1,910 2,918 1916 225 13 311 200 852 5,954 1,079 2,828 1917 286 13 349 329 1,052 6,528 1,141 2,789 1918 235 14 201 478 1,223 8,465 1,435 2,317 1919 221 50 251 281 1,444 8,116 1,724 4,043 1920 142 37 239 342 1,850 6,713 2,004 4,989 1921 116 23 163 344 2,074 5,387 2,217 5,640 1922 155 35 13 388 2,507 3,703 1,264 5,447 1923 132 70 24 401 2,288 3,261 552 4,603 1924 142 65 32 443 2,133 3,619 549 4,775 47 Year. Notifications. Deaths. Death-Rate. Pulmonary. Other forms of Tuberculosis. Pulmonary. Other forms of Tuberculosis. Pulmonary. Other forms of Tuberculosis. 1913 765 289 215 49 1.34 0.31 1914 531 164 207 45 1.32 0.29 1915 461 97 198 51 1.29 0.34 1916 496 92 210 56 1.41 0.38 1917 582 118 191 49 1.32 0.34 1918 561 80 207 47 1.45 0.33 1919 433 145 468 42 1.014 0.27 1920 282 93 142 30 0.89 0.19 1921 287 76 153 31 0.96 0.19 1922 272 113 163 33 1.02 0.2 1923 319 155 149 32 0.92 0.19 1924 270 126 129 33 0.80 0.20 48 REPORT BY THE TUBERCULOSIS OFFICER (Dr. SULLIVAN) ON THE WORK OF THE TUBERCULOSIS DISPENSARY. The death rate from all forms of tuberculosis in Fulham has fallen from 1.63 per 1,000 of the population to 1.0 per 1,000, which is a decrease of over 39 per cent. in 10 years. There can be little doubt that this decrease has been due largely to the intensive campaign against the disease which has been going on for many years and of which the Dispensary is the centre. The objects of the Dispensary have been described in detail in previous reports, but it should be noted that it stands first and foremost for prevention. One of the most important responsibilities is the supervision of infectious cases which are under treatment in their own homes, and the great object of the supervision is to prevent infection of other persons living in close contact with these patients. The actual treatment is in most cases in the hands of private or hospital doctors. There are at the present time on the Dispensary books 248 cases of pulmonary tuberculosis with tubercle bacilli in the expectoration; 195 of these are under treatment at home and 53 are in institutions. Many of the former cases are in the later stages of the disease and ought to be in institutions. There is no doubt that a considerable number could be induced to accept treatment and remain away from home if suitable accommodation were available. From previous experience one knows that no matter how many visits are paid by doctors and nurses and others, these cases are certain to infect other people and thus produce a fresh generation of consumptives. Another important factor in dispensary work is the detection of early cases, and in this connection it may be mentioned that cases are now coming under treatment at an earlier stage than formerly and that a larger number are being sent by doctors each year. During 1924, 376 of the new patients were sent by medical men, and of these 287 were recommended by private practitioners; in 1923 the numbers were 298 and 231. 49 That a greater effort is now being made to detect early cases is also shown in the increase in the number of sputum samples examined; 1,665 sputum examinations were made in 1924 against 1616 in 1923. The facilities available for X.ray examination at Brompton Hospital are also being taken advantage of, and during the year 22 X-ray reports and skiagrams were received from Dr. Melville. In comparing the figures with those of 1923 it is seen that the number of new dispensary patients was 682 against 627 in 1923. The total number of cases notified by the Dispensary in 1924 was five more than during the previous year. The nurses made 4,775 home visits during 1924 against 4,603 during 1923. An endeavour has been made for some years to discharge patients not suffering from tuberculosis, as soon as a definite diagnosis has been made, in order to be able to devote more attention to the cases actually suffering from the disease. The total number of attendances has therefore fallen, although the number of physical examinations made has remained about the same during the past few years. In 1924, however, the number of physical examinations made was actually greater than during the previous year. During the year 364 contacts were examined, compared with 351 during 1923. Many of the contacts were kept under observation for a time before a definite decision was made as to whether they were free from tuberculosis or not; in all 407 attendances of contacts were recorded. According to the instructions of the Ministry of Health cases can now be removed from the tuberculosis register when the disease has been arrested for five years in the case of pulmonary tuberculosis and three years in non-pulmonary tuberculosis. These regulations will have the two-fold effect of freeing the tuberculosis staff from a good deal of unnecessary work and will also obviate irritation on the part of the patients. 50 Patients sent to Residential Institutions. 249 patients were sent to residential institutions on the recommendation of the Dispensary medical officers. (a) 159 by the London County Council. 98 to Sanatoria. 4 to Farm Colonies. 57 to Hospitals or Homes. Men 43 4 42 Women 45 — 14 Children 10 — 1 (b) 32 by the Poor Law Authorities. 16 to the Infirmary. 16 to Sanatoria or Convalescent Homes. Men 4 — Women 7 3 Children 5 13 (c) 35 children were sent to Convalescent Homes by the Invalid Children's Aid Association. (d) 13 by the Charity Organisation Society. 2 men sent to homes for advanced cases. 2 women sent to homes for advanced cases. 1 man sent to hospital. 5 women sent to Convalescent Homes. 3 children boarded out. (e) 6 by the United Services Fund. 2 men to Convalescent Homes. 4 children boarded out in the country. (/) Three children were boarded out by the Children's Country Holiday Fund. (g) One woman went away privately. Number of new patients— Insured 223 Uninsured 459 Total 682 Number of attendances— Insured 2,133 Uninsured 3,619 Total 5,752 51 Number of patients who have attended (both old and new)— Insured 525 Uninsured 912 Total 1,437 Number of notifications— Pulmonary 157 N on-pulmonary 77 Total 234 (of these, 207 were notifications of new patients). Number of contacts examined for the first time 364 Number of attendances of contacts 407 Number of physical examinations 2,827 Number of reports sent to public bodies 894 Number of reports sent to doctors 354 Number of home visits paid by doctors 549 Number of home visits paid by nurses 4,775 Number of ex-service men attending 223 Number of ex-service men notified as suffering from tuberculosis 166 Number of sputum examinations for tubercle bacilli 1,665 Number of urine examinations 60 Number of blood examinations .9 Table I.—Showing who recommended the patients. 237 were recommended by private doctors. 36 „ „ the Medical Officer of Health. 27 „ „ the School Medical Officers. 15 ,, „ the school authorities. 15„ „ hospitals. 5 ,, „ other dispensaries. 3 „ „ sanatoria. 3 „ „ infirmaries. 18 „ „ the Army authorities. 88 „ „ the Dispensary staff. 8 „ „ the London County Council. 98 „ „ friends. 39 „ „ other patients. 16 „ „ the door plate. 8 „ „ the Invalid Children's Aid Association. 5 „ „ the Charity Organisation Society. 2 ,, „ the relieving officers. 2 „ „ the district nurses. 2 „ „ employers. 1 was recommended by High Commissioner for S. Africa. 4 were contacts. 682 52 Table II.—Sex and age of new patients for 1924. Under 5 yrs. 10 yrs. 15 yrs. 25 yrs. 35 yrs. 45 yrs. 45 yrs. & over All ages. Males 46 54 44 57 43 42 42 328 Females 41 64 27 58 79 52 33 354 Both Sexes 87 118 71 115 122 94 75 682 Table III.—Diagnosis in males and females. (New Patients.) Total Cases. Pulmonary Tuberculosis. Other forms. Suspects. NonTuber cular. Percentage Tuberculous. 328 males 77 30 16 205 32.62 354 females 65 35 16 238 28.24 682 both sexes 142 65 32 443 30.35 Although more females attended the Dispensary, more males suffered from tuberculosis. The preponderance of cases in the male sex is due to pulmonary tuberculosis. Table IV.—Diagnosis at various age periods. (New Patients.) Pulmonary Tuberculosis. Other forms. Suspects. NonTuber cular. Percentage Tuberculous. Under 5 years 1 11 4 71 13.79 „ 10 „ 3 27 7 81 25.42 „ 15 „ 1 10 6 54 15.49 „ 25 „ 54 9 4 48 54.78 „ 35 „ 37 6 4 75 35.24 „ 45 „ 25 2 5 62 28.72 45 years and over 21 — 2 52 28.00 All ages 142 65 32 443 30.35 53 142 new patients were suffering from tuberculosis of the respiratory organs and of these 96 had tubercle bacilli in the sputum. The majority of cases occurred between the ages of 15 and 35. 46 patients suffered from tuberculosis of the glands of the neck, and the majority of these occurred between the ages of 5 and 10. Housing and Tuberculosis. A great deal of overcrowding exists in the Borough and it is to be hoped that definite steps will be taken in the near future to remedy the present state of affairs. It is obvious that there is little room in Fulham for new buildings and this is borne out by the census returns for 1921 as well as by an inspection of the Borough for possible sites. In 1921, according to the Registrar-General's returns, the number of occupied rooms per person (including living rooms, bedrooms and kitchen but excluding scullery and bathroom), was 0.96, which was the same as for the whole of the administrative County of London (including the City). In Fulham therefore the available accommodation was equal to the average in London. When the density of population was, however, judged by the number of persons per acre, it was found that the figure for Fulham was 93 per acre against 60 per acre for the whole of London. Tables V to VII deal with the housing conditions of new cases of tuberculosis attending the Dispensary. In 1914, 215 new cases of tuberculosis were visited by the nurses and their home conditions investigated; 97 were found to be living in houses of three rooms or less, equal to 45.1 per cent. of the total. In 1924, 194 new cases were visited and 110, or 56.6 per cent. of the total were living in houses of three rooms or less, which tends to show that the housing conditions are worse. 54 In 1914, 56 of the families in which a new case of tuberculosis occurred occupied the whole house, equal to 26 per cent. of the total, whereas in 1924 only 30 out of 194 families or 15.4 per cent. of the total had the whole house to themselves. Below a few examples are given of the lack of proper housing accommodation in the poorer districts. Mrs. A.—Aged 29, who is an infectious case of pulmonary tuberculosis has lived on the first floor of a tenement building in a squalid neighbourhood in the North-East district for nine years. Five persons live and sleep in one room, including the patient, her husband, a baby one month old, and two other children. The patient had three months' sanatorium treatment last year, but the disease is still active. The husband is in regular work but is unable to find accommodation elsewhere. Fortunately up to the present time none of the others have been infected with the disease, but doubtless under present conditions this is only a matter of time. Mr. B.—Aged 44, who lives with his wife and four children, suffers from active tuberculosis of the lungs and discharges tubercle bacilli in the sputum. He is able to continue at work as a motor driver and refuses the offer of sanatorium treatment as he fears that he will be unable to find work on his discharge from an institution. The six persons live in a basement room and kitchen in the St. Clements district. Already one of the children has contracted tuberculosis of the glands of the neck as a result of living under unhealthy conditions in contact with the patient. Mr. C.—An ex-soldier of 42, has been unfit for work for some years on account of pulmonary tuberculosis. He has had several periods of treatment in sanatorium and is at present in Collindale Hospital. His wife and six children live in a room and kitchen in a poor locality. None of the others have contracted the disease, doubtless because the man's pension allows of sufficient nourishment for the family, and because the man has been away from home for long periods and the opportunities for conveying the infection have thus been reduced. Mr. D.—Aged 50, with his wife and six children occupied part of a house consisting of two rooms and a small kitchen. He was an ex-soldier and had sanatorium treatment and died at home after a long illness. The eldest son aged 16, has now contracted active pulmonary tuberculosis and is awaiting admission to a sanatorium. 55 Mr. E.—Was a young man of 22 who when he first came to the Dispensary in 1924 was found to be suffering from pulmonary tuberculosis. The family consisted of the parents and five children and occupied a cottage of four rooms. The patient shared a bedroom with his two brothers and died at home early in the autumn. Since then both brothers have contracted the disease; one is a severe case and is not likely to recover. He was sent to an institution but was discharged after four months' treatment and is still unfit for work. The other was also sent away but discharged himself from the sanatorium after one week. Table V.—Housing conditions. Of 194 of the 207 tuberculous patients found in 1924— 10 lived in the basement. 50 „ on the ground floor. 54 „ „ first floor. 7 „ „ second floor. 6 „ „ third floor. 8 „ „ top floor. 29 „ on more than one floor. 30 „ in the whole house. 194 Table VI.—Housing accommodation. — Number of Families occupying 1 room. 2 rooms. 3 rooms. 4 rooms. 5 rooms. 6 rooms or over. Patient living alone — — — — — — Patient living with 1 other 5 9 6 2 2 — „ „2 others 5 10 11 3 3 i „ „ 3 „ 2 3 13 10 1 6 „ „ 4 „ 3 4 13 10 3 3 „ „ 5 „ 1 1 11 10 1 2 „ „ 6 „ — 1 6 8 — 1 „ „ 7 „ — — 2 5 3 4 „ „ 8 „ — — 4 2 — — „ „ 9 „ — — — — — 2 „ „ 10 „ — — — — 1 — „ „ 11 „ — — — 1 — — Total 16 28 66 51 14 19 56 Table VII.—Sleeping accommodation of 194 tuberculous patients. The patient slept— In a separate room In 66 cases. Alone in bed with one other in room „ 23 „ ,, ,, two others in room 22 „ „ „ three others in room 9 „ „ „ four others in room 1 case. In bed with one person and no others in room In 41 cases. „ „ one other in room „ 13 „ ,, ,, two others in room „ 5 „ „ „ three others in room „ 4 „ „ „ four others in room „ 1 case. In bed with two persons and no others in room „ 4 cases. „ ,, one other in room „ 1 case. „ „ two others in room „ 2 cases. In bed with three persons and no others in room „ 1 case. „ „ one other in room 1 „ Table VIII. Occupations of 82 tuberculous men in 1924. 1 art metal worker. 1 hawker. 1 asylum attendant. 2 hotel porters. 2 baker's roundsmen. 1 infirmary porter. 1 billiard marker. 1 inspector R.S.P.C.A. 1 bootmaker. 1 kitchen hand. 2 boot repairers. 4 labourers. 1 box-maker. 1 lift repairer. 2 butchers. 1 messenger. 1 bus driver. 1 motor salesman. 1 carpet planner. 1 newsagent. 1 checker. 4 painters. 1 china rivetter. 2 plumbers. 1 cinema operator. 1 potman. 11 clerks. 2 refreshment stall holders. 1 coach builder. 5 shop assistants. 1 coachman. 3 shop porters. 1 commissionaire. 1 stage manager. 2 electricians. 1 time keeper. 5 engineer's mates. 1 tobacconist. 1 fireman. 1 traveller. 1 fitter's mate. 1 window cleaner. 1 furnaceman. 6 no occupation. 57 Occupations of 12 tuberculous women in 1924 1 actress. 2 milliners. 2 bar cleaners. 2 nurses. 1 box office attendant. 1 packer. 1 china rivetter. 1 pianist. 8 clerks. 1 printer. 7 domestics. 1 relief stamper. 2 dressmakers. 3 shop assistants. 1 embroideress. 1 tailoress. 4 factory hands. 2 telephonists. 21 housewives. 4 typists. 1 machinist. 1 upholstress. 4 of no occupation. Children under 15. 25 boys. 28 girls. The Tuberculosis Care Committee. The object of the Care Committee is to supplement the medical treatment so that the latter can be rendered more effective. The majority of the members of the Committee are voluntary workers with many years experience of social or other public service, and are also members of the various organisations to which cases are referred for help. Each member represents one of these agencies and is thus able to speak on behalf of patients requiring assistance. In this way help is obtained from the Charity Organisation Society, the Invalid Children's Aid Association, the British Red Cross Society, the United Services Fund, the Peterborough Benevolent Society and the Guardians. The work of the Committee has been described in some detail in previous annual reports, and it is only necessary to mention a few of the outstanding features. The Committee itself gives no financial help and acts purely in an advisory capacity. The meetings take place once a fortnight and the members, more especially those representing the Charity Organisation Society and the Invalid Children's Aid Association, also visit the patients' homes for various purposes. Patients or their relatives are expected to pay part of the cost of institutional treatment according to their circumstances, and a member of the Committee visits in order to ascertain the income and expenditure. The weekly payments have to be collected by the visitor and this 58 enables the Committee to ascertain any change in the circumstances of the family. The Committee have been able to send a large number of patients to convalescent or other homes or to be boarded out in the country; many of these patients could not be sent away by a purely official body such as a local authority. A considerable number of patients have been given financial help or have been provided with food or clothing during the year. Beds and bed-clothing are lent out in order to enable patients to sleep alone. The accompanying table and illustrative cases compiled by Miss Sargent, secretary of the Committee, will give an indication of the amount of useful work that is being done. Summary of Cases referred by the Care Committee to different agencies for assistance, showing the Help Given by each Agency. Charity Organisation Society. 4 patients sent to homes for advanced cases. 5 patients sent to Convalescent Homes. I patient sent to hospital. 3 children (not patients) boarded out. 9 patients helped with dental treatment (extractions and dentures). 3 patients helped with clothing. 7 families assisted financially. 1 patient assisted with surgical appliance. 5 families referred for friendly advice—in one of these the visit resulted in the Society making arrangements for the future of the orphan child. In addition to these cases, eight* patients were recommended for convalescent treatment, seven of whom withdrew their applications and one the Society declined to arrange for. Three other patients were referred for dental treatment which it was not possible to arrange. 59 Two families referred for boarding out of children finally made their own arrangements. Invalid Children's Aid Association. 35 children were sent away for convalescence. Red Cross Society. 5 patients assisted financially. 2 patients assisted with clothing. 3 patients assisted with surgical appliances. United Services Fund. 5 families assisted financially. 4 children boarded out. 2 patients (men) sent to Convalescent Homes. The Borough Council. 36 patients assisted with grants of milk and eggs for varying periods. The Guardians. 16 patients sent to the Infirmary. 16 patients sent to sanatoria or convalescent homes. 4 families assisted financially. 3 children boarded out on account of home ditions. 1 patient in sanatorium provided with clothing. It must be noted that some patients make their own applications for assistance to the various agencies mentioned in this table ; these have not been included but only those in whose cases the reference was made directly by the Care Committee. Illustrative Cases dealt with by the Care Committee. A.—Was an ex-service man who was sent to a Farm Colony for treatment. He and his wife had furnished on the hire-purchase system and their weekly payments for furniture took the whole of his pension but they hoped that the wife would be able to support herself during his absence. Unfortunately she fell ill and was thus unable to earn. The Care Committee had been in touch with the family before and she accordingly came to them in her difficulties. Temporary help was obtained from the British Red Cross and later on a little work until she found regular employment for herself. When the husband returned much the better for his period of treatment she was able to welcome him with a home cleared of debt. B.—Was a widow whose husband died of pulmonary tuberculosis, leaving her unprovided for and with one daughter, a girl 60 of 19. The patient herself developed the disease and though sent to sanatorium continued to go downhill. The daughter tried hard to earn enough for both but in spite of some help from a married brother was not always able to do this. Extra nourishment was obtained from the Town Hall and later on from the Charity Organisation Society who also helped financially for a very considerable period. Finally when the patient grew much worse this Society obtained a bed for her in the Hostel of God where she was very happy and well-cared for until the end, and they also sent the daughter to the seaside for several weeks as a measure of prevention. The latter is now happily employed and looking forward to being married. C.—Was a man with a wife and three children living in one room. The Tuberculosis Officer applied to the Guardians to take charge of the children, but this they declined to do unless the patient would go into the Infirmary and this he steadily refused to do. The doctor renewed the application pointing out the fear of infection to the children and at last the Guardians rescinded their decision and placed the children in their homes. This is only one of the ways in which the Guardians have helped us in the care of our consumptive families. D.—Was a middle-aged woman absolutely without means or relatives. She had kept herself by dressmaking but had gradually been able to do less and less and finally had to part with her furniture and go into the infirmary. From there she was to be transferred to a sanatorium and when the case came before the Care Committee they felt how miserable it would be for her to go away without a penny in her pocket. Application was therefore made to the Charity Organisation Society who discovered a fund for making small grants to " Distressed Needlewomen without male Relatives " and one of these was obtained for the patient. At the end of the year she was still away in sanatorium. E.—Was not a patient but had nursed her daughter for three months from her discharge from hospital till her death and was very tired out and run down in consequence. The Committee referred her to the Charity Organisation Society who sent her away for a period of convalescence from which she returned much benefitted. F.—Was a married woman with two children. When she had to be sent to a sanatorium she made arrangements for the children to be boarded out with friends for a weekly sum. During her absence from home her husband's affairs went from bad to worse and the Committee applied to the London County Council to give the sanatorium treatment free of cost; this the Council at once agreed to do. A little later the husband found himself unable to continue the weekly payments for the children's board and the Care Committee were able to arrange with the United Services Fund to take over the maintenance of the children. The family is now happily re-united; the patient much improved and the husband again employed. 61 TABLE VI.—PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Summary of notifications during the period from Ist January, 1924, to 31st December, 1924. Age Periods. Number of Notifications on Form A. Number of Notifications on Form B. (by School Medical Officers). Number of Notifications on Form C. of admission to Primary Notifications. Total Notifications on Form A. Primary Notifications. Total Notifications on Form B. Poor Law Institu tions. Sanatoria. 0-1. [ 1-5. 5-10. 10-15. 15-20. 20-25. 25-35. 35-45. 45-55. 55-65. 65 and upwards. Total Primary Notifications. Under 5. 5-10. 10-15. Total Primary Notifications. Pulmonary— Males 1 7 3 2 13 24 29 24 21 9 3 136 226 — — — — — 13 158 Females 1 1 10 4 13 22 36 16 13 3 1 120 189 — — — — — 11 104 Non-Pulmonary— Males 2 8 27 10 4 1 1 1 — 2 1 57 66 — — — — — 1 28 Females — 14 16 8 7 3 7 3 — 1 — 59 75 — — — — — — 19 62 New Cases of Tuberculosis coming to the knowledge of the Medical Officer of Health otherwise than by notification on Forms A or B during the year 1924: — Age Periods. 0-1. 1-5. 5-10. 10-15. 15-20. 20-25. 25-35. 35-45. 45-55. 55-65. 65 and upwards. Total. Pulmonary males — — 1 1 1 2 3 3 2 2 — 15 „ females — — 2 — 1 1 1 1 — — — 6 Non-pulmonary males — — 1 1 — — — — — 1 — 3 „ females — — — — — — — — — — — — 63 Food. During 1924 public attention has been focused to a considerable extent on the many questions connected with the purity of our foodstuffs and the conditions under which they are manufactured and kept. This has been due, amongst other things, to the issue of the report of the Departmental Committee of the Ministry of Health on food preservatives and also to the issue of the Public Health (Meat) Regulations, 1924. These two matters are of some considerable importance and it will not be out of place if I review them briefly. The following is a summary of the conclusions and recommendations of the Departmental Committee on preservatives and colouring matters in food:— (1) Preservatives should be prohibited in all articles of food and drink offered or exposed for sale whether manufactured in this country or imported, except that:— (A) Sulphur dioxide only should be permitted:— (i) In sausages in amounts not exceeding 3 grains per pound, (ii) in jam in amounts not exceeding 0.3 grains per pound; (iii) in dried fruit in amounts not exceeding 7 grains per pound; (iv) in preserved (but not dried) whole fruit or fruit pulp in amounts not exceeding 5 grains per pound; (v) in beer and cider whether in bottle or in cask in amounts not exceeding 5 grains per gallon; (vi) in alcoholic wines, non-alcoholic wines and cordials and fruit juices, sweetened and unsweetened, in amounts not exceeding 3 grains per pint; (B) Benzoic acid only should be permitted:— (i) In coffee extract in amounts not exceeding 3 grains per pound; 64 (ii) in non-alcoholic wines and cordials, and sweetened and unsweetened fruit juices (as an alternative to sulphur dioxide) in amounts not exceeding 5 grains per pint; (iii) in sweetened mineral waters and in brewed ginger beer in amounts not exceeding 1 grain per pint. The method of estimating the foregoing preservatives should be prescribed by the Minister of Health. 2. The sale of any preparation as a food preservative or for use in such circumstances that it may be introduced into food should be declared illegal unless such preparation:— (a) Bears a description clearly indicating its position and strength; (b) Is free from impurities and in particular contains not more than 1/100th part of 1 grain of arsenic per pound or more than 1/7th part of 1 grain of lead per pound. 3. The use of preservatives so far as they are permitted should be upon the condition that the nature and quantity of the preservative present in the article of food should be declared in a manner prescribed by the Minister of Health. In cases in which the declaration of the preservative might be difficult to enforce or might result in undue harm to the industry without compensating advantage to the consumer, exception to this requirement might be made, but the exception should in no circumstances apply to sausages. 4. The employment of a copper salt to colour or preserve the colour of peas and other vegetables should be prohibited. 5. A schedule should be issued by the Minister of Health, after such enquiry as is necessary, of colouring matters the use of which may be considered noninjurious to health, such schedule to be subject to amendment or extension from time to time as occasion 65 may require. Within a suitable period after the publication of this list the use of any other colouring matter should be prohibited unless and until it shall have been approved by the Minister. 6. Before the prohibition of preservatives or of colouring matters in food (including the use of copper salts for the so-called greening of vegetables) is enforced, a period of grace should be allowed sufficient to enable manufacturers and importers to adjust their methods and processes and to allow stocks to be cleared. 7. Improved methods in the storage and transport of food by rail, road and water, especially as regards the use of refrigeration and cool air storage, are urgently required. 8. It should be provided by law that any Regulations or Statute prohibiting or limiting the use of preservatives and colouring matters should bind the courts in proceedings taken under the Sale of Food and Drugs Acts in respect of their use. 9. An amendment of the law is required to render more expeditious the prosecution of a person actually responsible for offences under these Acts, where a warranty defence is pleaded. 10. Further powers of control by registration, licensing or inspection should be given to Local Authorities in relation to all places concerned in the production, sale, storage and distribution of food. The above report is dated September, 1924, and it is satisfactory that on 17th February, 1925, the Ministry of Health issued draft regulations proposed to be made by the Minister of Health dealing with this important subject of preservatives and colouring matter in foodstuffs. The draft regulations follow in the main the recommendations of the Departmental Committee, and if they become law as they stand they will be exceedingly useful. Unfortunately, however, interested parties in the trade are already making strenuous efforts to 66 influence the Minister of Health towards amending the regulations in various particulars. Such emendations, if carried into effect, would stultify to a very large extent the purpose of the regulations. Amongst others the liquid egg trade appear to be doing their utmost to retain the use of boric acid in their products. It is difficult to see how the Ministry could justify their procedure in allowing this, unless they also allowed boric acid in many other articles and this would defeat one of the main recommendations of the Departmental Committee. We can only hope that the Minister will stand firm by the recommendations of the Departmental Committee and issue his regulations on those lines. The second important matter to which I have referred above is the Public Health (Meat) Regulations, 1924. These Regulations deal firstly with the operation of slaughterhouses and slaughtering, secondly with meat marking, thirdly with the cleanliness and sanitation of stalls, shops and stores where meat is sold, and fourthly with the transport and handling of meat. So far as this Borough is concerned the most important parts of the Order refer to the regulation of shops and stalls. Regarding slaughtering the most important regulations are as follows:— (1) A person shall not slaughter an animal for sale for human consumption unless he has, not less than three hours before the time of slaughtering, delivered or caused to be delivered to the local authority notice of the day and time and of the place on or at which the slaughtering will take place. Exceptions to this rule are allowed where a slaughterhouse has a fixed regular day and time for slaughtering and where by reason of accidental injury illness or exposure to infection it is necessary that an animal should be slaughtered without delay. In the latter case notice of the slaughtering must be given to the local authority as soon as possible either before or after the slaughtering takes place. 67 (2) Where on the slaughter of an animal for sale for human consumption it appears that any part of the carcase or internal organs is or may be diseased or unsound the person by or on whose behalf the animal was slaughtered shall forthwith give notice of the fact to the Local Authority. (3) Except in certain specified cases the person by or on whose behalf an animal is slaughtered shall not cause or permit the carcase of the animal including the mesentery and internal organs other than the stomach, intestines and bladder, to be removed from the place of slaughter until such carcase with its organs has been inspected, or its removal has been authorised, by an Inspector of the Local Authority. (4) No gut-scraping, tripe cleaning, manufacture or preparation of articles of food for man or for animals, household washing or work of any nature, other than is involved in the slaughter and dressing of carcases, shall be carried on in any slaughterhouse. (5) No person shall blow or inflate with his breath, or in any manner likely to cause infection or contamination, the carcase or any part of the carcase of any animal slaughtered for human consumption. (6) No person shall use a slaughterhouse for the slaughter of any animal which, previous to slaughter, is not intended for human consumption. The next part of the Regulations deals with meat marking and enables a Local Authority to use a special mark on any carcases passed by their inspectors. Part 4 of the Regulations deals with the sale of meat from stalls and the most important parts are as follows:— (a) A person selling meat or exposing or offering meat for sale from any stall shall cause such stall to be suitably covered over and to be screened at the sides and back thereof 68 in such a manner as to prevent mud, filth or other contaminating substance being splashed or blown from the ground upon any meat on the stall. (b) Shall take all such steps as may be reasonably necessary to guard against the contamination of the meat by flies. (c) Shall not place any meat on or within 18 inches of the ground or floor unless the meat is placed in a closed cupboard not less than 9 inches from the ground or floor. (d) Shall cause all trimmings, refuse or rubbish to be placed in properly covered receptacles kept for the purpose and apart from any meat intended for sale. Part 5 of the Regulations deals with the sale of meat from shops, stores, etc. The first and second sub-sections of part 5 (section 20) lay down certain definite sanitary requirements as to the shop or store, and deal with such matters as the proximity of W.C.'s, drains, etc. Sub-section 3 requires the walls and ceiling to be white-washed, cleansed or purified as often as may be necessary, while sub-section 4 requires the occupier to observe due cleanliness in regard to the room and all articles, apparatus and utensils therein. Sub-section 5 lays down similar rules regarding shops to those previously quoted as applying to stalls, particularly regarding the necessity for causing the meat to be so placed as to prevent mud, filth or other contaminating substance being splashed or blown thereon and to prevent the contamination of the meat by flies. This subsection will probably in practice be found to be one of the most important of the whole Regulations. Part 6 (section 21), deals with the transport and handling of meat and requires that "any person who conveys meat in a vehicle shall cause the outside and the covering of the vehicle to be kept clean, also the receptacles in which meat is placed and such parts of any slings or 69 any implements or apparatus used for loading or unloading." If the vehicle is open at the top the meat must be adequately protected by means of a clean cloth or other suitable material and no live animal may be conveyed in the vehicle at the same time as meat. A person engaged in the handling and transport of meat must not permit any part of the meat to come into contact with the ground and shall take such other precautions as are reasonably necessary to prevent the exposure of the meat to contamination. Sub-section 3 of this section requires every person who employs a person to carry meat in or about a market or other place in which meat is sold by wholesale, etc., to cause such person to wear a clean and washable headcovering and overall. It will be seen that these Regulations show a considerable advance on our present-day methods of slaughtering, selling and handling meat. There are many matters of detail which will require to be adequately considered by the Public Health Committee before the Regulations come into force on 1st April, 1925 but it is hoped that some uniform action may be taken for the whole of London. Milk.—The number of adulterated samples of milk has fallen from 4.5 per cent. in 1923 to 1.6 per cent. in 1924. This is the lowest percentage of adulteration which has ever been recorded in the Borough and is most satisfactory. Two factors have combined to bring about this result. Firstly, the many years of constant watchfulness which Inspector Jones has devoted to the inspection of milk sellers and to the sampling of their milk, and secondly, the fact that a large number of retailers in this Borough obtain their milk from the United Dairies Milk Combine. This Combine devotes particular attention to the adulteration of their milk and regularly takes samples from the retailers who deal with them. In this way an additional control is maintained over the small milkseller. 70 Legal proceedings were instituted by the Council in 6 cases. Details will be found on page 74. Milk sellers— Number on Register 31st December, 1923 90. Number who discontinued sale of milk during year, or business transferred 9. Number of licences issued during 1924 24. Number on Register 31st December, 1924 105. Costers and Food Stalls.—Constant watchfulness has again been required during the year in order to deal with the many unsatisfactory places where costers have been found to keep food, especially fruit, prior to its sale on their barrows or stalls. In my report for 1923 I stated that a Bill had been presented to Parliament requiring the registration of costers, market stalls and food storage places. This Bill unfortunately appears to have vanished and at present there is no talk of a similar Bill. Nevertheless, it is undoubtedly badly required. Cream (Milk and Cream Regulations, 1912 and 1917). —Fourteen samples of cream and eighteen samples of preserved cream were purchased for analysis. The following particulars of proceedings taken in 1924 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 Board 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 616 nil. Cream 14 5 71 2. Cream Sold as Preserved Cream. (a) Instances in which samples have been submitted for analysis . to ascertain if the statements on the label as to preservatives were correct:— (1) Correct statements made 18 (2) Statements incorrect — Total 18 (b) The examination made of milk fat in cream sold as preserved cream:— (1) Above 35 per cent 18 (2) Below 35 per cent — Total 18 (c) Instances where (apart from analysis) the requirements as to labelling of preserved cream in Article 5 (1) and the proviso in Article 5 (2) of the Regulations have not been observed Nil (d) Particulars of each case in which the Regulations have not been complied with and action taken Nil 3. Thickening substances. Evidence of their addition to cream or preserved cream Nil 4. Other observations Nil The Milk (Special Designations) Order, 1923. Number of licences granted to sell certified milk 24 Number of supplementary licences to sell certified milk 2 Number of licences granted to sell Grade A (Tuberculin Tested) Milk 10 Number of supplementary licences granted to sell Grade A (Tuberculin Tested) Milk 1 Number of samples taken in accordance with the instructions of the Ministry of Health 20 Number of samples not up to the standard as laid down by the Ministry of Health Nil Bakehouses.—Inspector Jones has again this year devoted particular attention to the condition of the bakehouses in the Borough. He has paid 154 visits of inspection to the 68 registered bakehouses. There has undoubtedly been a very considerable improvement in the general condition of the bakehouses during the past two years. Of the 68 bakehouses in the Borough, 43 are situated underground. 72 Slaughterhouses—There are two licensed slaughterhouses in the Borough:— No. 611, Fulham Road, and No. 640, King's Road. 85 visits of inspection have been made to these slaughterhouses during the year and the conditions have been found satisfactory on every occasion. Food-Preparing Places.—Attention was devoted during the year to all places where food is prepared, particularly to the various food kitchens, restaurants and eating places. These places are as a rule systematically visited by the woman sanitary inspector, Mrs. Davies, and during 1924 she has made 415 inspections, as compared with 384 during 1923. In connection with these kitchens 29 notices to improve the premises were served. We have a record of 92 such kitchens in the Borough but as there is no obligation on such premises 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 1924 the usual arrangements have continued 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. Unsound Food.—The following articles, examined at the request of owners, were condemned and destroyed:— Apples 8 cwts. Strawberries 5 baskets. Tomatoes 45 boxes. William pears 77 boxes. Potatoes 11 sacks. Australian grapes 16 „ Winter greens 2 ,, Apricot pulp 10 tins. Savoy greens 12 „ Cockles 1 basket. Spring greens 4 „ Skate 12 stones. Cauliflowers 31 nets. Mackerel 1 box. Chestnuts 4 sacks. Haddocks 8 boxes. Whiting 1 box. 73 Samples Purchased for Analysis during 1924:— Article. Number of samples taken officially. Number Adulterated. Number of samples taken unofficially. Number Adulterated. Total Samples. Total Adulterated. Percentage of Adulteration. Milks 613 10 3 616 10 1.6 Butters — — 126 — 126 — — Cheese — — 10 — 10 — — Cream 4 — 10 5 14 5 35.6 Preserved cream — — 18 — 18 — — Lard — — 16 — 16 — — Margarine — — 5 — 5 — — Condensed milk — — 16 — 16 — — Dried milks — — 8 — 8 — — Cofiee — — 24 — 24 — — Coffee extract — — 2 — 2 — — Chicory — — 6 — 6 — — Cocoa — — 11 — 11 — — Peppers — — 6 — 6 — — Mustard — — 17 — 17 — — Self-raising flour — — 28 — 28 — — Sweets — — 6 — 6 — — Peas — — 5 2 5 2 40.0 Beans — — 1 — 1 — — Mince meat — — 5 — 5 — — Malt vinegar — — 14 — 14 — — Sponge cake — — 11 — 11 — — Beef sausage 2 1 5 1 7 2 28.5 Pork sausage 1 1 3 1 4 2 50.0 Fish paste — — 6 — 6 — — Emulsion of cod liver oil — — 1 — 1 — — Malt extract and cod liver oil — — 1 — 1 — — Syr. Ferri Phos. Co. — — 1 — 1 — — Brawn — — 4 1 4 1 25.0 Spinach — — 1 1 1 1 100.0 Jams — — 5 — 5 — — Camphorated oil — — 4 1 4 1 — Cream cheese — — 1 — 1 — — 620 12 380 12 1,000 24 2.4 74 Proceedings were instituted in the undermentioned cases:— Defendant. Offence. Result. Penalty. Costs. The Great Ponton Dairies, Ltd., 23, High Street, Grantham. Selling milk adulterated with 3 per cent. of added water. Convicted .. £ s. d. £ s. d. 2 0 0 — The Great Ponton Dairies, Ltd., 23, High Street, Grantham. 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. (Same samples as above.) Withdrawn — — Adolphus Randall, 14, Hanbury Place, Tottenham. Unlawfully carrying on the trade of a purveyor of milk without being registered on 26.12.23. Convicted 0 1 0 0 10 0 Adolphus Randall, 14, Hanbury Place, Tottenham. Unlawfully carrying on the trade of a purveyor of milk without being registered on 13.1.24. Convicted 0 1 0 — Adolphus Randall, 14, Hanbury Place, Tottenham. Unlawfully carrying on the trade of a purveyor of milk without being registered on 20.1.24. Convicted 0 1 0 — Adolphus Randall, 14, Hanbury Place, Tottenham. Unlawfully carrying on the trade of a purveyor of milk without being registered on 21.1.24. Convicted 0 1 0 — Adolphus Randall, 14, Hanbury Place, Tottenham. Unlawfully carrying on the trade of a purveyor of milk without being registered on 27.1.24. Convicted 0 1 0 — Gwilym Thomas Richards, 105, Munster Road. Selling milk 10 per cent. deficient in fat. Warranty pleaded. Summons dismissed — — Leslie Thomas Headland, 153, Dawes Road. Selling milk 46 per cent. added water. Convicted 8 0 0 — General Sanitary Administration. Bacteriological Work.—The following bacteriological examinations were made during 1924 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., during week-ends, on public holidays and in special emergency. During the year under review, 75 of 2,505 specimens examined, only 98 were done by the Clinical Research Association, the remainder being done in the Borough Laboratory. Bacteriological examinations made during the year 1924:— Material from cases of suspected diphtheria— Diphtheria bacillus isolated 67 Negative result 669 736 Blood from cases of suspected Enteric Fever— Widal reaction for typhoid or para-typhoid obtained 4 Negative result 11 15 Pathological specimens for enteric organisms— Positive result Nil Negative result 8 8 Sputa from cases of suspected tuberculosis— Tubercle bacillus found 237 „ „ not found 1,437 1,674 Examinations of urine 66 Blood counts 9 Other examinations 77 2,585 Disinfection.—The following rooms were disinfected and cleansed after infectious disease:— Rooms fumigated after Scarlet Fever 345 ,, „ Diphtheria 247 „ ,, Measles 488 ,, ,, Phthisis 311 „ Erysipelas 53 ,, „ Encephalitis Lethargica 14 „ „ Smallpox 9 „ ,, Chickenpox 4 Carried forward 1,471 76 Brought forward 1,471 Rooms fumigated after Polio Myelitis 2 ,, „ Cerebro Spinal Meningitis 2 „ „ Puerperal Fever 22 „ ,, Scabies 30 „ „ Enteric Fever 11 „ ,, Pneumonia 3 „ „ Mumps 1 „ „ Whooping Cough 3 „ „ Ophthalmia Neonatorum 1 „ ,, for Vermin 23 Rooms sprayed 32 „ fumigated by request 58 1,659 The following articles were disinfected at the Council's Disinfecting Station :— [###Articles. From Private Houses. From Institutions. Total. Beds 752 752 Mattresses 827 132 959 Palliasses 168 — 168 Spring beds 11 — 11 Pillows 1,898 149 2,047 Cushions 267 — 267 Bolsters 738 — 738 Blankets 2,095 525 2,620 Sheets 1,158 209 1,367 Covers 324 — 324 Counterpanes 680 36 716 Curtains 229 — 229 Carpets 285 — 285 Hearth rugs 274 — 274 Articles of clothing 2,443 474 2,917 Eiderdowns 171 — 171 Sundries 469 62 531 12,789 1,587 14,376 77 Public Mortuary.—Ninety-eight bodies were removed to the Mortuary during the year and were admitted as follows :— By order of the Coroner 74 Brought by Police 7 By order of the M.O.H. 1 For convenience till funeral 16 98 Sixty-six post-mortem examinations were made, and inquests were held in 79 cases. Sanitary Inspection of the District.—The following inspections of dwelling-houses were made during 1924 by the District Sanitary Inspectors:— Cause. Premises Inspected. *In consequence of complaint 2,336 In consequence of infectious disease 842 House-to-house inspections 206 Re-inspections 12.533 *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 31st Dec., 1924. Number served. Number complied with up to 31st Dec., 1924. 2,369 1,985 296 256 The following works were carried out and repairs effected as a result of the action of the Sanitary Inspectors:— Drains tested. 1,112 Drains relaid 158 Drains repaired 489 Soil pipes renewed 168 78 Soil pipes repaired 154 Eaves and downspouting repaired 578 Sinks renewed or repaired 377 W.c.'s and flushing apparatus repaired 681 Cisterns cleansed and covered 385 Water supply provided from main 76 Yards and forecourts paved 468 Roofs, chimneys and walls repaired 1,106 Dustbins provided 559 Dampness of walls remedied 585 Internal house repairs done 1,780 Rooms cleansed 3,616 Overcrowding abated 40 Other nuisances abated 1,190 The following additional matters were dealt with by the Sanitary Inspectors:— Ice-cream premises— No. of inspections 196 Other food places— No. of inspections 566 Smoke nuisances— Complaints 18 Observations 222 Notices served 7 No. abated 7 FACTORIES, WORKSHOPS AND WORKPLACES. I—Inspection of Factories, Workshops and Workplaces. Inspections made by Sanitary Inspectors. Premises. (•) Number of. Inspections. (2) Written Notices. (3) Prosecutions. (4) Factories (including factory laundries) 155 24 — Workshops (including workshop laundries) Workplaces (other than outworkers' 294 46 — mises) 523 14 — Total 972 84 — 79 II.—Defects found in Factories, Workshops and Workplaces. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. (1) (2) (3) (4) (5) Nuisances under the Public Health Acts:— Want of cleanliness 76 76 — — Want of ventilation 2 2 — — Overcrowding 2 2 — — Want of drainage of floors — — — — Other nuisances 29 29 — — Sanitary accommodation— Insufficient 3 3 — Unsuitable or defective 23 23 — — Not separate for sexes 5 5 — — Offences under the Factory and Workshop Acts :— Illegal occupation of underground bakehouse (s. 101) — — — — Other offences (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921) — — — — Total 140 140 — — In addition 763 visits of inspection were paid to the premises of outworkers and 32 notices were served in respect of defects found. Work of Female Inspector.—The greater part of the work under the Factory and Workshops Acts is carried out by the Woman Sanitary Inspector, Mrs. Davies. She also carried out the following work during 1924:— Visits. Notices served. To verminous cases 44 8 To infectious disease 119 6 Food kitchens 415 29 80 Drainage of buildings.—The following drainage plans were submitted to and approved by the Public Health Committee during 1924:— Plans for drainage of new buildings, including block of flats (30), lock-up shops, garages, stove and meter works, joinery factory and workshop, church, bungalows, billiard hall, service filling station 61 Additions to existing buildings 42 Reconstruction of the drains of existing buildings 98 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 1,778 visits to works under construction. Legal Proceedings.—Proceedings under the Public Health (London) Act, etc., were instituted by the Council in the following cases:— Defendant. Offence. Result. Penalty. Costs. £ s. d. £ s. d. Arthur Parrott, 43, Waterford Road Nuisance from overcrowding Convicted 0 5 0 — Reckitt & Sons, Ltd., Dansom Lane, Hull Furnace not effectually consuming smoke at Bluebell Polish Works, De Morgan Road Withdrawn — — John Bucknell, 55, Tynemouth Street, Fulham Negligent use of furnace at Bluebell Works Convicted 1 0 0 — Mrs. Helen Hubbard and Mrs. Helen Baker, 1, Sotheron Road, Fulham Application for ejectment warrants Warrants granted — — Albert James Frost, 3, Welford Terrace, Fulham Nuisance from overcrowding Withdrawn — — Mrs. Rayner, 12, St. Peter's Square, Hammersmith Failing to abate nuisance at 105, Chancellors Road Order within 21 days — 1 1 0 Mrs. Rayner, 12, St. Peter's Square, Hammersmith Failing to supply dustbin Convicted 0 10 0 — Frederick Rayner, 12, St. Peter's Square, Hammersmith Nuisance at 198, Munster Road Withdrawn, nuisance remedied — — Frederick Rayner, 12, St. Peter's Square, Hammersmith Vermin, 198, Munster Road Withdrawn, nuisance remedied — — James Harman, 35, Earl's Court Road, W. Nuisance, 2, Yeldham Road Withdrawn, nuisance remedied — — Frederick Mann, 42, Radipole Road, Fulham Failing to abate nuisance at 2, Pownall Road Withdrawn, nuisance remedied — — 81 Defendant. Offence. Result. Penalty. Costs. £ s. d. £ s. d. Frederick Mann, 42, Radipole Road, Fulham Failing to abate nuisance at 4, Pownall Road Withdrawn, nuisance remedied — — Edward Neal, 7, The Bungalows, Lampton, Hounslow Failing to abate nuisance at 154, New King's Road Order within 28 days — — Edward Neal, 7, The Bungalows, Lampton, Hounslow Drainage in bad order at 154, New King's Road Withdrawn, work done — — Mrs. R. G. Board, 260, Munster Road, Fulham Failing to abate nuisance at 15, Varna Road Withdrawn, nuisance remedied — — John Sedgwick, 351, London Road, Thornton Heath Repairing drain so as to be a nuisance at 42, Ewald Road Convicted . . 1 0 0 2 2 0 John Flood, 608, Fulham Road, S.W. 6 Nuisance—no water supply . Order within 7 days — 2 2 0 A. White, 94, Coomer Road, Fulham Failing to abate nuisance at 19 Mulgrave Road Order within 14 days — 1 1 0 Stephen Chapman, 5, Albert Mews, Fulham Failing to abate nuisance from overcrowding Order to abate within 3 months — 0 3 0 Rita Praeger, 16, Montpelier Road, Brighton Failing to abate nuisance at 51, Comeragh Road Order within 14 days — 0 6 0 Rita Praeger, 16, Montpelier Road, Brighton Failing to provide dustbin at 51, Comeragh Road Convicted 0 5 0 0 6 0 John Flood, 608, Fulham Road, S.W. 6 Failing to comply with Nuisance Order Convicted .. 3 0 0 1 1 0 James Harman, 35, Earl's Court Road, W. Failing to abate nuisance at 2, Yeldham Road Order to abate in 14 days — 0 6 0 Rat Destruction.—Poison was laid as follows by the Rat Officer during the year :— Private houses 226 Other premises 13 Sewers 445 £4 15s. was paid by property owners to the Council for the services of the Rat Officer in connection with the above work. Housing. Certificate of Water Supply.—One application was received during the year for a certificate of water supply, which was granted. 82 Rent and Mortgage Interest Restrictions Act, 1923.— 20 applications for certificates under the above Act that " the house is not in a reasonable state of repair " were received. Certificates were granted in three of these cases. Houses Let in Lodgings.—The proposed by-laws under Section 26 of the Housing, Town Planning, etc., Act, in respect of houses let in lodgings are still apparently in a state of suspended animation. These by-laws have been tossed hither and thither between the Borough Council, the County Council, and the Ministry of Health over a period of nearly three years, but so far nothing has materialised in legal form. The most recent information is that a conference is to be held between the Borough Councils and the County Council in respect to these by-laws, after which possibly they may reach maturity. They are undoubtedly badly required under present-day conditions of housing in Fulham. No action has been taken during the year 1924 under the old by-laws, as they are comparatively useless. House Repairs.—In my Annual Reports for 1922 and 1923 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. This policy has been adhered to during 1924. Despite the fact, however, 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. It should be borne in mind, 83 however, that the Public Health (London) Act only enables us to remedy such housing defects as can be clearly proved to the satisfaction of a magistrate, if necessary, as being nuisances. For that purpose Section 2 of the Public Health (London) Act, 1891, merely states that a nuisance is (1) "any premises in such a state as to be a nuisance or injurious or dangerous to health"; (2) any accumulation of deposit which is a nuisance or injurious or dangerous to health ; (3) any house or part of a house so over crowded as to be injurious or dangerous to the health of the inmates whether or not members of the same family ; (4) any such absence from premises of water fittings as is a nuisance by virtue of Section 33 of the Metropolis Management Act, 1871. The Metropolis Management Acts enable us to deal efficiently with drainage matters, and the London County Council (General Powers) Acts enable effective action to be taken in regard to vermin. There are, however, many other matters which render the house "not in all respects reasonably fit for human habitation" but which cannot legally be dealt with without the use of Section 28 of the Housing Act, 1919. The termination of the appointment of the temporary housing inspector in June, 1923, has resulted in a considerable reduction of the amount of house-to-house inspection. I am strongly of opinion that house-tohouse inspection should be pursued in Fulham with the greatest energy, but owing to the excessive and varied duties imposed upon district sanitary inspectors at the present time it is almost impossible for them to devote more than a very limited amount of time to house-to-house inspection. It is not merely the original inspections and the writing up of the records which occupy the time but the following up of any notices which may be issued as a result of the inspection. It would be of the greatest possible advantage to the Borough to have one or more special housing inspectors ; I would suggest at least two. There are many tenants whose premises are badly in need of repair but who are deterred, through fear of annoying their landlord, from making complaints to the Public 84 Health Department and it is only by house-to-house inspection that such cases can be discovered. Further, because a tenant is prepared to live under insanitary conditions rather than make a complaint that is no reason why the Council, as a public health authority, should allow him to do so. Much of the property in Fulham has got into a very unsatisfactory condition owing to the lack of repairs during the War, the ravages of age and of sub-let tenancies. Certainly, if and when the new Houses-Let-in-Lodgings by-laws come into force it will be necessary to appoint additional inspectors if the by-laws are to be efficiently administered. Closing Orders.—Seven Closing Orders were made during the year with respect to Nos. 1 and 3, Jerdan Place, and 4, 6, 10, 12 and 14, Vanston Place. These houses constituted a little group facing the old Walham Green. Those in Vanston Place were rather picturesque old-fashioned cottages built at the time when the surrounding land was open country. Year by year the property had deteriorated; it had been scheduled eventually by the District Surveyor as a dangerous structure and the Council, although regretting the action from many points of view, were reluctantly compelled to make Closing Orders and to evict the tenants in order that the District Surveyor might demolish the property. The greatest difficulty was found in finding accommodation for the evicted tenants. There were no fewer than 40 persons inhabiting these seven houses; 17 of them were eventually able to obtain alternative accommodation, but as a last resort the Council were compelled to purchase two empty houses in the Borough in order to house the remaining live families consisting of 23 persons. This clearance of a very bad block of insanitary property was most necessary, and although it aroused at the time a considerable amount of trouble and criticism on account of the eviction of the tenants, I cannot but feel that the Council were justified in their action and that the tenants are now much better off under their new conditions. 85 Housing Accommodation.—The Fulham Borough Council has at present no Housing Scheme. During 1924 the Housing Committee, which had previously ceased to function, was reconstituted. This Committee has been engaged for several months in examining possible sites which might be suitable for a Housing Scheme even on a small scale. So far their search lias proved unavailing and no suitable site has been acquired. It should be remembered that Fulham is already largely built up. There are extremely few pieces of open land left, and already this Borough bears upon it a number of persons per acre much in excess of that for London as a whole and probably as great as it should be asked to bear. In Fulham we have 93 persons per acre compared with an average of 60 persons for London. As I pointed out in my Report for last year, previous efforts to obtain part of the Hurlingham Polo Ground proved abortive. We must not, however, lose sight of the fact that a very large number of people in Fulham are living under grossly overcrowded conditions, not possibly so bad as many areas in the East End and other parts of London, but nevertheless quite sufficient to call for remedy. The figures which Dr. Sullivan has supplied in his report on tuberculosis, while by no means conclusive, certainly tend to show that the overcrowding in some parts of Fulham is getting worse. Fulham is a borough lying on the outskirts of the Metropolitan area and as persons get squeezed out of their houses in the more central parts of London owing to the increase of shops and businesses, so they tend to gravitate towards the periphery, of which Fulham forms a part. This being the case it makes one hesitate to some extent to put further houses on our already limited area. If such houses are erected will they, in effect, diminish the overcrowding in Fulham or will they merely provide accommodation for some overcrowded people in Fulham whose places will be immediately taken by people coming into Fulham from outside ? The housing problem in Fulham is only part of the greater problem in London as a whole and the London County Council are, to some extent, dealing with that. It appears to me, however, that many of the 86 houses being erected by the London County Council and the situations in which such houses are being placed make them quite beyond the reach of the poor overcrowded tenant who exists in Fulham. The housing problem in London cannot, I think, be dealt with merely by the building of comparatively betterclass properties in outlying neighbourhoods. This will undoubtedly to some extent relieve the position generally, but I doubt whether it will help us in Fulham very materially for many years. What is really required is the provision of working-class dwellings at a reasonable rental and within reasonable distance of the place where such people have to work. If the Castlenau site at Barnes or other accessible sites are developed on economical lines it might materially assist the condition of overcrowding in Fulham, always provided that such sites are used to accommodate persons from Fulham, Hammersmith and the adjoining boroughs and not those from the other end of London. HOUSING CONDITIONS. Year ending 31st December, 1924. Number of new houses erected during the year :— (a) Total 2 (b) With State assistance under the Housing Acts, 1919, 1923 or 1924 (i) By the Local Authority — (ii) By other bodies or persons 1. Unfit dwelling houses:— Inspection :— (1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 3,384 (2) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 206 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 7 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 2,369 87 2. Remedy of defects without service of formal notices:— Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their officers 124 3. Action under statutory powers:— A.—Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919:— (1) Number of dwelling houses in respect of which notices were served requiring repairs 1 (2) Number of dwelling houses which were rendered fit after service of formal notices:— (a) by owners 1 (b) by Local Authority in default of owners — (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close — B.—Proceedings under Public Health Acts :— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 296 (2) Number of dwelling houses in which defects were remedied after service of formal notices :— (a) by owners 256 (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 7 (2) Number of dwelling houses in respect of which Closing Orders were made 7 (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit — (4) Number of dwelling houses in respect of which demolition orders were made 7 (5) Number of dwelling houses demolished in pursuance of demolition orders 7 88 CONT ENTS. Page. Babies' Hospital 28 Bacteriological work 74 Bakehouses 71 Births (notification of) 26 Day Nursery 29 Death, causes of 12 Disinfection 75 Drainage of buildings 80 Factory and Workshops Acts 78 Food 63 Food preparing places 72 Food, unsound 72 Sanitary administration 74 Nursing 33 Housing 81 Infantile mortality 21 Infant Welfare Centres 27 Infectious diseases 36 Infectious disease among parturient women and infants 32 Introductory 5 Legal proceedings (Sanitary and Housing) 80 Legal 82 Maternity and Child Welfare 26 Maternity Home 30 Milk 69 Milk (Special Designations) Order, 1923 71 Milk, provision of free 71 Mortuary 77 Poor Law Relief 35 Proceedings under Food and Drugs Acts 74 Public Health (Tuberculosis) Regulations 61 Rat destruction 81 Samples purchased for analysis 73 Sanitary inspection of the district 77 Slaughterhouses 72 Staff—Public Health Department 4 Tuberculosis 43 . Tuberculosis dispensary 48 Vaccination 34 Venereal disease 40 Vital statistics 7