Ful-24 Metropolitan Borough of Fulham. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1925. A. MIDDLETON HEW AT, M.D., Ch.B., D.P.H. (Edin.), Medical Officer of Health. 3 Fulham Borough Council PUBLIC HEALTH COMMITTEE. Chairman : Councillor W. Wilcox. Vice-Chairman : Councillor W. Fowell. His Worship The Mayor (W. J. Waldron, Esq., J.P.) Ex-officio. Councillor J. W. Banfield, J.P. Councillor H. Dodimead. F. J. Bellenger. „ A. W. Driver. H. M. Bowden. „ A. W. Ford. Mrs. W. Brooks. „ C. Harwood. W. R. Corbin. „ G. L. Hodge. Mrs. H. L. Cummins. „ Miss H. A. Packer. Councillor G. Solley. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman: Councillor F. J. Bellenger. Vice-Chairman : Councillor Mrs. H. L. Cummins. His Worship The Mayor (W. J. Waldron', Esq., J.P.), Ex-officio. Councillor Mrs. W. Brooks. Councillor W. A. White. S. T. Cave. *Mrs. Corbin. Major C. R. Fryer, *Mrs. Pritchard. M.C. *Mrs. Van den Bergh. G. L. Hodge. *Miss Wickham. C. Lancaster. * 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.). Deputy Medical Officer of Health and Tuberculosis Officer:— * John Sullivan, M.B., Ch.B. (Edin.), D.P.H. (Lond.) A ssistant Medical Officers :— *Ruby Thomson, M.B., Ch.B., D.P.H. (Edin.). G. F. Hardy, M.C., M.R.C.S., L.R.C.P. Florence M. Wilson, M.B., Ch.B. (Glas.) (part-time). *Dorothy M. Stewart, B.Sc., M.B., B.S.(Lond.) (part-time). Public Analyst:— Cecil H. Cribb, B.Sc. (Lond.), F.I.C. (part-time). Clerical Staff:— A. T. Hurford, Chief Clerk. A. W. Gammack. F. E. Walsh. Miss B. Baron. Miss M. Wacksmith. B. Garrod, Senior Sanitary Inspector:— 1 *Charles Bristow Jones (Food and Drugs). Sanitary Inspectors:— 1*Frederick H. Manning. 12*Charles B. Lloyd. 13*Alfred J. Parsons. 1*Albert E. Clutterbuck. 12*Mark Canton. 1*Edgar Drake. 12 *Thomas H. Robey. 12 *John Castley. 1*Mrs. M. E. Davies. Health Visitors:— 16 6 *Miss M. L. Durnford. 4 6 6 *Mrs. J. Bryning. 456* Miss E. Beckett. 1 4 6*Miss A. Perrett. 456*Miss M. Green. 1,58*Miss W. K. Watts. Tuberculosis Dispensary Staff:— Nurses : 4*Miss H. M. Turner. 4*Miss J. Tinnion. 4 6 *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 : 4 6 *Miss M. Bustard. Superintendent of Disinfecting Station : 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. 1 Trained Nurse. 2 Food Inspector's Certificate. 6 Health Visitor's Certificate. * Registered Plumber. 6 Certificate of Central Midwives' Board. 5 Town Hall, Fulham, S.W. 6. April, 1926. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Fulham. Mr. Mayor, Ladies and Gentlemen, I have the honour to submit herewith the Annual Report on the health and sanitary condition of the Borough for the year 1925, this being my fourth and last Annual Report as your Medical Officer of Health. The year 1925 has not been marked by any noteworthy happenings so far as the health of the Borough is concerned. I would, however, draw attention to the following matters :— (1) The death-rate for 1925 was 10.7 per thousand, compared with 11.1 for the previous year. (2) The infantile mortality rate rose from 72 in 1924 to 76 this year. (3) We have to record the lowest birth-rate, 16.9, ever recorded in the Borough with the exception of the one war-year 1918, with a rate of 16.7. Recent years have seen a steady fall in the birth-rate. (4) The estimated population of 163,700 for 1925 is the largest number of persons ever estimated to live in the Borough. (5) The death-rate from cancer shows a small decline from 1.35 to 1.20 per thousand. (6) An additional health visitor was appointed during the year bringing the number of municipal health visitors up to six. 6 (7) The Voluntary Infant Welfare Centres were opened for two additional sessions per week and a new whole-time Assistant Superintendent was appointed in place of the former part-time Assistant Superintendent. Official circulars were issued during the year 1925 dealing with the following matters :— Food and Drugs :— 12.6.25 No. 604 Re Public Health (Meat) Regulations, 1924. —.8.25 No. 616 Tuberculosis Order of 1925 (No. 2)—Meat Inspection. 4.8.25 No. 755 Public Health (Preservatives in Food) Regulations, 1925. 11.8.25 No. 606 Ditto. Tuberculosis :— 7.8.25 No. 615 Public Health (Prevention of Tuberculosis) Regulations, 1925. —.9.25 No. 37/T Tuberculosis (England). Maternity and Child Welfare :— —.2.25 No. 101 Training of Health Visitors. M.C.W. 9.2.25 No. 557 Training of Health Visitors. Housing :— 29.6.25 No. 608 Re Housing Act, 1925. Housing Act, 1925. 1.9.25 No. 866 Housing Consolidated Regulations, 1925. Infectious Disease :— —.5.25 No. 103 Pemphigus Neonatorum. Med. According to the instructions of the Ministry of Health this report forms the first "survey" report under the new arrangements for annual reports. The Minister of Health suggests that in this " survey" report Medical Officers of Health should deal comprehensivelywith :— (a) The measure of progress made in the area during the preceding five years in the improvement of the public health. (b) The extent and character of the changes made during that period in the public health services of the area. 7 (c) Any further action of importance in the organisation or development of public health services contemplated by the Local Authority or considered desirable by the Medical Officer of Health. I have endeavoured so far as can be done with reasonable brevity to carry out these instructions. I am indebted to the Borough Surveyor, Mr. A. F. Holden, for that part of the report dealing with the removal and disposal of refuse, while Dr. J. Sullivan, the Tuberculosis Officer, is responsible for the section of the report dealing with the work of the Tuberculosis Dispensary. With the completion of this report I terminate my duties with the Fulham Borough Council. It is with feelings of real regret that I leave Fulham, and it is some satisfaction to know that in my new position under the London County Council I shall still be intimately in touch with the work which I have been carrying on in Fulham during the past four years. I should like to express my gratitude for the unfailing kindness and support which I have received from the members of the Council, particularly from the Chairmen of the Public Health and Maternity and Child Welfare Committees, with whom my work has been particularly associated. To my brother officers also I would desire to express my thanks for unvarying help and support ; particularly does this apply to the members of the staff of the Public Health Department. The voluntary workers associated with the Infant Welfare Centres, Babies' Hospital, Day Nursery and District Nursing Association have also done everything possible to make me look back upon my period of office in Fulham with feelings of gratitude and pleasure. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, A. MIDDLFTON HEWAT, Medical Officer of Health. 8 1.—General Statistics. Area (acres) 1,706 Population 163.700 No. of inhabited houses (1921 Census) 25,979 No. of families or separate occupiers (1921 Census) 40,436 Rateable value £995,140 Sum represented by penny rate £4,045 2.—Extracts from Vital Statistics of the Year. Births— Total. Males. Females. Legitimate Illegitimate 2,628 143 1,366 72 1,262 71 Birth-rate 16.9. Deaths 1,754 866 888 Death-rate 10.7. No. of Women dying in, or in consequence of, child-birth— From sepsis 4 „ other causes 7 Deaths of infants under one year of age per 1,000 births:— Legitimate 77 Illegitimate 56 Total 76 Deaths from— Measles (all ages) 2 Whooping cough (all ages) 35 Diarrhoea (under 2 years of age) 37 Population.—The Registrar-General has estimated the population of the Borough at the middle of 1925 to be 163,700. (Males, 75,791 ; females, 87,909). Marriages.—The number of marriages registered was 1,305, and the marriage rate, i.e., the number of persons married per 1,000 of the population was 7.9. In the two preceding years the marriages numbered 1,288 in 1924 and 1,284 in 1923, thus showing an increase of 17 for 1925. 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 2,771, of whom 1,438 were boys and 1,333 were girls. The 9 birth-rate was 16.9 per 1,000 inhabitants, being 1.3 per 1,000 below that of 1924. The birth-rate for the whole of London was 18-0 and for England and Wales 18.3. Illegitimacy.—The illegitimate births numbered 143 (72 males, 71 females), or 5.1 per cent., of the total births, against 4.4 in 1924 and 4.7 in 1923. Natural increase of the Population.—The natural increase of the population by excess of births over deaths was 1,017, against 1,147 in 1924 and 1,415 in 1923. Deaths.—During the year ended 31st December, 1925, 1,620 deaths were registered in the Borough. Of these, 209 were of persons not belonging to the borough, while 343 inhabitants of Fulham died outside the borough, chiefly in various public institutions. There were, therefore 1,754 deaths of persons— 866 males and 888 females—having their usual residence in Fulham, representing an annual rate of 10.7 per 1,000 of the estimated population, being 0.6 per 1,000 below that of 1924. The death-rate of males was 11.3, of females 10.1. Using the factor for correction for age and sex supplied by the Registrar-General, the corrected deathrate for the Borough works out at 10.4 per 1,000 population. The following comparative death-rates are of interest:— Death-rates, 1925— England and Wales 12.2 London 11.7 105 large towns (average) 12.2 Fulham 10.7 Zymotic deaths.—The mortality from zymotic diseases was higher than in 1924, 88 deaths being due to the seven principal epidemic diseases, against 82 in 1924. The zymotic death-rate was 0.53 per 1,000 population, as compared with 0.50 for 1924. 10 Seasonal mortality.—The mortality in the four quarters of the year was as follows :— Deaths. Death-rate. First Quarter 503 12.3 Second Quarter 407 9.9 Third Quarter 298 7.3 Fourth Quarter 546 13.3 It is interesting to note that whereas during the year under review the worst seasonal mortality took place during the fourth quarter, in the preceding year the worst mortality was in the first quarter when the death-rate was 11.1. The difference is due to the fact that whereas in 1924 the high rate of the first quarter was influenced by a measles epidemic, there was no measles epidemic in that quarter of 1925, and moreover, during the fourth quarter of 1925 the high death-rate was influenced by several periods of extremely cold weather causing many deaths from bronchitis and pneumonia, especially among the aged. 11 Table I.—Vital Statistics of Whole District during 1925 and ten previous years. Year. Population Estimated to Middle of each Year. Births. Total Deaths Registered in the District. Transferable deaths.f 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. Rate per Number. 1,000 * Nett Births. Number, * Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1915 a153,161 3,736 3,870 c24.3 1,787 11.7 130 677 446 115 2,334 15.2 1916 al49,428 b162,580 3,600 3,754 c23.1 1,324 8.9 131 789 330 88 1,982 13.3 1917 a 145,186 2,852 2,971 cl8.4 1,251 8.6 139 882 323 109 1,994 13.7 b161,841 1918 al43,211 2,593 2,672 cl6.7 1,704 11.9 186 973 286 107 2,491 17.4 b160,463 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 a158,621 4,383 4,327 c27.2 1,888 11.9 457 396 320 74 1,827 11.5 b158,989 1921 159,400 3,546 3,528 22.1 1,865 11.7 381 382 291 83 1,866 11.7 1922 159,500 3,210 3,242 20.3 1,897 11.9 362 400 224 69 1,935 12.1 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 1925 163,700 2,780 2,771 16.9 1,620 9.9 209 343 211 76 1,754 10.7 (a) n,stimateci 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 Soldier a 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 (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 casts 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. 12 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 1,754 deaths registered, 1,605, or 91 -5 per cent., were certified by registered medical practitioners, 148 by coroners after inquest, and one death being uncertified. Deaths in Public Institutions. Fulham Hospital (formerly known as Fulham Infirmary).—The deaths of 665 persons occurred in the Fulham Hospital, of whom 569 lived in Fulham and 96 in other districts. Western Fever Hospital.—In this institution there were 17 deaths of residents in Fulham and 85 deaths of residents in other districts. Deaths occurring outside the Borough among Persons belonging thereto.— The deaths of Fulham residents outside the borough number 343, and occurred in the following places :— Deaths occurring outside the Borough among Persons belonging thereto.—-The deaths of Fulham residents outside the borough number 343, and occurred in the following places:— St. George's Hospital 49 West London Hospital 26 Other General Hospitals 76 Children's Hospitals 23 Hospitals for Women 10 Other Special Hospitals 25 Homes for advanced cases 14 Hospitals of Metropolitan Asylums Board 7 Poor Law Infirmaries 12 Mental Hospitals 48 Sanatoria 10 Nursing Homes, private houses and elsewhere 43 343 Of the deaths registered, 886 or 50-5 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 :— 13  Per cent. Deaths in Workhouses or Workhouse Infirmaries 33.3 Metropolitan Asylums Board Hospitals 1.2 Mental Hospitals 2.7 other Hospitals 13.3 50.5 Causes of Death.—The causes of deaths occurring in the Borough during 1925 will be found in Table II, page 15. From this it will be seen that the principal causes of death were heart disease (259 deaths) ; cancer (198 deaths) ; pneumonia (175 deaths) ; tuberculosis (173 deaths) ; bronchitis (135 deaths). It will be noticed that cancer still causes a heavy deathrate, although there is a decrease of 23 deaths as compared with the previous year. Pneumonia also shows a decrease of 14 and bronchitis a decrease of 21 as compared with the year 1924. Tuberculosis, however, unfortunately shows a slight increase of 11 deaths. Infantile Mortality.-—Of 1,754 deaths during 1925, 211, or 12-0 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 the registered births was 76 per thousand, being 4 per thousand above that for 1924. Particulars of the infantile mortality rate during previous years will be found in Table I, column 2, page 11. It would appear from the figures for the last five years that our infantile mortality rate is becoming stabilised at round about 70 per thousand births. This is by no means a satisfactory figure for a Borough like Fulham. The efforts and means taken to deal with the infantile mortality in the Borough remained the same during the past five years until towards the middle of 1925, when an additional Health Visitor was appointed, two additional clinics were opened and the part-time services of the Assistant Superintendent at the Voluntary Infant Welfare Centres were replaced by a whole-time officer. It is hoped that these improvements may show themselves during the next year or two in some decline in the infantile mortality rate. The infantile mortality 14 rate for London as a whole for 1925 was 67 and for England and Wales as a whole 75. It is unsatisfac tory to note that whereas for the last two years our rate has been exactly 3 per thousand above that for London as a whole this year it is 7 per thousand above the average for London. If, however, we take the rate for the 105 County Boroughs and Great Towns in England we find their average rate is 79 per thousand, 3 per thousand above that for Fulham. The figure for Fulham does not, however, compare favourably with the other Metropolitan Boroughs; in fact out of the 29 Metropolitan Boroughs, including the City of London, Fulham stands 24th. The only Boroughs with larger infantile mortality rates being Southwark 77, Bermondsey 78, Kensington 78, Bethnal Green 80 and Shoreditch 88. Everything possible must be done to improve this state of affairs. When one sees working-class Boroughs such as I.ewisham and Woolwich with rates of 55 each it is a clear indication that further work is necessary in Fulham. All our measures must be pushed on with the greatest energy. The causes of deaths of infants during 1925 are set out in Table III, and classified according to ward and age. Again the largest cause of death is premature birth. During 1925, 46 deaths were ascribed to this cause as compared with 50 during 1924. One is encouraged to hope that a considerable amount of this mortality from premature birth may be prevented when we are able to get a larger proportion of our mothers to attend the Ante-Natal Clinics or their medical attendant more regularly during the antenatal period. The other principal causes of infantile mortality during the year were pneumonia 33 deaths as compared with 43 during 1924 ; diarrhoea and enteritis 36 as compared with 18 during 1924 ; whooping cough 18 as compared with 4 during 1924 ; bronchitis 12 deaths as compared with 11 during 1924; atrophy and debility, however, has fallen from 12 in 1924 to 9 in 1925. 15 16 TABLE II. Causes of and Ages at Death during the Year 1925. Nett deaths at the subjoined ages of "Residents," whether occurring within or without the District (a). Nett deaths at all ages of " Residents " in the Wards of the Borough, whether occurring in or beyond the Wards. Causes of Death, 1 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. Total Deaths, whether of "Residents" or " Nonresidents " in Institutions in the District (b). Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. 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) 1,753 210 54 17 10 8 18 66 128 136 430 676 741 176 267 185 196 382 99 266 182 Uncertified 1 1 — — — — — — — — — — — — — — — — — 1 1. Enteric Fever — — — — — — — — — — — 2 — — — — — — — 2. Smallpox — — — — — — — — — — — — — — — — — — — — 3. Measles 2 1 — 1 _ — — — 10 — — — 2 — — — — 4. Scarlet Fever 3 — — — 1 2 — — — — 5 — — 1 — — 2 — 5. Whooping Cough 35 18 10 4 2 1 — — — — — 26 2 4 5 3 10 1 5 5 6. Diphtheria 11 2 1 2 3 1 2 48 1 2 1 2 2 2 1 7. Influenza 44 1 4 1 2 2 3 9 22 4 6 7 6 13 2 3 7 8. Encephalitis Lethargica 4 — - 1 1 2 2 1 — — 1 2 — 9. Meningococcal Meningitis 3 1 1 1 3 — 2 — 10. Tuberculosis of Respiratory System 151 1 — - — 20 59 28 33 10 57 7 25 18 14 37 7 29 14 11. Disseminated I uberculosis 6 2 1 1 — — — 1 1 2 1 1 1 1 1 1 12. Other Tuberculous Diseases 16 3 4 — — — 2 3 1 2 1 6 3 3 3 3 3 1 13. Cancer, malignant disease 198 1 1 — 3 3 14 86 90 70 27 22 14 20 51 12 29 23 14. Rheumatic Fever 2 — — — — 2 3 1 1 15. Diabetes 23 — — — 2 2 — 7 12 7 1 4 2 1 5 1 3 6 16. Cerebral Haemorrhage, etc 68 1 — 1 4 19 43 30 10 10 7 8 13 3 8 9 17. Heart Disease 259 3 1 2 7 11 15 81 139 71 26 39 34 31 42 18 46 23 18. Arterio-sclerosis 70 - — — - — 9 61 48 11 13 7 5 9 5 10 10 19. Bronchitis 135 12 3 2 6 27 85 40 10 29 12 18 27 6 20 13 20. Pneumonia (all forms) 175 34 22 3 2 1 1 4 10 13 46 39 63 16 35 23 19 35 13 14 20 21. Other Respiratory Diseases 11 1 — 1 — - — — 1 2 2 4 3 1 2 — 2 1 1 2 2 22. Ulcer of Stomach or Duodenum 9 — — — — - — — — 3 4 2 3 1 1 1 2 2 2 23. Diarrhoea, etc. (under 2 years) 37 35 1 1 — — — — — — 26 2 5 10 4 7 4 4 1 24. Appendicitis and Typhlitis 12 — — — — — 1 1 6 — 3 1 8 — 4 — 1 3 — 2 2 25. Cirrhosis of Liver 11 — — — — — — 1 3 7 2 — 1 1 1 2 — 1 5 26. Nephritis and Bright's Disease 48 1 1 3 3 3 18 19 27 5 11 5 4 14 2 5 2 27. Puerperal Sepsis 4 — — — — - — — 1 2 1 4 — 1 1 — — 2 28. Other accidents and diseases of pregnancy and parturition 7 — — — — — — 2 3 2 — — 6 1 1 3 1 — — 1 29. Congenital Debility and malformation, premature birth 69 69 — — — — — — — —— — — 23 5 11 9 11 17 2 8 6 30. Suicide 11 — o 3 4 2 1 3 2 2 1 2 1 31. Other deaths from violence 61 5 3 3 — 2 3 8 6 7 13 11 36 7 3 3 3 19 4 19 3 32. Other defined diseases 268 23 3 1 2 4 6 14 27 54 134 105 32 35 28 30 63 14 43 23 33. Causes ill-defined or unknown 1 — — — — — — " 1 — — — — 1 Total 1,754 211 54 17 10 8 18 66 128 136 430 676 741 176 267 185 196 382 99 266 183 [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, (6) All deaths occurring in institutions for the sick and infirm situated within the district, whether of residents or of non-residents, are entered in column 14 of Table II. (c) All deaths certified by registered Medical Practitioners and all Inquest cases are classed as " Certified " J all other deaths are regarded as " Uncertified." 17 18 TABLE III. Infant Mortality during Year 1925. Nett Deaths from slated causes at various Ages under One Year of Age. Nett Deaths under One Year of Residents in the Wards of the Borough, whether occurring in or beyond the Wards. Cause of Death. Under 1 week. 1-2 weeks. 2-8 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under S months. 8 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths ijnl.n. One Yeab. Baron's Court Wand. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. H\irlingham Ward. Sands End Ward. Town Ward. All Causes Certified 44 14 7 8 74 35 39 31 32 210 13 39 29 30 41 e 28 22 Uncertified 1 — — — — — — — 1 — — 1 1. Smallpox — — — — — — —— — — —— — — — — — — — — 2. Chicken-pox — _ — — — __ — — — — — — — —— 3. Measles — — — — — — — —— — — — — — — — — 4. Scarlet Fever 5. Whooping Cough — — — 1 1 4 4 4 5 18 2 4 3 1 3 1 2 2 6. Diphtheria and Croup — — — — — 1 — — 1 2 — — 1 — 1 — —- — 7. Krysipelas — — — — — — 1 — 1 — — — — 1 — — —* 8. Tuberculous Meningitis — — — — — — _ 2 — 2 — — 1 1 — — — — 9. Abdominal Tuberculosis (a) 10. Disseminated Tuberculosis — — — — — — 1 2 — 3 — 1 — 1 i — 11 Other 1 uberculous Diseases —— — —- — — —— 1 — 1 —— 1 — ■—* — 12. Meningitis (not Tuberculous) — — — — — — — — — — — — — — — — — — 13. Convulsions 2 2 — — 4 — — 1 1 6 1 — — 2 — 2 — 14. Laryngitis — — — — — — — — — — — — — — — — — —■* 15. Bronchitis — 2 — — 2 4 1 2 3 12 1 4 — — 1 4 2 16. Pneumonia (all forms) — 1 — 1 2 3 8 7 13 33 1 8 5 4 5 3 2 5 17. Influenza — — — — — — — 1 — 1 — — — 1 — — — — 18. Diarrhoea — — — — — 2 7 3 2 14 1 3 3 1 3 1 2 — 19. Enteritis — 1 1 — 2 5 9 5 1 22 1 4 7 2 1 2 2 3 20. Gastritis — — — — — — — — — — — — — — — — — — 21. Syphilis — — — — — — 1 — — 1 — — — 1 — — — — 22. Rickets — — —— —— — — —— — — — — — — — — 23. Suffocation, overlaying 1 — — — 1 — 2 — — 3 — — — — 3 — — — 24. Injury by Birth 1 1 — — 2 — — — — 2 — — — 1 1 — — — 25. Atelectasis 5 — — 1 6 1 — — — 7 — 3 — 1 1 — — 2 26. Congenital Malformations 3 — — 1 4 1 — 2 1 8 — 2 — 2 4 — — — 27. Premature Birth 28 3 3 3 37 7 2 — — 46 5 3 9 6 10 1 7 5 28. Atrophy, Debility and Marasmus 1 2 1 1 5 3 1 — — 9 — 4 — 2 1 1 — 1 29. Other causes 4 2 2 — 8 4 2 1 c 2 a 2 — 5 5 — 6 1 Total 45 14 7 8 74 35 39 31 32 211 13 39 29 30 41 9 28 22 Nett Births in the Year— Legitimate 2,628 (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. Illegitimate .. .. .. 143 .. .. .. 203 Illegitimate infants .. .. 8 19 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 1925 76 I give below a table showing the infantile mortality rates for the last two years (1924 and 1925) for the various wards in the Borough:— Ward. Births and birth rates. Infantile deaths. Infantile mortality rate. 1924. 1925. 1924. 1925. 1924. 1925. Baron's Court 151 (11.4) 136 (10.1) 17 13 112 95 Lillie 342 (13.3) 309 (11.9) 39 39 114 126 Walham 296 (23.1) 262 (19.9) 33 29 111 110 Margravine 504 (26.1) 507 (25.9) 25 30 50 59 Munster 643 (16.6) 633 (16.1) 34 41 53 64 Hurlingham 105 (10.8) 86 ( 8.7) 9 9 85 104 Sands End 528 (19.1) 459 (16.4) 41 28 77 61 Town 398 (27.2) 379 (25.5) 16 22 40 58 The Borough 2,967 (18.1) 2,771 (16.9) 214 211 72 76 The most notable change is that whereas in 1924 the highest infantile mortality rate was found in Baron's 20 Court Ward this has now been improved and Baron's Court Ward for 1925 is fourth highest, Lillie Ward being the worst, followed by Walham Ward and Hurlingham Ward. Again, as in previous years, Town Ward has the lowest infantile mortality rate. Deaths of Illegitimate Children.—Of the 211 infants who died before attaining the age of one year, 8 were illegitimate, the mortality amongst them being in the proportion of 56 per thousand births against 77 per thousand amongst children born in wedlock. This is a most unusual state of affairs, as the illegitimate infantile mortality rate is usually considerably higher than the legitimate, but during the last three years in Fulham there has been a steady fall in the illegitimate infantile mortality rate ; in 1923 it was 155 per thousand, in 1924, 106 per thousand, and now in 1925, 56. Possibly this is due to the fact that the Health Visitors always pay very particular attention to illegitimate babies, but there would appear to be some other factor at work, possibly a moral one, of which I am unaware. Maternity and Child Welfare. It would be well to take the opportunity in this survey report to give in some detail the arrangements in force in the Borough in connection with the various branches of the Council's Maternity and Child Welfare Scheme. This scheme is the result of the gradual growth of various elements and the greater part of it came into operation during the period of office of my predecessor, Dr. Jackson. Certain alterations and additions have been made during the past five years, but the bulk of the work stands as he left it. In dealing with each individual institution, I shall therefore give a short account of its development. Notification of Births.—The notification of births first came into force in the year 1908, subsequent to the passing of the Notification of Births Act, 1907. This act has for its object the giving of early notification to the Medical Officer of Health as to all births, thus enabling the houses to be visited by the Health Visitors and advice given to the mothers where necessary. 21 Undoubtedly much of the success of Infant Welfare Schemes during recent years has hinged upon this Act Notifications of the births of 2,559 living children and 61 stillborn children were received during the year under this Act, 92-31 per cent, of births registered being notified. Of these 2,057, or 78-51 percent., were notified by midwives, 421 by doctors, and 142 by the parents or other persons present at the birth. Visitation of Mothers and Babies.—As pointed out above, the visitation of mothers and babies forms a most important item in any well organised Infant Welfare Scheme. As a general rule all births are visited on the 11th day and thereafter monthly up to and including the 4th month. From that period every other month until the 12th month. Thereafter, every six months up to two years of age and yearly up to five years of age. This is a routine instruction to Health Visitors, but of course it is varied according to the necessities of each case, many cases being visited much more than monthly during the early weeks of life. During these visits the Health Visitors give instructions to the mothers as to the nursing, feeding and general hygienic care of the children. Parents are also advised to attend the Infant Welfare Centres as regularly as possible in order that the children may be regularly weighed and that the mother may receive the benefit of the free medical advice which is there provided. The number of Health Visitors employed by the Borough Council is now six. During the past five years there were five, an additional Health Visitor was appointed during 1925. This addition has materially increased the efficiency of the work. During the year the visits paid by the Health Visitors were as follows :— First visits to infants 2,729 Re-visits to infants 9,530 Re-visits to children aged 1 to 5 years old 7,875 Visits to cases of ophthalmia neonatorum 32 „ „ measles 644 „ „ pneumonia 66 „ „ diarrhoea 64 „ „ puerperal fever 20 Other visits 349 22 Infant Welfare Centres.—The Infant Welfare Centres in Fulham are carried on by a Voluntary Committee. This Committee has done excellent work for many years, and prior to 1919 it carried on purely on a voluntary basis and without any close co-operation with the other elements in the Infant Welfare Scheme. In 1919, however, the Borough Council adopted a scheme of co-ordination of all the Maternity and Child Welfare work of the Borough, and since that time the Infant Welfare Centres have continued to be managed by the Voluntary Committee and their work has been closely linked up with the other parts of the scheme. In connection with the present agreement between the Council and the Voluntary Committee the following are some of the more important conditions:— 1. The Council pay to the Voluntary Committee the sum of £500 per annum, one half of which is repaid to the Council by the Ministry of Health. 2. The Council provides the necessary medical staff for the centres ; this is done partly by the whole-time Assistant Medical Officers of the Council and partly by part-time Medical Officers. The Council arranges for their Health Visitors to attend the centres as and when required. 3. The Voluntary Committee provides the requisite staff for the conduct of the centres other than the medical staff and the Health Visitors. In practice this has meant the provision of a lady superintendent, an assistant superintendent and caretakers. 4. The Council is represented by three persons on the Voluntary Committee. 5. The centres must be maintained and conducted to the satisfaction in all respects of the Council and their Medical Officer of Health, who shall be considered as Medical Superintendent of the Centres. 23 6. The expenditure of the Voluntary Committee must not be increased by any extendedactivities without the previous consent of the Borough Council. At the present time the Medical Officers concerned in this work are Dr. Ruby Thomson, Dr. G. Frank Hardy, Dr. Florence Wilson and Dr. Dorothy Stewart. The last-named was added to the staff during the current year, owing to the extension of the work. Three centres are in operation, viz., 92, Greyhound Road; 170, Wandsworth Bridge Road ; and Melmoth Hall, Eustace Road. These divide the Borough into three districts, with a centre within reasonable distance to the mothers residing in each district. During 1925, the work of the centres was increased at the suggestion of the Ministry of Health, an additional ante-natal clinic was provided at 170, Wandsworth Bridge Road, and an additional infant clinic at the same centre. This necessitated the appointment of a wholetime assistant superintendent of the centres in place of the previous part-time assistant. The consultations held at these centres are divided into two classes (1) ante-natal and (2) post-natal. There are now three ante-natal clinics held each week and eight post-natal clinics. It will be seen from the figures given below that many of the clinics even now are having larger attendances than can be efficiently dealt with. I give below particulars of the attendances at these clinics during the year :— Infant Welfare Clinics. Number of consultations. First attendances of babies. Total attendances. Average attendances. 92, Greyhound Road 139 490 6,1 58 44 170, Wandsworth Bridge Rd. 126 341 4,285 34 Melmoth Hall, Eustace Road 97 279 4,024 41 24 In connection with these clinics the following are particulars of children who attended for special treatment :— At 92, Greyhound Road. Number of children who attended for massage or treatment of minor ailments 216 Number of attendances 1,025 At The School Treatment Centre, 18, Bagleys Lane. For operative treatment for enlarged tonsils and adenoids—Number of children 17 For dental treatment (Number of children) 13 For dental treatment (Number of women) 85 Total attendances of women for dental treatment 242 Of these 85 women, 21 were provided with dentures. For visual defects— Number of mothers treated 25 Ante-Natal Clinics. At 92 Grkyhound Road. Number of women who attended 354 Number of attendances 1,273 At 170, Wandsworth Bridge Road. Number of women who attended 66 Number of attendances 217 Number of ante-natal visits to homes 914 Fulham Babies' Hospital, Broomhouse Road.—This hospital is conducted by a Voluntary Committee and receives a grant of £700 per annum from the Council, one half of this sum is repaid to the Borough Council by the Ministry of Health. It contains 21 beds, 14 of which are reserved solely for the use of Fulham residents by agreement between the Hospital Committee and the Borough Council. The Medical Officer of Health is Medical Superintendent of the Hospital and the clinical work is in charge of Dr. G. Frank Hardy, one of the Assistant Medical Officers of Health. The primary function of the hospital is the treatment of nutritional and dietic disorders in 25 infants, but in addition a considerable number of acute medical cases are taken such as Pneumonia and Enteritis. During the past year, the Battersea Borough Council have availed themselves of the opportunity of using some of the beds not especially earmarked for Fulham children. A charge is made by the Committee to the Battersea Borough Council of £1 per week per case. The following is a summmary of the work of the hospital during 1925 :— In hospital, January 1st, 1925 20 Number of babies admitted during the year 148 Average duration of stay (days) 35-9 Number of cases discharged : (a) In good health 67 (b) Improvement 33 (c) No improvement 18 (d) On account of the development of tious disease 14 Viz.— Scarlet Fever 3 Pertussis 4 German Measles 2 Diphtheria - 3 Epidemic Diarrhoea 2 Number of deaths 19 Number in hospital, 31st December, 1925 17 The average daily number in the wards during the year was approximately 15-5 as compared with 16 during 1924 and 14 in 1923. The hospital was closed from 17th March to 20th April for re-decoration. Fulham Day Nursery, Eridge House, Fulham Park Road.-—This day Nursery is conducted by a Voluntary Committee of which your Medical Officer of Health is Chairman. This Committee receives a grant of £300 per annum from the Borough Council, one half of which is repaid to the Council by the Ministrv of Health. 26 The object of the Day Nursery is to take charge during the day, of the children of mothers, who, for some economic reason are compelled to go out to work. The medical supervision of the Nursery is in charge of Dr. Ruby Thomson, Assistant Medical Officer of Health. It is satisfactory that during the year under review the attendances at the Day Nursery have shown an increase over those for 1624, although they have not yet reached the figures for 1923. The total whole day attendances were, in 1923, 6,579; in 1924, 4,967 ; and in 1925, 5,092. The half-day attendances were, for 1923, 1,333 ; for 1924, 1,338 ; and for 1925, 1,434. Ihe Nursery was closed from August 17th to Sept. 7th owing to an outbreak of German Measles. The attendances during the year were as follows :— Individual children attended— Under three years of age 76 Over three years and under five 22 The total attendances made by the above children were :— Under three years— Whole day 3,875 Half day 1,112 Over three years— Whole day 1,217 Half day 322 T otal— Whole day 5,092 Half day 1,434 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. Emergency cases are also dealt with by Dr. V. D. C. Wakeford. As this is a survey report and as the Maternity Home had at the end of 1925 been open almost exactly five years, it may be interesting to consider briefly the history of these years. 27 The home was opened in January, 1920, with seven beds. The number of admissions have been as follows : First Year (1920) 137 Second Year (1920) 163 Third Year (1922) 169 In 1923 the Home was enlarged. An annexe was built in the garden, providing three bedrooms and a bathroom for the staff and thus enabling an additional ward to be opened in the Home itself. The accommodation was thus increased to ten beds. Since then the admissions have been as follows :— Fourth Year (1923) 189 Fifth Year (1924) 176 Sixth Year (1925) 203 The Home has been extremely fortunate in that it has enjoyed the services of the same medical officer and the same matron since it was opened .This undoubtedly has led to a feeling of confidence amongst the mothers, and this is fully borne out by the number of women who have been in the Home on more than one occasion and by the recommendations which are given by one patient to another. All candidates for the Maternity Home are required to attend regularly at the ante-natal clinic and only the apparently normal cases are admitted to the Home. Abnormalities and cases likely to require special medical attention are as a rule referred to Queen Charlotte's Hospital or one of the other large London hospitals, where there is a resident physician. The primary object of the Home is to provide for the confinements of persons living under unsatisfactory home conditions where it is impossible to conduct the confinement with safety or even decency. In 1921 the Home was recognised by the Central Midwives Board as a training school for midwives, and all pupils have been successful, up to date, in obtaining the C.M.B. certificate ; there has never been a failure. 28 The staff consists of four midwives, all of whom are also fully trained nurses, and one pupil midwife, who is always a general-trained nurse. The domestic staff includes three whole-time maids and one daily woman. 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 power to reduce these fees. Additional charges are of course made where the income of the patient warrants them. During the year 1925 the average fee paid by patients was £4 7s. 10d., for the fortnight. The admissions during 1925 were the highest ever recorded since the Home has been open. The following is a record of cases admitted to the Home during the year 1925:— Cases admitted 203 Average duration of stay (days) 14 Number of cases delivered by— (a) Midwives 198 (b) Doctors 5 Number of cases notified as puerperal sepsis - Number of cases in which the temperature was above 100.4 for 24 hours 1 Number of cases notified as ophthalmia torum 3 Number of cases of inflammation of eyes, however slight 2 Number of infants not entirely breast-fed while in the institution - Number of maternal deaths - Number of foetal deaths (stillborn or within ten days of birth) 1 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. 29 During the year grants of milk were made to expectant mothers and to children under 5 years of age, in 225 cases. The amount exDended was:— £ s. d. For dried milk 62 5 8 For fresh milk 18 4 7 £80 10 3 This compares with the sum of £131 5s. 7d. in 1924, £169 10s. 9d. in 1923, £337 18s. Id. in 1922, £1,041 15s. in 1921, and £1,169 14s. in 1920. The usual careful enquiries have been made into the financial circumstances of each applicant for free or reduced price milk, and the Maternity and Child Welfare Committee have been much helped in these enquiries by the Charity Organisation Society. In addition to the milk given free or at reduced price, 10,229 lbs. of dried milk, value £940 18s. lid., were sold at cost price to persons recommended by the Health Visitors or the Infant Welfare Centres. In 1924 the amount of dried milk distributed was 13,481 lbs., value £1,028 ; while in 1923 the amount was 15,079 lbs., value £1,339 2s. 4d. Incidence of Infectious Disease amongst Parturient Women and Infants. Puerperal Fever.—21 cases, equal to 7.5 per 1,000 births, were notified during 1925, compared with 26 cases for the previous year and 32 for 1923. There were four deaths from this disease, this being the same number as during 1924. Every case was removed to hospital. Although the number of cases of this disease notified in the Borough is still high, certainly higher than it ought to be, it is some consolation to know that the number of cases for 1925 is the lowest recorded during the five-year period covered by this survey report. It is further satisfactory that for the last two years there have been only four deaths each year from this complication of child birth. These figures compare with nine deaths for 1923, eight deaths for 1922 and six deaths for 1921. Included in the number of notifications of puerperal fever are 10 cases 30 which have followed upon miscarriages, many 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. If we deduct those cases of puerperal fever which occurred subsequent to miscarriages the incidence rate of this disease in Fulham would be reduced from 7.5 per 1,000 births to 3.9 per 1,000 births. The corresponding figure for 1924 was 6.7 and for 1923, 6.0. The Committee will remember that in the year 1922, arrangements were made with the Fulham Board of Guardians whereby medical practitioners could send to the Fulham Hospital suspicious cases of puerperal fever without waiting for the diagnosis to be absolutely certain. This enables such cases to be brought under effective treatment at the earliest possible moment, thus giving the patient the best chance of recovery. It is a recognised fact that the earlier such cases are thoroughly treated, which in many instances is impossible in working-class houses, the better the outlook for the patient. One hopes that this arrangement may have had something to do with the fall in the mortality rate from this disease during the last two years. Ophthalmia Neonatorum.—Thirty-two infants were notified as suffering from ophthalmia neonatorum, of whom 16 were removed to hospital. This total compares with 27 notifications during 1924 and 22 during 1923. 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. 32 16 16 nil. 25 nil. 1 6 31 It is most satisfactory that of these cases none became totally blind or had the vision impaired so far as we were able to discover. One child, however, died and six left the district. Measles.—Of the total of 589 cases of measles notified during 1925, 246 occurred in children under the age of five years. Diarrhoea.—70 cases of infantile diarrhoea were notified during 1925 as compared with 40 cases during 1924 and 79 during 1923. The marked fall during 1924 was probably due to the absence of hot summer weather during that year, whereas during 1925 we had at least two periods of considerable heat. Epidemic diarrhoea (zymotic enteritis) is notifiable in this Borough, if occurring in children under the age of five years, 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. Epidemic diarrhoea is now admitted to the hospitals of the Metropolitan Asylums Board on the certificate of the Medical Officer of Health of the Borough. Cases are also admitted to the Fulham Hospital. Special attention is drawn to a report on the subject of infantile diarrhoea which appears on page 38. Home Nursing.—-Arrangements are in operation in the Borough whereby home nursing is provided for :— (a) Cases of infectious disease, particularly fluenza and pneumonia, in persons over five years of age. (b) For any cases of serious illness in children under five and occasionally for pregnant and nursing mothers. This nursing is only available for persons who are in such a financial position as to be unable to pay for the services of a private nurse. The arrangements are made by the Public Health Committee and the Maternity and Child Welfare Committee with the Borough of Fulham District Nursing Association, which is affiliated to Queen Victoria's Jubilee Institute. 32 The fee paid by the Council is Is. for each visit and during the year these fees amounted to £78 payable by the Public Health Committee and £50 13s. payable by the Maternity and Child Welfare Committee. Half of this latter sum is repaid to the Borough Council by the Ministry of Health. The number of visits paid during they ear was as follows :— To persons over 5 years of age 921 To persons under 5 years of age 1,652 The work carried out by these District Nurses is most valuable and the Borough Council were extremely fortunate in being able to come to a satisfactory arrangement with the Association. 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. 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 192S, 1,811 successful primary vaccinations were carried out, compared with 2,042 during the year 1924, and 2,789 during 1923. I give in the following table fuller details of the vaccinations carried out during the year ended 31st December, 1924, but similar detailed figures are not yet available for 1925 :— Number of births registered from 1st January, 1924 to 31st December, 1924 2,979 Successfully vaccinated 1,819 Insusceptible of vaccination 2 Dead—unvaccinated 150 Postponed by medical certificate 71 Certificates granted under clause 2 of the Vaccination Act, 1898 655 Removed to districts in which Vaccination Officer has been notified 72 Removed to places unknown 175 Outstanding 35 33 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 1925 is less by eight than in 1924 and that the number for 1924 was 747 less than for 1923 in which year two cases of smallpox were notified. 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. Date. (Half-year ending) (1) Number receiving lief. Indoor and door, but excluding Lunatics and figures in column 2. (2) Persons in receipt of outdoor medical lief 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 |uly, 1919 1,376 43 1st Jan., 1920 1,430 46 1st July, 1920 1,426 44 1st |an, 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 | uly, 1924 2,328 63 1st Jan, 1925 2,366 51 1st July, 1925 2,705 68 1st Jan, 1926 3,489 69 34 Infectious Diseases. The total number of cases of infectious diseases notified during the year was 2,199, compared with 3,258 for the year 1924, 3,608 for the year 1923 and 4,388 for the year 1922. Towards this total of 2,199 measles contributed 589. It will be noticed that there is a very considerable drop in the number of notifications as compared with the three previous years, the drop as compared with the year 1924 being over 1,000 cases. This is accounted for almost entirely by measles, the notifications of which fell from 1,692 in 1924 to 589 in 1925. The gains and losses in the other diseases as compared with the year 1924 are almost negligible, the figures for the two years being approximately the same. There are perhaps two exceptions which might be noted. In the. first place it is satisfactory that the notifications of encephalitis lethargica fell from 21 in 1924 to 10 in 1925. This fall of 50 per cent, is the more welcome in this disease as it is one of extreme gravity, having a case mortality of round about 40 to 50 per cent. The other disease to which attention should be drawn is epidemic diarrhoea which has produced 70 notifications during 1925, compared with 40 during 1924. This was accounted for very largely by an outbreak in the early months of the year, a somewhat unusual occurrence and one which I deal with later in this report in detail. It should, however, be stated that although the figure for epidemic diarrhoea for this year is 70 compared with 40 for the previous year, the figure for 1923 was 79. Full particulars of all notifiable infectious diseases arranged according to disease, ward and age will be found in Table IV, page 41. In connection with Diphtheria and Scarlet Fever, I have had special note made during the year as to 35 whether the diagnoses as notified were confirmed in the hospital to which the patients were admitted. As a result we find that 66 notifications of diphtheria, or 23.9 per cent., and 54 notifications of scarlet fever, or 13.5 per cent., were not confirmed in hospital. The corresponding figures for the year 1924 were for diphtheria 24.3 per cent, and for scarlet fever 8.0 per cent. Smallpox.—Although smallpox still continues to be prevalent in the North of England and the Midlands, it is extremely satisfactory that during the year under review we had no case in Fulham. The present immunity from smallpox in London and the South of England as compared with the North of England and the Midlands is a peculiar feature of this disease and one which cannot entirely be accounted for. Personally, I see no reason why this present outbreak in the North of England and the Midlands should not make a serious effort to gain a foothold in London. The state of vaccination in London is not such as to justify us in having great hopes that this valuable preventative will help us very much. Until the Public realise what a serious mistake they are committing in not availing themselves fully of the enormous benefit of vaccination, we must rely upon the efforts of the Public Health Services to deal as rapidly and efficiently as possible with each case as and when it arises. Measles.—589 cases of measles were notified during the year 1925. This was the commencement of a serious epidemic of this disease which, as I write (February, 1926), is just reaching its peak with notifications at the rate of over 500 a week. This epidemic commenced to make itself felt in the first week in November with 24 notifications, and during the remainder of November and December notifications averaged between 40 and 50 per week. Fortunately, only two deaths occurred owing to this disease. In my annual report for 1922 I gave in some detail the steps which are taken in Fulham to deal with this disease and as this is a survey report it may be as well to repeat them. 36 In the first place measles is a notifiable disease in this borough under a special order of the Ministry of Health dated 20th March, 1920. This enables each case to be visited, which is valuable, not so much in checking the spread of the disease which has its most infectious period before the rash appears, but rather as an important step towards checking the mortality and morbidity. It is unfortunately only too frequently the custom of poorer class parents when dealing with a case of measles to send for the doctor in the first place and, as soon as he has made a diagnosis of measles to think that they can cope with the illness themselves. Accordingly the doctor's first visit is very often his last and thus symptoms of complications are missed. Owing to notification all these cases are visited by the Health Visitors who take the opportunity of giving advice to the mother and if necessary urging her that the doctor should be again summoned or that nursing assistance or removal of the case to hospital is necessary. The Council will be aware that hospital accommodation is provided by the Metropolitan Asylums Board for severe cases of measles where in the opinion of the Borough Medical Officer of Health the home conditions are unsatisfactory. Unfortunately in the heat of an epidemic the accommodation provided in these hospitals is seldom sufficient to meet the demand and occasionally even urgent cases have to wait one or two days before admission to hospital. The Poor Law Guardians also admit cases of measles to certain wards in the Fulham Hospital. Further, home nursing is provided for cases of measles by the Council through the agency of the Fulham Branch of the Queen Victoria Jubilee District Nurses. Encephalitis Lethargica.—As stated earlier in this report the number of cases of encephalitis lethargica (sleepy sickness) has fallen from 21 in 1924 to 10 in 1925. It is as a general rule extremely difficult to find any connection between one case of this disease and another and therefore I think it may be interesting 37 to give the following details regarding a small localised outbreak which occurred in Fulham during this year. The first case was notified to us on the 6th October, 1925, from 18, Glenrosa Street in the person of D.T. A few days later, on the 28th October, another case, F.C., was notified from 24, Glenrosa Street. Upon making careful inquiries, it was found that another case, G.C., belonging to a different family from F.C., had died of this disease at the same house, namely, 24, Glenrosa Street, on February 25th, 1925. This case was unfortunately never notified to the Public Health Department. These two cases occurring at 24, Glenrosa Street are still further interesting in that the man who died first, namely, G.C., would appear to have been infected by F.C., although he was only notified to the Public Health Department some nine months after G.C.'s death. The history of F.C., however, is that he was admitted to St. George's Hospital in April, 1924, having been suffering apparently from encephalitis lethargica for the past six months, but unfortunately the case was not notified. When F.C. was admitted to the Fulham Hospital at the time of notification (October, 1925) he was suffering from post encephalitic Parkinsonism. The connection between F.C. and D.T. of 18, Glenrosa Street, also is interesting. It appears that for some months prior to the admission of F.C. to the Fulham Hospital in June, 1925, and while that man was living at 24, Glenrosa Street, he was visited on several occasions by D.T., who developed encephalitis lethargica about September, 1925. I am of the opinion that both G.C. and D.T. were infected by F.C., and perhaps the most interesting point in this connection is that it would appear that F.C. must have remained in an infectious condition from about November, 1923, when his disease first commenced, till September, 1925, when apparently he infected D.T., at which time F.C. was himself suffering from post encephalitic Parkinsonism. It is much to be regretted in connection with this little outbreak, that the cases of F.C. and G.C. were not notified at the time of their onset to the Public Health Department; possibly the obscure nature of 38 the incipient symptoms in these cases made it difficult for the medical attendant to be quite definite in his diagnosis and as time slipped on the duty of notification was forgotten. Epidemic Diarrhoea.—A small outbreak of epidemic diarrhoea occurred in Fulham, commencing at the beginning of October, 1924, and lasting until the end of January, 1925. This outbreak is worthy of attention, as the majority of cases occurred during December and January, two months which are not as a rule associated with outbreaks of infantile diarrhoea. Altogether 23 cases were notified in October, November and December, 1924, and nine in January, 1925, making a total for the period of 32. There were 11 deaths, giving a case mortality of 33-7 per cent. Of the total cases, no less than 29 were notified by the Fulham Hospital. It was necessary, firstly, to endeavour to establish whether these cases were true cases of epidemic diarrhoea, and secondly, if so, how and where they were becoming infected. I had three consultations with Dr. Parsons, Medical Superintendent of the Hospital, on the subject, and I went carefully through the medical history of all the cases which occurred during December and January, that is to say when the outbreak was at its height. Out of 21 cases which occurred during that period and were admitted to the Fulham Hospital, I am of the opinion that nine of these cases would certainly have been notified as true epidemic diarrhoea had they occurred as individual cases. The other 12 would not, I think have been so diagnosed, had it not been that they occurred in the Hospital or were admitted to the Hospital during the period of the outbreak. These latter cases undoubtedly suffered from gastric derangement and diarrhoea in some degree, but both Dr. Parsons and I are of the opinion that the diagnosis of true epidemic diarrhoea was in these cases doubtful. An interesting point is that in eight of these cases there appeared to be a definite relationship between the diarrhoea and an attack of bronchitis, the bronchitis being the first signs of illness. The history of a case typical of several which were admitted to the Infirmary about this time is as follows :— 39 The child was said to have had bad diarrhoea for several days before admission, accompanied by a cough. On admission the eyes were sunken, the child pale and flabby, the stools frequent and green; the temperature was 103°. During the first few days in the Hospital the cough became very violent causing much distress and there was a patch of consolidated lung. Eventually convulsions supervened, the temperature rose still higher and the child died. On analysing these cases further, one found that in 17 cases the child was admitted to the Hospital obviously suffering from diarrhoea, whereas in four other cases the child appeared to have contracted the diarrhoea in the Hospital itself. All practicable steps were taken by the Hospital medical and nursing staff to obviate the possibility of passing the infection from one child to another, but as the outbreak occurred in the middle of winter, when the children's wards in the Hospital are always fully occupied, it was almost inevitable that a certain amount of infection should be transmitted from one case to another. Early in January, however, it was possible to clear one of the wards and this was used as an isolation ward for these cases. Any cases which could not be accommodated in this ward were nursed at one end of the children's ward and special instructions were given to the nurses as to bed isolation. Special inquiries were made by the Health Visitors as to the possible source of infection in the homes. In the first place, the geographical position of the cases was studied, but it was found that with the exception of three cases in Heckfield Place and two in the adjoining Avenues, all the others appeared to be fairly evenly distributed about the borough. No particular method of feeding Could be blamed, as breast feeding, dried milk, fresh cow's milk, condensed milk and in the older children, even a mixed diet, were found to be in use in different cases. The only cause to which one could attribute such an unusual outbreak, would appear to be the prolonged period of wet and sunless weather, which prevailed during July, August and September, 1924. 40 and which probably lowered the vitality of many children, thus making them more subject to infection. Venereal Diseases.—The education of the public on the subject of venereal diseases is carried out in the borough by a local voluntary committee, under the auspices of the British Social Hygiene Council. 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 1925 :— Lectures and Film Displays held under the auspices of the fulham propaganda committee of the British Social Hygiene Council, Incorporated. (Late—n.c.c.V.D.) Date. Where held. Subject. Lecturer. Number attending. 8.1.25 Langford Road School Film Dr. R. C. Verney 80 31.3.25 Hugon Road School . . Film Colonel Probyn 70 29.4.25 Women's Co-operative Guild Film Miss Dugdale 30 21.5.25 New King's Road School Film Dr. Rose Turner 60 15.7.25 Open Air Meeting Film Dr. Feldman 50 3.9.25 William Street School Film Dr. Sloan Chesser 80 8.9.25 Kingwood Road School Film Dr. Rose Turner 130 9.10.25 Town Hall, Fulham Film Mr. E. b. Turner 400 Total attendances 900 Table IV.—Cases of Infectious Diseases notified, during the Year 1925. Notifiable Diseases. Number of Cases Notified. Total Cases Notified in each Ward of the Borough. Total Cases removed to hospital. Deaths. At all Ages. At Ages—Years. Barons Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. 0-1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-35 35-45 45-65 65 and upwards. Smallpox — — — — — — — — — — — — — — — — — — — — — — — Cholera, Plague — — — — — — — — — — — — — — — — — — — — — — — Diphtheria (including Membranous Croup) 276 10 14 15 19 30 85 34 19 40 6 4 12 56 39 39 52 33 28 17 267 11 Erysipelas 74 1 — 1 — — — 1 6 14 9 29 13 4 15 8 13 18 1 7 8 44 4 Scarlet Fever 398 3 14 20 34 50 156 75 16 24 5 1 — 12 88 48 57 88 20 62 23 382 3 Typhus Fever — — — — — — — — — — — — — — — — — — — — — — — Enteric Fever 10 — — — — — 2 — 3 2 1 2 1 — 1 1 3 2 6 — Relapsing Fever, Continued Fever — — — — — — — — — — — — — — — — — — — — — — — Puerperal Fever 21 — — — — — — — — 15 6 — — 1 3 2 2 5 2 2 4 21 4 Cerebro-Spinal Meningitis 3 1 1 1 — — — — — — — — — — — 1 1 — — 1 — 3 1 Polio-myelitis 3 1 — 1 — 1 — — — — — — — — 1 — — 1 — 1 — 1 — Ophthalmia Neonatorum 32 32 — — — — — — — — — — — 5 4 3 5 7 — 4 4 18 1 Tuberculosis of Respiratory System 279 1 — 1 1 1 6 15 30 126 42 51 5 23 52 26 39 58 10 54 17 — 151 Disseminated Tuberculosis 1 1 — — — — — — — — — — — — 1 — — — — — — — 6 Other Tuberculous Diseases 113 2 9 5 2 6 32 21 8 17 2 9 — 4 29 6 12 29 4 21 8 — 16 Measles 589 12 45 33 66 90 280 35 12 13 3 — — 60 84 30 212 112 10 68 13 28 2 Encephalitis Lethargica 10 — — — — — 1 — 3 4 — 2 — 1 1 — — 3 — 5 — 9 4 Pneumonia 320 26 46 30 13 3 21 9 13 56 39 46 18 11 52 86 48 54 12 40 17 193 173 Diarrhœa 70 46 19 2 1 2 — — — — — — — 2 9 17 11 14 5 10 2 54 37 Malaria — — — — — — — — — — — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — — — — — — — — — — — Trench Fever — — — — — — — — — — — — — — — — — — — — — — — Total 2,199 136 148 109 136 183 583 190 109 309 115 144 37 137 396 266 440 442 100 305 113 1,026 413 41 42 Tuberculosis. Three hundred and ninety-three new cases of tuberculosis were notified during the year. Of these, 279 were cases of tuberculosis of the respiratory system, one was of disseminated tuberculosis, and 113 cases of tuberculosis of other organs. In Table IV, page 41, the notifications of tuberculosis will be found classified according to age and ward. Below I give figures relative to the deaths and the number of such deaths previously notified as suffering from tuberculosis. Mortality from Tuberculosis. Respiratory system— 151 deaths 84 males, 67 females. Death-rate 0.92 per 1,000, being 0.12 higher than in 1924. 139 notified (92.0 per cent.), 12 not notified (8.0 per cent., of whom 4, or 33.3 per cent., died in institutions). Other Tuberculous Diseases— 22 deaths 10 males, 12 females (including 6 deaths from disseminated tuberculosis'). Death-rate 013 per 1,000, compared with 0.2 for 1924. 15 notified (68.2 per cent)., 7 not notified (31.8 per cent., of whom 6, or 85.7 per cent., died in institutions). Period between Primary Notification and Death. Respiratory System— Under 1 month 18 (12.9 per cent.). 1-3 months 17 (12.2 per cent.). 3-6 months 10 ( 7.2 per cent.). 6-12 months 20 (14.4 per cent.). 1-2 years 39 (28.1 per cent.). Over 2 years 35 (25.2 per cent.). Other Tuberculous Diseases— Under 1 month 9 (60.0 per cent.), including 3 disseminated tuberculosis. 1-3 months 2 (13.3 per cent.). 3-6 months — 6-12 months 3 (13.3 per cent.). 1-2 years — Over 2 years 3 (13.3 per cent.)., including 1 disseminated tuberculosis. 43 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. 44, an interesting summary of the whole position of the tuberculosis problem in Fulham. TABLE V.—DISPENSARY STATISTICS, 1913-25. 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 1925 162 44 46 414 1,956 3,405 605 5,421 44 45 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 433 145 168 42 1.01 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 1925 279 114 151 22 0.92 0.13 46 REPORT BY THE TUBERCULOSIS OFFICER (DR. SULLIVAN) ON THE WORK OF THE TUBERCULOSIS DISPENSARY. It is of some interest to review the annual statistics and to compare them with those of the preceding year. The number of new cases attending the Dispensary was 666 compared with 682 for 1924. The number of new cases notified by the Dispensary to the Medical Officer of Health was, however, only one less for 1925 than for 1924, viz., 206 compared with 207. The total number of old and new cases notified was 241 compared with 234 for the previous year. 1,511 patients attended the Dispensary in 1925 and 1,437 in 1924. The number of attendances fell from 5,752 to 5,361. This was due to the fact that considerable , effort was made to discharge non-tubercular patients as soon as the diagnosis was made. Although there were fewer attendances, 3,117 physical examinations were made compared with 2,827 in 1924, and 1,707 sputum specimens were examined against 1,665 during the preceding year. 383 medical reports were sent to doctors in 1925 and 354 in 1924. The number of reports to public authorities was less on account of the gradual decrease of work for the War Pensions Ministry. During 1925, the nurses' visits totalled 5,421, an increase of 646. The increase is due to the fact that in 1924 one of the nurses was absent from duty for several months on account of illness. The tuberculosis officers made 605 visits, an increase of 56 over the previous year. On 31st December, 1925, there were 1,581 cases of tuberculosis on the dispensary books, 270 of which were cases with tubercle bacilli in the sputum. 277 patients were sent to institutions or to the country through the Dispensary. 47 The death-rate from tuberculosis which was 1.63 per 1,000 of the population in 1915 fell to 1 per 1,000 in 1924, the lowest recorded for the borough. In 1925, there was a slight rise to 1.05 per 1,000, .92 being due to pulmonary tuberculosis and .13 to other forms of the disease. 151 deaths from pulmonary tuberculosis and 22 from non-pulmonary tuberculosis were registered. On the other hand, 470 cases were struck off the books as cured. This figure is unusually high owing to the fact, that this is the first year during which the practice of removing names from the register has been in force. Institutional Treatment arranged through the dispensary. The accompanying table shows that 277 patients were sent away from home for treatment during 1925. The London County Council are primarily responsible for the institutional treatment of patients suffering from all forms of tuberculosis and also provide observation beds in hospital for doubtful cases. During the year the County Council sent 166 patients to various institutions including sanatoria, hospitals, homes for advanced cases and colonies. The County Council gave grants to the Invalid Children's Aid Association for boarding out 10 children under the contact scheme and also for sending 16 children to convalescent homes. Apart from the cases sent away with the aid of grants, the various voluntary bodies mentioned in the table sent 44 patients either to convalescent homes or to cottages in the country. The valuable and willing help of these Societies and of their representatives on the Care Committee must be gratefully acknowledged. 48 Table 1. 277 patients were sent to residential institutions on the recommendation of the Dispensary medical officers. (a) 166 by the London County Council. 93 to Sanatoria. 9 to Farm Colonies. 64 to Hospitals or Homes. Men 30 9 45 Women 45 — 18 Children 18 — 1 (b) 41 by the Poor Law Authorities. 18 to Fulham Hospital. 23 to Sanatoria or Convalescent Homes. Men 5 — Women 4 5 Children 9 18 (c) 29 children were sent to Convalescent Homes by the Invalid Children's Aid Association. (d) 17 by the Charity Organisation Society. 2 women sent to homes for advanced cases. 6 women sent to Convalescent Homes. 9 children boarded out. (e) 6 by the United Services Fund. 5 men sent to Convalescent Homes. 1 man sent to friends in the country. (f) 10 children boarded out under the L.C.C.'s contact scheme. (g) 8 children sent away through the Children's Country Holiday Fund. Advanced Cases. The available accommodation for advanced cases of pulmonary tuberculosis is still much below the requirements and the great majority of these patients are under treatment in their own homes, some of them spreading the infection to children and others; as a result many fresh cases are still being notified and deaths have occurred which might have been prevented. 49 Few patients suffering from advanced disease can be sufficiently isolated or efficiently treated in workingclass homes. The most obvious and sensible method of preventing infection is to provide a sufficient number of beds for these cases. The incubation period of tuberculosis is very variable and the disease may not declare itself for many years after the original exposure to infection, so that it is difficult for some people to realise the risk of living in intimate contact with advanced cases. In the course of our lives, we gradually acquire a certain amount of resistance or immunity to the disease and frequent exposure is required before this resistance is broken down. Occasionally, however, one is forcibly reminded of the danger by the occurrence of a case of tuberculosis meningitis in a young child who has not yet acquired even a small amount of immunity. At school age the disease is generally mild or latent, but the seeds sown in early life may cause active disease during adolescence or at a later age. The Metropolitan Asylums Board Hospital at Grove Park, which will accommodate 300 cases in the later stages of pulmonary tuberculosis, will soon be available, and this will remedy to a slight extent the scarcity of beds. The facts that the scheme for boarding out children was inaugurated in 1925 and that this Hospital will be opened in 1926, are encouraging, and the proposed Reform of the Poor Law which will lead to further developments is another hopeful sign. X-Ray Examinations. 57 patients were sent to Brompton Hospital for X-ray examinations during 1925, compared with 23 in 1924. These examinations are of great assistance in differentiating tuberculosis from other diseases, such as Bronchitis, bronchiectasis, catarrhal and pyogenic infections, fibrosis of the lungs, foreign bodies in the 50 lungs and carcinoma. A definite opinion can thus be given in many cases whose diagnosis would otherwise remain doubtful, and effective treatment can be commenced earlier both in the tubercular and non-tubercular cases. X-ray examinations are also essential in the pneumothorax treatment of tuberculosis and other diseases of the lungs. The arrangement of having the X-ray work done at Brompton Hospital is the best and most economical one at the present time and ensures that the work is done by a radiologist of great experience in diseases of the chest. The disadvantages are the distance of the Hospital from Fulham and the fact that patients may have to wait for over a week for an appointment. The ideal arrangement would be to have a radiological department somewhere in Fulham, if not actually at the Dispensary. This, of course, is out of the question at the present time on account of the initial cost and cost of upkeep. In all probability the reform of the Poor Law System will permit of increased facilities for X-ray examination and other scientific methods and will also facilitate co-operation between the various medical and surgical units in the neighbourhood. The London County Council Scheme for Boarding out Children. Arrangements were made early in the year by the London County Council in co-operation with the Invalid Children's Aid Association for the boarding out of children living in overcrowded and heavily infected homes in which a father, mother or other person was dying of pulmonary tuberculosis. The scheme came into operation on the 1st April, 1925, and is to continue as an experiment for twelve months from that date. Its primary object is to remove healthy children from danger of infection during the most infectious period of the patient's illness. This, however, is not the only object of the scheme as the Council also board out " children who are being discharged from sanatorium treatment and whose homes are unsuitable and inimical 51 to maintenance of health." The arrangements, therefore, include tuberculous as well as healthy children, but only tuberculous children in whose cases the disease has become quiescent. The original arrangement was to board out children for three or four months, for example, during the last stages of the father's or mother's illness, but the Council, in a letter dated 8th July, 1925, extended the scheme so as to permit children to remain away from home as long as the conditions in the home remained unfavourable. The Council's letter also stated that children were to be eligible even if their parents were in 'a sanatorium. The procedure after obtaining the parents' sanction is for the Tuberculosis Officer to apply to the London County Council stating the facts of the case, forwarding a medical report on the condition of the patient and a report by the Health Visitor on the home conditions of the family. If the County Council accept the case for boarding out it is referred to the Invalid Children's Aid Association who arrange the boarding out. Each family is asked to make a small contribution towards the cost and the Council pay the entire cost minus the parents' contribution. The amount of the contribution is decided by the Invalid Children's Aid Association. With regard to the necessity for such a scheme, the Dispensary records show that at the end of the year 270 Fulham patients, suffering from pulmonary tuberculosis, had tubercle bacilli in the sputum. Many of them were living in over-crowded homes under bad conditions with children, in close contact. It is obvious, therefore, that a considerable number of children are eligible for boarding out. Difficulties have, however, arisen in carrying out the scheme; it is a comparatively easy matter to persuade parents to have their children sent to a Convalescent Home when the children are ill; it is much more difficult to prove the necessity for sending them 52 away for the purpose of prevention when they are quite healthy. The parents have also to be informed that the children will be sent, not to a Convalescent Home, but to a cottage in the country, and that they will have to remain away for a considerable time. Another difficulty is the fact that, when the Tuberculosis Officer broaches the subject to the parents, he is not in a position to say definitely that the County Council will accept the child for boarding out. Under these circumstances, it is not surprising that in the short space of nine months only ten children have been boarded out. In most cases the parents have refused their consent and in a few cases the London County Council did not think the cases suitable. The actual boarding out is a matter of some difficulty. In its initial stage such a scheme is of course much more difficult to work than it will be later on. It will have to be developed and simplified before success can be attained. We may consider the removal of advanced cases as one of the front lines of defence and the boarding out system as a reserve measure. The scheme is a valuable addition to our defensive measures against tuberculosis. Co-ordination between Panel Doctors and Tuberculosis Officers. Under the contracts between panel doctors and their Insurance Committee the doctors agree to submit periodical reports on the cases of their tuberculous patients. This is also laid down in the Tuberculosis (Domiciliary Treatment in England) Order, 1916, now superseded by the National Health Insurance (Medical Benefits) Amendment Regulations, 1921, and amplified in a circular from the Ministry of Health in December, 1923. 53 The panel doctors are required to furnish medical reports on prescribed forms to the tuberculosis officer, (1) on becoming aware that any of their panel patients are suffering from tuberculosis, and, (2) subsequently at intervals of not less than three months. The tuberculosis officer is required to communicate with the panel doctor when the latter notifies the case of an insured patient and offer to collaborate with him regarding the case. The tuberculosis officer is also required to submit reports to panel doctors and the Ministry have issued model forms for the purpose. The object of the Regulations is to secure the early and accurate diagnosis of tuberculosis among insured persons; to promote early and effective treatment; to encourage preventive measures and to ensure that there should be a definite understanding at each stage of the disease as to who is for the time being immediately responsible for the patient's treatment. The forms suggested by the Ministry are somewhat elaborate, and their use involves much clerical work on the part of the tuberculosis officer and the panel doctors. They are, however, issued for the guidance of those concerned and are not compulsory. Most of the information contained in the panel doctors' reports is already known to the tuberculosis officer, but it is useful for him to have the right to ask for a report in certain circumstances. Personal letters between the dispensary and the panel doctors are, however, less automatic and irksome than printed forms and are more likely to encourage interest in the clinical aspect of the cases. The principles laid down by the Ministry are, however, very sound and should be acted upon for the benefit of all patients, insured and uninsured. During the year 130 medical reports were received from panel doctors in addition to a large number of short reports, letters and consultations over the telephone. 388 reports were sent by the tuberculosis officers to doctors. 54 The Care Committee.—No Care Committee existed until some time after the opening of the Dispensary in 1911 and cases were referred by the Medical Officers directly to the Charity Organisation Society or the Guardians when financial help was required. The Charity Organisation Society also sent many cases to Sanatorium and the Borough had six beds in Benenden Sanatorium. Subsequently a voluntary Care Committee was formed, composed of members of the Dispensary Executive Committee and representatives from the Charity Organisation Society, Invalid Children's Aid Association, School Care Committees, the Medical Officer of Health and the Tuberculosis Officer. Later on the Care Committee was taken over by the London County Council and in 1923 it became a sub-committee of the Public Health Committee of the Fulham Borough Council. The work of this Committee is of a high standard, recruited as it is from Borough Councillors who take a real interest in the work and by members of various voluntary societies engaged in helping the sick in the Borough. One of the members of the Board of Guardians also sits on the Committee and his services are of the greatest assistance. The Committee meets once a fortnight and is advisory, giving no help directly. It is a link between the Dispensary and the various sources from which the patients receive financial assistance. The details of the work of the Committee were described in the 1923 report and may be summarised as follows:— (1) Securing financial help, extra nourishment, clothing, beds and bedding for needy patients. The beds are lent in order to allow patients to sleep alone. (2) Friendly visiting and general advice which sometimes prevents patients from prematurely discharging themselves from sanatoria. 55 (3) Making assessments and collecting the weekly payments in cases where patients are sent to institutions by the London County Council. This is a somewhat laborious task, which is done by voluntary visitors. It also keeps the Dispensary in close touch with the patients' families. The assessments arc sanctioned by the London County Council. (4) Securing convalescent treatment for patients not requiring sanatorium treatment. This is done through the voluntary societies (Charity Organisation Society, Invalid Children's Aid Association, United Services Fund) and the Guardians. (5) Securing employment for patients in some cases. 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 Casks referred by the Care Committee to Different Agencies for assistance, showing the help given by each agency. Charity Organisation Society. 2 patients sent to Homes for advanced cases. 6 patients sent to Convalescent Homes. 9 children (not patients) boarded out. 7 patients helped with dental treatment. 1 patient helped with surgical instrument. 4 families helped financially. 2 families helped with clothing. 7 families referred for friendly advice. In addition four patients were referred for Convalescent treatment but withdrew their application and two the Society were not able to arrange for. 56 Two patients were referred for admission to Homes for advanced cases but died before the vacancies were obtained. Four families were referred for placing the children while the mothers were in institutions—in two of these arrangements were made with relatives and the other two were referred to the Guardians. Four patients were referred for dental treatment, two of whom withdrew their application and two the Society were unable to arrange for. Invalid Children's Aid Association. 29 children sent to Convalescent Homes. 10 children boarded out under the L.C.C.'s contact scheme. Red Cross and United Services Fund. 5 men sent to Convalescent Homes. 1 man sent to friends in the country. 11 families assisted financially. 4 patients assisted with clothing. The Borough Council. 34 patients assisted with grants of milk and eggs for varying periods. The Guardians. 18 patients sent into Fulham Hospital. 22 patients sent to Sanatoria or Convalescent Homes. 15 families assisted financially. 1 patient provided with teeth. 1 patient provided with clothing. 4 children taken permanently into the Guardians' Homes. Illustrative Cases dealt with by the Care Committee. A.—Was a woman of 35 whose invalid mother was wholly dependent on her. She was employed as a dressmaker, but when 57 she first came to the Dispensary was suffering from pulmonary tuberculosis and was too ill to work. Her only income was her National Health Insurance benefit. It was most essential that she should have sanatorium treatment and through the help of the Charity Organisation Society arrangements were made for the mother to stay with a sister, the Society helping financially so that the home could be kept together. Extra nourishment was given by the Borough Council till the patient went away and for a long period after her return home when she was once more in full work. Her old firm took her back and have treated her with special consideration and she is now doing well and working full time. B.—Was a woman of 33, who, on her father's death, was left absolutely alone, unable to work and without resources, but able to get about and most anxious to keep her home of one room. When she was a child she was treated for tuberculosis of the hip and although this was cured she was still very delicate. The Charity Organisation Society helped for a considerable time, trying also to find some employment suitable for her, but this was impossible. Ultimately she was referred to the Guardians, who gave her the maximum rate of out-relief and, in the summer, when she flagged a good deal, sent her away for six weeks to the seaside. The Guardians paid her rent while she was away, and through the kindness of the Charity Organisation Society, she was given pocket-money, the possession of which made her holiday all the more enjoyable. She came back, not fit to earn, but very much better in health and spirits. C.—Was an ex-service man who worked as a boot-repairer on his own. He became too ill to work, though not definitely tubercular, and was recommended for observation in a Hospital. As he was not in receipt of a pension, the Red Cross assisted, both with money and clothing, and on his discharge sent him down into the country to his brother's, paying for his fares and board. He is now home again, very much improved in health and able to carry on his work. D.—Was a married woman with three children who, on her first attendance, was found to be suffering from pulmonary tuberculosis and in urgent need of sanatorium treatment. Her husband was a sailor, fortunately with the Home Fleet, and was able to obtain leave in order to help make arrangements for his family. Two of the children were boarded out in the country under the London County Council's contact scheme by the Invalid Children's Aid Association. The third child, who was in need of treatment for enlarged tonsils, was admitted to a Children's Hospital, through the same Association; after some weeks of treatment there, he was accepted by the Council for boarding out and joined his sisters in the country. The children being arranged for, the patient was able to go away to sanatorium with her mind at ease about them and at the present time is still away. 58 E.—Was a married woman with six small children. She was suffering from pulmonary tuberculosis and was recommended for sanatorium treatment, but found it very difficult to leave home on account of her family. The case was referred to the Charity Organisation Society, who, as the husband was an ex-service man, were able with the help of the United Services Fund, to send the children away. At this juncture, one of the small boys broke his arm and was admitted to the Fulham Hospital. The baby was in the Babies' Hospital and there were thus four children to be placed. Of these, the little girl was sent to Broadheath and the three boys to a cottage in the country. The day the children left home, the patient herself went into Brompton Hospital, where she still remains. F.—Was a young girl of 19, who was sent to sanatorium and returned greatly improved, but not fit to work. Her home conditions were very crowded and poor and she was not likely to improve while there. She was referred to the Guardians for help and they sent her to Wales, paying her fares and also for her board and lodging while away, with the result that she returned after about two months greatly improved. She is now nearly well and is doing light domestic work. Summary of Statistics. Number of new patients— Insured 226 Uninsured 440 Total 666 Number of attendances— Insured 1,956 Uninsured 3,405 Total 5,361 Number of patients who have attended (both old and new) 1,511 Number of notifications— Pulmonary 187 Non-pulmonary 54 Total 241 (of these, 206 were notifications of new patients). Number of sputa examined 1,707 Number of physical examinations 3,117 Number of contacts examined 409 Number of ex-service men attending 214 Number of ex-service men notified as suffering from tuberculosis 133 Number of home visits paid by doctors 560 Consultations 45 Total 605 59 Number of home visits paid by nurses 5,421 Number of reports sent to public bodies 879 Number of reports sent to doctors 388 Number of patients referred to Brompton 8 For X-ray 57 Number of notified patients on dispensary books at end of 1925 1,581 Number of Fulham patients with tubercle bacilli in their sputum 270 Number of patients sent to institutions or to the country 277 Table II.—Showing who recommended the patients. 257 were recommended by private doctors. 51 „ „ the Medical Officer of Health. 28 „ „ the school medical officers. 9 ,, „ the school authorities. 17 „ „ hospitals. 4 „ „ other dispensaries. 3 „ „ other sanatoria. 9 „ „ infirmaries. 21 „ „ the Army authorities. 101 „ the Dispensary staff. 11 „ „ the London County Council. 92 „ ,, friends. 22 „ ,, patients. 17 „ ,, the door plate. 13 „ „ the Invalid Children's Aid Association. 2 ,, ,, Charity Organisation Society. 2 „ ,, the relieving officers. 1 was recommended by the Red Cross. 1 „ „ Insurance Committee. 1 „ „ the district nurse. 1 ,, ,, House of Help. 1 „ „ Royal United Kingdom Benevolent Association. 1 ,, „ the British Legion. 1 „ „ Aylesbury Dairy Company. 666 Table III.—Sex and age of new patients for 1925. Under 5 yrs. 10 yrs. 15 yrs. 25 yrs. 35 yrs. 45 yrs. 45 yrs. & over All ages. Males 54 79 34 51 51 36 41 346 Females 33 51 31 57 77 41 30 320 Both Sexes 87 130 65 108 128 77 71 666 60 Table IV.—Diagnosis in Males and, Females. (New Patients.) Total Cases. Pulmonary Tuberculosis. Other forms. Suspects. NonTuber cular. Percentage Tuberculous. 346 males 90 31 21 204 34.97 320 females 72 13 25 210 26.56 666 both sexes 162 44 46 414 30.93 This Table shows that more males were found to be tuberculous than females and also that the percentage notified was greater in the male sex. Table V.—Diagnosis at various age periods. (New Patients.) Pulmonary Tuberculosis. Other forms. Suspects. NonTuber cular. Percentage Tuberculous. Under 5 years 2 13 4 68 16.32 „ 10 „ 2 15 10 103 13.07 9 10 2 44 29.23 25 „ 46 4 7 51 46.29 „ 35 „ 49 2 14 63 39.84 „ 45 „ 27 — 7 43 35.06 45 years and over 27 - 2 42 38.02 All ages 162 44 46 414 30.93 The majority of the new cases of pulmonary tubercusis notified occurred between the ages of 15 and 35 as in previous years. The great majority of the cases of tuberculosis of the glands occurred in children. 61 Table VI.—Housing conditions. Of 198 of the 206 tuberculous patients found in 1925— 4 lived in the basement. 50 ,, on the ground floor. 52 ,, „ first floor. 10 „ „ second floor. 5 „ ,, third floor. 2 „ ,, fourth floor. 31 „ on more than one floor. 35 ,, in the whole house. 198 Table VII.—Housing accommodation. — Number of Families occupying 1 room. 2 rooms. 3 rooms. 4 rooms. 5 rooms. 6 rooms or over. Patient living alone ... 3 — — — — — Patient living with 1 other .. 4 9 9 3 1 — „ „ 2 others .. 5 6 21 14 2 1 ,, ,, 3 ,, 2 4 25 10 3 4 ,, ,, 4 ,, 1 1 9 6 1 1 ,, ,, 5 ,, — — 6 12 2 1 ,, ,, 6 ,, — 3 5 5 3 1 ,, ,, 7 ,, — 1 5 2 — — ,, ,, 8 ,, — — 1 1 1 1 ,, ,, 9 ,, — — — — 1 — ,, ,, 10 ,, — — 1 — — 1 Total 15 24 82 53 14 10 In 1914 only 45.1 per cent, of the notified cases occurred in small houses of three rooms or less compared with 50.7 per cent, in 1923, 56.6 per cent, in 1924 and 61.1 per cent, in 1925. 62 Table VIII.—Sleeping accommodation of 198 tuberculous patients. The patient slept— In a separate room 59 cases. Alone in bed with one other in room 19 „ „ ,, two others in room 15 „ ,, „ three others in room 3 „ In bed with one person and no others in room 53 cases. „ „ one other in room 27 „ „ „ two others in room 13 „ „ „ three others in room 1 case. „ „ five others in room 1 ,, „ „ six others in room 1 „ In bed with two persons and no others in room 5 cases. „ „ four others in room 1 case. 198 cases. Table IX. Occupations of 87 tuberculous men in 1925. 2 bakers. 1 milk roundsman. 1 baker's roundsman. 6 motor drivers. 1 blacksmith's mate. 1 newsagent. 1 boot repairer. 1 newsvendor. 1 brush-hand. 1 pastrycook. 2 butchers. 1 packer. 2 bank messengers. 1 painter. 1 carpet planner. 1 plumber's mate. 1 cellarman. 1 porter. 1 clothes presser. 1 printer. 19 clerks. 2 salesmen. 1 coal porter. 1 sales' manager. 1 dentist. 1 shop assistant. 3 electricians. 1 signalman. 2 engineers. 1 stoker. 1 electrician's mate. 1 storekeeper. 1 fitter's mate. 1 surgical last fitter. 1 flowerseller. 1 student. 1 gardener. 1 telephone jointer. 2 hairdressers. 1 transport worker. 1 house-parlourman. 1 upholsterer. 1 jobbing builder. 1 vocalist. 6 labourers. 2 waiters. 2 laundrymen. 1 window cleaner. 1 no occupation. 63 Occupations of 68 tuberculous women in 1925. 1 actress. 6 domestics. 1 bookfolder. 3 dressmakers. 1 book-keeper. 1 factory hand 1 boxmaker. 31 housewives. 3 charwomen. 1 kitchenhand. 5 clerks. 1 laundress. 2 cloakroom attendants 2 machinists. 1 confectionery hand. 1 shop assistant. 3 cooks. 1 silver stamper. 3 no occupation. Children under 15. 35 boys. 16 girls. The Open-Air School. The open-air school for 25 tuberculous children was opened on the 21st May, 1917, at the dispensary under the management of the Dispensary Committee. It was soon found that the applications for admission exceeded the accommodation and the school was transferred to Broomhouse Lane on the 18th May, 1921. The new school—The Elizabethan School—is entirely under the management of the London County Council and accommodates 60 children, whose ages vary from 7 to 16. Like other special schools it is intended for children who are unable to benefit from instruction in an ordinary elementary school. Only early non-infectious cases of tuberculosis are admitted. The classes are held in the open air, or in two open-air shelters in bad weather. The schoolhouse is only used when the weather is at its worst. The tuberculosis officer acts as school doctor and is officially appointed assistant school medical officer by the County Council and one of the dispensary nurses is the school nurse. The medical officer attends one clinic weekly at the school and the nurse devotes one-third of her time to her school duties. It is thus possible to keep the children under stricter observation 64 than at an ordinary elementary school and to give treatment when necessary either through the dispensary or elsewhere. As the school has been in existence since 1917 we can speak definitely of the results, and there is no doubt of the great value of this work both from the point of view of health and education. If no such school were in existence, the children would either be attending an ordinary elementary school irregularly, to the detriment of their health, or would be receiving no education at all. The children improve mentally and physically and especially in spirits and this improvement is maintained on leaving school. We have kept in touch with the former pupils and found that with few exceptions they have developed into normal young men and women with a healthy outlook on life. Apart from the question of tuberculosis, which is the chief consideration, many of the children have been found during the last few years to be also suffering from other disabilities, such as nervous traits (e.g., want of confidence, habit spasm, stammering), diseases of the nose, throat and ears, eye strain, lateral curvature of the spine, flat-foot, deformities of the chest, defective methods of breathing and of voice production and deportment, and in some cases rheumatic affections. Most of these complications can be treated successfully if attended to in the early stages, and a short description of some of the cases sent to other centres during 1925 may be of interest. Nineteen children were sent to the dental department of the School Treatment Centre for fillings and extractions. The condition of the children's teeth is excellent. Two children were operated on for enlarged tonsils and adenoids at the School Treatment Centre, Bagley's Lane. Seven were examined at the Centre by the Ophthalmic Surgeon and six were treated for minor ailments. 65 Four children were recommended for special remedial exercises and massage. Two of these cases were treated at Melmoth Hall, one for flat-foot and the other for scoliosis. The other two children attended the Chelsea Polytechnic for scoliosis. All four are making good progress. Three of the children were recommended for Artificial Sunlight treatment at Humanity House, Westminster. These children all suffered from tuberculosis of the glands of the neck. The first case was a girl of 11 years, who had treatment three times a week for eight months. Prior to receiving this treatment she had a mass of glands in the right posterior triangle and in the sub-maxillary region, also enlarged glands under the right lower jaw. Some of the masses were as big as grapes; they are now greatly reduced in size, the largest being as big as haricot beans. The second case was a girl of twelve years, who had a mass of glands under her right lower jaw. They entirely disappeared after treatment three times a week for nine months with two intervals of one month and three months during which the radiations were stopped. A boy of nine years was also treated intermittently for 18 months with marked benefit. The glandular enlargement, which was considerable in bis case, disappeared entirely with the exception of a small gland in the left sub-maxillary region. These three children improved markedly in general health and spirits. 66 TABLE X.—PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Summary of notifications during the period from Ist January, 1925, to 31st December, 1925. 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 2 2 5 6 17 23 38 24 24 9 4 154 254 — — — — — 3 148 Females — 1 2 8 12 17 44 19 12 8 2 125 213 — — — — t— 12 114 Non-Pulmonary— Males — 12 21 15 4 2 6 — 3 1 — 64 87 — — — — — 1 18 Females 2 10 11 6 4 3 8 2 3 1 — 50 56 — — — — — — 26 67 Food. During 1925, the usual careful attention has been given to foodstuffs sold in the Borough as to the conditions under which they are manufactured and kept. A particular matter which has engaged our attention in this regard is the Public Health (Meat) Regulations, 1924. I gave these Regulations in some detail in my last annual report, and it is unnecessary, therefore, for me to recapitulate them. The main matter with which we are concerned in Fulham is the state of the butchers' shops and the exposure of meat to contamination from dust, dirt, etc., from the street. The Regulations are unfortunately not worded very definitely, and the position has been rendered still more difficult by the issue of Circular 604 by the Minister of Health in which the following paragraph occurs:— "Article 2 (1) (Definition of Meat):—The Minister's intention in making the Regulations was that, apart from the special case of bacon and ham, they should apply to what is ordinarily known as butchers' meat, that is to say the raw and untreated edible parts of the carcases of slaughtered cattle, swine, sheep and goats. Questions have been raised whether the Regulations apply to rabbits, poultry, fish, butter, margarine and cheese. It is clear that the definition of meat would not include these articles, and the Minister thinks that Local Authorities might also properly treat cooked meat, lard, sausages and other preparations of or containing meat as outside the scope of the Regulations." It seems to the ordinary mind manifestly absurd that cooked meat, which is eaten in the condition in which it is sold, should be outside the scope of the Regulations, whereas raw meat, which is subsequently cooked, must be protected from contamination. Circular 604 also contains the following: " Article 20 (5) (a):—It was not contemplated that this provision should be construed as requiring all butchers' shops to be provided with glass fronts, and the precautions which it may be reasonable to require under this provision must depend on the circumstances of individual cases. It seems to the Minister that in its enforcement, the corresponding provisions of Article 19 (b) and (d) should be borne in mind and that the same general standard of freedom from contamination should be aimed at both for shops and for stalls. 68 The steps necessary to protect meat against contamination must depend on the circumstances of the shop or stall in relation to the sources of possible contamination and also on the conditions under which trade is carried on. In no circumstances, however, should meat be allowed to project outside the limits of the wall or screen of the shop or stall, where it would be especially exposed to contamination from the street, and it should be kept as far within those limits as is practicable. Where meat has to be kept near to an open window the general rule should be that it should be covered with clean muslin or other suitable material, but Local Authorities will no doubt realise that, when a brisk trade is being carried on, this precaution may have to be suspended so that meat may be readily accessible. The words in this paragraph, "It is not contemplated that this provision should be construed as requiring all butchers' shops to be provided with glass fronts," 'have unfortunately been defined by the butchers as meaning that glass fronts are an unnecessary precaution and in more than one case a magistrate has been so influenced. In Fulham, on the whole, the Regulations have undoubtedly raised the standard of cleanliness in most of our butchers' shops. In 10 cases, glass fronts have been provided voluntarily since the Regulations came into force and in several other cases butchers have promised to make the necessary alterations and are in process of getting out plans. Perhaps the place where this improvement is most evident is in the North End Road, and one hopes that within a few months most of the butchers' shops in this street will have removed their meat from the stalls in front of their shops and will be provided with glass fronts. At the present time every butcher's shop in the Fulham portion of Fulham Road, with the exception of one, is provided with glass fronts, and the one exception has promised to provide a new front in the near future. There are still, however, a number of meat traders other than butchers, such as grocers, selling bacon, who still display their wares on stalls in front of their shops. It appears difficult to secure a conviction in these cases, unless one can produce absolute proof that the meat is being contaminated, but I am of the opinion that unless within the next few months these stalls 69 are removed, the Council should take proceedings against the owners. I give this advice with some hesitation, as up to now we have proceeded in a friendly and co-operative manner with the butchers. At the same time, there are obdurate shops which are keeping back the general advance in food hygiene and these must, unfortunately, be dealt with. Food-preparing places.—The usual attention was devoted during the year to all places where food is prepared, particularly to the various food kitchens, restaurants and eating houses. These places are as a rule systematically visited by the woman sanitary inspector, Mrs. Davies, and during 1925 she made 325 visits as compared with 415 during 1924. In connection with these kitchens, 16 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 1925, the usual arrangements have been 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. Slaughterhouses. There are two licensed slaughterhouses in the Borough:— No. 611, Fulham Road, and No. 640, King's Road. 61 visits of inspection have been made to these slaughterhouses during the year and the conditions have been found satisfactory on every occasion. Milk.—The number of adulterated samples of milk was 1 per cent, in 1925, compared with 1.6 per cent, in 1924 and 4.5 per cent, in 1923. It is extremely rare nowadays to find an adulterated sample of milk. Milk sellers at last seem to have come to the conclusion that tampering with milk does not pay, and much of this success must be ascribed to the constant watchfulness which Inspector Jones has given in dealing with the milk sellers in the Borough. 70 Legal proceedings were instituted by the Council in one case. Details will be found on page 73. Milk sellers:— Number on Register, 31st December, 1924 105 Number who discontinued sale of milk during year, or business transferred 5 Number of registrations granted during 1925 9 Number on Register, 31st December, 1925 109 Costers and Food Stalls.—Careful supervision has been given 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. I caused the sanitary inspectors to prepare a list of all the costers in the Borough, giving the places where they sold their goods and also the places where they kept them prior to sale. All these places were subsequently inspected and in many cases alterations and improvements were effected. Cream (Milk and Cream Regulations, 1912 and 1917). 15 samples of cream and 18 samples of preserved cream were purchased for analysis. The following particulars of proceedings taken in 1925 under the above regulations, made in pursuance of the Public Health (Regulations 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 552 nil. Cream 15 8 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 26 Number of supplementary licences to sell certified milk 2 Number of licences granted to sell Grade A (Tuberculin Tested) milk 12 Number of supplementary licences granted to sell Grade A (Tuberculin Tested) milk 1 Number of licences granted to sell Pasteurised milk 8 Number of supplementary licences granted to sell Pasteurised milk 1 Number of licences granted to sell Grade A milk 1 Number of samples taken in accordance with the instructions of the Ministry of Health 9 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 much attention to the condition of the bakehouses in the Borough. He has paid 212 visits of inspection to the 68 registered bakehouses. Of the 68 bakehouses in the Borough, 43 are situated 72 ground. Since Inspector Jones took over the supervision of the bakehouses about three years ago, there has been undoubtedly a very great improvement in their general condition. Unsound Food.—The following articles, examined at the request of owners, were condemned and destroyed:— Haddocks 5 boxes. Chestnuts 6 bags. Winkles 4 cwt. Peaches 60 boxes. "Cat" fish 12 stone. Cherries 2 boats. Skate 18 lbs. Tomatoes 30 baskets. Rabbits 27 lbs. Greengages 40 boats. Samples Purchased for Analysis during 1925:— Articles. Number of Samples taken officially. Number Adulterated. Number of Samples taken unofficially. Number Adulterated. Total Samples. Total Adulterated. Percentage of Adulteration. Milks 548 6 4 — 552 6 1.0 Butter — — 136 — 136 — — Condensed Milk — — 7 — 7 — — Dried Milks — — 5 — 5 — — Cheese — — 33 — 33 — — Lard — — 27 — 27 — — Sponge Cakes — — 23 — 23 — — Coffee — — 4 — 4 — — Cocoa — — 20 1 20 1 5.0 Pepper — — 12 1 12 1 8.3 Mustard — — 14 — 14 — — Vinegar — — 11 — 11 — — Self-raising Flour — — 21 — 21 — — Peas 2 2 4 1 6 3 50.0 Whiskey — — 11 3 11 3 27.2 Ale 7 — — — 7 — — Cream 2 2 13 5 15 7 46.6 Preserved Cream — — 18 — 18 — — Sausages — — 8 — 8 — — Fish Paste — — 14 — 14 — — Port Wine — — 3 — 3 — — Borax — — 6 1 6 1 16.6 Olive Oil — — 15 — 15 — — Lemon Curd 6 — — — 6 — — Meat Pies 10 1 — — 10 1 10.0 Shredded Suet 6 — — — 6 — — Apples — — 10 — 10 — — 581 11 419 12 1,000 23 2.3 73 Proceedings were instituted in the undermentioned case:— Defendant. Offence. Result. Penalty. Costs. David Owen, 797, Fulham Road Selling milk adulterated with 7 per cent, of added water Dismissed. Warranty proved. — — Wm Reekie, 52, Pursers Cross Road (milk roundsman) Selling milk adulterated with 7 per cent, of added water Dismissed. Magistrate doubtful. — — General Sanitary Administration. Bacteriological Work.—The following bacteriological examinations were made during 1925 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, of 2,959 specimens examined, only 236 were done by the Clinical Research Association, the remainder being done in the Borough Laboratory. Bacteriological examinations made during the year 1925:— Material from cases of suspected diphtheria— Diphtheria bacillus isolated 70 Negative result 1,023 — 1,093 Blood from cases of suspected Enteric Fever— Widal reaction for typhoid or para-typhoid obtained 5 Negative result 9 — 14 Pathological specimens for enteric organisms— Positive result Nil Negative result 1 1 Sputa from cases of suspected tuberculosis— Tubercle bacillus found 260 „ „ not found 1,467 1,727 Examinations of urine 51 Blood counts 13 Other examinations 60 — 124 2,959 74 Disinfection.—The following rooms were disinfected and cleansed after infectious disease:— Rooms fumigated after Scarlet Fever 401 „ „ Diphtheria 268 „ „ Measles 125 „ „ Phthisis 318 „ „ Erysipelas 48 „ „ Encephalitis Lethargica 6 „ Smallpox 8 „ Chickenpox 5 „ „ Polio Myelitis 1 „ „ Cerebro Spinal Meningitis 1 „ „ Puerperal Fever 29 „ „ Scabies 17 „ „ Enteric Fever 11 „ „ Pneumonia 3 „ „ Mumps 3 „ „ for Vermin 36 Rooms sprayed 29 „ fumigated by request 107 1,416 The following articles were disinfected at the Council's Disinfecting Station :— Articles. From Private Houses. From Institutions. Total. Beds 663 663 Mattresses 796 139 935 Palliasses 151 —. 151 Spring beds 7 — 7 Pillows 2,044 123 2,167 Cushions 373 — 373 Bolsters 683 — 683 Blankets 2,014 419 2,433 Sheets 1,176 187 1,263 Covers 314 — 314 Counterpanes 776 37 813 Curtains 126 — 126 Carpets 329 — 329 Hearth rugs 433 — 433 Articles of clothing 2,872 418 3,290 Eiderdowns 222 — 222 Sundries 663 39 702 13,641 1,362 15,004 75 Public Mortuary.—84 bodies were removed to the Mortuary during the year and were admitted as follows:— By order of the Coroner 67 Brought by Police 10 For convenience till funeral 7 84 70 post-mortem examinations were made, and inquests were held in 77 cases. Sanitary Inspection of the District.—The following inspections of dwelling-houses were made during 1925 by the District Sanitary Inspectors:— Cause. Premises Inspected. * In consequence of complaint 2,223 In consequence of infectious disease 891 House-to-house inspections 250 Re-inspections 14,304 * 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., 1925. Number served. Number complied with up to 31st Dec., 1925. 2,599 2,324 460 393 The following works were carried out and repairs effected as a result of the action of the Sanitary Inspectors:— Drains tested 1,553 Drains relaid 159 Drains repaired 587 Soil pipes renewed 173 76 Soil pipes repaired 113 Eaves and downspouting repaired 680 Sinks renewed or repaired 406 W.Cs. and flushing apparatus repaired 672 Cisterns cleansed and covered 360 Water supply provided from main 103 Yards and forecourts paved 443 Roofs, chimneys and walls repaired 1,022 Dustbins provided 556 Dampness of walls remedied 806 Internal house repairs done 3,205 Rooms cleansed 3,833 Overcrowding abated 38 Other nuisances abated 1,314 The following additional matters were dealt with by the Sanitary Inspectors:— Ice-cream premises— Number of inspections 173 Other food premises— Number of inspections 1,025 Smoke nuisances— Complaints 10 Observations 160 Notices served 2 Number abated 3 FACTORIES, WORKSHOPS AND WORKPLACES. I.—Inspection of Factories, Workshops and Workplaces. Inspections made by Sanitary Inspectors. Premises. Number of Inspections. Written Notices. Prosecutions. (1) (2) (3) (4) Factories (including factory laundries) 147 22 — Workshops (including workshop laundries) 160 29 — Workplaces (other than outworkers' premises) 50 2 — Total 357 53 — 77 II.—Defects found in Factories, Workshops and Workplaces. Particulars. Number of Defects Found. Remedied. Referred to H.M. Inspector. Number of Prosecutions. (1) (2) (3) (4) (5) Nuisances under the Public Health Acts:— Want of cleanliness 12 12 — — Want of ventilation — — — — Overcrowding 2 2 — — Want of drainage of floors — — — — Other nuisances 5 5 — Sanitary accommodation— Insufficient 1 1 — — Unsuitable or defective 18 18 — — Not separate for sexes — — — — Offences under the Factory and Workshops A cts:— 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 38 38 — — In addition 727 visits of inspection were paid to the premises of outworkers and 24 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 1925:— Notices Visits. served. To verminous cases 28 11 Food kitchens 325 16 *Special housing supervision 843 277 *This relates to special house-to-house inspections carried out from time to time during the year in the bad area of Rock Avenue, Walham Avenue, Lodge Avenue and Heckfield Place. 78 Drainage of buildings.—The following drainage plans were submitted to and approved by the Public Health Committee during 1925:— Plans for drainage of new buildings, including block of flats (36), shops and flats (18), lockup shops, studios, bank, public-house, billiard hall, laundries, garages, covered tennis courts 67 Additions to existing buildings 39 Reconstruction of the drains of existing building 91 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 1,577 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.. H. Stokes, 98, The Highway, Moulscombe, Brighton. Nuisance—78, Estcourt Road. Withdrawn. Work done. — — Mrs. C. L. Holden, 57, Comeragh Road. Failing to abate nuisance at 57, Comeragh Road. Dismissed. Defendant not the "owner." — — Mrs. C. L. Holden, 57, Comeragh Road. Failure to comply with order to amend drains at 57, Comeragh Road. Dismissed. Defendant not the "owner." — Edward T. Fountain, 15, Edith Road. Nuisance from overcrowding. Order to abate. — — James W. Adams, 5, Lurgan Avenue. Nuisance from overcrowding. Order to abate. — — Maurice de Maire, 3, Vernon Street. Nuisance from overcrowding. Order to abate — — James S Harman, 35, Earl's Court Road Nuisance at 32, Munster Road Order within 14 days. — 1 1 0 James S. Harman, 35, Earl's Court Road. Nuisance at 4, Mimosa Street. Order within 14 days. — 1 1 0 James C. Warren, 28, North End Road. Nuisance from overcrowding. Order within 14 days. — 3 0 Mrs. Francis, 45, Crefeld Road. Nuisance from overcrowding Order within 1 month. — 3 0 Bertie R. Taylor, 45, Crefeld Road. Nuisance from overcrowding. Order within 1 month. — 3 0 Herbert G. Bosher, 42, St. Dunstans Road. Nuisance from fowls. Order within 7 days. — 1 1 0 Chas. Turnham, 80, Claybrook Road, Nuisance from overcrowding. Withdrawn. Nuisance abated. — — 79 Defendant. Offence. Result. Penalty. Costs. £ s. d £ s. d. Catherine Rich, 40, Epple Road. Nuisance—1st floor back room. Withdrawn. Defendant gone to Infirmary. — James S. Harman, 35, Earl's Court Road. Nuisance—6, Waldemar Avenue. Order within 14 days. — 1 1 0 Anley & Co., 853, Fulham Road. Nuisance—2, Strode Road. Withdrawn Nuisance abated. — Mrs. Sarah Rowe, 38, Comeragh Road. Nuisance at 38, Comeragh Road. Order within 7 days. — 3 0 Mrs. Sarah Rowe, 38, Comeragh Road. Failing to provide dustbin. Convicted 2 0 3 0 James S Harman, 35, Earl's Court Road, Kensington. Failing to comply with nuisance order re 32, Munster Road. Convicted 5 0 0 — Miss Bentley, 103, Sydney Street, Chelsea. Failing to abate nuisance at 113 Moore Park Road. Order within 21 days. — 2 8 0 Miss Bentley, 103, Sydney Street, Chelsea. Neglecting to repair drains at 113, Moore Park Road. Withdrawn. Work done — — John Pearce, 21, Rock Avenue. Overcrowding nuisance. Order within 28 days. — 3 0 John Smiles, 22, Star Road. Obstructing Sanitary Inspector in execution of duties in Munster Road. Convicted 1 0 0 — John Smiles, 22, Star Road. Assaulting Sanitary Inspector. Convicted 2 0 0 2 2 0 James S. Harman, 35, Earl's Court Road, Kensington. Failing to comply with nuisance order re 6, Waldemar Avenue. Adjourned — — Violet R. Francis, 45, Crefeld Road. Overcrowding, 45, Crefeld Road Withdrawn. Nuisance abated. — — James S. Harman, 35, Earl's Court Road, Kensington. Vermin—34, Munster Road. Adjourned — —— lames S. Harman, 35, Earl's Nuisance at 34, Munster Road. Adjourned — — Court Road, Kensington. James S. Harman, 35, Earl's Court Road, Kensington. Nuisance at 397, New King's Road. Adjourned — — Miss M. Pigott, "The Rhos," Picton, Haverfordwest. Nuisance at 14, Dieppe Street. Order within 21 days — 4 0 Mrs. Pigott, 14, Dieppe Street. Nuisance at 14, Dieppe Street. Order within 7 days. — 3 0 Harry Savage, 21, Chelmsford Street. Nuisance from fowls. Withdrawn. Abated. — — John D. Bird, 132, Lillie Road. Unlawfully occupying underground room. Convicted 1 0 0 — H. A. Raven, 143, Estcourt Road. Constructing drain without notice. Convicted 10 0 1 1 0 Fred. Mellor, 41, Chippenham Road, Paddington. Nuisance at 2a, Everington Street. Withdrawn. Work done. — — Florence P. Bennett, 30, Ongar Road. Nuisance at 30, Ongar Road. Withdrawn. Work done. — — Stephen J. Chapman, 5, Albert Mews. Nuisance from overcrowding. Order within 28 days. — — Patrick J. Murphy, 31, Breer Street. Nuisance from overcrowding. Adjourned. — — R. V. Notley, Hounslow Road, Feltham. Nuisance at 27, Biscay Road. Withdrawn. Work done. — — 80 Rat Destruction.—Poison was laid as follows by the Rat Officer during the year:— Private houses 257 Other premises 19 Sewers 421 £17 3s. was paid by property owners to the Council for the services of the Rat Officer in connection with the above work. Poultry Keeping. During the past year or two many complaints reached this department as to the sanitary condition of premises, particularly in back yards, used for the keeping of poultry. I came to the conclusion that it was necessary to draft some regulations which might be used by, and form a standard for, the Sanitary Inspectors in this regard. I, therefore got in touch with the National Poultry Council, and after some correspondence I drew up the following set of regulations, which were approved by the Council:— (a) 1. Fowls kept in back yards less than 400 sq. ft. in size should be kept on the intensive system, i.e., their run should be completely roofed over; the floor should be of some hard material, for example cement, wood or hard beaten earth, upon which should be placed a sufficient amount of scratching material. 2. The run must be boarded up sufficiently high all round so as to prevent scratching material being scratched out into the yard. 3. Fowls should not have less than 6 sq. ft., of floor space per bird in the run. 4. Fowls should not on any account be allowed out of the hen-house into the yard. 5. Hen-houses must not exceed 6 ft. in height and must be placed as far from a dwelling-house as possible. 6. Not more than one-third of the total yard space should be taken up with hen-houses. 7. The greatest cleanliness must be maintained, manure must be removed regularly, and no food left lying about so as to attract rats and other vermin. 81 8. There must be no offensive odour. 9. No open run without a roof may be used in any yard under 400 sq. ft., in size, and where such outside run is provided it must be kept sweet and clean, the earth, sand or gravel must be well drained to avoid a sloppy condition in wet weather, and the material of the run must be entirely renewed as often as is necessary. (b) That any premises or place within 10 feet of any dwellinghouse shall be deemed for the purposes 'of Section 18 of the Public Health (London) Act, 1891, to be a place unfit for the keeping of poultry. These Regulations have not the force of By-Laws as they are merely instructions to poultry keepers and Sanitary Inspectors and as such have been found extremely useful and tend to lead to some uniformity in dealing with this somewhat difficult matter, and one has the knowledge that in any prosecution owing to contravention of these regulations the defendant will not be backed by the National Poultry Council. The question of making by-laws to deal with this subject was considered, but it was thought that such by-laws as would be accepted by the Ministry of Health would not be of as much use to us as these regulations of our own. Poultry keepers are given copies of these regulations when necessary and are told that in the opinion of the Council any contravention of these regulations will render them liable to prosecution either under Sections 2 to 4 of the Public Health (London). Act for causing a nuisance, or under Section 18 of the Public Health (London) Act, 1891. This latter section provides that " where it is proved to the satisfaction of a petty sessional court that any locality, premises, or place are or is unfit for the keeping of any animal, the court may by summary order prohibit the using thereof for that purpose for the future." It was necessary to take one prosecution with regard to the keeping of fowls during the year. The magistrate made an order that the keeping of poultry on these premises should be given up within seven days and granted the Council one guinea costs. Since this prosecution no further difficulty has been experienced in dealing with such cases. 82 Method of Collection and Disposal of House Refuse. A weekly collection of house refuse by direct labour is in force in this Borough. In the case of certain public services such as hospitals and large blocks of flats, however, two or more collections per week are made as circumstances require. Under this system the number of complaints is negligible, although representations have been made from time to time for more frequent collections in summer especially in cases where the dustbin accommodation is restricted. In this connection, the Council circularised the ratepayers offering certain suggestions as to the maintenance and use of dustbins, particularly in regard to the elimination of liquid refuse and wrapping up all offensive refuse before placing it in the bins. Experience shows that where these precautions are adopted and the capacity of the dustbin or bins is sufficient to contain the refuse between collections no inconvenience from smell need arise even during hot weather. The refuse is mainly collected by horsed vans, but mechanical vehicles, with a capacity of two tons each, with low bodies to facilitate loading, are being successfully used in the outer districts, and it is proposed to purchase more of such vehicles. The bulk of the refuse is dealt with at the Refuse Destructor, but as the maximum capacity of this plant is approximately 110 tons per day, about 7,000 tons annually is barged away under contract. The Destructor was erected in 1901, and the question of its reconstruction is under consideration with a view to making it of sufficient capacity to deal with the whole of the refuse in the Borough, and at the same time embody the latest methods of destruction and handling of the materal. A Flag-making plant, a Clinker crushing and riddling plant and also a Bituminous mixing plant have been installed in conjunction with the Destructor. 83 These adjuncts, together with the value of the steam which can be raised from the refuse by an up-to-date destructor plant, render this method of disposal one of the most serviceable from an economical and sanitary point of view. The clinker, when treated through the plant, forms excellent roads, and there is an increasing demand for it in other directions. Steam has been supplied to the adjoining Electricity Works from the Destructor for a number of years but the present plant is now out of date for this purpose' The total amount of refuse collected for the twelve months ended 31st December, 1925, was 36,777 tons, of which 7,769 were barged away, the remainder being dealt with at the Destructor. Housing. •Rent and Mortgage Interest Restrictions Act, 1923.— Nineteen applications for certificates under the above Act that " the house is not in a reasonable state of repair " were received. Certificates were granted in four of these cases. In 15 other cases the necessary repairs were carried out at once by the owners, thus obviating the issue of the certificate. The use of this means of enforcing repairs appears to be increasing amongst certain tenants. It is naturally a potent means of persuading owners to do any necessary work, as failure on his part to carry out such repairs as may be necessary and the issue of the certificate by the Sanitary Authority means that the owner will lose that part, 25 per cent., of the increased rent which is allowed in order that the house may be kept in a reasonable state of repair. It is found in practice, that the majority of owners will sooner carry out the required repairs than lose the additional rent for an indefinite time. One difficult point with regard to these certificates is to judge fairly as between owner and tenant as to what constitutes the house being " in a reasonable state of repair." One must of course take into account 84 the locality, the type of house, the rent paid and in many cases also the type of tenant. Every case for a certificate under this Act is brought before the Public Health Committee, who use their discretion as to whether they will or will not act upon the report of the Sanitary Inspector. As a matter of fact, during the past year the opinion of the Sanitary Inspector has been upheld by the Committee on every occasion. Houses Let in Lodgings.—During 1925, the proposed by-laws under Section 26 of the Housing Act, 1925, in respect of houses let in lodgings, were still further deliberated upon by the County Council and the Metropolitan Borough Councils. As an outcome these by-laws have, early in 1926, been approved by the Minister of Health, with certain modifications. The main modification made by the Minister is the definition of " houses let in lodgings." In the draft by-laws a lodging-house was defined as " a house or part of a house intended for use or occupation by the working class let in lodgings and occupied by the members of more than one family, but shall not include a house in which the tenant resides on the premises and in which not more than two persons in addition to the tenant and his family also reside at any one time." The definition as modified by the Minister of Health excepts from the classification of a lodginghouse " a house in which the tenant resides on the premises and in which not more than one family is lodged." This alteration will meet to some extent the objections raised by many members of the Public Health Committee as to the wide scope of the original definition, but at the same time I am doubtful from a purely public health point of view whether the revised definition is an improvement, for it will certainly exempt from the provisions of the by-laws many houses to which it is desirable they should apply. It is hoped gradually to put these by-laws into operation during 1926. During the five-year period under review no action has been taken under the old by-laws of the Metropolitan Borough Council as they were found in practice to be comparatively useless. 85 Housing Repairs.—In my Annual Reports for 1922, 1923 and 1924, I gave in very full detail an account of the Council's activities under Section 28 of the Housing, Town Planning, etc., Act, 1919, now superseded by Section 3 of the Housing Act, 1925. I wiH only therefore in this report summarise the work which was done. Dyring the years 1921 and 1922, this Section was freely used by the Sanitary Inspectors. In 1921 376 notices were issued and in 1922 686 such notices, requiring owners to do the necessary repairs to make the house in all respects reasonably fit for human habitation. During this period some £2,105 was spent by the Borough Council on carrying out the necessary repairs under this Section in default of the owners. It was found in practice, however, that it was extremely difficult in certain cases to recover this money from the owners, owing to certain legal technicalities, and in the case of two Ministry of Health Inquiries the sums of £26 odd and £19 odd were deducted from the Borough Council's claims. In another case the Borough Council claimed the sum of £29 10s. 3d., and proceeded to endeavour to recover this amount from the owner by legal process. The stipendiary magistrate, however, in place of the sum of £29 10s. 3d., only awarded the Borough Council the sum of £10. After these and other similar experiences the Borough Council decided to proceed in the matter of housing repairs as a general rule under the Public Health (London) Act, 1891, and only to make use of Section 3 of the Housing Act, 1925, in exceptional cases. During the year under review it was found necessary to carry out certain repairs to numbers 5 and 7, Campbell Street, in default of the owners. The account for this work has not yet been rendered by the contractors, but every endeavour will be made in due course to recover this from the owners. House-to-House-Inspections have been continued during 1925 as in previous years and this has been carried out by each of the district inspectors. During the five years of this survey report the following number of house-to-house inspections have been made:— 86 1921 245 1922 444 1923 97 1924 206 1925 250 The sudden drop in the number of house-to-house inspections at the end of 1922 was due to the fact that the appointment of the temporary housing inspector was terminated in June, 1923. This inspector was responsible for a large number of the inspections done in 1922 and much of his time in the early months of 1923 was spent in following up the notices which had been served during the previous year. I am still of the opinion that considerably more houseto-house inspections should be done in the Borough, and I have consistently urged the Sanitary Inspectors to devote more of their time to this branch of their duties, but with the many other duties laid upon them by statute it seems almost impossible for them to give as much time as I should like to this work. There has been, however, a considerable improvement in this regard during the early months of 1926, and if the rate of house-to-house inspections carried out during the first quarter of 1926 is continued for the rest of the year, it should be possible to cover about 400 houses. I would strongly urge the Committee to maintain these inspections at the very least at 400 per year. In my Annual Report for 1924, I urged that it would be of the greatest possible advantage to the Borough to have one or more special housing inspectors and I am still of the same opinion even despite the increase in the number of inspections done by the district inspectors. Closing Orders.—During the five years dealt with in this report, there have been three closing orders of some magnitude carried out in the Borough. The first order made in 1922 concerned numbers 1 to 7, Sotheron Road. With the exception of numbers 4, 5 and 6, these houses are now closed. It is hoped to accommodate the remaining tenants in the Council's new Housing Scheme in Wyfold Road, and a demolition order has now been made with regard to this block of 87 houses. The second closing order concerned numbers 61 and 63, Aspenlea Road. These premises which comprised a number of tenements, with a large common yard in the centre, were found in a very bad sanitary condition and much dilapidated. The inhabitants of this yard were mainly Italians, who made ice-cream in small lock-up premises under the tenements in which they lived. Notices were served upon the owner in September, 1922, under Section 28 of the Housing, Town Planning, etc., Act, 1919. The owner served a counter-notice that the premises were incapable, without reconstruction, of being made fit for human habitation, and declaring his intention of closing the premises for human habitation. The Council accepted this Closing Order on the 29th November, 1922. The District Surveyor, who had previously inspected the premises, then served notices under the London Building Act, certifying the structure as dangerous, and the whole yard was consequently demolished about the end of the year. Eleven families were turned out. Nine succeeded in finding other accommodation, while two families went into the Workhouse. The third Closing Order was made in 1924 and concerned a little group of houses facing the old Walham Green and known as Nos. 1 and 3, Jerdan Place, and 4, 6, 10, 12 and 14, Vanston Place. 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 a Closing Order and evict the tenants. The property was subsequently demolished upon the order of the District Surveyor. 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 88 empty houses in the Borough in order to house the remaining five families consisting of 23 persons. I consider the three Closing Orders to which I have referred above as being absolutely necessary for the welfare of the inhabitants. Particularly in the cases of Aspenlea Road and Jerdan and Vanston Places the conditions under which the tenants were living were a disgrace to a Metropolitan Borough. No closing orders have been made during the year 1925. Housing Accommodation.—The Borough Council decided during the year 1925 to embark upon a small housing scheme. After many very great difficulties a suitable piece of land was secured in Wyfold Road and as I write the first block of buildings is nearing completion. This scheme will provide accommodation for 36 families in small three and four-roomed flats. An enormous number of applications have already been received and, moreover, the whole of these flats could be filled by families at present living in one room only in various parts of the Borough. Although this scheme is naturally a small contribution to the housing problem it is none the less welcome. As I have stated, however, in my previous reports, this Borough already bears upon it a number of persons per acre much in excess of London as a whole and as much as it should be called upon to bear. In Fulham we have 93 persons to the acre as compared with 60 persons to the acre for London. In this regard I feel I may be pardoned for repeating what I wrote in my last Annual Report. 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 89 outside ? The housing problem of 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. In dealing with housing accommodation in Fulham, I have obtained information through the kindness of the secretaries of the War Seal Mansions and the Lewis Trust Buildings as to the number of flats erected by them during the past five years. The War Seal Foundation have erected 72 flats during these five years and now have some 470 tenants accommodated in 138 flats, some flats having been erected prior to 1921. The Lewis Trust Buildings in Walham Green have provided during the last five years 372 flats, giving accommodation to 1,993 persons. Housing Conditions. Year ending 31st December, 1925. Number of new houses erected during the year :— (a) Total 0 (b) With State assistance under the Housing Acts, 1919, 1923 or 1924 (i) By the Local Authority 0 (ii) By other bodies or persons 0 1. Unfit dwelling houses :— (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 3,367 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 250 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 2 (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 2,621 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 408 90 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 0 (2) Number of dwelling-houses which were rendered fit after service of formal notices :— (a) by owners 0 (b) by Local Authority in default of owners 2 (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close 0 B.—Proceedings under Public Health Acts :—- (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 763 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) by owners 703 (b) by Local Authority in default of owners ... 0 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 0 (2) Number of dwelling-houses in respect of which Closing Orders were made 0 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit 0 (4) Number of dwelling-houses in respect of which demolition orders were made 0 (5) Number of dwelling-houses demolished in pursuance of demolition orders 0 91 CONTENTS. Page. Babies' Hospital 24 Bacteriological work 73 Bakehouses 71 Births, notification of 20 Day Nursery 25 Death, causes of 13 Disinfection 74 Drainage of buildings 78 Factory and Workshops Acts 76 Food 67 Food, unsound 72 Food preparing places 69 Home Nursing 31 House refuse, disposal of 82 Housing 83 Housing conditions 89 Infantile mortality 13 Infant Welfare Centres 23 Infectious diseases 34 Infectious disease among parturient women and infants 29 Introductory 5 Legal Proceedings (Sanitation and Housing) 78 Legal Proceedings (Food and Drugs Acts) 73 Maternity and Child Welfare 20 Maternity Home 26 Milk, provision of free 28 Milk supply, control of 69 Milk (Special Designations) Order, 1923 71 Poor Law Relief 33 Poultry keeping 80 Public Health (Tuberculosis) Regulations 66 Public Mortuary 75 Rat destruction 80 Samples purchased for analysis 72 Sanitary administration (General) 73 Sanitary inspection of the district 75 Slaughterhouses 69 Staff—Public Health Department 4 Tuberculosis 42 Tuberculosis Dispensary 43 Vaccination 32 Venereal disease 40 Vital statistics 8