FUL 25 Metropolitan Borough of fulham. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1926. JOHN SULLIVAN, M.B., Ch.B., D.P.H., Medical Officer of Health. 3 Fulham Borough Council PUBLIC HEALTH COMMITTEE. Chairman : Councillor W. Fowell. Vice-Chairman : Councillor G. L. Hodge. His Worship The Mayor (Alderman W. J. Waldron, J.P.), Ex-officio. Councillor H. M. Bowden. Councillor A. W. Driver. ,, F. J. Bellenger. „ A. W. Ford. „ Mrs. W. Brooks. „ C. Harwood. „ W. R. Corbin. „ C. Lancaster. ,, Mrs. H. L. Cummins. „ Miss H. A. Packer. „ . H. Dodimead. „ G. Solley. Councillor W. Wilcox. MATERNITY AND CHILD WELFARE COMMITTEE. Chairman : Councillor F. J. Bellenger. Vice-Chairman : Councillor Mrs. H. L. Cummins. His Worship The Mayor (Alderman W. J. Waldron, J.P.), Ex-officio. Councillor Mrs. W. Brooks. *Mrs. Corbin. S. T. Cave. *Mrs. Pritchard. H. Dodimead. *Mrs. Van den Bergh. G. L. Hodge. *Miss C. M. L. Wickham. „ C. Lancaster. * Co-opted Members. 4 STAFF IN THE PUBLIC HEALTH DEPARTMENT. Medical Officer of Health:— *John Sullivan, M.B., Ch.B.(Edin.), D.P.H.(Lond.). Assistant Medical Officers of Health:— *F. W. Hamilton, M.D.(Lond.), M.R.C.P.(Lond.), D.P.H.(Oxon.) (Tuberculosis Officer). *Ruby Thomson, M.B., Ch.B., D.P.H.(Edin.). *G. F. Hardy, M.C., M.R.C.S. (Eng.), L.R.C.P. (Lond.). 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. I. Wacksmith. B. P. Garrod. Senior Sanitary Inspector :— '♦Charles Bristow Jones (Food and Drugs). Sanitary Inspectors :— 1*Frederick H. Manning. 12♦Charles B. Lloyd. 13♦Alfred J. Parsons. 1♦Albert E. Clutterbuck. 1♦Edgar Drake. 12♦Thomas H. Robey. 12♦John Castley. 1♦John A. H. Brownlow. 1♦Mrs. M. E. Davies. Health Visitors :— 156♦Miss M. L. Durnford. 456♦Mrs. J. Bryning. 456♦Miss E. Beckett. 146♦Miss A. Perrett. 456♦Miss M. Green. 1456♦Miss W. K. Watts. Tuberculosis Dispensary Staff:— Nurses : '♦Miss J. Tinnion. '"♦Miss M. A. Shepherd. 46♦Miss R. Bowen. ♦Miss M. C. Robinson, Dispenser and Laboratory Assistant. ♦Miss M. E. Sargent, Clerk and Secretary of the Care Committee. ♦Miss Step, Clerk (part-time). ♦Mr. and Mrs. Roberts, Caretakers. Matron of Maternity Home: '"♦Miss M. Bustard. Assistant Matron : '"♦Miss M. M. Wedick. Superintendent of Disinfecting Station : H. Toy. Disinfectors : E. J. Eyles, W. Leaton, G. Passenger. Van Driver : A. V. Williams. Mortuary Keeper : D. MacKay. Rat Officer : H. W. Harvey. •The Council receives Exchequer grant towards the salaries of these Officers. 'Certified Sanitary Inspector. 4Trained Nurse. 2Food Inspector's Certificate. 5Health Visitor's Certificate. 3Registered Plumber. 6Certificate of Central Midwives Board. 5 Town Hall, Fulham, S.W. 6. July, 1927. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Fidham. Mr. Mayor, Ladies and Gentlemen, I have the honour to submit the Annual Report on the vital statistics and sanitary condition of the Borough for the year 1926. I was appointed Medical Officer of Health on 17th June, 1926, having acted in that capacity since 15th May, when Dr. Hewat's resignation came into effect on his appointment as Senior Medical Officer to the London County Council. The present organisation of the Public Health Department was evolved under the administration of the late Dr. Jackson, and its success was mainly due to his work, initiative and imaginative outlook. This work has been ably continued and built up by Dr. Hewat during his four years of office. Apart from the official public health work of the County and Borough Councils, Guardians, Metropolitan Asylums Board and insurance Medical Services, Fulham possesses several Voluntary Committees whose activities are of great value. The Maternity and Child Welfare Centres, the Babies' Hospital, the Day Nursery and the District Nursing Association are managed by Voluntary Committees and all perform essential services. The work of the Council and of the medical practitioners is supplemented in various ways by the Charity Organisation Society, the Invalid Children's Aid Association, the United Services Fund, the British Red Cross Society, the Children's Country Holiday Fund, the Women's Holiday Fund and the British Social Hygiene Council. It will be seen from the report that the estimated population, 164,300 for the year 1926, is the highest ever recorded for the Borough, but that the birth-rate has fallen from 16.9 per thousand of the population in 1925 to 16.2 per thousand in 1926. As an offset 6 to this declining birth-rate, however, the infantile mortality, 64 per thousand registered births during the year under review, is equal to that in 1923, which was the lowest recorded up to that time. The general death-rate has risen very slightly, being 10.8 per thousand of the population in 1926, compared with 10.7 during 1925. Nine hundred and thirty-eight, or 52.6 per cent. of the total deaths, were caused by five diseases, cancer, heart diseases, tuberculosis, pneumonia and bronchitis. During 1926 cancer occupied first place, whereas in 1925 heart diseases caused the highest mortality. During 1926 several changes took place in the personnel of the staff of the Public Health Department. The Council were fortunate in securing the services of Dr. F. W. Hamilton as Tuberculosis Officer and Assistant Medical Officer of Health. He was for many years Assistant Tuberculosis Officer to the Boroughs of Bethnal Green and Hackney. Mr. J. A. H. Brownlow entered on his duties as Sanitary Inspector in August, succeeding Mr.M. Canton, and Miss R. Bowen commenced duty as Tuberculosis Nurse in June on the resignation of Miss H. Turner. I have to record with great regret the death of ex-Councillor Booth, who was a member of the Council for 13 years, and a past Chairman of the Public Health Committee. I wish to acknowledge with gratitude the capable and strenuous work and help I have received personally from all members of the staff of the department since I entered on my duties. In conclusion I desire to express my appreciation of the kind consideration shewn to me by the Chairmen and Members of the Public Health and Maternity and Child Welfare Committees, and of the Council generally, and also to my colleagues in other Departments. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, JOHN SULLIVAN, Medical Officer of Health. 7 1.—General Statistics. Area (acres) 1,706 Population 164,300 No. of inhabited houses (1921 census) 25,979 No. of families or separate occupiers (1921 Census) 40,436 Rateable value £1,083,798 Sum represented by penny rate £4,489 2.—Extracts from Vital Statistics of the Year. Births— Total. Males. Females. Legitimate 2,505 1,289 1,216 Birth-rate 16.2. Illegitimate 165 79 86 Deaths 1,783 873 910 Death-rate 10.8. No. of Women dying in, or in consequence of, child-birth— From sepsis 3 „ other causes 7 Deaths of Infants under one year of age per 1,000 births— Legitimate 63 Illegitimate 91 Total 64 Deaths from— Measles (all ages) 47 Whooping cough (all ages) 6 Diarrhoea (under 2 years of age) 30 Population.—The Registrar-General has estimated the population of the Borough at the middle of 1926 to be 164,300. (Males, 76,073; females, 88,227.) Marriages.—The number of marriages registered was 1,265, and the marriage rate, i.e., the number of persons married per 1,000 of the population, was 7.7. In the two preceding years the marriages numbered 1,305 in 1925, and 1,288 in 1924, thus showing a decrease of 40 for 1926. 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 2,670, of whom 1,368 were boys and 1,302 were girls. The 8 birth-rate was 16.2 per 1,000 inhabitants, being 0.7 per 1,000 below that of 1925. The birth-rate for the whole of London was 17.1, and for England and Wales 17.8. Illegitimacy.—The illegitimate births numbered 165 (79 males, 86 females), or 6.2 per cent. of the total births, against 51 in 1925 and 4.4 in 1924. Natural increase of the Population.—The natural increase of the population by excess of births over deaths was 887, against 1,017 in 1925, and 1,147 in 1924. Deaths.—During the year ended 31st December, 1926, 1,578 deaths were registered in the Borough. Of these, 168 were of persons not belonging to the Borough, while 373 inhabitants of Fulham died outside the Borough, chiefly in various public institutions. There were, therefore, 1,783 deaths of persons—873 males and 910 females—having their usual residence in Fulham, representing an annual rate of 10.8 per 1,000 of the estimated population, being 0.1 per 1,000 above that of 1925. The death rate of males was 11.5, of females 10.3. The following comparative death-rates are of interest:— Death-rates, 1926— England and Wales 11.6 London 11.6 105 large towns (average) 11.6 Fulham 10.8 Zymotic deaths.—The mortality from zymotic diseases was higher than in 1925, 103 deaths being due to the seven principal epidemic diseases, against 88 during 1925. The zymotic death-rate was 0.6 per 1,000 of the population, as compared with 0.53 for 1925. 9 Seasonal mortality.—The mortality in the four quarters of the year under review was as follows:— Deaths. Death-rate. First Quarter 500 12.1 Second Quarter 416 10.1 Third Quarter 377 9.1 Fourth Quarter 490 11.9 It will be noted that the highest seasonal mortality occurred during the first quarter of the year, whereas during 1925 the mortality was highest during the fourth quarter. This was due to the epidemic of measles which commenced in the Autumn of 1925 and assumed its maximum height during the month of February, 1926. The following table shows the diseases which caused the largest number of deaths in 1926. Deaths Caused by the five Principal Diseases. Disease. Males. Females. Both Sexes. Percentage of total deaths. Cancer 117 145 262 14.6 Heart diseases 85 110 195 11.0 Tuberculosis (all forms) 105 73 178 10.0 Bronchitis 67 94 161 9.1 Pneumonia 72 70 142 7.9 Totals 446 492 938 52.6 It will be seen that 938 deaths, or 52.6 per cent. of the total, were caused by five diseases cancer, heart diseases, tuberculosis, bronchitis and pneumonia. During 1926 cancer headed the list with 262 deaths, and diseases of the heart took second place with 195. It may be mentioned, however, that in 1925 the position was reversed, as there were 259 deaths from diseases of the heart, compared with 198 from cancer, so that taking the two years together heart diseases caused four more deaths than cancer. In 1924 cancer and 10 heart diseases each caused 221 deaths. Tuberculosis was third on the list in 1926 and caused 178 deaths, compared with 173 for the previous year. Bronchitis came next, accounting for 161 deaths, compared with 135 for the previous year, and pneumonia was fifth, causing 142 deaths, as compared with 175 during 1925. It is interesting to note that diseases of the respiratory system accounted for 479 deaths or 27 per cent. of the total deaths. These were made up as follows:— Tuberculosis of the respiratory system 161, bronchitis 161, pneumonia 142, and other respiratory diseases 15. Diseases of the circulatory system caused 259 deaths, including 195 from diseases of the heart and 64 from arterio-sclerosis, but including cerebral hæmorrhage, the deaths from circulatory diseases were 337 in number. TABLE I.—Vital Statistics of the Whole Borough during 1926 and Ten preceding Years. Year Population Estimated to Middle of each Year. Births. Total Deaths Registered in the Borough. Transferable deaths.† Nett Deaths Belonging to the Borough. Uncorrected Number. Nett. Under 1 Year of Age. At all Ages. Number. Rate. Number. * Rate. Of NonResidents registered in the Borough. Of Residents not registered in the Borough. Number. * Rate per 1,000 Nett Births. Number. * Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1916 al49,428 3,600 3,754 c23.1 1,324 8.9 131 789 330 88 1,982 13.3 b162,580 1917 a145,186 2,852 2,971 c18.4 1,251 8.6 139 882 323 109 1,994 13.7 b161,841 1918 a143,211 2,593 2,672 cl6.7 1,704 11.9 186 973 286 107 2,491 17.4 b160,463 1919 al52,543 2,947 3,000 cl8.6 1,510 9.7 242 634 250 83 1,902 12.2 b155,904 1920 al58,621 4,383 4,327 c27.2 1,888 11.9 457 396 320 74 1,827 11.5 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 1926 164,300 2,691 2,670 16.2 1,578 9.6 168 373 173 64 1,783 10.8 11 (a) Estimated civil population. (b) Estimated total population. (c) Birth-rate calculated on estimated total population. Notes.—This Table is arranged to show the gross births and deaths registered in the borough 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 borough, but excluding the deaths of Soldiers and Sailors that have occurred in hospitals and institutionsn the borough. 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. † "Tr ansferable Deaths" are deaths of persons who, having a fixed or usual residence in England or Wales, die in a district other than that in which they resided. The deaths of persons without fixed or usual residence, e.g., casuals, are not included in Columns 8 or 9, except in certain instances under 3 (b) below. In Column 8 the number of transferable deaths of "non-residents" which are deducted is stated, and in Column 9 the number of deaths of "residents" outside the district which are added incalculating the nett death-rate of the Borough. The following special cases arise as to Transferable Deaths:— (1) Persons dying in Institutions for the sick or infirm, such as hospitals, lunatic asylums, workhouses and nursing homes (but not almshouses) are regarded as residents of the district in which they had a fixed or usual residence at the time of admission. If the person dying in an Institution had no fixed residence at the time of admission, the death is not transferable. If the patient has been directly transferred from one such Institution to another, the death is transferable to the district of residence at the time of admission to the first institution. (2) The deaths of infants born and dying within a year of birth in an Institution to which the mother was admitted for her confinement are referred to the district of fixed or usual residence of the parent. (3) Deaths from Violence are referred (a) to the district of residence, under the general rule ; (b) if this district is unknown, or the deceased had no fixed abode, to the district where the accident occurred, if known ; (c) failing this, to the district where death occurred, if known ; and (d) failing this, to the district where the body was found. Total population at all ages at the Census of 1921 157,938. Area of District in acres (land and inland water), 1706. 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 1,783 deaths registered, 1,617 or 90.6 per cent., were certified by registered medical practitioners, 164 by coroners after inquest, two deaths being uncertified. Deaths in Public Institutions. Fulham Hospital.—The deaths of 621 persons occurred in the Fulham Hospital, of whom 569 lived in Fulham and 52 in other districts. Western Fever Hospital.—In this institution there were 22 deaths of residents in Fulham and 99 deaths of residents in other districts. Deaths occurring outside the Borough among Persons belonging thereto.—The deaths of Fulham residents outside the Borough numbered 373, and occurred in the following places:— St. George's Hospital 43 West London Hospital 24 Other General Hospitals 88 Children's Hospitals 18 Hospitals for Women 6 Other Special Hospitals 35 Homes for Advanced cases 18 Hospitals of the Metropolitan Asylums Board 14 Poor Law Infirmaries 17 Mental Hospitals 41 Sanatoria 2 Nursing Homes, private houses and elsewhere 67 373 Of the deaths registered, 895 or 50.2 per cent., took place either in poor law institutions, in hospitals or in mental hospitals, the percentages in the various classes of institutions being as under:— Per cent. Deaths in Workhouses or Workhouse Infirmaries 34.4 „ Metropolitan Asylums Board Hospitals .7 ,, Mental Hospitals 2.2 „ Other Hospitals 12.9 50.2 13 TABLE II. Causes of and Ages at Death during the Year 1926. Nett Deaths at the subjoined ages of "Residents," whether occurring within or without the Borough (a). Total Deaths whether of "Residents" in Institutions in the District (b). Nett Deaths at all ages of "Residents " in the Wards of the Borough. Causes or Death. All ages. Under 1 year. 1 and under 2 years. 2 and under 3 years. 3 and under 4 years. 4 and under 5 years. 5 and under 10 years 10 and under 20 years. 20 and under 35 years. 35 and under 45 years 45 and under 65 years. 65 and upwards. Barons Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. All Causes Certified (c) 1,781 173 64 22 13 10 23 49 137 118 498 674 779 163 303 149 214 366 129 288 169 Uncertified 2 ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... 2 ... ... ... 1. Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... ... ... 2. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Measles 47 9 23 9 3 2 1 ... ... ... ... ... 37 1 7 9 3 13 1 11 2 4. Scarlet Fever 4 ... 1 1 1 ... 1 ... ... ... ... ... 10 1 1 1 ... ... 1 ... 5. Whooping Cough 6 3 3 ... ... ... ... ... ... ... ... ... 8 1 2 ... ... ... 2 1 ... 6. Diphtheria 14 1 3 ... ... 1 7 1 ... ... 1 ... 61 1 3 ... 1 5 ... 3 1 7. Influenza 15 ... ... ... ... ... ... 1 2 2 4 8 3 5 5 ... 2 2 1 2 ... 8. Encephalitis Lethargica 4 ... ... ... 1 ... ... ... 1 1 1 ... 1 5 3 2 z 1 1 1 2 ... 9. Meningococcal Meningitis 4 2 ... ... 1 ... 1 ... ... ... ... ... 2 ... 1 2 ... 1 ... ... ... 10. Tuberculosis of Respiratory System 161 ... 1 1 ... ... 2 12 69 23 42 11 63 8 39 10 25 28 10 31 10 11. Disseminated Tuberculosis 4 ... 1 ... ... ... ... 3 ... ... ... ... 2 ... ... 1 ... 1 ... 2 ... 12. Other Tuberculous Diseases 13 2 2 1 2 ... 2 1 ... 1 2 13 2 3 2 4 2 ... ... 13. Cancer, malignant disease 262 ... ... ... ... ... ... ... 3 21 112 126 97 33 39 18 25 46 24 40 37 14. Rheumatic Fever 8 ... ... ... ... ... ... 2 ... 1 1 4 3 ... 1 1 2 3 1 ... 15. Diabetes 14 ... ... ... ... ... ... 1 1 ... 6 6 6 2 2 ... 2 5 1 ... 2 16. Cerebral Haemorrhage, etc. 78 1 ... ... ... ... ... 1 1 ... 26 49 26 3 14 5 9 18 6 7 16 17 Heart Disease 195 3 ... ... ... ... 1 6 9 7 73 96 42 23 31 9 23 43 11 37 18 18. Arterio-sclerosis 64 ... ... ... ... ... ... ... ... ... 6 53 49 8 15 6 6 10 6 6 7 19. Bronchitis 161 9 2 1 ... ... ... ... 2 7 30 110 71 13 28 16 23 30 8 30 13 20. Pneumonia (all forms) 142 21 17 6 ... 1 1 2 7 15 43 29 53 9 28 12 19 38 9 16 11 21. Other Respiratory Diseases 15 ... 2 ... ... 1 1 ... 2 1 4 4 4 ... 2 1 4 2 ... 5 1 22. Ulcer of Stomach or Duodenum 2 ... ... ... ... ... ... ... ... ... 1 1 ... ... ... 1 ... 1 ... ... ... 23. Diarrhoea, etc. (under 2 years) 30 28 2 ... ... ... ... ... ... ... ... ... 24 ... 2 5 7 5 10 1 24. Appendicitis and Typhlitis 17 ... ... 1 ... 1 2 3 1 1 6 2 8 2 2 ... 1 3 1 10 6 2 25. Cirrhosis of Liver 18 ... ... ... ... ... ... ... 1 4 9 4 6 4 1 1 1 3 4 1 ... 26. Nephritis and Bright's Disease 42 ... ... ... ... ... ... ... 4 5 17 16 21 5 6 4 1 7 3 8 3 1 5 3 4 27. Puerperal Sepsis 3 ... ... ... ... ... ... ... 2 1 ... ... 4 1 ... ... 1 1 ... ... ... 28. Other accidents and diseases of pregnancy and parturition 7 2 ... ... ... ... ... ... 1 3 ... 1 3 ... 3 1 ... 1 ... ... 2 29. Congenital Debility and malformation, premature birth 67 65 ... ... ... ... 1 1 ... ... ... ... 29 5 9 10 8 10 3 13 9 30. Suicide 18 ... ... ... ... ... ... 1 4 3 8 2 6 2 1 1 2 4 2 4 2 31. Other deaths from violence 59 8 ... ... 2 ... 2 4 8 6 17 12 23 4 1 7 7 6 9 11 ... 32. Other defined diseases 307 19 6 2 3 4 3 9 18 17 87 139 100 32 47 23 32 75 25 45 28 33. Causes ill-defined or unknown 2 ... 1 ... ... ... ... ... ... ... ... 1 2 ... ... ... ... 1 ... 1 ... Total 1,783 173 64 22 13 10 23 49 137 118 500 674 779 163 303 149 214 368 129 288 169 14 (a) All "Transferable Deaths" of residents, i.e., of persons resident in the Borough 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 Borough, are in like manner excluded from these columns. For the precise meaning of the term "transferable deaths" see footnote to Table 1. (b) All deaths occurring in institutions for the sick and infirm situated within the Borough, whether of residents or of non-residents, are entered in column 14 of Table II. (c) All deaths certified by registered Medical Practitioners and all Inquest cases are classed as "Certified" all other deaths are regarded as "Uncertified" 15,16 TABLE III. Infant Mortality during Year 1926. Nett Deaths from stated causes at various ages under One Year of Age. Nett Deaths under One Year of Residents in the Wards of the Borough. CAUSE OF DEATH. Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3—4 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under One Year. Barons Court Ward. Lillie Ward. Walham Ward Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward All Causes Certified 44 10 10 10 74 24 32 18 25 173 11 19 29 19 38 7 35 15 Uncertified ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2. Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Measles ... ... ... ... ... ... ... ... 9 9 ... 1 3 ... 2 ... 3 ... 4. Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5. Whooping Cough ... ... ... ... ... 2 ... 1 3 1 2 ... ... ... ... ... ... 6. Diphtheria and Croup ... ... ... ... ... ... 1 ... ... 1 ... 1 ... ... ... ... ... ... 7. Erysipelas ... ... ... ... ... ... 1 ... ... 1 ... ... ... ... 1 ... ... ... 8. Tuberculous Meningitis ... ... ... ... ... 2 ... ... ... 2 ... ... 2 ... ... ... ... 9. Abdominal Tuberculosis (a) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 10. Disseminated Tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 11. Other Tuberculous Diseases ... ... ... ... ... ... 2 ... ... 2 ... ... 1 1 ... ... ... ... 12. Meningitis (not Tuberculous) ... ... ... ... ... 1 ... ... ... 1 ... ... 1 ... ... ... ... ... 13. Convulsions ... ... ... ... ... ... ... 1 ... 1 ... ... ... ... 1 ... ... ... 14. Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 15. Bronchitis ... 1 ... ... 1 2 3 1 2 9 2 2 ... ... 3 ... 2 ... 16. Pneumonia (all forms) 2 1 2 1 6 2 2 4 7 21 1 3 4 3 8 ... 1 1 17. Influenza ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 18. Diarrhœa ... ... ... ... ... 2 6 5 4 17 ... 1 3 4 4 ... 5 ... 19. Enteritis ... ... ... ... ... 2 6 2 1 11 ... 2 2 2 1 ... 3 1 20. Gastritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 21. Syphilis 1 ... ... 1 2 ... ... ... ... 2 ... ... ... ... ... ... 2 22. Rickets ... ... ... ... ... ... ... 1 ... 1 ... ... ... ... 1 ... ... ... 23. Suffocation, overlaying 1 1 1 1 4 1 ... 1 ... 6 1 ... 1 ... 1 3 ... 24. Injury by Birth 3 ... ... ... 3 ... ... ... ... 3 2 ... ... ... 1 ... ... 1 25. Atelectasis 4 ... ... 4 ... ... ... ... 4 1 ... ... ... 1 ... ... 2 26. Congenital Malformations 2 1 ... 1 4 2 1 1 ... 8 ... 1 1 ... 1 1 4 ... 27. Premature Birth 25 4 5 4 38 3 2 ... ... 43 3 4 9 6 4 1 8 8 28. Atrophy, Debility and Marasmus 1 2 1 2 6 3 5 1 ... 15 1 1 1 ... 6 1 5 ... 29. Other causes 5 ... 1 ... 6 4 1 1 1 13 ... ... 2 2 5 3 1 ... Total 44 10 10 10 74 24 32 18 25 173 11 19 29 19 38 7 35 15 Nett Births in the Year— Legitimate 2,505 Illegitimate 165 Nett Deaths in the Year of— Legitimate infants 158 Illegitimate infants 15 (a) Under Abdominal Tuberculosis are included deaths from Tuberculous Peritonitis and Enteritis, and from Tabes Mesenterica. Want of breast milk is included under Atrophy and Debility. 17 Causes of Death.—These will be found in Table II., pages 13 and 14. Infantile Mortality.—Of 1,783 deaths of persons of all ages 173, or 9.7 per cent., were deaths of infants under one year. The infantile mortality rate for the year, 64 per thousand registered births, was a marked improvement over the figure for 1925, which was 76 per thousand births, and was equal to the rate for 1923, which was the lowest ever recorded for the Borough. The rate for Fulham was much below the rates for England and Wales and for the Great and Small towns in England. The infantile mortality rate for England and Wales was 70, for the 105 County Boroughs and Great Towns 73, and for the 158 Small Towns 67. The rate for Fulham is equal to that for London as a whole, and in comparison with other Metropolitan Boroughs Fulham ties with Chelsea and Wandsworth for twelfth place. Table III records the number of deaths of infants at successive age periods under one year, both for Fulham, as a whole, and for each ward separately. It will be seen that the principal causes of death were as follows:— Premature birth 43 deaths in 1926 compared with 37 in 1925. Diarrhceal diseases (diarrhoea and enteritis) 28 „ „ „ 36 „ Pneumonia 21 „ „ „ 33 „ Atrophy, debility and marasmus 15 „ „ „ 9 „ Bronchitis 9 „ „ „ 12 „ Measles 9 „ „ „ nil. „ Seventy-four deaths of infants under four weeks occurred in 1926, which was the same number as in 1925. The fact that such a large proportion of the deaths occur in very young infants shows the importance of ante-natal care. The diminution of 38 in the number of infantile deaths in 1926 compared with 1925 was due to fewer deaths at age periods from one to twelve months from whooping cough (15 less), pneumonia (12 less) 18 and diarrhœal diseases (8 less). Fifty-three of the 173 deaths in infants or 30 per cent. were due to notifiable diseases. The infantile mortality rates for Fulham since 1886 are given in the subjoined table:— Infantile 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 1926 64 The following table shows the infantile mortality rates for the last two years (1925 and 1926) for the various wards in the Borough:— Ward. Births and birth rates. Infantile deaths. Infantile mortality rate. 1925. 1926. 1925. 1926. 1925. 1926. Baron's Court 136 (10.1) 133 ( 9.9) 13 11 95 82 Lillie 309 (11.9) 296 (11.3) 39 19 126 64 Walham 262 (19.9) 226 (17.1) 29 29 110 128 Margravine 507 (25.9) 586 (29.9) 30 19 59 32 Munster 633 (16.1) 556 (14.1) 41 38 64 68 Hurlingham 86 ( 8.7) 90 ( 9.1) 9 7 104 77 Sands End 459 (16.4) 409 (14.6) 28 35 61 85 Town 379 (25.5) 374 (25.1) 22 15 58 40 The Borough 2,771(16.9) 2,670(16.2) 211 173 76 64 19 In 1926 the highest infantile mortality was recorded in Walham Ward. In 1925 the figure was highest in Lillie Ward, whereas Lillie Ward in 1926 had the same infantile death rate as the whole of the Borough. Town Ward preserves its reputation, showing the lowest rate of all the Wards in the Borough. Maternity and Child Welfare. The Maternity and Child Welfare Scheme, which was adopted by the Council in 1919, links up the Welfare work of the Voluntary Bodies with that of the Council's Maternity and Child Welfare Department. Previous to 1919 the voluntary organisations carried out their valuable duties without official recognition, and to a large extent independently of one another. The units in the Scheme are as follows 1. Headquarters at the Town Hall represented by the Maternity and Child Welfare Department of the Borough Council, the functions of which are mainly organising and administrative. 2. The three Maternity and Child Welfare Centres, 90-92, Greyhound Road, 170, Wandsworth Bridge Road, and Melmoth Hall, Eustace Road. 3. The Fulham Day Nursery, Eridge House, Fulham Park Road. 4. The Fulham Babies' Hospital, 23, Broomhouse Road. 5. The Fulham Borough Council Maternity Home, 706, Fulham Road. The main object of these institutions is the prevention of infantile and maternal illness and mortality. It is satisfactory to be able to report that there has been a considerable fall in infantile mortality during the year, although the rate for London as a whole has increased (see page 00). Maternal deaths among Fulham residents due to conditions associated with 20 pregnancy and child-birth, which were 10 in number during 1926, compared with 11 in 1925, do not reflect the true position as the incapacity and invalidism resulting from child-birth must also be taken into consideration, hence the importance of ante-natal work and efficient midwifery practice. In addition to the care of infants and expectant and nursing mothers, which forms the basis of Maternity and Child Welfare work, Sir George Newman, in a memorandum to the Minister of Health entitled "An outline of the Practice of Preventive Medicine," points out the importance of the care of children at the preschool age. He states : "In this pre-school age there is, however, great need for preventive measures dealing with measles and whooping cough, rickets, mouth breathing, squint and certain special children's maladies particularly catarrhal and glandular conditions, due to overcrowding, airless rooms, contact, infection, faulty diet, etc. A rich harvest will reward the careful supervision and nurture at this age period." Notification of Births.—Under the Notification of Births Act, 1907, 2,540 births of living children and 76 births of still-born children were notified. 356 or 13.6 per cent. were notified by doctors, 2,092 or 80.0 per cent. by midwives, and 168 or 6.4 per cent. by fathers or persons in attendance at the birth. The still-births during 1926 were equal to 2.84 per cent. of the registered live births. By means of notification the Health Visitors are able to get into touch with mothers and children and the 1907 Act is therefore the first step in the Maternity and Child Welfare organisation. Home Visitation of Mothers and Children.—This is an essential feature of the work. Health Visitors must see that the doctor's instructions are carried out and must have cognisance of the hundred and one things necessary for the care and upbringing of infants and older children and the health of mothers. Housing conditions and accommodation and questions relating 21 to domestic and personal hygiene have to be considered so that training in the public health work is important. Training as a nurse and as a midwife is required in connection with the health and ailments of women and children. Knowledge of special branches of medicine or surgery, infectious diseases, diseases of women and children, are of great use, and experience in social work is of value if the medical work is to be supplemented by that of other agencies. On and after the 1st April, 1928, the appointment of a woman for the first time as a Health Visitor to a Local Authority will not be approved by the Ministry of Health unless (1) she is a trained nurse who has obtained the Certificate of the Central Midwives' Board and has completed an approved course of training in public health work lasting at least six months ; or (2) she has undergone an approved course of training of two years duration, together with six months training in hospital and has obtained the Certificates of the Central Midwives Board. The above mentioned qualifications are necessary for candidates for the new Certificate in Heath Visiting approved by the Ministry of Health. The qualifications of the Health Visitors in the Council's Service are stated on page 4. During the year under review the visits paid by the Health Visitors were as follows Firsts visits to infants 2,753 Re-visits to infants 11,212 Re-visits to children aged 1 to 5 years old 9,897 Visits to cases of ophthalmia neonatorum 29 „ „ measles 2,444 ,, ,, pneumonia 57 „ „ diarrhoea 44 ,, „ puerperal fever 11 Other visits 467 The Maternity and Child Welfare Centres are carried on by a voluntary committee and the Council contributes £500 a year, one half of which is repaid to the Council by the Ministry of Health. The Council 22 provides the medical and health visiting staff. The Clinics at the Centres are of two kinds: (1) ante-natal, and (2) post-natal or infant welfare clinics. The Ante-natal Clinics. (Clinics for the care of the expectant mother).—Three sessions per week are devoted to this purpose, two at the Greyhound Road Centre attended by Dr. Ruby Thomson, and one at Wandsworth Bridge Road under Dr. Dorothy Stewart. The work is co-ordinated with that of the Council's Maternity Home, of which Dr. Thomson is in charge, and it aims at the prevention and early diagnosis of the complications of pregnancy and childbirth and the reduction of maternal and infantile mortality. With a more efficient midwifery service and extension of ante-natal work much suffering and invalidism among women and many infantile deaths, especially of infants under a month, could be prevented. Midwives recommend a considerable number of patients to the antenatal Centres and medical reports are sent to them on their cases. The midwives are also informed as to the subsequent progress of their patients. Many private doctors have little opportunity for doing ante-natal work, as the majority of the midwifery cases are now attended by midwives. If treatment of the patients attending the clinics is found to be necessary they are referred to a doctor or to a hospital with a written statement of the case, and if special treatment is required, which cannot be obtained privately, the patients are referred to a hospital or special department, e.g., obstetrical, gynecological or venereal diseases department. The Post-natal Clinics.—The functions of these clinics are the care of infants and children up to school age and of nursing mothers. The women and children attend the clinics usually weekly or fortnightly and are visited in their homes by the health visitors and nurses. These centres differ from out-patient departments of children's hospitals, which are intended primarily for the treatment of sick children, whereas infant 23 welfare centres are almost entirely devoted to the prevention of illness in children and the training of mothers in mothercraft. The only methods of treatment carried out at the centres are the treatment of minor ailments, massage and remedial exercises. Dental treatment for mothers and children, operative treatment for children with enlarged tonsils and adenoids and treatment for eye defects are provided at the School Medical Treatment Centre, Bagley's Lane, Fulham, under an arrangement with the London Countv Council. The attendances at the Centre during 1926 were as follows :— Infant Welfare Clinics. Number of consultations. First attendances of babies. Total attendances. Average attendances. 92, Greyhound Road 146 503 6,148 42 170, Wandsworth Bridge Rd. 145 327 4,937 34 Melmoth Hall, Eustace Road 95 239 3,462 36 In connection with these clinics the following are details of children who attended during the year for special treatment :— At 92, Greyhound Road. Number of children who attended for massage or treatment of minor ailments 312 Number of attendances 1,130 At The School Treatment Centre, 18, Bagley's Lane. For operative treatment for enlarged tonsils and adenoids 10 For dental treatment (children) 25 For dental treatment (women) 94 Total attendances of women for dental treatment 244 Of these 94 women, 17 were provided with dentures. For visual defectsNumber of mothers treated 32 24 Ante-Natal Clinics. At 92, Greyhound Road. Number of women who attended 356 Number of attendances 1,355 At 170, Wandsworth Bridge Road. Number of women who attended 122 Number of attendances 378 Number of ante-natal visits to homes 1,099 It will be seen that 1,069 babies attended for the first time during the year and that the number of attendances amounted to 14,547 for the year. The Council's medical staff is doing everything possible to prevent encroachment on the legitimate sphere of medical men and women practising in the Borough, and I have pleasure in recording my thanks for much valuable help and co-operation from my colleagues. Co-operation between medical practitioners and medical officers in the public health service is of extreme importance for the health of the community. Although private doctors are mainly concerned with the diagnosis and treatment of their patients they have many opportunities for giving advice regarding the prevention of disease. During 1926 ten mothers and their babies were sent to the country from the Maternity and Child Welfare Clinics by the Women's Holiday Fund. Fulham Babies' Hospital, 23, Broomhouse Road, S. W. 6.—The Hospital is under the control of a voluntary Committee and is intended primarily for treatment of infants and children under five years of age suffering from dietetic disorders and malnutrition. The accommodation for such cases in children's hospitals is very limited. Children suffering from acute diseases are also admitted. The Borough Council gives a grant of £700, half of which is repaid to the Council by the Ministry of Health. 25 Fourteen beds are reserved for Fulham children, and the Battersea Borough Council also send patients for which a payment of £1 per week per case is made. The work of the Hospital is linked up with that of the Child Welfare Scheme, and Dr. Hardy (Assistant Medical Officer of Health) is in medical charge. In February, 1926, a mercury vapour lamp for artificial light treatment was installed in the Hospital through the generosity of Mrs. W. L. Leslie and an anonymous donor, and good results are being obtained in the treatment of malnutrition, wasting and rickets. Some weeks before Christmas a waiting-room and bath-room were added to the Hospital, and the kitchen was enlarged, and the re-building necessitated the closing of the small ward and reduced the number of admissions during the year. It is interesting to note that during the year 62 children were recommended by the Medical Officers of the Maternity and Child Welfare Clinics, 45 by the Fulham doctors, and 9 by the Battersea Borough Council. The following is a summary of the work done during the year. In hospital, January 1st, 1926 17 Number of babies admitted during the year 116 Average duration of stay (days) 39 Number of cases discharged :— (a) In good health 58 (b) Improvement 29 (c) No improvement 18 (d) On account of the development of infectious disease 5 Viz. :— Measles 3 Epidemic Diarrhoea 2 Number of deaths 15 Number of babies in Hospital, 31st December, 1926 13 26 The average daily number in the wards during the year was approximately 12.5, as compared with 15.5 during 1925 and 16 in 1924. During November and December only one ward was in use owing to the above-mentioned alterations being carried out. The Fulham Day Nursery, Eridge House, Fulham Park Road.—The Day Nursery is under the control of a voluntary committee, and the Borough Council contributes £300, half of which is repaid to the Council by the Ministry of Health. The Nursery is intended for the care during the day of children whose mothers are compelled to go to work. The building stands within its own grounds in a healthy neighbourhood, and the garden and open-air hut permit of sanatorium methods. Dr. Ruby Thomson is the medical officer in charge and visits the Nursery at least four times a week. The fees charged are now as follows :— 6d. per half day for one child. 10d. per day for two children. 1/6 „ „ „ of one family. 4/- per week of five days for one child. 7/- „ „ „ two children. The total attendances showed an increase in 1926 of 322 over the previous year, but were considerably below the total for 1923. The attendances during the year were as follows:— Individual children attended— Under three years of age 103 Over three years and under five 14 The total attendances made by the above children were :— Under three years— Whole day 4,796 Half day 1,059 Over three years— Whole day 730 Half day 263 Total— Whole day 5,526 Half day 1,322 Total 6,848 27 Borough Maternity Home, 706, Fulham Road, S.W.6.—The Home, which was opened in January, 1920, is intended for the reception of women resident in Fulham who have no proper accommodation for their confinement in their own homes. Applications for admission are made on a prescribed form three months before the probable date of the confinement, and the applicants must attend one of the Ante-natal Centres. Only apparently normal cases are admitted to the institution. Dr. Ruby Thomson is in medical charge and Dr. Wakeford is occasionally called in for emergency cases. The work of the Home is linked up with that of the Ante-natal and other centres, and the Matron and Sister both attend the Ante-natal clinics at Greyhound Road. The Home accommodates 10 patients and an isolation room with one bed is available. The staff consists of three midwives and two pupil midwives, all of whom are trained nurses, and the Home is recognised by the Central Midwives Board as a training school for midwives. The domestic staff includes two resident maids, one non-resident maid and a part-time daily woman. The minimum fee charged is £3 for the fortnight, but in exceptional circumstances the Maternity and Child Welfare Committee permit patients to be admitted below this figure. In one case a fee of £2 was charged for the fortnight. The average charge for the fortnight was £4 8s. 2d., and the highest was £7 15s. Od. The nett cost per patient to the Council was £1 18s. 7d. for the financial year 1926-27. The Home was enlarged in 1923, and the number of admissions each year since then have been as follows :— 1923 189 1924 176 1925 203 1926 195 28 The following is a record of cases admitted to the Home during the year 1926 :— Cases admitted 195 Average duration of stay (days) 14 Number of cases delivered by— (a) Midwives 186 (b) Doctors 9 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 neonatorum 2 Number of cases of inflammation of eyes, however slight 6 Number of infants not entirely breastfed while in the institution — Number of maternal deaths — Number of foetal deaths (stillborn or within ten days of birth) 2 Provision of Milk under the Maternity and Child Welfare Act, 1918. Milk is supplied free or at less than cost price to expectant and nursing mothers and to children under 3 years of age in necessitous cases and during the year under review grants were made in 217 cases. Applications are considered by the Sub-Committee of the Maternity and Child Welfare Committee. Under this scheme the cost to the Council for the year was :— £ s. d. For dried milk Ill 14 2 For fresh milk 9 11 10 Total £121 6 0 The comparative expenditure for the three preceding years was as follows : In 1925, £80 10s. 3d. ; in 1924, £131 5s. 7d. ; and in 1923, £169 10s. 9d. Milk is also sold at cost price in cases recommended by the Health Visitors or by the staff of the Infant Welfare Centres, and during 1926, under this part of the scheme, 9,996 lbs. of dried milk were supplied at a cost to the families of £919 13s. 2d., compared with 10,229 lbs. distributed in 1925 at a cost of £940 18s. 11d. 29 Home Nursing. This is carried out by the Fulham District Nursing Association, 56, Harwood Road, S.W. 6. The services of the nurses are available for attendance on persons unable to pay the fees of a private nurse. The arrangement under which the home nursing of certain cases is subsidised by the Borough Council has worked satisfactorily, thanks to the admirable management of Miss Watson, the Superintendent of the Association. The cases for which the Council is responsible come under three classes :— 1. Certain illnesses in children under 5 years of age. 2. Certain illnesses in expectant and nursing mothers, e.g., abscess of the breast. The expenditure on these two classes of cases is met by the Maternity and Child Welfare Committee, and one half of the cost is repaid to the Council by the Ministry of Health. It is to be noted that the District Nurses do not attend confinement cases. 3. Certain infectious diseases in persons of 5 years or more, e.g., pneumonia, influenza, measles, etc., for which the Public Health Committee are responsible. No grant is available from the Ministry of Health for the home nursing of persons in class 3. The number of visits made by the nurses under the Council's scheme was :— To persons under 5 years of age 2,796 To persons of 5 years or more 964 Total 3,760 A fee of one shilling is paid by the Council for each attendance on a case. The fees paid were:— 1926. 1925 £ s. d. £ s. d. By the Maternity and Child Welfare Committee 100 8 0 78 0 0 By the Public Health Committee 87 12 0 50 13 0 Total £188 0 0 £128 13 0 30 The increase during 1926 was due to the prevalence of measles during the early part of the year. Official circulars were issued during the year 1926 dealing with the following matters:— Food, and Drugs :— 6.7.26 No. 68577 Public Health (Imported Milk) Regulations, 1926. 6.7.26 No. 68578 Milk and Dairies Order, 1926. 10.12.26 No. 71203 Public Health (Preservatives, etc., in Foods) (Amendment) Regulations, 1926. 16.12.26 No. 751 Ditto. 20.12.26 No. 752 Sale of Food and Drugs Act, etc. Maternity and Child Welfare :— 22.3.26 No. 680 Training and Appointment of Health Visitors. 31.7.26 No. 971 Public Health (Ophthalmia Neonatorum) Regulations, 1926. 31.7.26 No. 972 Public Health (Puerperal Fever and Puerperal Pyrexia) Regulations, 1926. 9.8.26 No. 617 Notification and Treatment of Ophthalmia Neonatorum. 14.9.26 No. 723 Treatment of Tuberculosis and Diagnosis and Treatment of Venereal Disease. Tuberculosis :— 5.10.26 No. 726a Returns under Memo. 37t. Administration :— 1.1.26 No. 660 Widows, Orphans and Old Age Pensions Act, 1925. 27.5.26 No. 552 Sanitary Officers' Order. 4.10.26 No. 736 Training of Candidates for Sanitary Inspectors Certificate. 15.12.26 No. Ch.43 Public Health (Smoke Abatement) Act, 1926. 4.8.26 — L.C.C. (General Powers) Act, 1926. Infectious Disease :— 10.5.26 No. 698 Supervision of Smallpox contacts. Vaccination. Mr. H. Davies, Vaccination Officer to the Fulham Guardians, has, as in past years, very kindly supplied the following details with regard to vaccination. During the year under review, 1,817 successful primary vaccinations were carried out, compared with 1,811 during 1925, and 2,042 during 1924. Particulars 31 of the vaccinations carried out during the year ended 31st December, 1925, are set out in the following table. Similar detailed figures are not yet available for the year 1926 :— Number of births registered from 1st January, 1925, to 31st December, 1925 2,830 Successfully vaccinated 1,666 Insusceptible of vaccination 1 Dead—un vaccinated 133 Postponed by medical certificate 60 Certificates granted under clause 2 of the Vaccination Act, 1898 670 Removed to districts in which Vaccination Officer has been notified 73 Removed to places unknown 190 Outstanding 37 Poor Law Relief. I am indebted to Mr. E. J. Mott, Clerk to the Fulham Guardians, for the following figures relating to Poor Law Relief:— Date. (Half-year ending). (1) Number receiving relief. Indoor and outdoor, but excluding Lunatics and figures in column 2. (2) Persons in receipt of out-door medical relief only not included in column 1. 1st July, 1917 1,546 65 1st Jan., 1918 1,527 64 1st July, 1918 1,439 73 1st Jan., 1919 1,341 46 1st July, 1919 1,376 43 1st Jan., 1920 1,430 46 1st July, 1920 1,426 44 1st Jan., 1921 2,465 75 1st July, 1921 2,486 70 1st Jan., 1922 4,074 58 1st July, 1922 3,520 56 1st Jan., 1923 3,120 64 1st July, 1923 2,659 92 1st Jan., 1924 2,793 70 1st July, 1924 2,328 63 1st Jan., 1925 2,366 51 1st July, 1925 2,705 68 1st Jan., 1926 3,489 69 1st July, 1926 3,125 67 1st Jan., 1927 3,123 53 32 Infectious Diseases. Incidence.—The number of cases of infectious diseases notified during 1926 was 5,292, compared with 2,199 in 1925 and 3,256 in 1924. The cause of the increase was the prevalence of measles, which accounted for 3,700 of the notifications, whereas in the year 1925 the latter numbered 589. The notifications of diphtheria increased from 276 in 1925 to 345 in 1926, but there was a considerable decrease in the number of cases of scarlet fever, which fell from 398 in 1925 to 311 in 1926. The notifications of influenzal and primary pneumonia fell from 320 in 1925 to 288 in 1926, and this corresponded with a marked diminution in the deaths from all forms of pneumonia. Regarding the three notifiable infectious diseases of the nervous system, encephalitis lethargica (sleepy sickness), acute polio-myelitis (infantile paralysis) and cerebro-spinal fever (so-called spotted fever), all three showed an increase in the notifications. Twelve cases of encephalitis lethargica were notified compared with 10 in 1925. Seven patients were notified as suffering from acute polio-myelitis, as compared with three during the previous year, and cerebro-spinal meningitis contributed four cases, an increase of one over the number for 1925. Typhoid or enteric fever accounted for eight of the notifications, against 10 during 1925. Mortality from Infectious Diseases.—Measles caused 47 deaths during 1926 and only two during 1925. Whooping-cough, although not a notifiable disease, is infectious, and therefore belongs to the same class as the cases under discussion. During 1925 this disease was very prevalent, causing 35 deaths, but in 1926 only six deaths were due to this disease. The deaths due to diphtheria increased from 11 in 1925 to 14 in 1926, and those due to scarlet fever increased from three to four. All the cases of typhoid and paratyphoid fever which occurred in 1925 and 1926 recovered, and there were also no deaths from infantile 33 paralysis during these two years. Encephalitis lethargica accounted for four deaths in 1925 and the same number in 1926. The deaths from cerebro-spinal meningitis increased from three to four. Measles.—3,700 cases were notified during 1926, compared with 589 in 1925, 1,692 in 1924, and 1,951 in 1923. The epidemic commenced in November, 1925, assumed its maximum height during the following February, and gradually declined until it subsided in July. The number of cases reported during each month of the year is shown in the following table:— 1st Quarter. 3rd Quarter. January 651 July 16 February 1,513 August 6 March 1,142 September 2 2nd Quarter. 4th Quarter. April 242 October 4 May 79 November 3 June 39 December 3 Males and females were affected in the proportion of 1,980 to 1,720. Regarding the ages of the cases notified, 2,029 were in children under five, 1,527 in children between five and 10, and the remainder in persons over 10 years of age. Two of those affected were over 45 years of age. Forty-seven deaths were registered as due to measles in 1926, compared with two in 1925. Of the 47 deaths in 1926 all except one occurred in children under five years of age. Nine were in infants under one year, and 23, or nearly half of the total, occurred in children between one and two years of age. Regarding the case mortality, the percentage of cases which proved fatal was 1.27, but 5.63 per cent, of the children under two years who were affected died of tne disease. The case mortality of the cases under one year was approximately the same as in those 34 tween one and two years, but as the attack rate was much less under one year, fewer deaths actually occurred in infants. Twenty-eight of the deaths occurred in males and 19 in females. Hospital treatment is available in London in the hospitals belonging to the Metropolitan Asylums Board in severe cases in which the home conditions are unsuitable, and patients are also admitted to special wards in the Fulham Hospital. Of the cases treated 166 were attended by the Fulham District Nursing Association, and the work of the nurses was greatly appreciated. It will be remembered that during the height of the epidemic the Council's Health Visitors were unable to do the additional work without assistance and a temporary Health Visitor was engaged from the 25th January to 27th February, and on her relinquishing this duty another was engaged until the 10th April. Acute Poliomyelitis (Infantile Paralysis).—Seven cases were notified in 1926, compared with three in 1925. It is important to secure early treatment of this disease for the purpose of minimising or even preventing the paralysis. The diagnosis in the early stage is, however, a difficult matter, and in three of the cases it was found to be incorrect. One of the patients was suffering from rheumatism, one from an influenzal attack and the remaining case was found to be encephalitis lethargica. Two of the four remaining cases have recovered completely and two are improving. As showing the infectious nature of this disease it is interesting to record that one of the patients visited friends in Wandsworth and seven days later a child of the Wandsworth family was taken ill with the same disease. Epidemic Diarrhoea (Zymotic Enteritis).—Epidemic diarrhoea in children under five years of age has been 35 notifiable in Fulham since 1920. Fifty cases were notified during 1926, compared with 70 in 1925 and 40 in 1924. Thirty-five of those affected were under one year and 10 were between one and two years of age. Twelve of the 28 deaths of infants under one year from diarrhœal diseases were certified as due to epidemic diarrhoea. The number of deaths from diarrhceal diseases in infants corresponded to a rate of 10.48 per thousand registered births. This rate, although an improvement over the rate of 12.6 for the year 1925, is still high, and shows the need for education of the mothers in infant welfare. Encephalitis Lethargica. (,Sleepy Sickness.) Since 1919, when notification of the disease became compulsory 63 cases have been notified. The following table shows the number of cases notified during each year and during each quarter of the year from the beginning of 1919 to the end of 1926. Cases notified during each Quarter of the Year. Year. Quarter. First. Second. Third. Fourth. Total. 1919 3 1 - 2 6 1920 1 1 — — 2 1921 4 2 1 — 7 1922 — 1 1 1 3 1923 1 — 1 — 2 1924 8 9 2 2 21 1925 1 2 3 4 10 1926 4 2 6 12 Total 18 20 10 15 63 It has generally been found throughout the country that more cases occurred during the first and last 36 quarters of the year, but it will be seen that largest number was notified in Fulham during the second quarter. Cases occurred at all ages ; one case was notified at the age of five weeks, and another at the age of 76 years. All four patients over 60 years of age and three of the four children under the age of five years died. Regarding the case mortality 26 of the 63 cases died, equal to 41.2 per cent. The case mortality was lowest at school age, as none of the 14 children of ages five to 14 years succumbed to the disease. The notifications were almost equally divided between males and females, 32 cases occurring in males and 31 in females. The initial symptoms and signs of this disease are often ill-defined, and a definite acute stage may be entirely absent, so that many cases are not detected until weeks or months after the actual onset. Three of the cases were proved on post-mortem examination not to be suffering from encephalitis lethargica, and it is probable that the margin of error is even greater. These three cases were due to (1) suppurative meningitis, (2) acute cerebro-spinal meningitis, and (3) Bright's disease. The difficulty of diagnosis, therefore, reduces the value of the statistics to some extent. In the majority of fatal cases of encephalitis lethargica death occurs within a few weeks of the commencement of the illness, and in 13 of the 26 deaths in Fulham death ensued in less than three weeks. One death was due to suicide and occurred seven months after the onset of the disease. The results of encephalitis lethargica are disastrous ; as already stated, 26 of the cases notified died. Three of these were, however, cases wrongly diagnosed. Of the remainder, only 11 have been able to return to ordinary work or school, two are doing light work, 37 21 are totally unfit for work of any kind, and 3 cannot be traced. In addition to the high mortality and the diminution in working and earning capacity resulting from this condition, marked mental and physical changes occur which profoundly alter the patient's character and intellect and lead to paralysis and insanity. The disease causes congestion, infiltration and ultimately degeneration of the central nervous system. Cases are admitted to the Fulham Hospital in all stages of the disease, and those in the early stage are admitted to the infectious diseases hospitals of the Metropolitan Asylums Board. The London County Council make special provision for the institutional treatment of children under 15 suffering from the later manifestations and after effects of the disease, and provision will doubtless be available for adults as soon as this can be arranged. Institutional treatment is much needed for patients who are non-certifiable as insane, as home supervision and treatment are quite inadequate. Puerperal Fever and Puerperal Pyrexia.—There has been a steady decline in the incidence and mortality from puerperal fever during recent years, and in 1926 both the number of cases and the death-rate were the lowest on record for the Borough. During the four years from 1923 to 1926 the number of cases notified was 32, 26, 21 and 15. The incidence in 1926 was equivalent to 5.6 per thousand registered births. The number of deaths from 1923 to 1926 was nine, four, four and three respectively. The treatment of puerperal fever is best carried out in institutions, and in 1922, according to Dr. Hewat's suggestion the Council made arrangements with the Guardian" whereby suspicious cases could be admitted to the Fulham Hospital. The object of this arrangement, which was a forerunner of the 38 new regulations requiring notification of puerperal pyrexia, was to secure the earliest possible treatment of patients suffering from puerperal fever. The Council's arrangement with the Guardians is now continued and amplified by the scheme under the new Regulations. The Regulations, which require the notification of cases of puerperal pyrexia and puerperal fever, came into force on 1st October, 1926. Twelve cases of puerperal pyrexia were notified from October to the end of the year, and of these six were admitted to the Fulham Hospital. Of the twelve cases referred to two were notified subsequently as puerperal fever. The Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1926.—The regulations came into force on 1st October, 1926, and their object is the prevention and control of puerperal sepsis. Neither the number of notifications nor the deaths from puerperal fever give an adequate idea of the seriousness of the problem of puerperal sepsis. The question of maternal mortality associated with pregnancy and childbirth is referred to in Circular 517 of the Ministry of Health, which states : " In the first place, these women are for the most part young and healthy, and their loss involves exceptional domestic distress. Secondly, these deaths are indicative of an immense burden of suffering and ill-health among those women who are fortunate enough not to succumb to causes which prove fatal to others. Such deaths are necessarily associated with a large number of infant deaths before, during or shortly after birth, some at least of which might be prevented." More illness in women results from septic conditions after childbirth or miscarriage and gonorrhoea than from all other pelvic diseases combined. It is the duty of the Local Authority to give notice to all medical practitioners resident or practising in the Borough of the duties imposed upon them by the regulations, and the following letter, along with a copy 39 of the regulations, was sent to all Fulham doctors before the regulations came into force :— 25th September, 1926. The Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1926. Under the above Regulations the Local Authority is required to give notice to all medical practitioners resident or practising in its area of the duties imposed upon them by the Regulations, which come into operation on the 1st October next. Circular 722 of the Ministry of Health states that for a variety of reasons notification of cases of puerperal fever has been far from complete, with the result that not only are statistics relating to the disease misleading, but measures for the prevention and effective treatment of the condition have been seriously impaired. The main reason for the comparative failure to notify is to be found in the fact that puerperal fever is ill-defined and is not a specific disease comparable with scarlet fever or diphtheria. There is frequently a genuine doubt as to the correct diagnosis. The Ministry is advised that it will ultimately be desirable to replace the term " Puerperal Fever " by the term " Puerperal Pyrexia," but this is not practicable without further legislation. The Regulations therefore require the notification of cases of puerperal pyrexia irrespective of the cause, in addition to notification of cases of puerperal fever. Puerperal pyrexia is defined in the Regulations as " any febrile condition (other than a condition which is required to be notified as puerperal fever under the Infectious Disease (Notification) Acts) occurring in a woman within twenty-one days after childbirth or miscarriage in which a temperature of 100-40 Fahrenheit (38° Centigrade) or more has been sustained during a period of twenty-four hours or has recurred during that period." It is recognised by the Ministry of Health that the notification of cases of puerperal pyrexia, in addition to cases of puerperal fever, will lead to a great increase in the number of notifications, and that many cases so reported will be relatively trivial in degree, but the great importance of securing adequate treatment in the early stages of puerperal infection is regarded as outweighing any objection to the notification of a certain amount of minor illness. Unfortunately, the ordinary notification form in use for notifiable infectious disease does not meet the requirements of the Regulations, and two new notification forms are prescribed by the Ministry. Facilities for Diagnosis and Treatment. It will be seen that the notification forms enable medical practitioners to indicate whether assistance in dealing with the case is desired. Facilities for a second opinion and for 40 examination of the blood and lochia are not yet available, but these questions will be considered by the Council at an early date. The services of a trained visiting nurse may be obtained on application to the Fulham District Nursing Association, 56, Harwood Road, Fulham, S.W. 6 ('phone Putney 0477), on the recommendation of a medical practitioner. Cases of puerperal fever are admitted to the following hospitals of the Metropolitan Asylums Board, viz. : The Eastern Hospital, Homerton ; The North Western Hospital, Hampstead ; and the South Western Hospital, Stockwell; where special wards are set aside for these cases and special medical and nursing staffs are provided. Patients suffering from puerperal fever are also admitted to the Fulham Hospital, 103, St. Dunstan's Road, W. 6, on being recommended by a doctor. A brief history of the case should be forwarded to the Medical Superintendent of the institution. Admission to the Hospitals of the Metropolitan Asylums Board is arranged through the head office ('phone City 7200). When admission to the Fulham Hospital is desired, application should be made direct to the Hospital ('phone Riverside 3571), and not as in the case of other diseases to the Relieving Officer. With regard to cases of puerperal pyrexia, obviously the majority of these patients will be treated in their own homes, but admission to the hospitals referred to is also available when necessary. In cases in which special assistance is required either for diagnosis or treatment, the Medical Officer of Health is requested by the Ministry to ask medical practitioners to supply him with further information on some or all of the following points :— 1. Conditions in the patient, if any, prior to the labour, which might have been factors in producing the pyrexia, e.g., septic food, vaginal discharge, carious teeth, etc. 2. Names of all persons who have made internal examinations including the name of the person who delivered the patient ; their occupation and professional qualifications (if any). 3. Day and hour of commencement of labour or miscarriage. 4. The clinical course of labour or miscarriage, mentioning any special means used to assist labour, e.g., obstetrical operations or manual removal of placenta ; and any injuries incurred by the patient. 5. The duration of labour and time of termination of labour or miscarriage. 6. The clinical history subsequent to delivery, including the amount and character of lochia ; copy of temperature chart, etc. 7. The time of the onset and the probable cause of pyrexia. 41 8. Any cases of specific fevers, erysipelas, puerperal pyrexia or other possible forms of sepsis, visited recently by doctor or other attendant, giving dates. A subsequent letter was addressed to all practitioners in the Borough, informing them of the appointment of Mr. Alexander Galletly, of 33, Queen Anne Street, W. 1, as obstetric consultant under the regulations, and also stating that specimens of patients' blood and lochia would be examined at the Council's Laboratory, 114, New King's Road. The outfit necessary for the collection of the bacteriological specimens is supplied on application to the Public Health Department. Ophthalmia Neonatorum (a purulent discharge from the eyes of an infant commencing within twenty-one days of the date of its birth).—Twenty-nine cases were notified in 1926, compared with 32 in 1925 and 27 in 1924. The case rate per thousand registered births for 1926 works out at 11.05. Eleven of the infants were treated in hospital. All cases are visited by the Health Visitors in order to ensure that the treatment, which is so necessary to prevent impairment of vision or blindness, is carried out. Twelve cases were attended by the District Nurses under the supervision of doctors. Further details are shown in the subjoined table. Cases. Treated at home. Treated in Hospital. Vision impaired. Vision unimpaired. Total blindness. Deaths. Left the district. Still receiving treatment. 29 18 11 nil 24 nil nil 4 1 42 The Public Health (Ophthalmia Neonatorum) Regulations, 1926.—These regulations, along with an explanatory circular (Circular 617), were issued by the Ministry of Health in August, 1926. The regulations came into force on 1st January, 1927. According to the Rules of the Central Midwives' Board a certified midwife must call in a doctor in these cases. Under the Public Health (Ophthalmia Neonatorum) Regulations, 1914, a midwife was required to notify such cases to the Medical Officer of Health unless this had already been done by a doctor. Alternatively the doctor was required to notify. This dual notification has been found to be unsatisfactory and under the regulations of 1926 the midwife is not required to notify as the onus is placed entirely on the medical practitioner. Under Article 4 of the regulations the Borough Council is required to give notice forthwith to all medical practitioners resident or practising in the Borough of the duties imposed on them by the regulations. The Borough Medical Officer of Health must also send a copy of every notification he receives under the regulations to the Metropolitan Asylums Board within twelve hours of the receipt of the notification. The Borough Medical Officer of Health receives information of the existence of cases of ophthalmia neonatorum mainly from two sources, from the doctor notifying the case, and from the London County Council, whose Inspector of Midwives visits their homes on receiving a copy of the notice sent by the midwife calling in medical help. The cases are visited by the Borough Council's Health Visitors and kept under supervision. The services of the District Nursing Association are available for mild cases and accommodation is available both for mother and infant in St. Margaret's Hospital, Kentish Town, on application by a doctor to the Metropolitan Asylums Board. Circular 617 suggests that if the case was originally attended by a medical practitioner the Borough Medical Officer of Health should ascertain personally whether nursing or other assistance is required and 43 should arrange for the provision of such assistance. If a midwife was originally in attendance the Medical Officer of Health will already be in touch with the case through the Inspector of Midwives. The Danger of Smallpox. Fortunately no cases of smallpox occurred during the year but several Fulham persons were directly exposed to infection during the outbreak which occurred in London in September. The infected clothes of two smallpox patients were washed in a Fulham laundry, thus exposing the laundry workers and more particularly 11 of their number to grave risk. Four residents of Fulham, including two nurses, visited the ward of a general hospital from which two patients were removed suffering from the disease, and many other persons had also to be kept under supervision. It was therefore providential that the Borough escaped. The public are much in need of education regarding the necessity for vaccination and re-vaccination as a safeguard against this loathsome disease. It is unlikely that the present lucky record of escape will continue if a considerable section of the public neglect to take the most elementary and obvious precautionvaccination. Non-Notifiable Diseases. Diseases of the Heart.—The increase in the number of deaths from diseases of the heart is a matter of great importance to Public Health Authorities. In England and Wales 64,059 deaths were registered from this cause in 1925, compared with 60,650 in 1924. In Fulham the number remained more or less stationary from 1900 to 1909, but since then it has gradually increased, until 1925, when it reached 259 and exceeded the number of deaths due to cancer. In 1926, however, the deaths from heart diseases fell to 195, 44 responding to a mortality rate of 1.18 per thousand of the population. The following table gives the age and sex distribution of persons who died of diseases of the heart during the year:— 0-1 1-2 2-3 3-4 4-5 5-10 10-20 20-35 35 45 45-65 over 65 Males 1 — — — — — 3 3 3 33 42 Females 2 - — — - l 3 6 4 40 54 Males 85 Females 110 In addition to producing a high death-rate, heart diseases are responsible for much disablement, distress and financial loss. With regard to their causation, speaking broadly and excluding the less common causes the cases fall into three classes which have been called the rheumatic, arterio-sclerotic and syphilitic types. The first type of case commences in early life, generally as a result of acute rheumatism, but in rare instances it may result from one of the acute fevers (scarlet fever, diphtheria, influenza, pneumonia). Probably 80 to 90 per cent. of cases of organic heart disease in childhood are caused by rheumatism. The second class of case commences in middle life or old age as a result of degenerative changes in the heart and blood vessels, including arterio-sclerosis, and is due to a variety of causes among which are actual or premature old age, chronic alcoholism, habitual over-eating, especially in persons engaged in sedentary occupations, prolonged overwork or overstrain of the muscles or nervous system, and high blood pressure. These conditions are much commoner in men than in women. When the causes of these degenerative diseases of the heart and blood vessels are considered it is clear that they are, to some extent, preventable. Education of the public, and 45 especially the adult population, in health matters would have considerable influence in this respect by inducing people to lead active and healthy lives free from overstrain and excesses of all kinds. The third class, due to syphilis, is more common in men, and the symptoms do not show themselves until 10 to 20 years after the onset of the syphilis. The arrangements for co-ordinating the treatment of venereal disease in London is under the authority of the London County Council, and much propaganda work is being done by the British Social Hygiene Council. It is difficult to ascertain which class of heart disease accounts for the largest number of cases, and also whether the gradual increase in the death-rate is due to any particular type of heart disease. It is generally considered in this country that rheumatic heart disease is commonest. Dr. J. Wyckoff and Miss C. Lingg writing in the American Heart Journal in April, 1926, however, state, " about one-fourth of the cases presented rheumatic heart disease, about two-fifths were arterio-sclerotic, about one-tenth syphilitic, and about one-tenth heart disease of unknown origin. Other factors, such as scarlet fever, hyperthyroidism, nephritis, etc., comprised less than one-tenth of the total." Rheumatic Heart Disease.—Much pioneer work has been done by English physicians on heart disease, and especially on rheumatic heart disease. Recently reports have been issued by the British Medical Association and the Medical Research Council on the causation of rheumatism and rheumatic heart disease in children and much of the following statement has been obtained from these sources. Rheumatism in children is prevalent in temperate climates, and occurs most frequently during winter and spring. It is a disease essentially of school life (five to fifteen years), and although affecting principally the children of the working classes is relatively less common among the destitute 46 poor. Children in better circumstances are very seldom affected. Both rheumatism and rheumatic heart disease are commoner in industrial than rural areas. There is little doubt that rheumatism in children is a specific disease and that it is caused by microbic infection. Although much work has been done by Drs. Poynton and Payne and other research workers in this country the true bacterial cause still remains uncertain. Streptococci are commonly found on the tonsils in these cases, and the prevailing opinion is that they are the causal agents. Tonsillitis is present in three out of every four cases of acute rheumatism, and it is generally agreed that the tonsils are the main portals of entry of the invading organisms. Dental sepsis is seldom the cause of acute rheumatism, although it frequently causes rheumatism in adults. Foci of infection may be present in other parts of the body in addition to the tonsils (as in the intestine) although they are difficult to locate. Dr. Reginald Miller states that removal of the tonsils does not usually prevent recurrences of rheumatism, but severe symptoms and complications are less common after the operation. Rheumatism is common in the parents, brothers and sisters of rheumatic children. This family incidence may be due to infection, heredity, or environment. There is no conclusive evidence as to whether the disease is or is not infectious. Dr. W. St. Lawrence suggests that it may be transmitted by close contact with the patient over long periods of time, and Dr. G. F. Still states that " if rheumatism is due to infection its incidence may be determined by special frequency or closeness of exposure to infection or by some condition in the particular children concerned, rendering them especially susceptible to infection." Many eminent authorities believe that heredity has a considerable effect in causing acute rheumatism, but further investigation is required on this question. 47 Regarding the question of environment, living in damp houses, especially in low-lying districts or on clay soils which retain moisture and the wearing of damp clothes. or defective shoes have long been considered to be predisposing causes of rheumatism, and there is little doubt that they have a considerable influence. Part I. of the report of the British Medical Association by Dr. Miller states: (1) "that 62.2 per cent. out of 196 rheumatic patients were living in damp houses when first attacked by the disease," and (2) "it would appear that the proximity to water, the subsoil, and the altitude of site have all some predisposing power towards rheumatic infection, but their importance should not be over emphasized. If there is anything in the connection between damp houses and rheumatic infection it is the dampness of the home itself, which is primarily of importance. Its site is only of secondary importance as tending towards a damp house. That it is perfectly possible to live in a low-lying district close to water without the slightest fear of rheumatic infection is proved beyond criticism by the experience of Eton and Beaumont Colleges. Both these lie close to the Thames, and between them account for 1,350 boys, and yet I am told by Dr. W. Attlee that he has seen only one case of rheumatic fever at Eton in 17 years, and by Dr. L. O'Ferrall that he has met with no case at Beaumont College during his eight years as medical officer of the school." The possibility of overcrowding, uncleanliness, dust and vermin (e.g., rats, lice, fleas, bugs) being concerned in the production of the disease has been the subject of various investigations, but the available evidence indicates that they have no influence. Although rheumatism in childhood is a single disease caused in all probability by a specific microbe it shows itself in many forms according to the part of the body mainly affected. Thus Drs. Ingerman and Wilson describe: (1) "Growing pains and joint pains," in the tendons of the hamstring muscles behind the knee and rheumatism of the muscles of the neck (rheumatic wry-neck), (2) rheumatic tonsillitis or sore 48 throat, (3) rheumatic fever affecting the joints, (4) rheumatic heart disease, (5) chorea or St. Vitus' Dance which is rheumatism of the nervous system, (6) skin affections and (7) subcutaneous nodules (under the skin). It should be remembered that any of these forms may occur in combination. The great prevalence of rheumatic diseases, including rheumatic heart disease and chorea is clearly shown by the School Medical Officer of the London County Council in his annual reports. The latest report speaks of the number of children who were absent from school for over three months from all causes and the percentage of absence due to rheumatism during the month of November from 1922 to 1925. This percentage is as follows:— 1922. 1923. 1924. 1925. 23.5 23.92 25.02 24.71 The facts are summed up in the following extract from the report: "It will be seen that the rheumatic group of cases accounts for one-fourth of the chronic invalidity amongst school children, and rheumatism is by far the most important single cause for prolonged illness in children." The term "Rheumatism."—The rheumatism which occurs in adults is usually a different disease to that which occurs in children and adolescents, and rarely causes heart disease. The adult form of rheumatism is not really a single disease, as the name has been applied to several different diseases, such as rheumatic neuritis, osteo-arthritis, and rheumatoid arthritis, which have no connection with each other nor with the type of rheumatism which is so common in early life. Prevention and Treatment of Rheumatism and Rheumatic Heart Diseases.—The removal of the focus of infection, whether in the throat, nose or elsewhere, should be the first consideration, and the removal of infected tonsils and adenoids is indicated in many cases. A healthy condition of the nose and throat is important also in the prevention of the diseases of 49 the bronchial tubes and lungs. A low standard of environment has been proved to be an important predisposing factor in rheumatism and damp houses and sites are especially blamed. Doubtless other defects in houses have an indirect influence either by giving opportunities for infection or by lowering the resistance. It is essential to secure the co-operation of sanitary inspectors in the districts for the purpose of improving the housing conditions. Maternal care was found to be less in the rheumatic cases investigated by the Medical Research Council's Committee than in nonrheumatic cases. Exposure to wet was more common and clothing less satisfactory. The education of parents and others by leaflets and propaganda generally is recommended with the object of instructing them regarding the prevention and early signs of rheumatic infection, and health visitors, teachers and members of voluntary care committees have many opportunities to help in the propaganda work. Rheumatism may be difficult to detect in the early stages as pain may not be very severe. The symptoms may not be localised, but may consist of general languor, malnutrition and slight feverish attacks. Home treatment is unsuitable for children suffering from rheumatism, because faulty environment is one of the chief predisposing causes of the disease, and early treatment necessitates special care, which is unobtainable in a small house. A sufficiency of hospital beds is not available at present, and it has been suggested that special wards should be set aside in Poor Law Hospitals for the purpose just as special wards are provided for tuberculous cases. It has been found that ordinary convalescent homes are unsuitable for children with rheumatism and special convalescent homes or country hospitals are required. Rheumatic children are now being treated under open air conditions very similar to those in a tuberculosis sanatorium, with abundance of fresh air, sunlight and good food. The patients' rest and exercise, 50 and the amount of exposure to weather conditions is carefully graduated. Undue exposure is, however, harmful to rheumatic patients. The Invalid Children's Aid Association combine education with treatment under open air conditions in their two homes for rheumatic children. The Kurandai Home at Hartfield, Sussex, accommodates 50 children of both sexes, and the Edgar Lee Home at Willesden is available for 22 boys. I am indebted to Dr. Cotton, honorary consulting physician of the latter home, for much information regarding the campaign against heart diseases. The lease of the Kurandai Home expires shortly, and a new home is to be opened at West Wickham. The education of these children is even more essential than that of healthy children, as poor education involves laborious work in adult life. In this connection it may be mentioned that both of the Invalid Children's Aid Association's Homes are certified as special schools. Wards for rheumatic patients have also been opened at St. Mary's Hospital, Broadstairs, and under the Metropolitan Asylums Board at Queen Mary's Hospital, Carshalton. Sixty beds are available at Carshalton, where bacteriological research, as well as treatment, is being done, and the number will be increased to 350 at a later date. The cases are admitted from the out-patient departments of certain London hospitals or on application to the Medical Officer of Health, London County Council. Cancer. (Including Sarcoma and Carcinoma.) Two hundred and sixty-two deaths were registered in the Borough during 1926 as due to malignant tumours, compared with 198 in 1925, 221 in 1924, and 212 in 1923. Cancer caused more deaths than any other disease in 1926. The number of deaths occurring in males was 117, and in females 145. Only three persons died under 51 the age of 35 years, 21 deaths occurred between the ages of 35 and 45, 111 from 45 to 65, and 127 from the age of 65 years onwards. Twenty-four deaths were due to cancer of the womb and 24 to cancer of the breast. As is usually the case, cancer of the intestine (excluding the rectum) was more common in females than in males, 33 deaths occurring in women and 15 in men. The mortality from malignant disease of the stomach was also higher in females than in males, the proportion of deaths being 24 in females to 19 in males. A great deal has been added to our knowledge regarding the nature and cause of cancer as a result of recent researches. It has long been known that the tissue cells affected by the disease multiply uncontrollably and revert to a primitive type which has the power of invading the surrounding tissues. Opinion is again veering round to the view that the cause of cancer is a living virus or organism. Dr. Gye's work in the laboratories of the Medical Research Council led him to the conviction that this is the case, but that in addition a second factor, which he called " the specific factor," is also required. The specific factor, he states, is probably a chemical substance. The same virus is considered to be present in all malignant growths, but there is a specific factor for each species of animal and probably also for various classes of cancer. Mr. Barnard, working in collaboration with Dr. Gye, used ultra-microscopic methods and ultra-violet light in his work. The wave length of ultra-violet rays is much shorter than that of ordinary "visible" light and permits of much smaller objects being seen and photographed. By these methods Barnard demonstrated in malignant growths and in cultures of the virus minute spheroidal bodies which are considered by Dr. Gye and himself to be the virus of cancer. 52 The investigations of Professor Blair Bell and his co-workers of the Liverpool Cancer Research Organisation into the nature and treatment of cancer are of importance. The treatment of the disease by intravenous injections of preparations of lead has been carried out in Liverpool on a large scale and with success in some cases. This treatment, which is at present only in the early stages of its development, must not be considered to be a substitute for early surgical treatment. Other research workers are investigating the possibility of applying serum treatment, which has been shown to possess curative properties in some cases of cancer of animals, to human cancer. Cancer of the Breast.—The Ministry of Health, on the 16th September, 1926, issued the fifth of a series of circulars and memoranda on cancer, the first of which was published in 1923. The memoranda are prepared by the Departmental Committee on Cancer appointed by the Ministry of Health, and their object is "to summarise in non-technical terms our present knowledge with regard to the aetiology and incidence of cancer, and to offer for the consideration of local health authorities some suggestions which it is hoped may be useful to them in their efforts to inform public opinion on this subject." The 1926 Circular (Circular 716) and Memorandum deal with cancer of the breast and bring up-to-date and confirm the statements in the 1924 Circular on the same subject. The conclusions are based on cases which have been followed up in England and Wales during the last 15 years, and "have demonstrated that the results secured by complete operation at an early stage are even better, in terms of length of subsequent healthy life, than had been demonstrated by the literature." I shall endeavour to extract some of the important features of the memorandum. Cancer of the breast occurs chiefly, although not exclusively, in women, and causes a higher mortality among women in England and Wales than cancer of 53 any other organ. It occurs at any period of adult life, and with increasing frequency as age advances. The deaths over the age of 45 years are a very serious factor in the total mortality. The right and left breasts are affected approximately with equal frequency, but certain portions of each breast are more liable to be attacked; thus the upper and outer quarter is the most common situation and the central part around the nipple comes next. Since, however, cancer may affect any portion of the breast the essential consideration is that whenever a lump in the breast of a woman of any age is in question the possibility of its being malignant should not be lost sight of. Natural Course.—The growth consists of a hard lump which in the early stages is usually unattended by pain. It grows and causes contraction of the surrounding tissues, retraction of the nipple and alteration of its position. The glands in the armpit become enlarged, usually within a few months from the time of the local mass being recognised. The mass extends to the surrounding tissues and secondary growths or metastases appear in the chest, liver and other organs, and in the bones in some cases. This extension occurs by way of the lymphatics or the blood stream. The average natural duration of cancer of the breast appears to be a little over three years; some cases, however, run an acute, others a chronic course. Cancer probably takes on the whole a more rapid course in the young than in the old and during pregnancy or lactation the course may be abnormally rapid. Antecedent Conditions.—It is often remarked that cancer attacks a diseased rather than a normal organ, and the memorandum refers to the local conditions which frequently precede cancer of the breast, such as chronic inflammation, acute transient inflammation, and deformity or abnormality of the breast. A history of injury to the breast is a frequent antecedent of 54 malignant disease. There is no evidence that disturbances of the menstrual period or menopause have any influence as predisposing causes. Diagnosis.—"It is most important to the success of treatment that the diagnosis should be made at the earliest possible stage. In view of what has already been said in regard to conditions precursory to cancer several of which also give rise to a mass in the organ, it will be obvious that, on first recognition of a lump in the breast, the difficulty frequently becomes one of distinguishing between an early cancer and a non-malignant condition. It is at this early stage of the disease, before invasion of the axillary glands (i.e., the glands in the armpits) has taken place, that diagnosis is of such great importance and may be attended with such difficulty." Treatment.—"Whatever may be the result of future investigations and whatever may be the case with cancer in other regions, it is beyond question that at the present time, early surgical operation affords the one chance for a patient suffering from cancer of the breast. Cases of cancer treated only with internal medicines, or external applications, or any dietetic methods are not being effectually treated. This does not mean that such agents as radium and X-rays cannot be usefully employed as aids to surgery, or in cases in which surgical operation is impossible. "The patient views the entire operation (including the anaesthetic) with repugnance, and as a proceeding which, even if completely successful in a surgical sense, is an evil of no little magnitude. These obstacles naturally do not carry equal weight in all cases, but in some degree they influence patients and must be given their due weight. Sometimes patients assert that they have not noticed a mass in the breast until it is so extensive that no surgical measures are possible. When this is so, no more can be said; but often the patient has recognised the condition some time previously, but from reluctance to submit to operation, 55 and all that it may entail, or owing to aversion from what she regards as mutilation, she puts off the decision until pain or ulceration or her fears render concealment no longer possible. Though it is impossible to withhold sympathy from the patient in such a case, it is certain that she has deprived herself of her best chance. How good this chance is, if the cancer be adequately treated by operation in an early stage, will appear in succeeding paragraphs." Results of Operation.—"Under modern conditions deaths directly attributable to the operation, if performed by skilful surgeons and in well-equipped institutions, have been reduced in the case of breast operations to a fraction of one per cent. Operations performed at a late stage of the disease involve, as would be expected, a greater risk than those at an early stage." A comparison between the average duration of life in patients whose disease has followed a "natural" course with that of patients treated by operation clearly shows the value of surgical treatment. We have seen that the average in cases which have followed a " natural " course is little more than three years. "Recently, by means of a special investigation, it has been possible to ascertain the results in a considerable number of patients suffering from undoubted cancer of the breast, confirmed by microscopical examination, at varying intervals up to ten years after operation. They show that, with the modern complete operation, 52 per cent. are alive and well after a three-years' interval, 39 per cent. after five years, and 30 per cent. after ten years. These statistics, however, relate to patients who at the time of operation were in various stages of the disease, some in such a condition that, although the surgeon could be reasonably sure that operation would afford relief and might eradicate the disease altogether, he could have little confidence that the disease would not recur. When, however, the results were examined according to the stage (early, middle or late) the disease had 56 reached, at the time of the operation, a much more propitious condition of affairs was revealed. It was found that of patients subjected to early operation, i.e., before the disease had extended beyond the breast itself 94 per cent. were alive and well at the end of three years, 91 per cent. at the end of five years, and 87 per cent. at the end of ten years. In contrast with these figures may be quoted those of patients operated upon at a later stage. They necessarily vary with the degree of advance of the disease and range from 31 to 38 per cent. at three years, 15 to 20 per cent. at five years, and 5 to 6 per cent. at 10 years. Figures so contrasted speak for themselves and emphasise the absolute need for early operation if prolonged or permanent freedom from the disease is to be hoped for." Practical Applications.—"About one in four of all patients undergoing operation in large hospitals does so at a stage early enough to secure the good chance of cure referred to in the preceding section. In the case of the other three, application for treatment is delayed, largely through ignorance or fear, to such a late stage of the disease that the patients' chances of complete relief are very considerably diminished. Here, then, lies a vast field for effort directed towards the reduction of mortality. It is highly desirable that every possible means should be taken to try to induce all women who are conscious of any abnormal condition in the breast to seek medical advice without delay, particularly if they are reaching or have reached middle age. If this could be effected it would secure that a larger proportion would undergo proper treatment before the condition reached a hopeless stage, and that more women would receive suitable treatment at some stage. How may this be attempted under present conditions? By dissemination of such information as that set out in the preceding sections through all suitable channels, such as leaflets, 'talks,' advice 57 by local cancer committees, doctors, health visitors, social workers and in other ways. There seems little doubt that the good results achieved by operation at an early stage are imperfectly appreciated, even by the medical profession as a whole, and therefore still less by the community at large, who look for guidance in such matters to the profession. It is inconceivable that if the facts were fully realised the average delay that now exists between recognition of an abnormality and application for treatment would not be considerable reduced. Educative advice directed towards securing effective treatment of those earlier conditions which have been shown commonly to precede cancer and to the avoidance, so far as possible, of injury, would doubtless also be of value. Intensive efforts on a wide scale are now being devoted to the search for the cause or causes of malignant disease, and it is earnestly hoped that they will result in furnishing humanity with some direct means of controlling the disease through the application of preventive measures. It must always be remembered, however, that the discovery of a cause may not necessarily indicate a means of prevention, and even though it did, preventive measures could not be expected to secure early results in cancer, since the bulk of the evidence indicates that the disease is one of slow development, due to effective or predisposing causes operating over a prolonged period. Pending an achievement of this kind, therefore, no effort should be spared to reduce suffering and mortality by all educative and remedial measures now available, and it is the aim of this memorandum to indicate the value of such measures in so far as cancer of the breast is concerned." 58 Lectures and Film Displays held under the Auspices of the Fulham Propaganda Committee of the British Social Hygiene Council, Inc. Date. Where held. Subject. Lecturer. Nos. 29.1.26 Fulham Town Hall Film Mr. P. H. Jones 150 2.3.26 Lady Margaret School ,, Dr. R. C. Verney 120 29.3.26 Peterborough Road School ,, Dr. Newton-Davies 60 3.5.26 Lillie Road School ,, Mr. E. B. Turner 75 8.9.26 Walham Grove - Mr. P. H. Jones 400 10.11.26 Langford Road School Film Dr. Sloan-Chesser 100 30.11.26 Lillie Road School ,, Dr. Rose Turner 50 6.12.26 St. Augustines — Miss Dugdale 60 10.12.26 Fulham Rangers, Walham Green Film Miss Peto 30 23.12.26 Fulham Central Library ,, Mr. E. B. Turner 300 Total attendances 1,345 59 Table IV.—Cases of Infectious Diseases notified during the Year 1926. 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) 345 11 4 20 30 33 133 42 24 37 5 6 - 18 77 45 56 64 15 51 19 339 14 Erysipelas 77 1 1 — 1 - 3 1 2 14 10 33 11 3 17 6 14 11 4 16 6 49 1 Scarlet Fever 311 4 13 19 29 37 120 47 19 21 1 1 — 10 56 38 34 74 18 63 18 295 4 Typhus Fever — — — — — — — — — — — — — — — — — — — — — — — Enteric Fever 8 — — — — — 1 — 2 2 - 3 — 3 — 1 — 2 — — 2 5 — Relapsing Fever, Continued Fever - - - - - - - - - - - - - - - - - - - - - - - Puerperal Fever 15 - - - - - - - 1 11 3 - - 2 2 - 4 4 — 2 1 13 3 Puerperal Pyrexia 12 - - - - - - - - 9 3 - - 1 2 - 3 5 - 1 — 6 — Cerebro-Spinal Meningitis 4 2 — — 1 — 1 — - - - - — — — 1 — 1 — 2 — 4 3 Polio-myelitis 7 1 1 - - 1 1 2 - - - 1 - - - 1 - 1 1 3 1 7 - Ophthalmia Neonatorum 29 29 - - - - - - - - - - - 2 9 3 6 3 1 3 2 10 — Tuberculosis of Respiratory System 312 - 1 1 - 1 17 10 30 132 53 60 7 26 44 40 31 74 15 53 29 - 161 Disseminated Tuberculosis 2 — — — — 1 1 — — — — — — — — 1 — 1 — — — — 4 Other Tuberculous Diseases 120 12 2 5 4 6 37 10 13 13 12 6 — 4 10 22 19 33 4 20 8 — 13 Measles 3,700 164 386 460 470 549 1,527 51 45 36 10 2 — 129 676 605 265 874 175 717 259 201 47 Encephalitis Lethargica 12 - - - 1 - 2 - - 8 - 1 - - 1 2 1 3 — 5 — 5 4 Pneumonia 288 13 25 23 22 15 21 14 10 43 29 53 20 11 52 68 35 52 4 54 12 160 142 Diarrhœa 50 35 10 1 2 2 — — — — — — — — 16 13 7 4 2 7 1 29 28 Malaria - - - - - - - - - - - - - - - - - - - - - - - Dysentery - - - - - - - - - - - - - - - - - - - - - - 1 Trench Fever — — — — — — — — — — — — — — — — — — — — — — — Total 5,292 272 443 529 560 645 1,864 177 146 326 126 166 38 209 962 846 475 1,206 239 997 358 1,123 425 60 Tuberculosis. During the year the Tuberculosis Register has been corrected by the removal of all cases under the following headings : Cured, arrested, diagnosis not confirmed, lost sight of, left the district and died, and the addition of all new cases notified, in accordance with the Public Health (Tuberculosis) Regulations, 1924. At the end of 1926 the number of cases remaining on the Register was as under:— Pulmonary. Non-pulmonary. Males. Females. Males. Females. Number of cases on Register at commencement of 1926 577 435 311 258 Number of cases removed during the year 177 140 48 38 400 295 263 220 Number of cases notified for the first time during 1926 174 138 67 55 Number of cases remaining on Register at 31st December, 1926 574 433 330 275 It will be seen from Table IV. that 434 cases of tuberculosis were notified during the year. Of these 312 were cases of tuberculosis of the respiratory system, two were cases of disseminated tuberculosis, and 120 were due to tuberculosis of other organs. Table IV. classifies the cases according to the ages of the persons affected, and also gives the number of cases in each ward of the Borough. Mortality from Tuberculosis. Respiratory system— 161 deaths 97 males, 64 females. Death rate 0.98 per 1,000, being 0.04 higher than in 1925. 139 notified (86.3 per cent.), 22 not notified (31.7 per cent., of whom 11, or 50 per cent., died in institutions). 61 Other Tuberculous Diseases— 17 deaths 9 males, 8 females (including 4 deaths from disseminated tuberculosis). Death rate 0.10 per 1,000, compared with 0.13 for 1925. 15 notified (88.2 per cent.), 2 not notified (11.8 per cent., both of whom died in institutions). Period Between Primary Notification and Death. Respiratory system— Under 1 month 23 (16.5 per cent.). 1-3 months 22 (15.8 per cent.). 3-6 months 17 (12.2 per cent.). 6-12 months 17 (12.2 per cent.). 1-2 years 28 (20.1 per cent.). Over 2 years 30 (21.4 per cent.). Notified after death 2(1.4 per cent.). Other Tuberculous Diseases— Under 1 month 13 (86.6 per cent.), including 2 seminated tuberculosis. 1-3 months 1 (6.7 per cent.). 3-6 months — 6-12 months — 1-2 years — Over 2 years 1 (6.7 per cent.), disseminated tuberculosis. Prevention and Treatment of Tuberculosis.—The Tuberculosis Dispensary is situated at 114, New King's Road. The working arrangements are exactly as detailed in previous reports. Table V., page 62, gives a summary of the whole position of the tuberculosis problem in this Borough. 62 TABLE V.—DISPENSARY STATISTICS, 1913-26. 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 1926 183 53 37 318 1,741 2,876 481 5,355 63 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 0.20 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 1926 312 122 161 17 0.98 0.10 64 REPORT BY THE TUBERCULOSIS OFFICER (DR. HAMILTON) ON THE WORK OF THE TUBERCULOSIS DISPENSARY. Fulham Tuberculosis Dispensary, Annual Report, 1926. During the past year alterations have taken place in the personnel of the Dispensary Staff. Following on the resignation of Dr. Hewat, in May, Dr. Sullivan was selected at first temporarily, and later permanently, to the position of Medical Officer of Health. There thus ensued an interval of four months before the post of Tuberculosis Officer was filled, and throughout this period Dr. Hardy carried on the entire medical work of the department, single-handed and with complete success. Seeing that the department was shorthanded for more than a third of the period under review, one would have expected a considerable drop in the number of cases dealt with, contacts examined, domiciliary visits paid, etc., but, as a matter of fact, the decrease has been very slight. Moreover, in a Borough in which the following-up work has been so thorough as it has been in Fulham, the natural tendency would be for the numbers recorded in the various branches of the report to arrive at a point of equilibrium, and for the new patients taken on the books approximately to counterbalance those discharged. In addition it may be of interest to mention that during 1925 a memorandum was circularised by the Ministry of Health, having reference to the mode of procedure and the keeping of statistics to be adopted in dispensaries throughout the country. The scheme set out therein is a complicated one, and one may be permitted to doubt whether in many respects it is an improvement on its predecessors, but one of its main features is that it lays down certain definite principles regarding the removal of the names of persons from the Dispensary register whom, for various 65 reasons, tuberculosis officers may have hitherto felt unwilling to take the responsibility of discharging. The chief result of the introduction of the new system will be that in future it will be possible for the staff to concentrate attention more especially on those cases that require rigorous supervision, and whose families are particularly liable to exposure to infection. Having regard to the preceding considerations one may proceed to a comparison of the figures of 1926 with those of the previous year. The number of new cases attending the Dispensary was 591, as compared with 666 in 1925, whilst the number notified from the Dispensary was 236, as against 206. The total number of old and new cases notified was 275, compared with 241 in the preceding year. One thousand, four hundred and sixty-five patients attended in 1926, and 1,511 in 1925. Once again the number of attendances showed a decline, on this occasion from 5,361 to 4,617, the decrease being due to further efforts to discharge non-tubercular and cured cases at the earliest possible date in order to comply with instructions received from the Ministry of Health. In spite of the diminution in the number of attendances, the number of physical examinations rose from 3,117 in 1925 to 3,412 in 1926. Three hundred and twenty-four reports were sent to doctors in 1926 and 388 in 1925. It must be understood that numerous communications with doctors, personally, by telephone, and otherwise are carried out concerning patients, and that they do not figure in the above which refers only to letters giving full details of clinical findings on cases sent up for an opinion. During 1926 the nurses' visits totalled 5,355, a decrease of 66, while those of the tuberculosis officers fell to 481, the drop in each case being due to temporary depletion of staff. 66 It is pleasing to be able to record that the large number of 351 patients were sent to institutions or to the country through the Dispensary, this figure representing an increase of 74, approximately 23 per cent. Institutional Treatment arranged through the Dispensary.—The London County Council is responsible for the residential treatment of tubercular persons domiciled in London. In the past this work has been criticised on several grounds, and mainly on the following:— (1) The inadequancy of the number of beds able for all cases, and especially for those with advanced disease, and (2) The prolonged period of waiting that has elapsed between the recommendation of the patient and his admission. Fortunately, both these drawbacks have been less in evidence during the past year, though it cannot yet be said that one is able to offer to every patient the opportunity of sanatorium or hospital treatment with the certain knowledge that he will be accepted, and discretion has still to be exercised in the selection of cases for recommendation, especially if the person has been away at some previous date. Apart from actual treatment, one very important function of the London County Council scheme is the provision made for the observation of doubtful cases, in which the tuberculosis officer does not feel justified in making a diagnosis with the facilities at his command. Such observation carried out by skilled physicians in an up-to-date hospital is bound to result in the detection of early cases, with the possibility of the immediate provision of appropriate treatment, or, equally important, in the discharge of others in whom the diagnostic criteria adopted have proved freedom from disease. Such persons have not only been saved much mental anxiety, but they have also been spared the grave inconvenience resulting from unnecessary notification. Table VI. sets out in detail the number of cases sent away through the London County Council and 67 Poor Law Authorities, and also emphasizes the gratitude we owe to the Invalid Children's Aid Association, The Charity Organisation Society, the United Services Fund and the Children's Country Holiday Fund for their admirable work in this connection. Table VI. 351 patients were sent to residential institutions on the recommendation of the Dispensary Medical officers. (a) 221 by the London County Council. 95 to Sanatoria. 6 to Convalescent Homes. 7 to Farm Colonies. 113 to Hospitals or Homes. Men 41 — 7 59 Women 30 – — 43 Children 24 6 — 11 (b) 61 by the Poor Law Authorities. 30 to Fulham Hospital. 31 to Sanatoria or Convalescent Homes. Men 11 2 Women 9 9 Children 10 20 (c) 37 children were sent to Convalescent Homes by the Invalid Children's Aid Association. (d) 14 by the Charity Organisation Society. 1 woman sent to a Home for advanced cases. 1 woman sent to Eversfield Chest Hospital. 6 women and a baby sent to Convalescent Homes. 5 children boarded out. (e) 7 by the United Services Fund. 4 men sent to Convalescent Homes. 3 children boarded out. (f) 6 children boarded out under the L.C.C.'s Contact scheme. (g) 5 children sent away through the Children's Country Holiday Fund. 68 Advanced, Cases.—The problem of the advanced case is still a very grave one. It is naturally difficult to persuade persons who realise that they have no prospect of cure to leave their homes, especially to enter an institution situated at a distance, and there is often reluctance on the part of relations to agree to a separation which they feel may be permanent. On the other hand, the fact that there is not yet sufficient accommodation available results in the refusal of admission to many whose presence in the home is a burden and a danger to the other occupants, and who cannot receive the skilled attention necessary for their comfort. The natural solution of the matter would be the provision of a small home situated in the locality, and catering for the needs of one borough, or of two adjoining boroughs, and taking the form of an institution in which the patients would be allowed every possible latitude, and in which the prevailing atmosphere would be one of homeliness and informality. This scheme has, so far, not been found practicable, but it is to be hoped that in the course of the development and expansion of the anti-tuberculosis campaign it may find a place in the future. It is fortunate that in this Borough the patients have learned by experience to form a high opinion of the treatment provided in the Fulham Hospital, the universal appreciation of which renders it comparatively easy in most cases to secure their consent if recommended to enter there. X-ray Examinations.—During the year 58 cases were sent to Brompton Hospital for X-ray examination. The films received have been most helpful, and the accompanying reports have added greatly to precision in diagnosis, and to the interest in the work, coming as they do from a radiologist of high repute and of great experience in this special branch. It has been pointed out in previous reports that there are certain disadvantages entailed in the present arrangement and these may be summarised as follows :— (1) The necessity for limitation of the number of cases referred owing to the expense involved. 69 (2) The distances which some patients have to travel from their homes to a centre outside the Borough. (3) The inevitable delay which must ensue between the making of the appointment and the reception of the report, which may occasionally be as long as a fortnight. This may appear a long time, but it is only owing to the courtesy of the Brompton Hospital Authorities that it is no longer. Till an X-ray plant is provided in the Borough these objections cannot be overcome. London County Council Scheme for boarding-out Child Contacts.—Full details of this scheme were given in last year's report. The aim of the project is one which must meet with hearty approval from all those engaged in anti-tuberculosis work, but the unfortunate fact remains that in practice it is so beset with diffculties, that its application has been very limited. During 1926 only six cases were dealt with, and it would appear that in future this number is not likely to be very greatly exceeded. Co-ordination between Panel Doctors and Tuberculosis Officers.—Collaboration between panel practitioners and tuberculosis officers is essential to ensure continuity of treatment, and to facilitate early diagnosis. The system approved by the Ministry of Health has already been described in a previous report, together with the modus operandi adopted in this Borough. During the year all of the prescribed forms received from panel doctors have been answered by a personal letter from the tuberculosis officers, which has been found preferable to the use of the more stereotyped method of replying on the printed forms originally suggested by the Ministry, the use of which is optional. There can be no doubt as regards the satisfactory position that the Dispensary holds as a consulting centre in the Borough, when one considers that no fewer than 248 of the new patients attended 70 on the recommendation of private practitioners, while a considerable number of further consultations were requested on cases that were already on the books. In this connection one cannot refrain from pointing out that the presence of a large Chest Hospital in an adjoining borough must, to some extent, result in the deflection of cases that would otherwise be dealt with at the Dispensary, a fact which renders all the more striking the significance of the figures just quoted. The very frequent visits paid to the Dispensary by local practitioners are greatly appreciated by the tuberculosis officers, and do much to establish the spirit of friendly co-operation that is so essential for success in the work. The Care Committee.—One must, at the outset, insist on the fact, previously emphasized, that the Care Committee has no funds directly at its disposal, and that its functions being chiefly advisory, it has to act mainly by bringing necessitous persons into touch with the agencies already existing for their relief. In spite of this the activities of this Committee cover a wide field, and the members, being all experienced and enthusiastic in social work, are of great assistance to the medical staff in smoothing over difficulties and altering conditions which might nullify the effects of treatment. Representatives of the different charitable societies and of the Board of Guardians sit on the Committee, and in many of the cases that come up for adjudication they have already an intimate knowledge of the home and the domestic circumstances, while in dealing with others their insight into local conditions is of invaluable assistance. While all do good work one would like to express especial gratitude to the representatives of the Invalid Children's Aid Association and the Charity Organisation Society, who not only secure the information necessary to enable assessments to be made in cases about to receive residential treatment, but also make themselves responsible for the weekly collection of payments, tasks which are most arduous and not 71 always very pleasant. The interest taken by the Borough Council in the work is shown by the fact that three Councillors, including the Chairman of the Public Health Committee, are regular attendants at the meetings. As typical of the multifarious problems that may fall to the lot of a Care Committee for consideration, the following may be mentioned :— (1) Arranging for the disposal of children during the absence of the mother in sanatorium. (2) Assistance of patients who are in difficulties over questions of insurance, pensions, accumulations of debts, or dealings with money lenders. (3) Provision of clothing, fares, etc., for those about to enter sanatorium. (4) Friendly visiting of patients in institutions and also in their own homes. (5) Securing improved home conditions for patients on their return. (6) Interceding with employers to grant special terms and facilities to men who cannot carry on their work at the previous productive level. (7) Using influence to place individuals in situa- tions known personally to members either in the country or the town. (8) Securing employment for patients recently discharged from sanatorium. (9) Making provision for the care of children or adolescents who are under the charge of drunken or immoral parents or guardians. This list is not intended to be in any way exhaustive, but the accompanying description of illustrative cases compiled by Miss Sargent, Secretary to the Committee, 72 will convey a more accurate impression of the valuable work done :— A.—Was a lad of eighteen who worked as a mixer of fruit drinks before his illness. He was sent under the London County Council's tuberculosis scheme first to Brompton and then to Godalming, where he did very well. On his discharge the Care Committee got in touch with the Welfare Department of his firm, asking for more suitable work to be given him. A light open-air job was found, which he has now had for five months and in which he has maintained his recovered health. B.—Had broken down in health when first we heard of him. He was under the Middlesex Hospital, but his wife and children were persuaded by the Dispensary Nurse to be examined as Contacts, and as the two children were found to be very debilitated after pneumonia, they were referred to the Invalid Children's Aid Association for convalescence and were sent to Worthing. The mother, relieved temporarily of their care, was able to make arrangements for the future, which necessitated her becoming the breadwinner of the family, as B. died while away in sanatorium. C.—Was a married woman with three small children, and when it was necessary for her to go away for treatment, arrangements had first to be made for the family. As the husband was an exservice man, the children were referred to the United Services Fund, by whom they were sent down to a " Home " at Yarmouth. On the return of the patient from sanatorium, as it was still desirable that the children should not be with her, they were referred to the London County Council for boarding-out under the Contacts scheme and were accepted. They are still away, and will, we hope, remain so until better accommodation can be found for the family on one of the L.C.C. housing estates. D.—Was a woman suffering from pulmonary tuberculosis who had had no holiday in her married life, and who was losing weight and going downhill under stress of daily work, plus home duties. The husband was in work at the time and his mother agreed to look after the four children while the patient was away. Extra nourishment was given from the Town Hall until a vacancy could be obtained, and D. finally departed for Broadstairs, where she was extremely happy. However, one Friday, we learnt by telephone that she had been summoned home, and unless she could return on the Monday the vacancy would be filled. A visit to the home showed that the husband was now out of work and could not afford to pay for the care of the children. D. was advised to apply to the Guardians on the Saturday and to come to the Dispensary on the Monday, and a letter to the Clerk to the Guardians made him aware of the facts of the case. D. appeared on the Monday, saying the Guardians were providing for the family, so that she could return to Broadstairs, but she had no money for the fare and the 73 train left in a few hours. A telephone message to the London County Council procured the promise of a refund if the money could be advanced as there was no time to send a voucher, and D. returned that afternoon to Broadstairs to complete her treatment. E.—Came to us on her discharge from sanatorium in September, 1925. She was then twenty-one, and had lost her father and brother from tuberculosis, but her mother, by money earned by going out as a daily cook (together with the patient's insurance benefit), was able to keep a home together. This, however, necessitated the girl being left alone for the whole of the day, and early in 1926 application was made to the London County Council for further residential treatment, but was refused. The case was then referred to the Charity Organisation Society, who procured her admission to the Eversfield Chest Hospital, and kept her there for three months. She came back improved, but not fit for work, and another application to the London County Council resulted in her admission to a residential institution, where she still is. Summary of Statistics. Number of new patients— Insured 218 Uninsured 373 Total 591 Number of attendances— Insured 1,741 Uninsured 2,876 Total 4,617 Number of patients who have attended, both old and new 1,465 Number of Notifications—Pulmonary 208 Non-pulmonary 67 Total 275 Number of sputa examined 1,610 Number of Physical examinations 3,412 Number of Contacts examined 405 Number of home visits paid by doctors 411 Consultations 70 Total 481 74 Number of home visits paid by nurses 5,355 Number of reports sent to public bodies 847 Number of reports sent to doctors 324 Number of patients referred to Brompton Hospital 4 „ ,, „ „ „ „ For X-ray 58 Number of notified patients on dispensary books at end of 1926 1,117 Number of patients sent to institutions or to the country in 1926 351 Table VII.—Showing Sources of New Cases. 248 were recommended by private doctors. 27 „ „ the Medical Officer of Health. 10 „ „ the School Medical Officers. 16 „ „ the School Authorities. 20 ,, ,, Hospitals. 10 ,, „ other Dispensaries. 8 „ „ the Army authorities. 106 „ „ the Dispensary staff. 2 ,, „ the London County Council. 93 ,, „ friends. 26 „ „ patients. 11 „ „ the door-plate. 8 „ „ the Invalid Children's Aid Association. 4 „ ,, the district nurses. 1 was „ „ the Relieving Officer. 1 „ „ the Ministry of Health. 591 Table VIII.—Diagnosis in Males and Females (New Palients). Total Cases. Pulmonary Tuberculosis. Other forms. Suspects. NonTuber cular. Percentage Tuberculous. 297 males 109 31 17 140 47.13 294 females 74 22 20 178 32.65 591 both sexes 183 53 37 318 39.93 75 Table IX.—Sex and Age of New Patients for 1926. Under 5 yrs. 10 yrs. 15 yrs. 25 yrs. 35 yrs. 45 yrs. 45 & over All ages. Males 41 65 28 50 48 34 31 297 Females 32 46 28 65 47 44 32 294 Both Sexes 73 111 56 115 95 78 63 591 Table X.—Diagnosis at various Age periods (new patients). Pulmonary Tuberculosis. Other forms. Suspects NonTuber cular. Percentage Tuberculous. Under 5 years 2 7 4 60 12-33 „ 10 „ 8 24 3 76 28-82 „ 15 „ 5 7 2 41 21-42 „ 25 ,, 62 6 8 40 58-62 ,, 35 „ 49 4 7 35 55-78 „ 45 „ 32 4 12 30 46-15 45 and over 25 1 1 36 41-26 All ages 183 53 37 318 39-93 Table XI.—Housing Conditions. Of 217 of the 236 tuberculous patients found in 1926— 6 lived in the basement. 53 „ on the ground floor. 75 „ „ first floor. 14 „ „ second floor. 3 „ „ third floor. 7 „ „ top floor. 33 „ on more than one floor. 26 ,, in the whole house. 217 76 Table XII.—Housing Accommodation. Number of families occupying 1 room. 2 rooms. 3 rooms. 4 rooms. 5 rooms. 6 rooms or more. Patient living alone 7 – – – 1 – Patient living with 1 other 7 6 7 2 — – ,, „ 2 others 4 15 17 10 3 – „ „ 11 „ 5 8 21 17 5 5 „ „ 4 „ — 1 17 8 1 1 „ „ 5 „ — 3 9 8 2 1 „ „ 6 „ — — 4 3 1 1 „ „ 7 „ — — 3 5 1 1 „ „ 8 „ — — 2 1 — — „ „ 9 „ – – 3 1 – – Total 23 33 83 55 14 9 In 1914, 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. This year's figures show an even worse state of affairs, the percentage having risen to 64. Table XIII.—Sleeping Accommodation of 217 Tuberculous Patients. The patients slept— In a separate room In 64 cases. Alone in bed with one other in room „ 24 „ ,, „ two others in room „ 17 „ „ „ three others in room „ 8 „ „ „ four others in room „ 3 ,, In bed with one person and no others in room „ 49 „ ,, „ one other in room „ 27 „ „ „ two others in room „ 13 „ ,, ,, three others in room „ 1 „ In bed with two persons and no other in room „ 6 „ ,, ,, one other in room „ 3 ,, „ ,, three others in room „ 2 „ 217 cases. 77 Table XIV Occupations of 110 Tuberculous Men in 1926. 1 actor. 1 foreman in ice house. 1 baker. 1 gardener. 2 baker's roundsmen. 1 greengrocer. 1 barman. 1 horse-keeper. 1 blacksmith. 2 joiners. 2 bricklayers. 1 inspector of dairies. 1 builder and decorator. 5 labourers. 1 omnibus conductor. 1 laundryman. 2 omnibus drivers. 1 marble sawyer. 2 butcher's assistants. 1 maker of fruit drinks 1 butcher's roundsman. 3 messengers. 1 canvasser. 2 mechanics. 1 carman. 2 motor drivers. 1 cashier. 1 platen hand. 1 carpenter. 3 plumbers. 1 chef. 1 piano maker. 1 chemist. 1 potter. 18 clerks. 5 shop assistants. 1 coach painter. 1 shop-keeper. 1 copper glazier. 3 shop porters. 1 dairyman. 2 stokers. 1 dancing master. 2 school teachers 1 dental mechanic. 1 storekeeper. 1 dining-car attendant. 1 tailor. 2 engineers. 1 ticket collector. 1 engineer's cleaner. 1 tram conductor. 2 electricians. 1 warehouseman. 1 designer. 2 warders (Museum). 1 factory hand. 1 wood machinist. 3 litters. 1 wire worker. 5 no occupation. Occupations of 74 Tuberculous Women in 1926. 1 book-keeper. 28 housewives. 1 box-maker. 1 house-keeper. 1 canvasser. 1 laundress. 1 cashier. 1 laundry packer. 8 clerks. 1 nurse. 1 charwoman. 7 shop assistants. 1 cook. 1 school teacher. 1 coffee-stall attendant. 1 telephonist. 6 domestics. 1 typist. 1 door-maid. 3 waitresses. 1 dress-maker. 1 worker in ice-house. 1 hairdresser. 4 no occupation. 30 boys under 15. 22 girls under 15. 78 TABLE XV.-PUBLE HEALTH (TUBERCULOSIS REGULATIONS, 1912. Summary of notifications during the period from 1st January, 1926, to 31st December, 1926. 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 Institutions. Sanatoria. 0-1. 1-5. 1 5-10. j 10-15. 15-20. 20-25. 25-35. 35-45. 45-55. 55-65. 65 and upwards. Total Primary Notifications. Under 5. 5-10. 10-15. Total Primary Notifications. Pulmonary— Males - 3 11 3 12 27 44 32 29 11 3 175 305 – – – – – 11 169 Females - - 8 7 18 26 36 20 15 5 3 138 216 - - - - – 15 91 N on-pulmonary Males 4 10 21 5 8 3 2 7 3 – – 63 77 – – – – – 3 21 Females 8 7 15 5 5 6 2 5 2 1 - 56 73 - – – – – 1 25 79 Table XVI. NEW CASES OF TUBERCULOSIS COMING TO THE KNOWLEDGE OF THE MEDICAL OFFICER OF HEALTH OTHERWISE THAN BY NOTIFICATION ON FORMS "A" OR " B " DURING THE YEAR 1926, e.g., AFTER DEATH OF THE PERSON. [###Age Periods. 0-1 1-5 5-10 10-15 15-20 20-25 25-35 35-45 45-55 55-65 65 & upwards Total Cases.[/### Pulmonary— Males — 1 — — — — — — — — 1 2 Females — — — — — — — — — — — — Non-Pulmonary— Males — — — — — — — — — — — — Females — — — — — — — — — — — — 80 The Public Health (Preservatives in Food) . Regulations, 1925. The following is a summary of the Public Health (Preservatives in Food) Regulations, 1925, as amended by the Public Health (Preservatives in Food) Amendment Regulations, 1926. The Regulations apply to food and drink for human consumption and their object is to abolish or restrict the use of chemical preservatives in food, and where permitted to allow only those which are harmless. Definition of the term " Preservative."—The following are not included in the definition :— Common Salt. Saltpetre (Sodium or Sugars. sium Nitrate). Glycerine. Hop Extract. Acetic Acid or Vinegar. Spices and essential oils for Alcohol or potable spirits. flavouring purposes. Substances added during the process of curing or smoking. Manufacture for Sale and Sale of Articles of Food containing Preservative. (Article 4 (1) and First Schedule).—No articles of food are allowed to contain preservative except those enumerated in the First Schedule, which are Sausages. Gelatine. Sausage meat containing raw Unfermented grape juice. meat, cereals and condiments. Non-alcoholic wines, cordials and fruit juices sweetened Fruit and fruit pulp. and unsweetened. Dried fruit. Sweetened mineral waters. Jam and Marmalade. Brewed ginger beer. Jelly made like jam. Cider. Sugar (including solid glucose). Beer. Alcoholic Wines. Corn Syrup or Liquid Glucose. Coffee Extract. Pickles and Sauces made from Crystallised Glace or Cured fruit or vegetables. Fruit, including Candied Peel. The Schedule gives the amount and kind of preservative allowed in each article, and the only preservatives allowed are sulphurous acid (including sulphites) and benzoic acid (including benzoates). 81 It is to be noted that many common articles of food are not included in the list, e.g., meat, fish and maragarine, and therefore they must contain no preservative. Manufacture and Sale of Articles containing colouring matter. (Article 4 (1) and First Schedule.)—The First Schedule gives a list of colouring matters prohibited in food, viz.:— Metallic Colouring Matters.—Antimony, arsenic, cadmium, chromium, copper, mercury, lead and zinc. Vegetable Colouring Matter.—Gamboge. Coal Tar Colours.—Picric acid, Victoria yellow, Manchester yellow, aurantia and aurine. Copper and arsenic are now entirely prohibited, e.g., copper in peas. It is to be noted that all colouring matters are not prohibited, but they must be non-injurious to health. Cream Containing Thickening Agents.—Prohibited under Article 4 (3). Articles sold as Preservatives or Colouring Matters for food or as Thickening Agents for Cream.—Article 5 prohibits any person either from selling them or recommending them verbally or in any advertisement or notice if their use would be contrary to the Regulations. Labelling of Articles of Food containing Preservatives. —Article 2 (3) of the Amendment Regulations, 1926, and Second Schedule of the 1925 Regulations.—Certain classes of articles if preserved must be labelled. They are sausages, sausage meat, coffee extract, pickles and sauces, grape juice and wine. In the case of grape juice and wine labelling is only required if the amount of preservative is over 600 parts per million. No other articles need be labelled, e.g., preserved jam does not require to be labelled. The labelling must be done in the way prescribed under the Second Schedule. 82 Articles Exposed or Offered for Sale by Retail.— Must either be labelled or a general notice put up on the premises. The notice to be easily readable and in a conspicuous place. Articles of Food when Sold.—Must be labelled. There are two provisos to the labelling rules, and these are as follows :— (1) If delivered to the actual purchaser on the vendor's premises or stall, labelling is unnecessary so long as a notice is put up. (2) In the case of hotels, restaurants and such other places where articles of food may be exposed or offered for sale or sold for consumption on the premises neither notice nor labelling is required. Duties of Local Authorities and their Officers.—The enforcement of the Regulations is almost entirely in the hands of the Local Authorities. Imported articles are dealt with by the Customs, but an arrangement has been made with the Commissioners that so far as imported meat, fish and fresh fruit (except fruit pulp) are concerned, the enforcement will normally be left to the Local Authorities. Power of Entry to Officers and of Taking Samples.— Given under Article 6. Dates when the Regulations come into Force.—1st January, but in the case of certain articles, viz., bacon, ham, egg yolk, butter and cream, a period of grace has been given, varying from six months to eighteen months, to enable methods to be adjusted and existing stocks to be cleared by manufacturers and traders, and during the period of grace preservatives may be present in these foods if non-injurious to health. The dates of coming into force are :— (1) All foods except those specified below, 1st January, 1927. (2) Bacon, ham, egg yolk and articles containing preserved margarine, 1st July, 1927. (3) Butter, cream and articles containing preserved cream, preserved bacon, preserved ham, preserved egg yolk, 1st January, 1928. (4) Articles containing preserved butter, 1st July, 1928. 83 Note regarding Cream containing Preservative.— Small quantities of boric acid (including borax) and of peroxide of hydrogen are allowed in cream under the Public Health (Milk and Cream) Regulations, 1912 and 1917, if the cream contains 35 per cent., or more, of milk fat. It must be labelled " Preserved." The Milk and Cream Regulations are revoked by the Public Health (Preservatives in Food) Regulations, 1925, but not until 1st January, 1928. It is not until 1928, therefore, that all preservatives are forbidden in cream. The Regulations will encourage clean methods in food factories and other food premises, and will also be an incentive to cleanliness in the home. More use is now being made of cold storage methods, which are preferable to the addition of preservatives. Mr. Cecil H. Cribb, B.Sc., F.I.C., Public Analyst for the Borough of Fulham, has kindly prepared the following notes on the Regulations :— "In the actual execution of the new Regulations some serious difficulties appear, though time and experience will no doubt overcome them. (1) In addition to the ban on all preservatives in the case of a number of foods, etc., there are about seventeen classes of foods in which limited proportions of specified antiseptics are to be allowed, but are not to be exceeded. Some of these classes comprise a number of individual substances, e.g., various kinds of wines, fruit pulps, sausages, etc., so that 50 or 60 articles, many hitherto rarely examined, should be sampled. If only one or two samples are to be examined annually the Regulations would be reduced to a farce. Some reduction in the number of samples of the more commonly taken substances may have to be made, or a larger total number of samples must be taken. (2) In addition to the ordinary examination of the samples for adulterants proper, i.e., other than 84 preservatives, at least four or five of the most commonly employed antiseptic substances should be searched for and, if found, the proportion must be determined. This means a great amount of additional work, and will certainly involve considerably larger samples than have hitherto been purchased. In some instances this will arouse suspicion on the part of the vendors and tend to defeat the intentions of the Act, unless special precautions are taken. (3) The permitted preservatives, e.g., benzoic acid and sulphurous acid, when in the presence of certain foods, are difficult to detect and still more difficult to estimate, and one of them, sulphurous acid, is more or less fugitive and disputes between different analysts and between the Public Analysts and the Government Chemist may give rise to serious trouble. The responsibility falling on the prosecuting authority will therefore be greatly increased. (4) In the same connection difficulty may arise from the fact that some preservatives have been found to occur naturally in the samples under examination or may be unavoidably produced during the process of manufacture, e.g., benzoic acid, boric acid, sulphurous acid and formaldehyde. Fortunately, as far as is known at present, only small proportions of these have been so found, but before legal proceedings are instituted discretion will be required to avoid possible injustice to vendors." Food Preparing Places. There are known to be 103 food preparing places, excluding bakehouses, in the Borough. These are as follows :—One large biscuit and cake factory, one large sauce factory, three pie shops, seven restaurants, nine ham and beef shops and 82 eating houses or dining rooms. These premises are under the supervision of the woman sanitary inspector, Mrs. Davies, who made 300 visits of inspection during 1926, compared with 85 325 during the previous year. Twenty-nine notices were served during 1926. Food Shops and Food Stalls. All food shops, stalls, barrows and the Fulham Market have been kept under careful supervision during the year, and two of the sanitary inspectors have been on special duty, as in previous years, every Friday and Saturday night with regard to these food premises. Slaughterhouses.—There are two licensed slaughterhouses in the Borough situated at :— No. 611, Fulham Road, and No. 640, King's Road. Inspector Manning has made 117 visits of inspection to these premises during the year. The total number of animals killed was 1,442, including 1,170 sheep and lambs, 232 bullocks and 40 pigs. None of the carcases or organs examined were found to be diseased, with the exception of 24 sheep's livers, which were affected with liver fluke and were destroyed. The slaughterhouses, lairs and utensils have been kept in a cleanly condition. Milk.—Of 522 samples examined, 3 or 0.57 per cent., were adulterated. This is a marked decrease compared with the percentage during the last three years, viz. :—1.0 per cent, in 1925, 1.6 per cent, in 1924, and 4.5 per cent, in 1923. Legal proceedings were instituted by the Council in two cases where milk was found to be deficient in fat, and in three instances in which whiskey proved, on analysis, to be below the recognised standard. Details of these prosecutions will be found on page 89. Milk Sellers.— Number on Register, 31st December, 1925 109 Number who discontinued sale of milk during the year, or business transferred 5 Number of registrations granted during 1926 8 Number on Register, 31st December, 1926 112 86 Cream (Milk and Cream Regulations, 1912 & 1917) Fourteen samples of cream and 19 samples of preserved cream were purchased during the year for analysis. The following particulars of proceedings taken in 1926 under the above-mentioned 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, dated 27th October, 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 522 nil Cream 14 2 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 19 (2) Statements incorrect — Total 19 (b) The examination made of milk fat in cream sold as preserved cream :— (1) Above 35 per cent. 19 (2) Below 35 per cent. — Total 19 (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 87 (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 22 Number of supplementary licences granted to sell certified milk 1 Number of licences granted to sell Grade "A" (Tuberculin Tested) milk 11 Number of supplementary licences granted to sell Grade "A" (Tuberculin Tested) milk 1 Number of licences granted to bottle Grade "A" (Tuberculin Tested) milk 2 Number of licences granted to sell Pasteurised Milk 10 Number of supplementary licences granted to sell Pasteurised Milk Nil Number of licences granted to sell Grade "A" milk 1 Number of samples taken in accordance with the instructions of the Ministry of Health Nil Number of samples not up to the standard as laid down by the Ministry of Health Nil Bakehouses.—There are 68 registered bakehouses in the Borough, two of which are factories, and 43 are underground. Inspector Jones made 106 visits and served 16 notices, 14 in writing and two verbally. The notices were principally for the purpose of requiring the cleansing of the interior of the bakehouses. Unsound Food.—The undermentioned articles, examined at the request of the owners, were condemned and destroyed :— Grapes 2 barrels. Winkles 2 bushels. Tomatoes 10 boxes. Skate 42 lbs. Apples 54 „ „ 6 wings. Greengages 40½ bushels. „ 1 box. Plums 34f „ Kippers 9 boxes. Chestnuts 10 bags. Haddocks 3 „ Potatoes 49 „ Plaice 1 box. Rabbits 18 dozen. Dog Fish 4 boxes. Cod 8 stone. Bully Beef 15 cases. 88 Samples Purchased for Analysis during 1926:— Article. Number of Samples taken officially. Number Adulterated Number of Samples taken unofficially Number Adulterated. Total Samples Total Adulterated. Percentage of Adulteration. Milk 519 3 3 — 522 3 57 Separated Milk — — 1 — 1 — — Butter — — 118 — 118 — — Cream 1 — 13 2 14 2 14.3 Preserved Cream — — 19 — 19 — — Dried Milk — — 1 — 1 — — Lard — — 25 — 25 — — Tea — — 1 — 1 — — Cream Cake — — 3 — 3 — — Malt Vinegar — — 12 3 12 3 25.0 Whiskey 12 6 39 14 51 20 39.2 Gin — — 4 3 4 3 75.0 Rum — — 6 2 6 2 33.3 Coffee — — 11 — 11 — — Borax — — 3 — 3 — — Cayenne Pepper — — 4 — 4 — — White Pepper — — 4 — 4 — — Cocoa — — 19 — 19 — — Chocolate — — 10 — 10 — — Jam — — 5 — 5 — — Camphorated Oil — — 12 — 12 —. — Tinned Herrings — — 1 — 1 — — Pork Sausages — — 11 — 11 — — Beef Sausages — — 10 1 10 1 10.0 Milk of Sulphur — — 6 — 6 — — Margarine — — 8 — 8 — — Baking Powder — — 4 2 4 2 50.0 Self-raising Flour — — 24 — 24 — — Tinned Prawns — — 2 — 2 — — Mustard — — 20 1 20 1 5.0 Condensed Milk — — 8 — 8 — — Cheese — — 15 — 15 — — Beef Dripping — — 5 — 5 — — Olive Oil — — 3 — 3 — — Pork Pie — — 1 — 1 — — Veal and Ham Pie — — 1 — 1 — — Sponge Cakes — — 13 — 13 — — Ground Ginger — — 5 — 5 — — Peas — — 7 4 7 4 57.1 Fish Pastes — — 4 — 4 — — Calomel Ointment 2 — 5 2 7 2 28.6 534 9 466 34 1,000 43 4.3 89 Proceedings were instituted in the undermentioned cases:— Defendant. Offence. Result. Penalty. Costs. £ s. d. £ s. d. Hill, A. R., "The Crown," 248, North End Road Selling whiskey 43 degrees under proof Convicted. 10 0 0 — Fairbairn, V. D., "The Imperial," 577, King's Road Selling whiskey 46.5 degrees under proof Convicted. 15 0 0 — Gt. Eastern Dairy Co., Old Montague Street, Whitechapel, E. 1 Selling to the prejudice of the Fulham Guardians milk 9 per cent, deficient in fat Convicted. 2 0 0 — March, G. H., 11, Seagrave Road Selling milk 12 per cent, deficient in fat Dismissed under P.O. Act — 2 0 0 James, F. W., "White Horse," Parsons Gn. Selling whiskey 41 degrees under proof Dismissed under P.O. Act — 3 3 0 General Sanitary Administration. Bacteriological Examinations.—Of the 3,041 specimens sent by doctors during the year, 2,757 were examined at the Council's Laboratory, 114, New King's Road. The remaining 284 specimens were examined by the Clinical Research Association during week-ends, holidays and emergencies. Bacteriological examinations made during the year 1926 :— Material from cases of suspected diphtheria— Diphtheria bacillus isolated 154 Negative result 1,085 1,239 Blood from cases of suspected Enteric Fever— Widal reaction for typhoid or para-typhoid obtained 4 Negative result 10 14 Pathological specimens for enteric organisms— Positive result Nil Negative result 9 9 Sputa from cases of suspected tuberculosis— Tubercle bacillus found 237 ,, „ not found 1,372 1,609 Examinations of urine 66 Blood counts 7 Other examinations 8 81 90 Swabs examined for Gonococci— Gonococci found 19 „ not found 43 62 Special examination of— Sputa 7 Urine 20 27 3,041 Public Mortuary.—Ninety-seven bodies were removed to the Mortuary during 1926, and were admitted as follows :— By order of the Coroner 76 Brought by Police 13 For convenience till funeral 8 97 Eighty-two post-mortem examinations were made, and inquests were held in 87 cases. Disinfection.—The following rooms were disinfected and cleansed after infectious disease :— Rooms fumigated after Scarlet Fever 299 „ „ Diphtheria 313 ,, ,, Measles 82 „ „ Phthisis 387 „ „ Erysipelas 43 ,, ,, Encephalitis Lethargica 7 „ „ Cancer 40 „ „ Chickenpox 4 „ „ Poliomyelitis 4 „ „ Influenza 1 „ „ Puerperal Fever 14 „ „ Scabies 14 ,, ,, Enteric Fever 10 „ „ Epidemic Diarrhœa 1 „ „ Mumps 4 „ „ Venereal Disease 1 for Vermin 76 Rooms sprayed 13 „ fumigated by request 96 1,409 91 The following articles were disinfected at the Council's Disinfecting Station:— Articles. From Private Houses. From Institutions. Total. Beds 677 4 681 Mattresses 924 91 1,051 Palliasses 68 — 68 Spring beds 11 — 11 Pillows 1,859 138 1,997 Cushions 373 — 373 Bolsters 651 — 651 Blankets 2,056 435 2,491 Sheets 1,369 96 1,465 Covers 293 — 293 Counterpanes 691 17 708 Curtains 113 — 113 Carpets 257 — 257 Hearth rugs 427 1 428 Articles of clothing 2,497 252 2,749 Eiderdowns 199 2 201 Sundries 513 93 696 12,978 1,129 14,233 Sanitary Inspection of the District.—The following inspections of dwelling-houses were made during 1926 by the District Sanitary Inspectors:— Cause. Premises Inspected. *In consequence of complaint 2,130 In consequence of infectious disease 719 House-to-house inspections 223 Re-inspections 13,690 * This number includes houses reported as insanitary by Tuberculosis Nurses, Health Visitors, etc. 92 The following notices requiring the abatement of nuisances found were served:— Intimation Notices. Statutory Notices. Number served. Number complied with up to Dec. 31st, 1926. Number served. Number complied with up to Dec. 31st, 1926. 2,153 2,016 336 290 The following works were carried out and repairs effected as a result of the action of the Sanitary Inspectors :— Drains tested 1,375 Drains relaid 159 Drains repaired 490 Soil pipes renewed 138 Soil pipes repaired 104 Eaves and downspouting repaired 481 Sinks renewed or repaired 307 W.C.'s and flushing apparatus repaired 570 Cisterns cleansed and covered 253 Water supply provided from main 96 Yards and forecourts paved 372 Roofs, chimneys and walls repaired 1,002 Dustbins provided 394 Dampness of walls remedied 733 Internal house repairs done 2,695 Rooms cleansed 4,554 Overcrowding abated 32 Other nuisances abated 1,695 The following additional matters were dealt with by the Sanitary Inspectors :— Ice-cream premises— Number of inspections 131 Other food premises— Number of inspections 876 Smoke nuisances— Complaints 10 Observations 228 Notices served 7 Number abated 7 93 FACTORIES, WORKSHOPS AND WORKPLACES. I.—Inspection of Factories, Workshops and Workplaces. Inspections made by Sanitary Inspectors. Premises. Number of Inspections. Written Notices. Prosecutions. (») (2) (3) (4) Factories (including factory laundries) 70 13 - Workshops (including workshop laundries) 33 10 - Workplaces (other than outworkers' premises) 20 8 — Total 123 31 — II.—Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector, j (1) (2) (3) (4) (5) Nuisances under the Public Health Acts Want of cleanliness 18 18 — — Want of ventilation - - — — Overcrowding - - — — Want of drainage of floors - - — — Other nuisances 35 35 — — Sanitary accommodation— Insufficient — — — — Unsuitable or defective 7 7 - — Not separate for sexes 4 4 — — Offences under the Factory and Workshops Acts:Illegal occupation of underground bakehouse (s. 101) - - - - Other offences (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921) - - - - Total 64 64 — — 94 In addition 570 visits of inspection were paid to the premises of outworkers and 25 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 undertaken by the Woman Sanitary Inspector, Mrs. Davies. During the year under review she carried out the following work :— Notices Visits. served. To verminous cases 149 19 Food kitchens 300 30 Workshops and workplaces 242 19 Factories 64 1 Infirm and dirty tenants 41 7 Measles 481 27 Drainage of Buildings.—The following drainage plans were submitted to and approved by the Public Health Committee during 1926 :— Plans of drainage of new buildings, including block of flats (200), hostel (83 apartments), shops and flats (14), factory, Jewish Synagogue, laundries, public house, gas works, laboratory and garages 59 Additions to existing buildings 44 Reconstruction of the drains of existing buildings 99 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 1,827 visits to works under construction. Rat Destruction. One hundred and fifty-five complaints were received regarding infestation by rats, and poison baits were laid in the following positions :— Private houses 267 Other premises 24 Sewers 246 Special dustbin traps were introduced in July and accounted for 186 rats up to the end of the year. The amount received by the Council from property owners for the services of the Rat Officer was £17 5s. Od. 95 Legal Proceedings.—Proceedings under the Public Health (London) Act, etc., were instituted in the following cases:— Defendant. Offence. Result. Penalty. Costs. £ s. d. £ s. d. P. J. Murphy, 31, Brecr Street. Nuisance from overcrowding. Withdrawn. Nuisance abated. – – Bird, J. D., 132, Lillie Road. Unlawfully occupying underground room. Convicted. 1 10 0 — Goldblum, H., 76, St. Bartholomew Close, E.C. Nuisance—34, Aintree Street. Order within 21 days. — 1 1 0 Harman, J. S., Earls Court Road, W. Nuisance—12a, Buer Road. Abated. Summons withdrawn. — — Harman, J. S., Earls Court Road, W. Nuisance—12c, Buer Road. Abated. Summons withdrawn. — — Harman, J. S., Earls Court Road, W. Nuisance—68, Waldemar Avenue. Order within 28 days. — 1 1 0 Chapman, J. S., 5, Albert Mews, Field Road. Failing to comply with nuisance order. Convicted. 1 0 0 — Coomer, R., Laindon, Essex. Nuisance—33, St. Thomas' Road. Order within 28 days. — 0 3 0 Harren, F., 36, Church Path, and Cain, M., 50, Heckfield Place. Exposing unsound greengages for sale in North End Road. Convicted and each fined. 1 0 0 — Keen, C. P., 74, May Street. Failing to abate nuisance. Order within 28 days. — 0 6 0 Health Week. Health Week was held from the 21st to the 26th November, 1926. The Health Exhibition, in the Concert Hall of the Town Hall, was opened by Sir James Dundas Grant, with the Mayor (Alderman W. J. Waldron, J.P.) in the chair, supported by Sir Cyril Cobb and Lieut.-Col. Vaughan-Morgan, the Members of Parliament for the Borough. The Institute of Hygiene, the Central Council for Maternity and Child Welfare, the National Baby Week Council, the Dental Board of the United Kingdom, the Metropolitan Water Board, the British Social Hygiene Council and other organisations kindly took stands at the Exhibition, and many trade firms who took stands assisted in the educational work. 96 Lectures were given at the Fulham Central Library by Dr. Harry Campbell on "Diet," Mr. E. B. Turner on "Venereal Diseases," and Dr. Charles Thomson on "Sunshine and Darkness." Dr. J. Rhys-Herbert lectured on "Teeth and their Relation to Health," and Mr. P. B. Tustin on " Milk—The Ideal Food." Cinema films (12 in number) were shown at the six cinemas in Fulham. Health week was most successful from the educational point of view as the majority of those attending were school children. Approximately 7,500 persons attended the Exhibition and 857 persons attended the lectures. The demonstrations given at the Exhibition were also a source of interest and were well attended. Increase of Rent and Mortgage Interest (Restrictions) Act, 1920, Rent and Mortgage Interest Restrictions Act, 1923. Twelve applications for certificates that the houses occupied were not in all respects reasonably fit for human habitation or were otherwise not in a reasonable state of repair were made during 1926, and certificates were granted in three cases. In the other nine cases the repairs were carried out at once by the owners so that the issue of certificates was unnecessary. Housing. In 1924 the London County Council informed the various Metropolitan Boroughs that they were prepared to consider cases of overcrowding and special hardship for accommodation on estates about to be built, and it was decided to allow each borough a proportion of the available accommodation, amounting to 15 houses for every thousand erected. Estates have now sprung up in various parts under this scheme in and around London. The accommodation in the London County Council houses consists of two to six rooms with scullery and bathroom, and the rents vary from 10s. to 23s. 6d. per week. 97 Up to the end of the year 1926, 57 Fulham families were successful in obtaining flats or cottages under this scheme, one during 1924, 15 during 1925, and 41 during 1926. The estates are situated at Becontree, near Barking (Essex) ; Downham, near Bromley (Kent), Roehampton (Surrey) ; Watling, near Hendon (Middlesex) ; and at White Hart Lane, Tottenham ; and, it will be noted that, with the exception of Roehampton, they are all at a considerable distance from Fulham. A great difficulty with regard to this scheme is that many of the applicants are only in receipt of incomes of from £2 10s. 0d. to £2 15s. 0d. per week to provide for the needs of four or five persons, and a considerable number have been refused accommodation as it was considered that the rents and travelling expenses would be too much of a drain on their resources. Overcrowding has certainly been relieved by the erection of these houses, with great benefit to many families. On account of the distance from Fulham and the travelling expenses the scheme does not entirely meet the needs of those in receipt of very small wages. The Borough Council's Estate in Wyfold Road, although on a small scale, is an effort in the right direction, and has provided houses in the vicinity for 36 families who were in urgent need of accommodation. The erection of these model flats was decided upon in the Autumn of 1925, and the site was acquired after a good deal of consideration. Mr. A. F. Holden, M.I.C.E., Borough Surveyor and Engineer, was the architect for the scheme. The dwellings are in three blocks of 12 flats, and each block is three storeys in height. Eighteen of the flats consist of two bedrooms, with a living room, scullery and bathroom, and eighteen have an additional bedroom. It is realised that accommodation on a much larger scale than that already provided is required, and the 98 success of this scheme will, doubtless, be an incentive to further efforts in the same direction. There are, however, difficulties in the way of housing schemes in the Borough, although they are not insurmountable. Fulham is already much built up and very little land is available for any purpose for which it is not already in use. According to the last available figures the density of population was 50 per cent. greater in this Borough than in London as a whole (i.e., the Administrative County of London, including the City), but as there were so many houses to the acre the actual housing accommodation was equal to the average for London Boroughs. Great discretion will be required in the choice of sites in order to preserve a sufficient area of open spaces which are necessary, from the health point of view, for the purpose of providing fresh air, rest, recreation and change of scene. Patches of green should be encouraged as a contrast to the eternal prospect of bricks and mortar. Borough Councils have power under the Housing Act not only to acquire vacant land, but also land already built up, as sites for the erection of dwelling houses for the working classes, and they may also adapt existing buildings by altering, repairing, improving or enlarging them. All these questions have received, and are still receiving, consideration at the present time by the appropriate Committees. Housing Conditions. Year ending 31st December, 1926. Number of new houses erected during the year :— (a) Total 36 (b) With State Assistance under the Housing Acts, 1919, 1923 or 1924:— (i.) By the Local Authority 36 (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) 3,072 99 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Consolidated) Regulations, 1925 233 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 1,593 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 1,349 3. Action under statutory powers :— A.—Proceedings under Section 3 of the Housing Act, 1925 :— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 2 (2) Number of dwelling-houses which were rendered fit after service of formal notices :— (a) by owners 1 (b) by Local Authority in default of owners 1 (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 336 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) by owners 228 (b) by Local Authority in default of owners 0 C.—Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925 :— (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 dwellinghouses 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 suance of demolition orders 0 100 It will be seen from the preceding table that 3,072 houses were inspected for housing defects, of which 1,593 were not in all respects reasonably fit for human habitation, and one was in a state so dangerous and injurious to health as to be unfit for human habitation. Of the 1,593 houses referred to, 1,349 were rendered fit as a result of informal action by the Sanitary Inspectors, and in 290 cases the service of Statutory Notices was necessary. Of this latter number the defects were remedied after the service of notices in 229 cases, and in the remainder the notices had not been complied with up to the end of the year. A Closing Order became operative on the 16th July, 1926, under Section 3 of the Housing Act, 1925, as the result of a notice by the Council and a counter notice by the owners of No. 15, Campbell Street, but the premises are still in occupation at the present time. During the year it was found necessary for the Council to order the demolition of seven houses in Sotheron Road (Nos. 1 to 7). Closing Orders were served on the owners as far back as October 1922, under Section 17 of the Housing and Town Planning Act, 1909, and formal notices to quit were served on the tenants, but on account of the difficulty of obtaining alternative accommodation the houses were only closed when they actually became vacant. All the tenants had quitted the houses in 1926, when the last three families were accommodated in the Borough Council flats in Wyfold Road. Formal notices were served on the owners under Section 14 of the Housing Act, 1925, that the question of demolition would be considered on the 29th March, 1926. Demolition Orders were served on the 21st April, 1926, and the demolition has since been completed. 101 CONTENTS. Page Ante-natal clinics 24 Babies' Hospital 24 Bacteriological examinations 89 Bakehouses 87 Births, notification of 20 Clinics, ante and post-natal 22 Committees, Public Health and Maternity and Child Welfare 3 Circulars of Ministry of Health 30 Day Nursery 26 Deaths, causes of 13 Disinfection 90 Diseases, notifiable infectious 32 Diseases, non-notifiable 43 Drainage of buildings 94 Factory & Workshops Acts 93 Food 80 Food preparing places 84 Food (unsound) 87 Health Week 95 Housing 97 Infantile Mortality 15 Infant Welfare Clinics 23 Infectious diseases 32 Introductory 5 Legal proceedings (Sanitary and Housing) 95 „ „ (Adulteration of Food) 89 Maternity and Child Welfare 19 Maternity Home 27 Milk and Cream 85 Milk (Special Designations) Order, 1923 87 Milk, provision of free 28 Mortuary 90 Mothers and Children, home visitation of 20 Nursing, home 29 Post-natal clinics 22 Poor Law Relief 31 Principal diseases, deaths from 9 Rat Destruction 94 Rent Restrictions Act 96 Samples purchased for analysis 88 Sanitary Inspection of the district 91 Slaughterhouses 85 Staff—Public Health Department 4 Tuberculosis 60 Tuberculosis Dispensary 62 Tuberculosis, report by Dr. Hamilton, Tuberculosis Officer 64 Vaccination 30 Venereal disease 58 Vital statistics 7