FUL 26 Metropolitan Borough of Fulham. ANNUAL REPORT of the Medical Officer of Health for the Year 1927. JOHN SULLIVAN, M.B., Ch.B., D.P.H., Medical Officer of Health. Shield and Spring, Printers, 26 and 28, Lancelot Place, Brompton Road. S.W. 7. 3 Fulham Borough Council PUBLIC HEALTH COMMITTEE. His Worship The Mayor (Alderman W. J. Waldron, J.P.) Ex-officio. Chairman : Councillor W. Fowell. Vice-Chairman : Councillor G. L. Hodge. Councillor Dr. T. J. Bokenham. Councillor A. W. Ford. „ Mrs. W. Brooks. „ C. Harwood. „ S. G. Carnt. „ C. Lancaster. „ W. R. Corbin. „ Miss H. A. Packer. „ Mrs. H. L. Cummins. „ W. Purves. „ H. Dodimead. „ G. Solley. „ A. W. Driver. „ W. Wilcox. MATERNITY AND CHILD WELFARE COMMITTEE. His Worship The Mayor (Alderman W. J. Waldron, J.P.) Ex-Officio. Chairman: Councillor Mrs. H. L. Cummins. Vice-Chairman: Councillor H. Dodimead. Councillor F. J. Bellenger. Councillor G. R. Renton. „ Mrs. W. Brooks. *Mrs. Corbin. „ S. T. Cave. *Mrs. Pritchard. „ G. L. Hodge. *Mrs. Van den Bergh. „ C. Lancaster. *Miss C. M. L. Wickham. *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. (Lond.) (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. 1A. W. Gammack. 1 F. E. Walsh. *Miss B. Baron. *Miss M. Wacksmith. L. Brooks. Senior Sanitary Inspector : 1*Charles Bristow Jones (Food and Drugs). Sanitary Inspectors: l *Frederick H. Manning. 1 3 *Alfred J. Parsons. 1 *Edgar Drake. 12 *Tohn A. H. Brownlow. 12 *Charles B. Lloyd. 1 * Albert E. Clutterbuck. 12 *Thomas H. Robey. 12 *George W. Herrick. *Mrs. M. E. Davies. Health Visitors : 4 5 6 *Mrs. J. Bryning. l 4 6 *Miss A. Perrett. 4 5 6 *Miss D. M. Hayward 4 5 6 *Miss E. Beckett. 1 4 5 6 *Miss W. K. Watts. 6 *Mrs. M. Clarke (tempy.) Tuberculosis Dispensary Staff : Nurses: 4 *Miss J. Tinnion. 4 6 *Miss M. A. Shepherd. 4 6 *Miss R. Bowen. *Miss M. C. Robinson, Bacteriological Assistant and Dispenser. *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: 4 6 *Miss M. Bustard. Assistant Matron: 4 6 *Miss M. M. Wedick. Superintendent of the Disinfecting Station : H. Toy. Disinfectors : E. J. Eyles, W. Leaton and G. Passenger. Van Driver A. V. Williams. Mortuary Keeper : D. MacKay. Rat Officer : H. Harvey. • The Council receives Excheauer erant towards the salaries of these Officers. 1 Certified Sanitary Inspector. 2 Food Inspector's Certificate. 3 Registered Plumber. 4 Trained Nurse. 5 Health Visitor's Certificate. 6 Certificate of Central Midwives Board. 5 Town Hall, Fulham, S.W. 6. August, 1928. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Fulham. 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 1927. During the year a number of changes occurred in the personnel of the staff. * I have with great regret to record the death of Miss M. L. Durnford, one of the Council's Health Visitors, which occurred on the 1st November after only a few days' illness and was a great shock to her many friends and colleagues. Owing to Dr. Hardy's illness Dr. Hamilton carried on the work of the Dispensary, single-handed, from 10th October to 7th November, and was then assisted by Dr. G. K. Stone during two sessions weekly. Miss D. M. Hayward took over Miss Green's duties as Health Visitor on 1st January, 1927, and Mr. G. W. Herrick succeeded Mr. J. Castley as Sanitary Inspector on 20th June, 1927. Mr. B. P. Garrod, office youth, was successful in obtaining an appointment as junior clerk in the Public Health Department of the Heston and Isleworth Urban District Council on 31st October, and was succeeded by Mr. L. Brooks. I am pleased to state that the members of the staff have given the most loyal and willing service, for which I am grateful. I desire to acknowledge the large amount of voluntary work done by the Chairmen and Members of the Public Health and Maternity and Child Welfare Committees, and of the societies associated with the Council in the prevention of disease ; also the help I have received from my colleagues in other departments. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, JOHN SULLIVAN, Medical Officer of Health. 6 1.—General Statistics. Area (acres) 1,706 Population 161,900 No. of inhabited houses (1921 census) 25,979 No. of families or separate occupiers (1921 Census) 40,436 Rateable value £1,088,769 Sum represented by penny rate £4,482 2.—Extracts from Vital Statistics for the Year. Births:— Total. Males. Females. Legitimate 2,319 1,183 1,136 Birth rate 15.1 Illegitimate 125 57 68 Deaths:— 1,833 945 888 Death rate 1 11.3 No. of women dying in, or in consequence of, child-birth :— From sepsis 2 From other causes Deaths of Infants under one year of age per 1,000 births:— Legitimate 63. Illegitimate 112. Total 66 Deaths from:— Measles (all ages) nil Whooping cough (all ages) 8 Diarrhoea (under 2 years of age) 19 Population.—The Registrar-General has estimated the population of the Borough at the middle of 1927 to be 161,900. (Males, 74,970; females, 86,930). Marriages.—The number of marriages was 1,401, and the marriage rate, i.e., the number of marriages per 1,000 of the population, was 8.6. In the two preceding years the marriages numbered 1,265 in 1926, and 1,305 in 1925, thus showing an increase of 136 for 1927. 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 2,444, of whom 7 1,240 were boys and 1,204 were girls. The birth rate was 15.1 per 1,000 inhabitants, being 1.1 per 1,000 below that of 1926. The birth rate for the whole of London was 16.1, and for England and Wales 16.7. Illegitimacy.-—The illegitimate births numbered 125 (57 males, and 68 females), or 5.1 per cent., of the total births, against 6.2 per cent, in 1926 and 5.1 per cent, in 1925. Natural Increase of the Population.—The natural increase of the population by excess of births over deaths was 611, against 887 in 1926 and 1,017 in 1925. 8 Table I.—Vital Statistics of the Whole Borough during 1927 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 i Year of Age. At all Ages. Of NonResidents registered in the Borough. Of Residents not registered in the Borough. Number. • Rate. Number. * Rate per 1,000 Nett Births. Number. * Rate. Number. Rate. 13 1 2 3 4 5 6 7 8 9 10 11 12 1917 al45186 2852 2971 cl8.4 1251 8.6 139 882 323 109 1994 13.7 b161841 1918 al43211 2593 2672 cl6.7 1704 11.9 186 973 286 107 2491 17.4 b160463 1919 al52543 2947 3000 cl8.6 1510 9.7 242 634 250 83 1902 12.2 b155904 1920 a158621 4383 4327 c27.2 1888 11.9 457 396 320 74 1827 11.5 b158989 1921 159400 3546 3528 22.1 1865 11.7 381 382 291 83 1866 11.7 1922 159500 3210 3242 20.3 1897 11.9 362 400 224 69 1935 12.1 1923 161600 3312 3123 19.3 1632 10.0 252 328 199 64 1708 10.5 1924 163100 2975 2967 18.2 1717 10.5 270 373 214 72 1820 11.1 1925 163700 2780 2771 16.9 1620 9.9 209 343 211 76 1754 10.7 1926 164300 2691 2670 16.2 1578 9.6 168 373 173 64 1783 10.8 1927 161900 2356 2444 15.1 1588 9.8 121 366 162 66 1833 11.3 (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 institutions in 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. † "Transferable Deaths" are deaths of persons who, having a fixed or usual residence in England or Wales, die in a district other than that in which they resided. The deaths of persons without fixed or usual residence, e.g., casuals, are not included in Columns 8 or 9, except in certain instances under 3 (b) below. In Column 8 the number of transferable deaths of " non-residents " which are deducted is stated, and in Column 9 the number of deaths of " residents " outside the district which are added in calculating the nett death-rate of the Borough. The following special cases arise as to Transferable Deaths :— (1) Persons dying in Institutions for the sick or infirm, such as hospitals, lunatic asylums, workhouses and nursing homes (but not almshouses) are regarded as residents of the district in which they had a fixed or usual residence at the time of admission. If the person dying in an Institution had no fixed residence at the time of admission, the death is not transferable. If the patient has been directly transferred from one such Institution to another, the death is transferable to the district of residence at the time of admission to the first institution. (2) The deaths of infants born and dying within a year of birth in an Institution to which the mother was admitted for her confinement are referred to the district of fixed or usual residence of the parent. (3) Deaths from Violence are referred (a) to the district of residence, under the general rule; (b) if this district is unknown, or the deceased had no fixed abode, to the district where the accident occurred, if known ; (c) failing this, to the district where death occurred, if known ; and (d) failing this, to the district where the body was found. Area of District in acres (land and inland water), 1706. Total population at all ages at the Census of 1921 : 157,938. 9 Births and Deaths Registration Act, 1926. This Act came into force on the 1st July, 1927. Under the previous Births and Deaths Registration Acts it was the duty of the registered medical practitioner to give the certificate of the cause of death to the relative or other responsible person, but Section 6 of the 1926 Act requires the doctor forthwith to deliver the death certificate to the Registrar and to give a written notice to the relative that he has signed the death certificate. As the relatives may obtain a copy of the death certificate from the Registrar the doctor is liable to omit the original cause of death in cases of syphilis and alcoholism where an accurate statement would hurt the feelings of the relatives. Provision is now made on the back of the new death certificate for the doctor to indicate that he is in a position to give the Registrar-General additional information, such as the above, which may be useful for statistical purposes. Under the Births and Deaths Registration Acts, 1836-1901, it is the duty of the father or mother of a live-born child, and failing them of certain other persons, to inform the Registrar of the birth within 42 days of the date of birth, and the Registrar must register the birth. Under the old Acts neither the birth nor the death of a still-born child was compulsory, but under Section 7 of the 1926 Act, registration of the birth of every still-born child issuing from the mother after the 28th week of pregnancy is required, and the relatives must inform the Registrar that the still-birth has taken place. Under Section 5 of the Act it is not lawful for a still-born child to be buried until either a certificate from the Registrar or, if an inquest has been held, an order from the Coroner has been delivered to the person who has control of the burial ground. Section 7 states that when a still-birth is registered the relatives giving information must either :— 10 (i.) Deliver to the Registrar a written certificate that the child was not born alive, signed by a registered medical practitioner or certified midwife who was in attendance at the birth or who has examined the body of the child, or (ii.) Make a declaration in the prescribed form to the effect that a doctor's or midwife's certificate cannot be obtained and that the child was not born alive. Circular 802a of the Ministry of Health states that if the Local Authority is given notice by the Registrar of cases under heading (ii.) in which no doctor or midwife was in attendance or where his or her certificate cannot be obtained, it is advisable for the Medical Officer of Health to arrange for enquiry to be made, as by a Health Visitor, in order that he may be in a position to inform the Registrar whether he is satisfied that the child was really still-born or whether there are any suspicious circumstances attached to the case. The new Act may thus assist in the detection or prevention of infanticide. Deaths.—During the year ended 31st December, 1927, 1,588 deaths were registered in the Borough. Of these, 121 were of persons not belonging to the Borough while 366 inhabitants of Fulham died outside the Borough, chiefly in various public institutions. There were, therefore, 1,833 deaths of persons—945 males and 888 females—having their usual residence in Fulham, representing an annual rate of 11.3 per 1,000 of the estimated population, being 0.5 per 1,000 above that of 1926. The death rate of males was 11.6, of females 10.9. The following comparative death rates are of interest:— Death rates, 1927:— England and Wales 12.3 London 11.9 107 Large towns (average) 12.2 Fulham 11.3 It is worthy of special mention that the death rate per 1,000 persons living in Fulham was lower than that of any of the other five Boroughs in the West district of London. 11 Zymotic deaths.—The mortality from zymotic diseases was lower than in 1926, 41 deaths being due to the seven principal epidemic diseases, against 103 during 1926. The zymotic death rate was 0.2 per 1,000 of the population, as compared with 0.6 for 1926. Seasonal mortality.—The mortality in the four quarters of the year under review was as follows :— Deaths. Rate. First quarter 657 16.2 Second quarter 386 9.5 Third quarter 330 8.1 Fourth quarter 460 11.3 Causes of death.—There are classified in Table II., pages 15 and 16. The following Table shows the diseases which caused the largest number of deaths :— Disease. Males. Females. Both sexes. Percentage of total deaths. Cancer 98 122 220 120 Bronchitis 112 104 216 11.9 Heart diseases 98 101 199 10.8 Pneumonia 78 89 167 9.1 Tuberculosis (all forms) 99 48 147 8.0 Totals 485 464 949 51.8 It will be seen that 949 deaths, or 51.8 per cent., of the total were caused by five diseases. Although there was a reduction of 47 in the number of deaths from cancer, this disease, as in 1926, caused the largest number of deaths. There was a marked rise in the figures for bronchitis which occupied second place in 1927 causing 216 deaths, compared with 161 in 1926. Diseases of the heart were third on the list. 12 The deaths from pneumonia, which numbered 142 in 1926, rose to 167 in 1927. The increase in the mortality from bronchitis and pneumonia was probably due to the severe climatic conditions during the year. The tuberculosis death rate was the lowest ever recorded for the Borough and the number of deaths, which was 178 in 1926, fell to 147. If one is to consider the steps necessary in an attempt to reduce the mortality it is worth noting, not only the diseases which cause the highest mortality, but also the organs of the body which are affected by these conditions. There were 536 deaths in 1927 from diseases of the respiratory organs, equal to 29.2 per cent., of the total deaths. This number was made up as follows:— bronchitis, 216 ; pneumonia (inflammation of the lungs), 167; tuberculosis of the lungs, 126; other respiratory diseases, 27. A large number of the deaths from bronchitis (60 per cent.), were in persons over 65. In the case of the deaths from pneumonia less than 30 per cent, were over 65 years of age and 25 per cent, were in children under 2 years. There is little doubt that a great deal could be done to educate the public regarding the prevention of these conditions. Many diseases of the chest and of other parts of the body are caused or aggravated by septic material draining downwards from the nose, throat and teeth, and the prevention and early treatment of nasal catarrh, adenoids, enlarged tonsils and dental caries are obvious measures. The pollution of the atmosphere by smoke and other impurities also predispose to respiratory diseases and could be obviated by the more general use of smokeless fuel, gas and electricity. Overcrowding of our towns and houses are other causes and general debility partly caused by neglect of the rules of hygiene are also predisposing factors. Diseases of the organs of circulation caused 284 deaths in 1927, including 195 from heart diseases and 13 85 from arterio-sclerosis, but including haemorrhage into the brain, the deaths from circulatory diseases were 368 in number. The causes of heart diseases were described in last year's Annual Report. Sixty-six persons succumbed to inflammation of the kidneys (nephritis and Bright's disease). Forty-seven deaths were caused by influenza during 1927, whereas only fifteen were due to this cause in 1926. Nineteen of the deaths from influenza in 1927 were of persons over 65, and sixteen occurred in persons between 45 and 65 years of age. Infantile Mortality. Of 1,833 deaths of persons of all ages in Fulham during 1927, one hundred and sixty-two, or 8.8 per cent., occurred in infants under one year of age. The infantile mortality rate (the number of deaths of infants under one year per 1,000 births) was 66 per 1,000 in 1927 compared with 64 per 1,000 in 1926, but although the infantile mortality rate was higher the actual number of infants' deaths was less than during the previous year, being 162 in 1927 compared with 173 in 1926. The reason for the apparent anomaly was the fact that although the number of deaths was fewer, the number of births on which the infantile mortality is based declined still more. The infantile mortality rate for England and Wales was 69 and for London 59. The rate for Fulham compares favourably with that of the other five Boroughs in the West district of London. The rates for these boroughs are as follows :— Hammersmith 61 Kensington and Fulham 66 Westminster 68.6 Chelsea and Paddington 79 It will be seen from Table III., pages 19 and 20, that the principal causes of infantile mortality are as follows :— 14 Premature birth 40 deaths in 1927 compared with 43 in 1926 Pneumonia 25 ,, ,, 21 ,, Atrophy, debility and marasmus 19 ,, ,, 15 ,, Diarrhœal disease; (diarrhoea and enteritis) 16 ,, ,, 28 „ Bronchitis 15 ,, ,, 9 „ Seventy-four deaths of infants under four weeks of age occurred in 1927, which was the same number as in both the years 1925 and 1926. Infantile Mortality in Fulham. Deaths of infants under one year of age per 1,000 births :— Average for five years :— 1886-1890 170 1921 83 1891-1895 168 1922 69 1896-1900 167 1923 64 1901-1905 144 1924 72 1906-1910 117 1925 76 1911-1915 109 1926 64 1916-1920 92 1927 66 The following table shows the infantile mortality rates for the last two years (1926 and 1927) for the various wards in the Borough :— Ward. Births and Birth rates. Infantile deaths. Infantile mortality rates. 1926 1927 1926 1927 1926 1927 Baron's Court 133 ( 9.9) 130 ( 9.8) 11 8 82 62 Lillie 296 (11.3) 260 (10.2) 19 35 64 134 Walham 226 (17.1) 184 (14.1) 29 15 81 128 Margravine 586 (29.9) 522 (27.0) 19 19 32 36 Munster 556 (14.1) 522 (13.4) 38 45 68 86 Hurlingham 90 ( 9.1) 101 (10.3) 7 4 77 40 Sands End 409 (14.6) 388 (14.0) 35 29 85 74 Town 374 (25.1) 337 (22.9) 15 7 40 21 2670(16.2) 2444(15.1) 173 162 64 66 15 16 Table II. Causes of and Ages at Death during the Year 1927. Nett deaths at the subjoined ages of " Residents," whether occurring within or without the District (a). Total Deaths, whether of "Residents " or " Nonresidents " in Institutions in the District (b) Nett deaths at all ages of " Residents " in the Wards of the Borough, whether occurring in or beyond the Wards. Causes of Death. All ages. Under 1 year. 1 and under 2 years. 2 and under 3 years. 3 and under 4 years. 4 and under 5 years. 5 and under 10 years. 10 and under 20 years. 20 and under 35 years. 35 and under 45 years. 45 and under 65 years. 65 years and upwards. Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 All Causes | Certified (c) 1832 162 34 17 3 10 21 55 120 136 525 749 809 181 331 170 169 439 93 274 175 { Uncertified 1 — - - - - - - - - 1 - 1 - - - — - - 1. Enteric Fever 2 1 1 — — 2 — — — — 1 — — 1 2. Small-pox - - - — - - - - 4. Scarlet Fever 1 - - - 8 5 1 2 24 — — — — 5 — 2 1 6. Diphtheria 11 1 4 1 1 2 — 1 1 — — 37 — 3 — 3 1 1 2 1 7. Influenza 47 — — — — 2 1 — 4 5 16 19 12 13 10 — 4 7 3 6 4 8. Encephalitis Lethargica 1 — — — — — — — — — 1 — — — — — — — — 1 — 9. Meningococcal Meningitis 6 1 2 1 — 1 — 1 — — — — 3 1 — 3 — 1 — 1 — 10. Tuberculosis of Respiratory System 126 14 38 33 34 7 46 10 27 11 12 29 11. Disseminated Tuberculosis 2 — 1 — — — — 1 — — — — — — 2 — — — — — — 12. Other Tuberculous diseases 19 2 2 3 — — 4 2 3 — 3 — 8 2 2 3 2 6 — 3 1 13. Cancer, malignant disease 220 — — — — — — — 5 9 103 103 82 23 42 22 13 53 13 27 27 14. Rheumatic Fever 5 — — — — 1 2 — — — 1 1 4 — 1 — 1 1 — 1 15. Diabetes 12 - 2 — 5 5 7 — 2 1 1 5 — — 3 16. Cerebral Haemorrhage, etc. 84 - 1 — 1 23 59 30 8 15 7 4 23 6 12 9 17. Heart Disease 199 4 — — — — 1 10 8 11 70 95 — 50 23 36 18 18 31 16 31 - 18. Arterio-sclerosis 85 - — — — — — — — — 14 71 60 13 11 8 8 22 4 14 5 19. Bronchitis 216 15 2 2 2 1 9 47 138 114 16 46 22 27 56 8 28 13 20. Pneumonia (all forms) 167 25 16 1 5 6 11 14 43 46 69 17 29 13 17 47 8 22 14 21. Other Respiratory Diseases 27 1 1 1 — — 1 4 10 9 7 2 4 3 1 4 4 7 2 22. Ulcer of Stomach or Duodenum 17 - 1 — 1 9 5 1 8 — 3 2 2 4 2 2 2 23. Diarrhoea, etc. (under 2 years) 19 16 3 — — — — — — — — 14 — 2 4 - 24. Appendicitis and Typhlitis 16 - — 1 2 2 4 1 5 1 12 — 2 2 1 6 — 5 — 25. Cirrhosis of Liver 12 - — — — — — — — — 8 4 6 5 3 1 1 1 — — 1 26. Nephritis and Bright's Disease 66 - 6 4 29 27 31 6 11 3 7 19 3 8 9 27. Puerperal Sepsis 2 - 2 — — — — — — 1 — 1 — — — 28. Other accidents and diseases of pregnancy and parturition - - - - - - - - _ 1 — — — — — — 29. Congenital Debility and malformation, premature birth 80 78 2 - - - - - - — — 36 7 21 6 10 18 1 13 4 30. Suicide 25 — — — — —— 5 7 13 — 12 8 2 - 31. Other deaths from violence 70 6 3 1 5 10 8 15 22 34 5 12 4 7 19 5 15 3 32. Other defined diseases 288 9 2 1 3 3 11 17 20 80 142 96 23 44 34 26 70 14 38 39 33. Causes ill-defined or unknown - - — — — — — — — — — — — - - - - - Total 1833 162 34 17 3 10 21 55 120 136 525 750 809 182 331 170 109 439 93 274 175 (a.) All "Transferable Deaths" of residents, i.e., of persons resident in the District who have died outside it, are included with the other deaths in columns 2—13, and columns 15—22. Transferable deaths of non-residents, i.e., of persons resident elsewhere in England and Wales who have died in the District, are in like manner excluded from these columns. For the precise meaning of the term " transferable deaths " see footnote to Table I. (b) All deaths occurring in institutions for the sick and infirm situated within the district, whether of residents or of non-residents, are entered in column 14 of Table II. „ (c) All deaths certified by registered Medical Practitioners and all Inquest cases are classed as Certified all other deaths are regarded as " Uncertified." . 17 The largest number of births occurred in Margravine and Munster Wards, 522 births taking place in each, but Margravine Ward had the highest birth-rate (i.e., the number of births in the year per 1,000 of the population). In addition to this distinction Margravine Ward had the second lowest infantile mortality. Town Ward also showed a good record as it had the second highest birth rate and the lowest infantile mortality. Baron's Court recorded the lowest birth-rate, nevertheless its infantile mortality was only a little below the average for the Borough. Lillie Ward had the highest infantile mortality with Walham Ward as a close second. Mortality among Young Infants and Still Births. Although the birth-rate and mortality rate among infants under one year have gradually fallen for many years, the mortality among very young infants and the number of still births have not diminished to the same extent. During the three years 1925 to 1927 it is somewhat striking that 74 deaths of infants under four weeks have occurred each year and the number of still births has remained almost stationary since 1923, averaging 65 each year. It is stated on high authority that with better pre-natal care and better care during delivery, the numbers of still births and neo-natal deaths (deaths of newly born infants) would be reduced by 40 to 50 per cent. The causation of these deaths has received a good deal of attention of late. Any of the conditions mentioned as causing maternal mortality (vide page 18) may also pre-dispose to still birth or death of the new born infant. According to recent investigations in America, about 40 per cent, of infant deaths were stated to be due to 18 injury of the child's brain during delivery and in a series of 1,673 cases in this country 25 per cent, were ascribed to this cause. It is probable that preventive measures such as attention to the general health of the mother, the early diagnosis of the toxaemias of pregnancy and of contracted pelvis and other causes of difficult labour would obviate a certain proportion of the mortality. According to the American investigations, syphilis caused 16 per cent, of the infant deaths, judging by blood examinations of the maternal blood, and although this is an extremely high estimate it is probable that timely and efficient anti-syphilitic treatment during pregnancy would lead to good results in some of the cases. Maternal Mortality. Notwithstanding the great reduction in the general death rate and in infantile mortality during the last twenty years in England and Wales, maternal mortality associated with childbirth has remained unchanged during that period. Dame Janet Campbell, in her admirable report to the Ministry of Health on "The Protection of Motherhood," points out that "child bearing demands the sacrifice of about one maternal life for every 250 babies born, and although many women pass through the experience unscathed many others suffer subsequently from injury due to childbirth which may lead to serious and even permanent physical disability." Sepsis is by far the commonest cause of maternal deaths connected with pregnancy and labour. Out of 2,860 such deaths in England and Wales in 1926, 1,109 were due to sepsis (puerperal fever) and in Fulham during the last six years 60 maternal deaths occurred, of which 30 were due to sepsis. Only two maternal deaths, however, occurred in 1927, both due to sepsis. The septic organisms which cause puerperal fever may be already present in the womb before labour, 19 20 Table III. Infant Mortality during Year 1927. 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. I 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. 1 Sands End Ward. Town Ward. All Causes Certified 52 7 8 7 74 23 24 25 16 162 8 35 15 19 45 4 29 7 Uncertified — — — — — — — — — — - - - - - - - - 1. Small-pox - - - - - - - - - - - - - - - - - 2. Chicken-pox - - - - - - - - - - - - - - - - - - 3. Measles — - - - - - - - - - - - - - - - - - 4. Scarlet Fever - - - - - - - -- - - - - - - - - - - 5. Whooping Cough — — — — — 1 1 — 3 5 1 - - - - - - 6. Diphtheria and Croup — - - - - - - - - - - - - - - - - - 7. Erysipelas —- - - - - - - - - - - - - - - - - - 8. Tuberculous Meningitis — - - - - 1 1 2 - 1 - 1 - - - - 9. Abdominal Tuberculosis (a) — — - - - - - - - - - - - - - - - 10. Disseminated Tuberculosis - - - - - - - - - - - - - - - - - - 11. Otlier Tuberculous Diseases — - - - - - - - - - - - - - - - - - 12. Meningitis (not Tuberculous) - - - - - - - - 1 - - - - - - - - - 13. Convulsions 3 1 1 — 5 2 - - - 7 1 - - - - - - - 14. Laryngitis — — — — - — - - - - - - - - - - - - 15. Bronchitis - - - - - 2 4 6 3 15 - 4 1 3 5 - 1 1 16. Pneumonia (all forms) — — — 3 3 5 4 7 6 25 - - 5 4 8 2 4 2 17. Influenza — — — — — — — - - - - - - - - - - - 18. Diarrhoea - - - - - 2 1 2 — 5 - 1 - 1 3 - - - 19. Enteritis — 1 — — 1 — 3 5 2 11 - - 2 1 5 - 3 - 20. Gastritis — - - - - - - - - - - - - - - - - - 21. Syphilis — - - - - - - - - - - - - - - - - - 22. Rickets — — — — — — - - - - - - - - - - - - 23. Suffocation, overlaying 2 — - — 2 2 2 — — 6 - 1 — - 3 - 2 - 24. Injury by Birth 1 — 1 — 2 — 1 — — 3 1 1 — - - - 1 - 25. Atelectasis 3 — — — 3 — — — — 3 - 1 - - 1 - 1 - 26 Congenital Malformations 4 — 1 — 5 2 — 1 — 8 - 4 — - 1 - 1 2 27. Premature Birth 27 2 5 3 37 3 — — — 40 3 13 6 3 6 — 8 1 28. Atrophy, Debility and Marasmus 5 1 — 1 7 1 8 3 — 19 2 5 — 5 4 2 1 - 29. Other Causes 7 2 — - 9 3 — - - 12 1 3 1 1 3 - 3 1 Total 52 7 8 7 74 23 24 25 16 102 8 35 15 19 45 4 29 7 Nett Births in the Year :— Legitimate 23l9 Illegitimate 125 Nett Deaths in the Year of:— Legitimate infants 148 Illegitimate infants 14 (a.) Under Abdominal Tuberculosis are included deaths from Tuberculous Peritonitis and Enteritis, and from Tabes Mesenterica. Want of breast milk is included under Atrophy and Debility. 21 sometimes lying more or less latent or causing only slight local symptoms, and the condition may be lighted up during childbirth by injury to the womb or by lowered resistance to infection due to prolonged and difficult labour. The septic organisms instead of being present before the confinement may be introduced from outside. Thus a septic throat or a septic finger occurring in any member of the household, in the patient herself, or in any person attending or assisting at the labour may conceivably be the cause of the infection. Dirty bedding and dressings may also be causes. There is much uncertainty in the minds of the medical profession (1) as to the exact causes of puerperal sepsis, and (2) as to the proportion of cases in which the infection is already present in the womb prior to the confinement, compared with those in which the condition is derived from an outside source. Much research is required on this question which is important from the point of view of prevention. There is, however, a prospect that efficient ante-natal work and good midwifery will reduce the number of cases. Antenatal examinations will lead to early diagnosis and treatment of abnormalities and to proper provision for confinements which are likely to be prolonged or difficult, such as those of contracted pelvis. Attention to cleanliness in the home and to personal hygiene on the part of the patient and the members of the family as well as those in attendance on the case are obviously indicated. Next to sepsis the commonest causes of maternal deaths are the toxaemias of pregnancy, including (1) those due to disease of the kidney, and (2) convulsions or eclampsia accompanied by temporary loss of kidney function. Those two conditions together caused over 500 deaths in England and Wales in 1926. Examination of the urine and treatment when necessary before the confinement are of superlative importance in preventing calamities due to such conditions. It has been found in many instances that septic teeth and gums were the origin of the toxaemia of eclampsia and that efficient dental treatment is a preventive factor. 22 Haemorrhage before, during or after labour, and difficult or obstructed labour, also account for many deaths, and it should be possible to avert the majority of fatalities from these causes by preparation for the confinement and efficient treatment. Maternity and Child Welfare Work. A description of the Council's Maternity and Child Welfare scheme was given in last year's Annual Report, so that it is unnecessary to enter into detail in the present report. There are three Centres in Fulham all managed by a Voluntary Committee which receives a grant of £500 per annum from the Borough Council, half of which is repaid to the Council by the Ministry of Health. The Centres are situated at 90-92, Greyhound Road, 170, Wandsworth Bridge Road and at Melmoth Hall, Eustace Road. The Borough Council has now purchased the premises at Greyhound Road and act as landlords for the Voluntary Committee. The Clinics are staffed by a Superintendent and Assistant Superintendent, both appointed and paid by the Voluntary Committee and the medical and health visiting staff are provided by the Council. Every effort is being made to establish a liaison between private doctors and hospitals to whom cases are referred for treatment when necessary and the Maternity and Child Welfare Centres, whose primary object is the prevention of illness. Close and cordial co-operation is necessary as prevention and treatment go hand-in-hand in the campaign against infantile and maternal illness and mortality. The only methods of treatment carried out at the Centres are the treatment of minor ailments, massage and remedial exercises. Cases requiring operation for 23 adenoids and enlarged tonsils, dental treatment or eye defects are sent to the School Treatment Centre at Bagley's Lane. Infant Welfare Clinics. Number of consultations. First attendances of babies. Total attendances. Average attendances. 92, Greyhound Rd 145 455 5943 41 170, Wandsworth bridge Road 144 323 4891 34 Melmoth Hall, Eustace Road 96 372 4044 42 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 352 Number of attendances 968 At The School Treatment Centre, 18, Bagley's Lane. For operative treatment for enlarged tonsils and adenoids 14 For dental treatment (children) 30 For dental treatment (women) 107 Total attendances of women for dental treatment 394 (Of these 107 women, 38 were provided with dentures). For visual defects :— Number of mothers treated 48 Supervision of Children of Pre-School Age. The need for supervision of children between two and five years of age has been emphasised by Sir George Newman, the Chief Medical Officer of the Ministry of Health. It is found by school doctors that over a 24 third of the children entering school at the age of five years suffer from physical defects of one kind or another. Dr. Margaret Hogarth, of the Ministry of Health, examined 1,000 children of the age of three years during 1926 in various parts of the country, and found that 48.7 per cent, suffered from manifestations of rickets, 24 per cent, from dental caries and a considerable number from enlarged tonsils, adenoids, eye and ear defects and general debility. Dr. Hogarth was impressed during her investigations by the high standard of parental care and sense of responsibility compared with 15 years ago. She also found that the standard of cleanliness was higher. The Committee of the Voluntary Maternity and Child Welfare Centres has now secured the services of Dr. Lilian Butler, who has kindly volunteered to hold a toddlers' clinic for the care of children of pre-school age and this is being well attended. The purpose of the clinic is to detect abnormalities or ill health in the early stages. The work is preventive in character and if treatment is required the children are referred to the family doctor or to hospital. Ante-Natal Clinics. At 92, Greyhound Road. Number of women who attended 310 Number of attendances 1242 At 170, Wandsworth Bridge Road. Number of women who attended 149 Number of attendances 510 Number of ante-natal visits to homes 1033 It will be seen that 1,150 babies attended for the first time during the year and that the number of attendances amounted to 14,878 for the year. Notification of Births.—Under the Notification of Births Act, 1907, 2,265 births of living children and 59 births of still-born children were notified. 332, or 14.3 per cent., were notified by doctors, 1,794, or 77.2 per cent., by midwives, and 198, or 8.5 per cent., by 25 fathers or persons in attendance at the birth. The still-births during 1927 were equal to 2.3 per cent, of the registered live births. Home Visitation of Mothers and Children.—The home life and surroundings have a fundamental influence on the physical and mental health of the mothers and children and the home visits of the Health Visitors constitute an important part of the Maternity and Child Welfare Scheme. Each of the Health Visitors has a district of her own and her local knowledge is an asset to her in her work. As the Health Visitors are all trained nurses and qualified midwives, in addition to having special experience in public health and infant welfare, their advice and assistance is of the greatest service to the mothers in their districts. During the year 1927, the visits paid by the Health Visitors were as follows :— First visits to infants 2443 Re-visits to infants 10664 Re-visits to children aged 1 to 5 years old 10947 Visits to cases of ophthalmia neonatorun l 33 Ditto measles 508 Ditto pneumonia 48 Ditto diarrhoea 10 Ditto puerperal fever 7 Ditto puerperal pyrexia 26 Other visits 921 Maternity Home, 706, Fulham Road, S.W. 6.—This home, which is a Borough Council undertaking, being owned by the Council and staffed by its Officers, is under the medical charge of Dr. Ruby Thomson, Assistant Medical Officer of Health. It contains accommodation for ten patients. It is intended for women who have no proper accommodation for their confinements in their own homes. Only apparently normal cases are admitted, and it differs in this respect from maternity and other hospitals. There is 26 an isolation ward to which cases which are possibly infectious may be transferred from the wards when necessary. The minimum fee is £3 for the fortnight, during which patients are treated in the home. The highest fee charged during 1927 was £9 2s., for the fortnight, and the average fee was £4 5s. The net cost per patient to the Council for the financial year 1927-28 was £2 6s. 8d., equivalent to £1 3s. 4d. per week. The following is a record of cases admitted to the Home during the year 1927:— Cases admitted 188 Average duration of stay (days) 14 Number of cases delivered by:— (a.) Midwives 179 (b.) Doctors 9 Number of cases notified as puerperal sepsis Number of cases notified as puerperal pyrexia 3 Number of cases in which the temperature was above 100.4 for 24 hours 3 Number of cases notified as ophthalmia neonatorum 1 Number of cases of inflammation of eyes, however slight 3 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) 1 Fulham Babies' Hospital, 23, Broomhouse Road, S.W. 6.—This institution, which was opened in 1916 at 706, Fulham Road and transferred to Broomhouse Road in 1919, has accommodation for twenty-one children under 5 years of age. It is under the control of a Voluntary Committee. Fourteen beds are reserved for Fulham children and the Fulham Borough Council give a grant of £700 per 27 annum, half of which is repaid by the Ministry of Health. Dr. G. F. Hardy is in medical charge. The types of cases admitted are chiefly those suffering from dietetic errors, malnutrition, wasting, rickets ana anaemia. Acute cases, such as those of pneumonia, are also treated. There is a special arrangement whereby children who have just had operations in larger hospitals may be transferred to the Babies' Hospital. This is especially useful in the case of minor operations such as circumcision and the removal of tonsils and adenoids, when the home conditions are unsuitable for aftertreatment. The veranda at the back of the hospital which looks on the lawn has been an asset in securing more fresh air and sunlight for the children during the warmer months. The ultra-violet ray treatment which was applied in twenty cases has been useful for cases of rickets and impetigo, but no apparent benefit resulted in cases of malnutrition and wasting. The following is a summary of the work done during the year:— In hospital, January 1st, 1927 14 Number of babies admitted during the year 109 Average duration of stay (days) 52 Number of cases discharged:— (a.) In good health 46 (b.) Improvement 34 (c.) No improvement 15 (d.) On account of the development of infectious disease 4 viz.: Pertussis 4 Number of deaths 9 Number of babies in hospital, December 31st, 1927 18 28 The average daily number in the wards during the year was approximately 16.5, as compared with 12.5 during 1926, and 15.5 during 1925. The Fulham Day Nursery, Eridge House, Fulham Park Road.—This Institution was inaugurated at 56, Harwood Road, in 1906, and was transferred to its present abode in 1916. It is intended for the care during the day of children under five years of age whose mothers are compelled to go out to work. It is also a training ground for children's nurses, and certificates are granted after examination at the end of a year's training by the Day Nursery Committee, which is affiliated to the National Society of Dav Nurseries, 117, Piccadilly, W. 1. Dr. Ruby Thomson is Medical Officer to the Nursery. There has been an increase of 679 in the total number of attendances in 1927 as compared with 1926, largely due to the fact that the fees have been reduced. The attendances during the year were as follows:— Individual children attended:— Under three years of age 98 Over three years and under five 15 The total attendances made by the above children were:— Under three years:— Whole day 4756 Half day 1122 Over three years:— Whole days 1404 Half days 245 Total:— Whole days 6160 Half days 1367 Total 7527 29 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 177 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 113 15 10 For fresh milk 9 13 0 Total £123 8 10 The comparative expenditure for the three preceding years was as follows: in 1926, £121 6s.; in 1925, £80 10s. 3d. ; in 1924, £131 5s. 7d. 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 1927, under this part of the scheme, 10,171 lbs. of dried milk were supplied at a cost to the families of £957 18s. 3d., compared with 9,996 lbs. distributed in 1926 at a cost of £919 13s. 2d. Home Nursing. This is carried out by the Fulham District Nursing Association, 56, Harwood Road, S.W. 6, the arrangements being exactly similar to those detailed in my Annual Report for 1926. The number of visits made by the nurses under the Council's scheme was:— To persons under 5 years of age 677 To persons of 5 years or more 816 Total 1493 A fee of one shilling is paid by the Council for each attendance on a case. 30 The fees paid were:— 1927. 1926. £ s. d. £ s. d. By the Maternity and Child Welfare Committee 33 17 0 100 8 0 By the Public Health Committee 40 16 0 87 12 0 Total £74 13 0 £188 0 0 Vaccination. Mr. H. Davies, Vaccination Officer to the Fulham Guardians, has, as in past years, very kindly supplied the following details regarding vaccination. During the year under review 1,614 successful primary vaccinations were carried out, compared with 1,817 during 1926, and 1,811 during 1925. Particulars of the vaccinations carried out during the year ended 31st December, 1926, are set out in the following Table. Similar detailed figures are not yet available for the year 1927 :— Number of births registered from 1st January, 1926, to 31st December, 1926 2690 Successfully vaccinated .. .. .. 1581 Insusceptible of vaccination .. .. 8 Dead—unvaccinated .. .. .. 118 Postponed by medical certificate .. 55 Certificates granted under clause 2 of the Vaccination Act, 1898 .. 672 Removed to districts in which Vaccination Officer has been notified 77 Removed to places unknown 145 Outstanding 34 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:— 31 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 1546 65 1st January, 1918 1527 64 1st July, 1918 1439 73 1st January, 1919 1341 46 1st July, 1919 1376 43 1st January, 1920 1430 46 1st July, 1920 1426 44 1st January, 1921 2465 75 1st July, 1921 2486 70 1st January, 1922 4074 58 1st July, 1922 3520 56 1st January, 1923 3120 64 1st July, 1923 2659 92 1st January, 1924 2793 70 1st July, 1924 2328 63 1st January, 1925 2366 51 1st July, 1925 2705 68 1st January, 1926 3489 69 1st July, 1926 3125 67 1st January, 1927 3123 53 1st July, 1927 2656 59 1st January, 1928 3328 50 Infectious Diseases. Incidence.—Full particulars of all notifiable infectious diseases, arranged according to disease, ward and age will be found in Table IV., page 45. The number of cases of infectious diseases notified during 1927 was 2,055, compared with 5,292 in 1926 and 2,199 in 1925. The cause of the difference in the numbers during these three years was the epidemic of measles which occurred in 1926. Excluding measles, 1,592 cases were notified in 1927 and exactly the same number in 1926. The diphtheria notifications increased from 345 in 1926 to 390 in 1927 and the number of cases of scarlet 32 fever rose from 311 to 360. The notifications of influenzal and primary pneumonia were 310 in number in 1927, compared with 288 in 1926. On the other hand there was a considerable fall in the figures for tuberculosis (see page 45). Erysipelas notifications numbered 58 in 1927 compared with 77 in the previous year, and cases of infantile diarrhoea fell from 35 to 14. The number of cases of infectious diseases of the nervous system, of which 23 were notified in 1926, dropped to 15 in 1927. These included 7 cases of cerebro-spinal meningitis, 5 of encephalitis lethargica (sleepy sickness) and 3 of polio-myelitis or infantile paralysis. Mortality from Infectious Disease.—There were 354 deaths from notifiable diseases in 1927 compared with 425 in 1926. Whereas 47 children, all under 10 years of age, died of measles in 1926, there were no deaths from this cause in 1927. Although the notifications of diphtheria and scarlet fever increased in number in 1927, the deaths were fewer; 14 deaths were due to diphtheria in 1926 and 11 in 1927, while four persons died of scarlet fever in 1926 compared with one in 1927. There were 7 deaths from infectious diseases of the nervous system (cerebro-spinal meningitis and encephalitis lethargica) compared with 8 in 1926. Eight children died of whooping cough, five of whom were infants under one year, while the other three were all under 3 years of age. Diphtheria. Notifications of Diphtheria.—Three hundred and ninety notifications were received during 1927, which was equal to a case incidence of 2.4 per thousand of the population. The two sexes were affected in the proportion of 211 cases in females to 179 in males. 33 Regarding the ages of those affected, the following table shows that more cases occurred in children of 5 and 6 years of age than at other ages. 0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 6 to 7 7 to 8 8 to 9 9 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 & up Total. 11 13 31 33 33 45 46 39 21 7 40 23 39 3 5 1 390 The disease was prevalent all the year round, but more so in March and November. The largest number of notifications was received during the first quarter of the year, and the second largest number in the last quarter. First Quarter:— Third Quarter:— January 34 February 29 March 53 July 25 August 29 September 28 Second Quarter:— April 23 May 40 June 26 Fourth Quarter:— October 27 November 48 December 28 Deaths from Diphtheria.—Eleven deaths were due to diphtheria, thus giving a case mortality of 2.5 per cent. Eight deaths occurred in females and three in males. Of the eleven deaths two were in adults aged 33 and 35 years respectively; four deaths occurred in children aged 2 years and one in a child of one year. The remaining four persons whose illness ended fatally were aged 3, 4, 5, and 7 years respectively. The Prevention of Diphtheria.—I have already submitted two reports to the Public Health Committee recommending the adoption of the Schick test and immunisation against diphtheria. This method has been used in America and in several large towns in this country and elsewhere for 34 some years, and has been adopted by twelve Metropolitan Boroughs. It is in general use in fever hospitals in London for the purpose of preventing the members of the staff from contracting diphtheria. The procedure is as follows:— 1. The Schick test is done to determine whether the person is susceptible to diphtheria. This consists of an injection into the skin of the left forearm of a small amount—about two drops—of standardised diphtheria toxin (recently diluted). The injection is given by means of a syringe with a very fine needle and is practically painless. A control injection is given at the same time into the skin of the right arm. This consists of diphtheria toxin which has been heated to destroy its activity. If a positive reaction occurs at the spot where the needle was inserted into the left arm, this indicates that the person is susceptible to diphtheria and that preventive treatment is necessary. A positive reaction consists of redness and thickening of the skin over an area of half to one inch in circumference and takes place one to three days after the injection. The reaction lasts seven to ten days and subsides gradually. If no reaction occurs, the person is insusceptible or immune to diphtheria and the preventive injections are therefore unnecessary. In young children of preschool age the preliminary Schick test is generally omitted as it has been found that they are practically all susceptible and it is unnecessary to test them all individually. The preventive injections are therefore given without the preliminary Schick test. After the age of six, and in adults, the test is always done and only those who react positively need be immunised. 2. The Preventive Injections.—In this country toxoidanti-toxin mixture is generally used as its use is free from risk, whereas several accidents have occurred when the toxin-anti-toxin mixture has been employed. Three injections of 1 c.c. of the mixture (about seventeen drops) are given at weekly intervals under 35 the skin of the forearm and they are painless. The immunity does not develop immediately after the injections but takes several months and it is usual to give a Schick test at the end of six months to ascertain if the person has been protected. Approximately 90 per cent. of children can be immunised by three injections and only in about 10 per cent. of cases are further injections required. The immunity probably lasts throughout life. There is little doubt in view of the increase in the number of cases of diphtheria during recent years that the adoption of immunisation would lead to useful results, at first only in preventing the individuals who were immunised from contracting the disease, but in the course of years as more and more parents brought their children to be immunised there would be a considerable reduction in the number of cases notified and ultimately a reduction in the death rate. Fewer cases would have to be treated in hospital and money would be saved both on administration and treatment. Diphtheria, like other infectious diseases, interferes with the education, not only of those who contract it, but of the other children in the house who have to remain away from school for two weeks after the patient's admission to hospital. Scarlet Fever. Notification of Scarlet Fever.—Three hundred and sixty cases of scarlet fever were notified during 1927 which was equal to 2.2 cases per thousand of the population. Females were more affected by the disease than males in the proportion of 193 to 167 cases and the only death which occurred was in a female child of two years. The mildness of the disease can be judged by the fact that there was only one death out of 360 cases. The ages at which the disease occurred will be seen from the following table which shows that, as in 36 the case of diphtheria, children of 5 and 6 years of age were the chief sufferers. 0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 6 to 7 7 to 8 8 to 9 9 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 & up Total. 2 12 17 25 31 46 48 33 10 10 57 30 31 5 3 — 360 As regards the season, scarlet fever prevailed all the year round with a slight increase in the number of cases during the last quarter of the year. First Quarter:— January 37 February 10 March 29 Third Quarter:— July 40 August 17 September 31 Second Quarter:— April 28 May 36 June 25 Fourth Quarter:— October 32 November 38 December 37 Puerperal Pyrexia.—Puerperal Pyrexia is defined in the Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1926, as " any febrile condition, other than a condition which is required to be notified under the Infectious Diseases (Notification) Acts, occurring in a woman within twenty-one days after childbirth or miscarriage in which a temperature of 100.4° Fahrenheit (38° Centigrade) or more has been sustained during a period of twenty-four hours or has recurred during that period." Twenty-eight cases were notified under the Regulations in 1927. The Regulations only came into operation on 1st October, 1926, and twelve cases were notified during the remaining three months of that year. Puerperal Fever (Puerperal Sepsis).—Sixteen cases were notified during 1927, compared with 15, 21, 26 and 32 during the four preceding years. The incidence 37 in 1927 was equivalent to 6.5 per 1,000 registered births. There were two deaths from puerperal fever in Fulham in 1927 and this was the smallest number ever recorded, comparing with 3, 4, 4 and 9 deaths during the four preceding years. Ophthalmia Neonatorum (a purulent discharge from the eyes of an infant commencing within twenty-one days of the date of its birth).—Thirty-three cases were notified during 1927 compared with 29 in 1926 and 32 in 1925. The case rate per 1,000 registered births for 1927 works out at 13.4. Eleven of the infants affected 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. Further details are shown in the subjoined table:— Cases Notified. Treated. Vision. Total Blindness. Deaths. Left the Borough. Still receiving treatment. At home. In hospital. Impair ed. Unim paired. 33 22 11 nil. 33 nil. 1 2 nil. The Infectious Diseases (London) Regulations, 1927. These Regulations came into force on 1st January, 1928, and they revoke the Public Health (Pneumonia, Malaria and Dysentery, etc.) Regulations, 1919. They contain the same provisions as the latter Regulations with the following exceptions:— 1. Trench Fever, which was notifiable under the old Regulations, is no longer a notifiable disease. 38 2. Under the 1919 Regulations if a case of malaria had been notified within six months of the date of the medical practitioner becoming aware of its existence he did not require to notify the case ; under the new Regulations he must do so whether the case has been previously notified or not. 3. Cases of General Paralysis of the Insane are sometimes treated by artificially giving them malaria. Under the new Regulations if malaria is induced in a hospital for therapeutic purposes it is not notifiable unless the medical practitioner in charge of the patient considers that the patient is liable to relapses of malaria. In such a case a notification must be sent within four days of the patient's discharge from hospital to the Medical Officer of Health of the district in which the patient proposes to reside. 4. Under the Regulations the Local Authority, in order to prevent the spread of enteric fever or dysentery, may serve notices which result in persons employed in food occupations having to discontinue their work through no fault of their own. Compensation may now be given in these cases under Article 7 of the new Regulations which make Section 308 of the Public Health Act, 1875, applicable to enteric fever and dysentery. Cancer. In 1926, cancer caused 53,220 deaths in England and Wales which represented between one-eighth and one-ninth of the mortality from all causes and this disease accounted for more deaths than any other cause, except diseases of the heart. In Fulham, during the last two years, the number of deaths from cancer exceeded that from any other disease, 262 deaths occurring in 1926 and 220 in 1927. The mortality frorn malignant disease has increased during recent years; for example, the deaths in Fulham numbered 220 in 1927 compared with 176 in 1913, while the cancer death-rate per thousand of the population was 1.4 in 1927 compared with 1.1 in 1913. Part of the increase is only an apparent one; more cases are diagnosed because the facilities for diagnosis in difficult cases such as those occurring in inaccessible 39 organs are more readily available nowadays than formerly. Part of the increase is due to the fact that people live longer and that fewer babies are born so that there are proportionately more adults and especially more elderly adults in the general population who are more liable to cancer than the younger generation. It is, however, generally agreed that in addition to the apparent increase due to better diagnosis and the larger number of adults in the population there is a real increase in the cancer death-rate. Cancer in males and females.—Ninety-eight deaths were recorded in males and 122 in females. This shows a greater excess in the number of female deaths than in the country as a whole, but the figures for Fulham are too small to enable us to base conclusions as to the relative liability of males and females to cancer. The fact that more deaths from cancer occur in females than in males might give the impression that females are much more liable to contract the disease. It is to be remembered, however, that females outnumber males in the general population and when allowance is made for the relatively large number of females* it is found that taking the country as a whole and especially in London, males are actually more liable to cancer than females except between the ages of 25 and 45 at which age period cancer of the female generative organs, especially the uterus, occurs. The number of deaths during recent years from cancer in the Borough is shown in the following table:— Number of deaths from cancer in Fulham, 1923 to 1927. 1923 212 1924 221 1925 198 1926 262 1927 220 * The standardised cancer death-rate which takes into account the relative number of males and females as well as the ages of the individual is greater in males except between the ages of 25 and 45. 40 The age periods at which the deaths from cancer in Fulham occurred were as follows:— Age periods. Males. Females. Total. 20 to 35 2 3 5 35 to 45 3 6 9 45 to 65 48 55 103 65 upwards 45 58 103 Twenty-four deaths were due to cancer of the breast and 19 to cancer of the uterus (womb). Cancer of the intestines, excluding the rectum, caused 32 deaths in males and 29 in females. The mortality from cancer of the stomach, as is generally the case, was higher in males than in females, the proportion of deaths being 16 in males and 13 in females. There were 10 deaths from cancer of the rectum—4 in males and 6 in females—although cancer of this region is generally commoner in men. Cancer is divided into two main classes—carcinoma and sarcoma. Five of the deaths certified were stated to be due to sarcoma, 189 to carcinoma and 26 to cancer not otherwise defined. During 1927 the Ministry of Health have published reports on Cancer of the Uterus and Cancer of the Rectum describing the results of the investigations made at the instance of the Departmental Committee on Cancer which was appointed in 1923. Sir George Newman points out in the Annual Report for 1926 that the object of the report is to enable Public Health Authorities to inform the community at large in order to encourage co-operation in the common struggle against the disease, and also to make developing knowledge regarding cancer easily accessible to the medical profession. The following statement is in great part taken from these official publications. Cancer of the Uterus or Womb. The Ministry's two reports and Circular 826 on this subject are based on an inquiry into 80,000 cases treated in hospitals in 16 different countries, including England. 41 Although not quite so common as cancer of the breast, cancer of the uterus accounts for one-fifth to one-sixth of the total mortality from cancer in women. It is now an axiom that cancer tends to attack diseased rather than healthy organs and although its actual cause is unknown many of the so-called precancerous conditions which predispose to its occurrence are recognised and are, in fact, preventable. Thus the lower part of the uterus (cervix) which is frequently torn during child-birth and is liable on that account to become the seat of chronic inflammation, is the part most commonly affected; cancer of the cervix is, in addition, more serious than cancer of the upper part or body of the uterus and affects on the whole younger women. It is fortunate that only a small percentage of women who have had such injuries subsequently develop cancer, and that women who have had many children are no more liable to the disease than those with one or two children. The reports lay stress on the value of increased care before, during and after child-birth, as a contribution towards the cancer campaign and is a reminder, if any is required, of the value of Maternity and Child Welfare Schemes. It is now definitely stated that, contrary to popular belief, there is no special tendency for cancer of the uterus to occur about the period of the menopause (change of life). Symptoms of Cancer of the Uterus.—There can be little doubt that in most instances the condition begins without producing any recognisable evidence of its presence. The most common initial symptom is haemorrhage (in nearly 70 per cent. of cases), especially haemorrhage unconnected with the monthly periods, although increased loss on these occasions may also be a manifestation. An abnormal discharge occurs in about 20 per cent. of cases as an early symptom either during the monthly period or between the periods. The discharge may be irritating, foul or mixed with blood. 42 It is important to note that pain only occurs as an early symptom in about 8 per cent. of cases, also that any of the above symptoms may be produced by causes unconnected with cancer but on their occurrence a doctor's advice should be sought. Treatment.—The importance of early operation, now almost a commonplace, is again referred to ; unfortunately women generally wait 6 to 9 months after the onset of symptoms before applying for hospital treatment which prejudices their chances of recovery, as it is proved beyond doubt that the results of treatment in the early stage are, roughly, twice as good as those in patients whose disease, though amenable to operation, is approaching the borderline of inoperability. The danger of delay before commencing treatment is obvious when one remembers that the average duration of life in untreated cases is only one year and nine months. As regards the result of operation, about 40 per cent. of the patients survive over five years. Treatment by radiation (either radium or X-rays combined with radium) is of great value both in the early and late stages, but facilities for this treatment are not generally available in this country. This treatment requires very special and prolonged training and experience and is used more extensively on the Continent than in England. Radiological treatment has been successful in a small proportion of cases too advanced for operation, 10 to 12 per cent. of this type surviving over 5 years, thus establishing a high probability of cure. The unprecedented results in the more advanced cases have been such that radiation treatment is now being used on the Continent in early cases in place of operation and the results in these cases are stated to be as good as those obtained by operation. The author of the reports (Dr. Janet E. Lane Claypon) however, states that radiological treatment has not yet been tested over a sufficiently long period to enable a strict comparison to be made with the best results of operative surgery. 43 Cancer of the Rectum. This disease may occur not only during middle and advanced age, but also in younger persons. A report on the subject prepared by Dr. Darbyshire was published by the Ministry of Health during 1927, and several points noted by the Chief Medical Officer are of special interest. "The report is based on the examination of rather less than 6,000 cases in which operations for radical cure were performed in 10 different Countries." "On the average a period of twelve months was allowed to elapse between the occurrence of the first symptom of the disease and the patient coming to the surgeon." As in the case of cancer of the uterus, "rather less than half the cases when seen by the surgeons were considered to be operable." "Two out of every five of those submitted to operation were alive three years afterwards." The opinion that cases are more amenable to operation in women than in men has been confirmed, "whereas no evidence has been forthcoming to ratify the common belief that cancer of the rectum is of graver importance in young persons than in older ones, a result which is in agreement with that obtained in the inquiry into cancer of the uterus." "Another point that has emerged is the frequency with which pain is an early symptom of this disease. With the exception of irregular action of the bowels it is the commonest first indication." Sir George Newman in his Annual Report for 1926, considers the question as to where the hope of the future lies and states, "It appears to lie primarily in the discovery of some means such as a bio-chemical test of early and certain diagnosis followed by the application of some method of treatment not involving 44 operation and secondarily in providing an explanation of the method of causation opening up a way to prevention." 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. 4/2/27 Halford Road Film Dr. Dorothy Logan 30 7/2/28 School. St. Augustine's ,, Miss Dugdale 70 9/2/27 Hall, Lillie Road. St. Dunstan's Road School. ,, Dr. Rose Turner 57 7/3/27 Central Library, Fulham. ,, Dr. Rose Turner 250 6/4/27 St. Augustine's ,, Miss Dugdale 15 9/5/27 Hall, Lillie Road. Queensmill Road School. ,, Dr. Rose Turner 70 10/5/27 Fulham Conservative Club, ,, Dr. Dorothy Logan 70 28/6/27 Shorrolds Road. Walham Grove ,, Mr. Spence Duncan 250 12/7/27 Walham Grove ,, Mr. Spence Duncan 200 12/9/27 William Street School. Film Mrs. Altentop 20 14/9/27 Munster Road ,, Dr. Rose Turner 120 20/9/27 School. Walham Grove — Mr. Spence Duncan 120 16/11/27 All Saint's Church Room. Film Dr. Rose Turner 25 19/11/27 Munster Road School. ,, Dr. Rose Turner 70 22/11/27 New King's Road School. ,, Dr. Rose Turner 60 5/12/27 Fulham Town Hall ,, Dr. Mary NewtonDavis. 230 Total attendances 1657 45 Table IV.—Cases of Infectious Diseases notified during the Year 1927. 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) 390 11 13 31 33 33 158 40 23 39 3 5 1 21 88 41 65 99 13 42 21 389 11 Erysipelas 58 1 2 — — — 2 — 3 5 7 28 10 5 12 8 6 11 2 11 3 35 2 Scarlet Fever 360 2 12 17 25 31 147 57 30 31 5 3 — 15 74 37 40 84 26 56 28 348 1 Typhus Fever — — — — — — — — — — — — — — — — — — — — — — — Enteric Fever 11 — — — 1 — 1 — 1 6 2 — — 1 1 — — 2 — 2 5 8 2 Relapsing Fever, Continued Fever — — — — — — — — — — — — — — — — — — — — — — — Puerperal Fever 16 — — — — — — — — 12 4 — — 1 3 2 4 4 — — 2 16 2 Puerperal Pyrexia 28 — — — — — — — 2 18 8 — — 1 3 2 2 10 2 3 5 20 — Cerebro-Spinal Meningitis 7 1 1 — — — 1 2 1 1 — — — — 1 — 2 1 2 1 — 7 — Polio-myelitis 3 — — 1 — — 1 — — — 1 — — 1 — — — 1 — — 1 3 Ophthalmia Neonatorum 33 33 — — — — — — — — — — — 3 4 8 3 6 2 6 1 11 1 Tuberculosis of Respiratory System 251 1 — — 2 — 4 10 31 107 39 51 6 23 43 19 33 59 17 34 23 — 126 Disseminated Tuberculosis 1 — — — — — 1 — — — — — — — — 1 — — — — — — 2 Other Tuberculous Diseases 94 5 2 4 2 5 20 19 6 18 5 7 1 5 22 9 13 23 5 12 5 — 19 Measles 463 13 27 34 56 80 235 10 4 2 1 1 — 23 187 122 20 39 16 49 7 44 — Encephalitis Lethargica 5 — — — — — 1 1 — 2 — 1 — — — 1 1 2 1 — 4 1 Pneumonia 310 9 19 17 12 10 33 7 16 53 47 60 27 12 56 52 43 70 5 56 16 169 167 Diarrhoea 18 14 4 — — — — — — — — — — — 4 3 2 7 — 2 — 14 19 Malaria 1 — — — — — — — — 1 — — — — — — — — — — 1 — — Dysentery 6 1 2 — — — 2 — — 1 — — — 6 — — — — — — — 6 1 Trench Fever — — — — — — — — — — — — — — — — — — — — — — — Total 2055 91 82 104 131 159 606 146 117 296 122 156 45 117 498 305 234 418 90 275 118 1074 354 46 Tuberculosis. During the year under review the Tuberculosis Register has been corrected by the removal of all cases under the 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 1927, 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 1927 574 433 330 275 Number of cases removed during the year 243 187 77 61 331 246 253 214 Number of cases notified for the first time during 1927 132 120 54 40 Total number of cases maining on the Register at 31st December, 1927 463 366 307 254 It will be seen from Table IV. that 346 cases of tuberculosis were notified during the year. Of these, 251 were cases of tuberculosis of the respiratory system, one was of disseminated tuberculosis and 94 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:— 126 deaths 86 males, 40 females. Death rate 0.77 per 1,000, being 0.21 lower than in 1926. 112 notified (88.8 per cent.), 14 not notified (11.1 per cent.), of whom 5, or 35.7 per cent., died in institutions. 47 Other Tuberculous diseases:— 21 deaths. 13 males, 8 females (including 2 deaths from disseminated tuberculosis). Death rate. 0.13 per 1,000, compared with 0.10 for 1926. 16 notified (76.2 per cent.), 5 not notified (23.8 per cent.), of whom 4, or 80 per cent., died in institutions. Period between Primary Notification and Death Respiratory system:— Under 1 month 24 (21.4 per cent.) 1-3 months 12 (10.7 per cent.) 3-6 months 8 (7.1 per cent.) 6-12 months 19 (17.0 per cent.) 1-2 years 22 (19.7 per cent.) Over 2 years 27 (24.1 per cent?) Notified after death — Other Tuberculous diseases:— Under 1 month 12 (75.0 per cent.) 1-3 months — 3-6 months 2 (12.5 per cent.) 6-12 months — 1-2 years — Over 2 years — Notified after death 2 (12.5 per cent.) including one death from 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. Tables V. and VI., pages 48 and 49, give dispensary statistics, notification and mortality figures for the Borough since 1913. 48 TABLE V.—DISPENSARY STATISTICS, 1913-27. 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 2361 11967 2175 1517 1914 203 45 261 361 2276 8084 2385 2547 1915 174 28 260 323 1171 5568 1910 2918 1916 225 13 311 200 852 5954 1079 2828 1917 286 13 349 329 1052 6528 1141 2789 1918 235 14 201 478 1223 8465 1435 2317 1919 221 50 251 281 1444 8116 1724 4043 1920 142 37 239 342 1850 6713 2004 4989 1921 116 23 163 344 2074 5387 2217 5640 1922 155 35 13 388 2507 3703 1264 5447 1923 132 70 24 401 2288 3261 552 4603 1924 142 65 32 443 2133 3619 549 4775 1925 162 44 46 414 1956 3405 605 5421 1926 183 53 37 318 1741 2876 481 5355 1927 143 56 14 431 1612 2666 592 5422 49 TABLE VI. 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 1927 251 95 126 21 0.77 0.13 50 REPORT BY THE TUBERCULOSIS OFFICER (DR. HAMILTON) ON THE WORK OF THE TUBERCULOSIS DISPENSARY. Fulham Tuberculosis Dispensary. Annual Report, 1927. The work of the Dispensary has been carried on during the past year along the lines which have been followed hitherto, and no alterations in the routine beyond those of detail have been made. The personnel of the department has remained unaltered, but unfortunately several members of the Staff have been absent for varying periods owing to ill-health, while I regret to have to record that Dr. Hardy was for this reason away from duty for the last three months of the year, at the end of which he had not been able to return, his absence being severely felt both by his colleagues and by the patients. In spite of the handicaps thus imposed, it is gratifying to be able to report that the work of the Dispensary has been well maintained, and this can be realised by a perusal of the statistics for the year, a summary of which is appended at the end of this section. The figures present certain points of interest which reflect the general trend and objects of the Dispensary system as set forth in the various memoranda issued from time to time by the Ministry of Health and I do not propose to institute a close comparison between the numbers recorded in the different tables this year and those of last year but merely to draw attention briefly to those which illustrate some of the features most characteristic of the type of work done in Fulham. There has been an increase in the number of new cases seen from 591 in 1926 to 644 in 1927 but at the same time the notifications have fallen from 275 to 225. Coincidentally with this decrease and as a result of vigorous following up of old cases in order to weed out those cured and those no longer needing super- 51 vision, the number of tuberculous patients on the Register has dropped from 1,117 to 902. This in itself is advantageous since it permits of a closer concentration by the Staff on patients whom we feel it necessary to keep under frequent observation both in their own homes and at the Dispensary itself. The number of persons who have attended the clinics during the year has risen from 1,465 to 1,602 but the number of attendances made has diminished, the figures being 4,278 for 1927 as against 4,716 in 1926. It is the policy of the Medical Staff to make complete physical examinations at as frequent intervals as possible, and the number of such examinations made during the year reached the high figure of 3,847. In my opinion this is one of the most important features of our work. It is well known that the Ministry of Health does not sanction the routine treatment of patients at dispensaries, and not only does frequent examination of those who attend reveal any early changes that may be taking place in the course of the disease, but the mere fact that a patient has been examined tends to engender his confidence, and to suggest to him that a personal interest is being taken in his welfare which goes a long way to discount any disappointment he may feel on being told that he is not entitled to receive cod liver oil, medicines, etc. The number of contacts examined still remains at a high level, and was 479 in 1927. This is a most important side of tuberculosis work, and the figures recorded this year are a tribute to the energy of the Nursing Staff on whom the chief duty of securing these persons devolves and who during the year with this and other objects have paid 5,422 visits to the homes of the patients. It will also be seen that the number of domiciliary visits made by the Medical Officers has increased and was in fact in excess of what would probably be necessary in an average year, the chief reason for this of course being the desire of the Tuberculosis Officer during his first year in the Borough to make himself acquainted as rapidly as possible with the housing conditions of the patients. 52 As showing the increase of work which is being undertaken in the laboratory, it is to be observed that the number of sputum examinations made in 1927 was 1,776, compared with 1,610 in the previous year, this representing of course only a part of the bacteriological and pathological work for the year. There has been a fall in the number of patients sent away to Sanatoria or other institutions but it must be remembered that this fact has to be correlated with the decrease previously mentioned in the notifications and in the number of cases retained on the Register. Nevertheless, during 1927, 249 persons were given institutional treatment and a reference to Table 1 will show how much help we have received in this respect through the kindness of voluntary agencies such as the Invalid Children's Aid Association, Charity Organisation Society, United Services Fund, and also from the Fulham Board of Guardians. Finally, I should like to mention that the number of deaths from tuberculosis of all forms in the Borough has dropped from 178 to 147. It is, of course, very gratifying to be able to report this decline but it would, in my opinion, be unwise to assume that next year and subsequent years will show a similar and progressive fall. The circumstances which influence the death rate are so various, e.g., the occurrence of an epidemic of some disease such as influenza, an exceptionally severe winter, industrial strife, etc., and often so entirely beyond our control, that it would be unduly optimistic to ascribe any decrease in the mortality to the success of our system of dealing with Tuberculosis until the test of time has proved such inference to be correct. Summary of Statistics. No of New Patients:- Insured 252 Uninsured 392 Total 644 53 No. of Attendances:— Insured 1612 Uninsured 2666 Total 4278 No. of patients who have attended, both old and new 1602 No. of Notification:- Pulmonary 162 Non-pulmonary 63 Total 225 No. of Sputa examined 1776 No. of physical examinations 3847 No. of Contacts examined 479 No. of Home visits paid by Doctors 592 Consultations 76 668 No. of Home visits paid by Nurses 5422 No. of Reports sent to Public Bodies 727 No. of Reports sent to Doctors 396 No. of Patients referred to Brompton 4 For X-ray 56 No. of Notified patients on Dispensary books on 31st December, 1927 902 No. of Patients sent to Institutions or to the country in 1927 249 Institutional Treatment arranged through the Dispensary.—The authority responsible for the provision of sanatorium treatment in London is the London County Council, and patients whom the Tuberculosis Officers consider it advisable to send away are referred to the Medical Officer of Health, London County Council, who makes the necessary arrangements with the different sanatoria and hospitals for their admission. In the past year the great majority of the cases that have been sent forward have been accepted and on the whole the scheme may be said to have run smoothly, but it must be understood that it is only when the stage of disease 54 is early or intermediate that one can be certain of securing a bed, and in many cases one refrains from recommending a patient with advanced disease because one knows that he does not come within the category of cases likely to be admitted. The latter course of action is adopted because the situation which arises on the refusal of a patient is in several respects unsatisfactory, and more especially for two reasons:—(1.) The moral effect upon a person of not being accepted may quite easily be severe since it brings home to him, perhaps for the first time, the knowledge of the dangerous and possibly hopeless outlook of his illness. (2.) The prestige of the Dispensary is liable to suffer as the Tuberculosis Officer has to confess both to the patient and his friends and also to his doctor that he has been unable to effect the object for which, in most of the cases, the patient has been referred to him, namely, to arrange for his removal from home for treatment. In fact from every point of view the question of dealing satisfactorily with advanced and active disease in patients who, in many cases, are bedridden, is the most difficult one that confronts us at the present time. It seems difficult to imagine that any rapid progress towards the solving of the greater problem, the eradication of tuberculosis, can be made while so many foci of infection are thickly scattered amongst a susceptible population. At the present time the accommodation for advanced cases is undoubtedly inadequate. The London County Council provides a certain number of beds for this purpose but disclaims the responsibility of removing from their homes all infectious persons and, in fact, does not guarantee to provide treatment at all unless the patient recommended shows some prospect of a definite degree of recovery, if not of cure. During 1927, out of 82 persons on the Dispensary Register who died, the death occurred in 58 in Fulham Hospital or at the patient's home, and in 18 in London County Council institutions, the remaining 6 being in voluntary hospitals or at the houses of friends or relatives. However, it would, I think, be a mistake to assume that all these people would have been willing to go to institutions at a distance from Fulham had such been 55 available, and one must hope that ultimately it may be found possible to provide the necessary accommodation in smaller Homes designed to cater for one or perhaps more Boroughs, and easily accessible at all times to the relatives. Table VII. 249 patients were sent to residential institutions on the recommendation of the Dispensary Medical Officers. (a.) 162 by the London County Council:- 62 to Sanatoria. 5 to Convalescent Homes. 1 to a Farm Colony. 94 to Hospitals or Homes. Men 26 — 1 49 Women 22 — — 36 Children 14 5 — 9 (b.) 35 by the Poor Law Authorities:— 23 to Fulham Hospital. 12 to Sanatoria or Convalescent Homes. Men 13 — Women 9 2 Children 1 10 (c.) 30 Children were sent to Convalescent Homes by the Invalid Children's Aid Association. (d.) 4 by the Charity Organisation Society:— 1 Woman sent to Eversfield Chest Hospital. 3 Children boarded out. (e.) 11 by the United Services Fund:— 2 Women convalesced. 9 Children boarded out. (f.) 7 Children boarded out under the L.C.C.'s Contact scheme. The Care of Tuberculous Children.—It has become the custom of recent years to regard the supervision and treatment of tuberculous children, and children in contact with tuberculous adults, as one of the most important measures in the general campaign against tuberculosis. It is recognised that it is during this 56 age period that infection is most usually contracted though it is, of course, to be understood that those so infected only in a small proportion of cases show definite physical signs of the disease. Nevertheless, there can be no doubt but that efforts to raise the standard of health both in children of pre-school and school age will eventually bear fruit in a reduction of the incidence of active disease in adult life. For this reason the special attention which has been devoted to this aspect of the problem is greatly to be welcomed, though it would be a pity if the impression were to become widespread that a large proportion of the children in the community are actually suffering from the disease in an active form and liable to endanger the lives of others, since this certainly is not the case. In this Borough, as in others, the number of children on the Dispensary register is considerable, but many are infected in minor degree and make good progress with general treatment at the clinic. There is a large class, however, who require more active treatment and for these there are other courses open. Heretofore, the London County Council has accepted such children freely for treatment in Sanatoria or in special surgical Homes, and they remain away for long periods. The Fulham Board of Guardians also makes itself responsible for others, especially those coming from poorer families. The treatment in the great majority of cases produces arrest of the disease, and many of these children are drafted on to special schools for the physically defective if any deformity, e.g., in spine or joints remains after the active condition has passed, or else to the Open-air School, if further continuous supervision is advisable. This school is situated in Broomhouse Lane and has accommodation for fifty boys and girls with a nominal roll of sixty, and the pupils include, in addition to some who have been in sanatoria, others whose condition has never been serious enough to necessitate their being sent away or whose parents are unwilling to allow 57 them to leave home. The scholars are under the constant supervision of one of the Dispensary nurses and there is a weekly medical inspection by the Tuberculosis Officer for the Borough. The main object of the school is to secure that classes are held under open air conditions, which approximate to some degree to those obtaining in sanatorium life, and which are obtained by the provision of two shelters in the playground where the children work unless the weather is too severe when they are accommodated in the class rooms in the school building itself. There are in addition special hours of rest and of exercise closely supervised by the headmistress, who also controls the diet, which is characterised by the fact that each child has an allowance of milk during the morning and an ample dinner of excellent quality in the middle of the day. Under this regime the most satisfactory results have been obtained, and during the past year the scholars have, without exception, shown marked progress. Another mode of treatment which has been used more especially among children is that by ultra violet rays (artificial sunlight). The Borough Council has now an agreement with the Victoria Hospital for Children, Tite Street, whereby cases from Fulham can receive a course of treatment under a specialist in Light therapy. The first patients were sent in August, 1927, and since that date nine have been referred to the Hospital. It is becoming generally recognised that one cannot expect rapid or dramatic cures, and that it is only by a careful consideration of results in many cases, and by a comparison as far as possible with similar numbers treated solely on general lines, that one can arrive at an accurate estimate of the advantages reaped. Judged by these standards, I think one can say at present that the results have been sufficiently good to justify a continuance of the scheme. The London County Council's plan for boarding out child contacts, of which details have been given in past reports, is still in operation, but its scope has not been extended greatly, and for various reasons 58 only seven children have been sent away under it during 1927. In concluding my remarks under this heading, I should like to refer to the great help which we receive from the local branch of the Invalid Children's Aid Association in dealing with children who, while not actually tuberculous, are debilitated as a result of acute or chronic illnesses and who are, therefore, liable to succumb to attacks by the tubercle bacillus or other organism. Many children in this category who come up to the Dispensary for examination are living under conditions prejudicial to their complete recovery, and often in actual contact with open cases of tuberculosis, and it is by getting these away for periods of convalescence in the country or at the seaside that the Association does such pre-eminently useful service. Co-ordination between local Practitioners and. Tuberculosis Officers.—At the present time the question of the attitude of the private practitioner towards the Public Health services is one which is the subject of some controversy both in the medical and lay press. It is obvious that if institutions, such as Tuberculosis dispensaries, are to be regarded as being in competition with medical men in general practice little progress can be made in any anti-tuberculosis work. The possibility of friction has always been uppermost in the minds of the Medical Staff in this Borough, and it may be of interest to point out here that every possible step is taken to safeguard the rights of doctors with whom we come in contact. For instance, no person is taken on to the Dispensary books if he is under medical care unless he produces definite evidence that his doctor is desirous that he should be examined, while in cases referred for an opinion a very special rule is observed that the Tuberculosis Officers invariably report straight to the doctor and make no verbal communication to the patient beyond that necessary to allay his immediate anxiety. As a report is always sent to the doctor concerned within a very short period, the patients do not suffer, and indeed when the position is explained to them we never find that they fail to 59 appreciate the fact that communication on their cases must be direct between doctors, and that it would not be to their own advantage if they themselves were to act as intermediaries. The observance of these and other similar rules in the past and their continuance at present has resulted in a cordial co-operation between the local practitioners and the Tuberculosis Officers, and I think that one can justifiably claim that the spirit that obtains in Fulham is one of collaboration rather than of competition. Practically all the local doctors realise that we do our best within the limits and restrictions imposed on us, to assist them in procuring the earliest diagnosis and the best treatment at present available in public institutions for their patients. The number of new cases referred by doctors— 244—is, I think, a testimony to the fact that the dispensary preserves its position as a unit for consultation. In this connection one may remark that many who write on the subject of tuberculosis find themselves at a loss to account for the fact that the proportion of early cases submitted for institutional treatment is comparatively small. This is undoubtedly an unfortunate fact, but I am convinced that it cannot be used, as it often is, as an argument for the suggestion that it implies a general lack of sympathetic working between Tuberculosis Officers and general practitioners. There are many reasons which are responsible for late diagnosis, but it must be admitted that in the great majority of cases it is not because of failure on the part of the medical man to detect early signs, but owing to failure on the part of the patient to present himself till too late. It is, moreover, a curious psychological phenomenom that a large number of these persons actually in their own minds have a strong suspicion that they are suffering from tuberculosis, but partly from a dread of having their fears confirmed, and partly owing to the unhappy social consequences that an unwise propaganda has led them to expect, they have refrained from seeking advice earlier. There remain, of course, a considerable number who, owing to the insidious onset and course of the disease, 60 have never felt sufficiently ill to realise that anything serious is wrong till increasing disability, or some more dramatic symptom, such as haemorrhage, suddenly awakens them to the need for consulting a doctor. The only way to track down early cases would, in my opinion, be by systematic and periodical examination of those in susceptible age periods, but the advisability of making this compulsory opens up a controversial topic into which it is undesirable to enter here. The Tuberculosis Care Committee.—The economic state of the country and the unhappy position of the labour market continue to render this branch of the work more difficult than it would be in more prosperous times. As their name implies, Care Committees in the most general sense are concerned with the social welfare both of the patients and of their dependents, and with the amelioration of any special home circumstances which may tend to nullify the value of medical treatment. It would serve no useful purpose to give once more in detail the duties which this Committee undertake, as their scope is extremely wide and can be better appreciated by a perusal of some illustrative cases which are appended by Miss Sargent, the Secretary to the Committee, and which give more clearly an idea of the difficulties encountered and of the good work done. It may be mentioned, however, that the members during recent years have been perturbed by the difficulty of securing employment for partially disabled tuberculous persons, and a considerable amount of time has been devoted to the discussion of this problem. An investigation into the local conditions existing in the Borough, and into the failure of employment schemes originated elsewhere, produced convincing proof of the undesirability of endeavouring to establish a special workshop for those of our patients who could not be received into their previous occupations. It was therefore decided that the best plan would be to make an effort to solicit the interest of local employers, and with the idea of the furtherance of this object, it was proposed in May last to ask the Mayor to receive informally a small deputation from 61 the Committee. The Mayor kindly granted the interview requested and showed great sympathy with the objects, but pointed out that his first preoccupation must be to help the healthy unemployed ex-service men with many of whose cases he was already dealing. He promised, however, to give his kindly attention to the matter in future and to help as far as possible any specific cases which might be brought to his notice. The Committee therefore decided that the best way of tackling the situation at the present time would be to go carefully into the social circumstances of all patients on their discharge from sanatoria, with special reference to their future work, a policy which was adopted during the latter half of the year. Apart from this innovation the work of the Committee has continued as previously, and I would like to thank the Chairman, the Secretary and the other members, for the time so ungrudgingly devoted to a task always difficult, and frequently one fears, disheartening. Illustrative Cases by Miss Sargent. A. was a young girl of seventeen when she first attended the Dispensary in 1926. Found to be suffering from pulmonary tuberculosis, she was admitted to Brompton Hospital and from thence to Winchmore Hill under the London County Council's tuberculosis scheme, returning home in November of that year. She gradually began to lose ground and in May, 1927, the London County Council were asked to send her away again but were unable to do so. The home circumstances were very straightened as the father was out of work and the Guardians were accordingly asked to allow extra nourishment for the patient, which they did. Recourse was then had to the Charity Organisation Society, who very kindly procured her admission to the Eversfield Chest Hospital, undertaking all financial responsibility and fitting the patient out with clothes which in themselves were an aid to recovery. A. made such good progress at Eversfield that when her time there was up, the London County Council undertook to continue her treatment and she was transferred practically direct to Winchmore Hill. B. was a girl of 22, who was recommended by St. George's Hospital for institutional treatment. On visiting the home 62 she was found to be living with her mother in one room, and the financial circumstances were hard to understand, as though apparently there was no income, the mother had not applied for a renewal of out-relief. The girl herself was neat and tidy and was able to provide her own outfit for her time away. When she returned at the end of six months she found her mother had been removed to a mental hospital, and that the man who had been partially supporting her had taken possession of the room and furniture and refused to give either up. An aunt was able to put the girl up temporarily and the Care Committee arranged for her to see a Poor Man's lawyer through whose aid she obtained possession of her furniture. The disappointing part of this story is that the girl has not chosen to keep in touch with us, but has moved away leaving no address. C. was a family of small children, only one of whom was a notified case of tuberculosis. They lived in a four-roomed house with basement in addition, but owing to the unsatisfactory state of the building only two rooms were habitable. The house was reported to the Medical Officer of Health as insanitary and pressure was brought to bear on the landlord. In the summer the notified child was not gaining ground and the London County Council were asked to arrange institutional treatment for her, which they did by sending her to Broadstairs. While awaiting a vacancy, however, violent rains so flooded the house that it became a problem as to what to do with the other children while repairs were being done. The United Services Fund were unable to help as the father was in full work, but the Charity Organisation Society very kindly arranged to send all three children into the country and kept them there till the home was habitable again. The London County Council also extended the period of treatment of the fourth child on account of the home conditions, and through the kindness of a friend the mother was sent to join her children in the country for the last week. D. was an ex-service man who had been under the Dispensary since 1922 and had not been fit for work since 1925. His pensionable disability was deafness and the family circumstances were very poor though the home was always beautifully clean. The wife added to the family income by charing but had not time to do very much in this way. D. was finally persuaded to go into hospital where he died in April, 1927. His wife was thus left to provide for the family and found daily work, but was much run down through the 63 care and worry consequent on her husband's illness. The family were accordingly referred to the United Services Fund, and by its means all three children were sent into the country for a time while a period of convalescence was also arranged for the mother. Table VIII.—Showing sources of New Cases. 244 were recommended by private doctors. 24 „ „ the Medical Officer of Health. 21 „ „ the School Medical Officer. 9 ,, „ the School Authorities. 15 „ „ Hospitals. 15 „ „ other Dispensaries. 4 „ „ Sanatoria. 12 „ „ the Army authorities. 24 ,, „ the London County Council. 173 ,, ,, the Dispensary Staff. 30 „ ,, friends. 43 „ „ patients. 22 „ „ the Doorplate. 6 „ ,, the Invalid Children's Aid Association. 1 was „ the Charity Organisation Society. 1 „ ,, the District Nurse. 644 Table IX.—Diagnosis in Males and Females (New Patients). Total Cases. Pulmonary Tuberculosis. Other Forms. Suspects. NonTuber cular. Percentage Tuberculous. 327 Males 75 33 9 210 33.02 317 Females 68 23 5 221 28.70 644 both sexes 143 56 14 431 30.90 64 Table X.—Sex and age of New Patients for 1927. Under 5yrs. 10 yrs. 15 yrs. 25 yrs. 35 yrs. 45 yrs. 45yrs. and over. All ages. Males 33 68 30 51 50 41 54 327 Females 34 58 33 72 67 29 24 317 Both Sexes 67 126 63 123 117 70 78 644 Table XI.—Diagnosis at various age periods (New Patients). Pulmonary Tuberculosis. Other Forms. Suspects. NonTuber cular. Percentage Tuberculous. Under 5 years 2 7 1 57 13.43 Under 10 years 1 10 2 113 8.73 Under 15 years 4 9 1 49 20.63 Under 25 years 43 12 4 64 44.71 Under 35 years 42 11 1 63 45.29 Under 45 years 26 4 4 36 42.85 45 and over 25 3 1 49 35.89 All ages 143 56 14 431 30.90 Table XII.—Housing Conditions. Of 178 of the 199 tuberculous patients found in 1927:— 5 lived in the basement. 37 lived on the ground floor. 55 lived on the first floor. 8 lived on the second floor. 1 lived on the fourth floor. 11 lived on the top floor. 34 lived on more than one floor. 27 lived in the whole house. 178 65 Table XIII.—Housing Accommodation. Number of Families occupying One room. Two rooms. Three rooms. Four rooms. Five rooms. Six rooms or more. Patient living alone 3 1 - - - - Patient living with 1 other 2 13 8 5 - 1 2 others 6 5 25 2 1 - 3 „ 3 6 16 10 5 1 4 „ - 4 10 3 - 4 5 „ - 2 5 4 2 5 6 „ - - 1 5 3 2 7 „ - - 5 2 - 2 8 „ - - - 2 1 - 9 „ - - 1 - - - 10 „ - - - 1 - - 11 „ - - - 1 - - 14 31 71 35 12 15 Table XIV. Sleeping accommodation of 178 tuberculous patients. The patient slept:- In a separate room in 53 cases Alone in bed with:— 1 other in room 13 „ 2 others in room 11 „ 3 „ 4 „ 4 „ 1 case. In bed with 1 person and:— no others in room in 46 cases. 1 other in room in 25 „ 2 others in room in 11 „ 3 „ 2 „ 4 „ 1 case. 66 In bed with 2 persons and:— no other in room in 4 cases. 1 other in room in 4 „ 2 others in room in 2 „ In bed with 3 persons and no other in room in 1 case. 178 cases. Table XV. Occupations of 89 Tuberculous Men in 1927. 1 Apprentice—Building trade. 1 Packer. 1 Apprentice—Decorative artist. 3 Painters. 1 Book-keeper. 2 Plasterers. 1 Bus conductor. 1 Plumber. 2 Carpenters. 1 Policeman. 1 Cabinet-maker. 1 Printer. 3 Chauffeurs. 1 Salesman. 1 Chemist's assistant. 1 Scaffolder. 11 Clerks. 1 School master. 1 Coal porter. 1 Shop manager. 1 Compositor. 1 Shop hand. 1 Cook. 3 Shoemakers. 1 Costermonger. 1 Stage manager. 3 Decorators. 1 Show card writer. 3 Engineers. 1 Store keeper. 1 Farmer. 2 Students. 1 Furniture remover. 1 Tailor. 1 Gas meter tester. 2 Travellers. 1 Glass blower. 1 Van boy. 2 Greengrocers. 1 Vacuum cleaner attendant 1 Hair dresser. 1 Waiter. 1 Handyman. 2 Warehousemen. 9 Labourers. 1 Window cleaner. 1 Milk roundsman. 1 Wood chopper. 2 Motor mechanics. 1 Yard foreman. 3 Officer messengers. 1 Stoker. Occupations of 77 Tuberculous Women in 1927. 1 Capper. 2 Machinists. 1 Canvasser. 1 Milliner. 10 Clerks. 1 Nurse. 6 Domestics. 5 Packers. 1 Dressmaker. 5 Shop assistants. 1 Factory hand. 1 Telephonist. 36 Housewives. 1 Theatre manageress. 2 Laundresses. 1 Upholstress. 1 Lift attendant. 1 No occupation. 19 Boys under 15. 14 Girls under 15. 67 TABLE XVI.—PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Summary of notifications during the period from lst january 1927, to 31st December, 1927. 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. 5—10. 10—15. 15—20. 1 20—25. 25—35. 35—45. 45—55. 55—65. 65 & upwards Total Primary Notifications. Under 5. 5—10. 10—15. Total Primary Notifications. Pulmonary: Males — — 3 3 12 14 31 27 23 15 4 132 228 — — — — — 11 133 Females 1 2 1 7 19 30 33 11 9 4 2 119 192 — — — — — 15 65 Non- pulmonary: Males 3 7 12 11 3 4 5 3 2 2 — 52 74 — — — — — 2 27 Females 2 4 8 8 3 6 3 2 3 — 1 40 61 — — — — — — 31 68 TABLE XVII. 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 1927, 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 5 1 1 — 9 Females — — — 1 — 2 1 2 — — — 6 Non-Pulmonary:— Males — 2 — — — — 1 — — — — 3 Females — 2 — — — 1 — — 1 — — 4 69 Outbreak of Dysentery. An outbreak of bacillary dysentery occurred during the latter half of June, 1927, in which four Fulham children were affected and were admitted to Hospital. Unfortunately, two children from a neighbouring borough contracted the infection. Two of the Fulham cases were of a severe type and one of them, a boy of five years, died after an illness lasting four days. None of the patients had ever been out of England. All the patients became ill within a fortnight of the date of onset of the first case. Case 1, aged 6 years and 10 months Onset 16th June. Case 2, aged 5 years Onset 22nd June. Case 3, aged 13 months Onset 24th June. Case 4, aged 15 months Onset 25th June. Case 5, aged 16 months Onset 28th June. Case 6, aged 2 months Onset 29th June. All the children were males, except the fourth. The illness in the two severe cases was typical of dysentery and was ushered in with shivering and headache. The abdominal symptoms consisted of abdominal pain and tenderness followed by vomiting and intense and frequent diarrhoea with straining. The stools were small in amount and contained mucus and blood. The general condition was marked by delirium, temperatures of 103° and 105°, rapid pulse, loss of flesh and profound prostration. The diagnosis was verified by the bacteriologist who isolated the bacillus of dysentery (Flexner) from the stools in all the cases. The type of Flexner bacillus was not investigated. Polyvalent anti-dysentery serum was administered to three of the patients with considerable benefit in two of the cases. At the post-mortem examination on the fatal case the lower end of the ileum and the large intestine were found to be acutely inflamed, the mesenteric glands were enlarged and fatty changes present in the liver. Investigations were made as to the source of infection, especially as to the possibility of a carrier case 70 being responsible for the outbreak, but no carrier could be discovered. Enquiries into the food and water supply also proved fruitless and the sanitary defects which were found did not account for the infection. The Fulham children who were affected had been in the habit of playing together. Three of them lived in the same house, their two families using the same W.C., and the same copper; without doubt these circumstances accounted for the spread of the disease. I am grateful to Dr. Elworthy and Dr. W. Gordon Sears for much valuable help during the outbreak. Outbreak of Food Poisoning at the Fulham Institution. An outbreak of food poisoning, due to Bacillus Aertrycke, occurred in this institution in September, 1927, and was investigated by Dr. G. C. Hancock, of the Ministry of Health, and myself. Thirty-two of the inmates were affected and two of the cases unfortunately proved fatal. The two patients who died were men aged 82 and 62 years respectively, and the majority of those attacked were over 60 years of age. Clinical features.—The first patient became ill on Friday, 2nd September, four hours after a mid-day meal containing tinned corned beef among other articles, and the times of onset of the illnesses in the thirty-two cases, including the first case, were as follows:— Ten cases on Friday, 2nd September. Two cases on Saturday, 3rd September, before the mid-day meal. Six cases on Saturday, 3rd September, after the midday meal. Thirteen cases on Sunday, 4th September. One case on Monday, 5th September. All the patients were admitted to the Fulham Hospital. 71 The illnesses were characterised by abdominal discomfort, amounting to pain in some cases, followed by diarrhoea with loose watery stools, yellow or green in colour. Mucus was mixed with some of the specimens of faeces, but no blood was visible to the naked eye. Nearly half of those affected suffered from vomiting, but in only three cases, including the two who died, was there any prostration. The temperature charts showed rises above the normal in three cases, but as the patients were not in hospital until the Monday (except in the two fatal cases) it is probable that some of them may have been feverish before admission. Post-mortem examinations were done in the two fatal cases by order of the Coroner and although nothing characteristic was discovered at the time of the examinations, the bacteriological examinations of the organs gave positive results. Bacteriological examinations.—These investigations were conducted at the Ministry of Health Laboratory. Bacillus Aertrycke was found practically in pure culture in the liver and spleen of the two fatal cases and the bacillus was also present in their intestines. The faeces were examined in eighteen cases, in thirteen of which Bacillus Aertrycke was present. There is no doubt therefore that the outbreak was due to Bacillus Aertrycke. The blood serum of nine of the patients was examined and eight of the specimens gave a positive agglutination reaction to B. Aertrycke. The highest dilutions of the patients' serum which agglutinated the bacillus in the eight positive cases were as follows:— 1 in 20 in three cases. 1 in 40 in two cases. 1 in 80 in two cases. 1 in 160 in one case. Dr. Scott, of the Ministry of Health, stated that the titres were lower than usual and suggested that 72 this may have been due to the advanced age of the patients. Source of infection.—All the patients except three ate tinned corned beef, served cold at the mid-day dinner on Friday, 3rd September, and most of them, including these three, had stew containing the remains of the corned beef at dinner on the following day. There was not the slightest suspicion against any other article of diet nor any probability of infection from animals in the institution. The water supply was also beyond suspicion. The evidence was consistent with the corned beef being the medium of infection, but was not absolutely conclusive as none of the beef was left after the suspected meal, so that it could not be examined. There was, however, another possible source of infection as two of the attendants (G. S. and E. W.) who carved the corned beef and assisted in serving the meals were found to have bacillus aertrycke in their stools, although they had no symptoms of illness. Either of them may, therefore, have been a carrier of the bacillus. G. S., however, admitted that he ate two ounces of corned beef on the Friday, and E. W. stated that he may have had some of the stew on the Saturday, and they may have been infected in this way. Food Preparing Places. There are known to be 112 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 91 eating houses or dining rooms. These premises are under the supervision of the woman sanitary inspector, Mrs. Davies, who made 272 visits of inspection during the year under review, compared with 300 during 1926. Twelve notices requiring cleansing were served during 1927. 73 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. During the year Inspector Manning has made 187 visits of inspection to these premises. The slaughterhouses, lairs and utensils have been kept in a cleanly condition. Milk.—Of 513 samples examined, 8, or 1.5 per cent., were adulterated, as compared with 0.57 per cent. in 1926, 1.0 per cent. in 1925, and 1.6 per cent. in 1924. Details of legal proceedings instituted by the Council will be found on page 77. Milk Sellers:- Number on Register, 31st December, 1926 112 Number who discontinued sale of milk during the year, or business transferred 5 Number of registrations granted during 1927 6 Number on Register, 31st December, 1927 113 During the year, eleven applications were received for permission to sell bottled sterilised milk from premises which were not suitable for registration as dairies. The necessary registrations were granted in every case, provided the milk was not to be supplied otherwise than in the closed and unopened receptacles in which it was delivered to the premises. 74 Cream (Milk and Cream) Regulations, 1912 and 1917. One sample of cream and eight samples of preserved cream were purchased during the year for analysis. The following particulars of proceedings taken in 1927 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 518 nil. Cream 1 1 2. Cream Sold as Preserved Cream. (a) Instances in which samples have been submitted for analysis to ascertain if the statement on the label as to preservatives were correct:— (1) Correct statements made 8 (2) Statements incorrect - Total 8 (b) The examination made of milk fat in cream sold as preserved cream:- (1) Above 35 per cent. 8 (2) Below 35 per cent. - Total 8 (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 75 (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 13 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 1 Number of licences granted to sell Grade "A" milk 2 Number of samples taken in accordance with the instructions of the Ministry of Health 4 Number of samples not up to the standard as laid down by the Ministry of Health - Bakehouses.—There are sixty-eight registered bakehouses in the Borough, two of which are factories and 43 are situated underground. Inspector Jones made 144 visits and served 68 notices, 2 in writing and 66 verbally. The notices were principally for the installation of suitable sinks for ablution and the provision of drinking-water for those employed in the bakehouses. Unsound Food.—The undermentioned articles, examined at the request of the owners, were condemned and destroyed:— Pears 86 boxes. Apples 2 boxes. Ox Liver 11 lbs. Winkles 1 bag. Chocolate 228 lbs. Cod 4 boxes. Walnuts 49 bags. Cod 4 stone. Skate 3 boxes. Cauliflowers 25 bags. Chestnuts 30 packets (3 cwts.) 76 Samples purchased for Analysis during 1927:— Article. Number of Samples. Total Samples Analysed. Total Samples Adulterated. Percentage of Adulteration. Taken officially. Adulterated. Taken unofficially. Adulterated. Milk 513 8 — — 513 8 1.5 Separated milk 2 2 — — 2 2 100.0 Skimmed milk — — 3 — 3 — — Condensed milk — — 3 — 3 — — Cream — — 1 1 1 1 100.0 Preserved cream 1 — 7 — 8 — — Butter — — 136 1 136 1 .7 Margarine — — 4 — 4 — — Cheese — — 15 — 15 — — Coffee 1 — 19 2 20 2 10.0 Cocoa — — 25 — 25 — Chocolates — — 13 — 13 — - Self-raising flour — — 24 — 24 — — Baking powder — — 3 — 3 — — Mustard — — 7 — 7 — — Pepper — — 5 — 5 — — Beef sausages — — 13 1 13 1 7.6 Pork sausages — — 7 2 7 2 28.5 Meat pie — — 9 — 9 — — Prawns — — 4 — 4 — — Jams — — 16 — 16 — — Tinned fruits and vegetables 1 — 13 1 14 1 7.1 Malt vinegar 1 1 8 1 9 2 22.2 Whisky 11 — 13 6 24 6 25.0 Gin — — 8 3 8 3 37.5 Rum — — 2 1 2 1 50.0 Brandy — — 2 — 2 — — Camphorated oil — — 9 2 9 2 37.5 Olive oil — — 3 — 3 — — Lard — — 21 — 21 — — Sponge cakes — — 8 — 8 — — Dripping — — 5 — 5 — — Ground ginger — — 8 — 8 — — Tea — — 9 — 9 — — Sugar — — 6 — 6 — — White pepper — — 6 — 6 — — Cayenne pepper — — 4 — 4 — — Cordials — — 3 — 3 — — Fish pastes — — 7 — 7 — — Bovril — — 2 — 2 — — Port wine — — 5 — 5 — — Ginger wine — — 7 — 7 — — Honey — — 2 — 2 — — Lemon cheese — — 4 — 4 — — "Hot dog" — — 1 1 1 1 100.0 530 11 470 22 1000 33 3.3 77 Proceedings were instituted in the undermentioned cases:— Defendant. Offence. Result. Penalty. Costs. £ s. d. £ s. d. A. Meredith, 118, Charlton St., Euston, N.W. 1 Selling milk 4% deficient in fat. Dismissed under P.O. Act. — 2 0 0 A. Meredith, 118, Charlton St., Euston, N.W. 1. Selling milk 6% deficient in fat. Do. — 2 0 0 G. Radcliffe, 33, Allestree Rd. Selling milk containing 52% of added water. Defendant absconded. Warrant issued for arrest. Do. Selling milk containing 48% of added water. Do. Unlawfully selling milk from can, can not being conspicuously marked. Do. Trading as dairyman without being registered. J. Salter, 104, Fulham Palace Road. Unlawfully filling bottles with milk in street. Convicted 1 0 0 — — — T. Evans, 117, Edith Road. Selling milk containing 5% of added water. Do. 2 0 0 — 10 6 Acts, Regulations and Orders dated 1927 relating to food and food premises. The Public Health (Preservatives, etc., in Food) Amendment Regulations, 1927.—These Regulations came into force on 5th April, 1927, and amend the Public Health (Preservatives, etc., in Food) Regulations of 1925 and 1926 in certain matters of detail. The Sale of Food and Drugs Act, 1927.—Under this Act, which came into operation on 12th April, 1927, any prohibitions or limitations imposed by the 78 servatives in Food Regulations and by the Condensed and Dried Milk Regulations bind the Courts in proceedings under the Sale of Food and Drugs Acts. Amendment of the Sale of Food and Drugs Act, 1899—Section 6 (2): Section 4 (5) of the Sale of Food (Weights and Measures) Act, 1926, which came into operation on 1st January, 1928, modifies the above Section, which states that no words except "Margarine" or "Margarine Cheese" are allowed to be printed on any wrapper containing these articles for sale by retail. The effect of the modification is that a statement of weight may also be printed on the wrapper. The Public Health (Dried Milk) Amendment Regulations, 1927.—These Regulations come into force on 1st September, 1928. The Public Health (Condensed Milk) Amendment Regulations, 1927, come into force on the same date with the exception of the provisions relating to importation of articles which came into operation on 1st May, 1928. These Regulations were primarily designed to secure that in the labelling of condensed and dried skimmed milk greater prominence should be given to the words "Unfit for Babies," and that these words should be printed on the outside of any wrapper containing the articles in question. They also make other minor amendments in the 1923 Regulations with regard to labelling. The Bakehouse Welfare Order, 1927, came into force on 1st May, 1927, and applies to factories and workshops where the baking of bread or flour confectionery is carried on. The Biscuit Factories Welfare Order, 1927, came into operation on 1st December, 1927, and applies to factories and workshops in which the processes of icing, creaming and filling of biscuits and wafers are carried on. 79 The Orders require the occupier to provide and maintain for the use of the persons employed in these processes:— 1. Suitable washing facilities as described in detail in the Orders with warm water, soap and clean towels. 2. Suitable accommodation for clothing put off during working hours and arrangements for drying wet clothing. 3. Arrangements for first-aid as under the Workmen's Compensation Act, 1923. 4. An adequate supply of drinking-water either laid on or in suitable vessels approved in writing by the Local Authority. The supply must be marked "Drinking Water." The cautionary notices regarding dermatitis in those handling flour and sugar must be prominently displayed. In biscuit factories the persons employed in the processes must be inspected systematically once a week for evidence of dermatitis. General Sanitary Administration. Bacteriological Examinations.—Of the 3,370 specimens sent by doctors during the year, 3,075 were examined by the Council's Laboratory, 114, New King's Road. The remaining 295 specimens were examined by the Clinical Research Association during week-ends, holidays and emergencies. Bacteriological examinations made during the year 1927 :— Material from eases of suspected Diphtheria:— Diphtheria isolated 133 Negative result 1201 1334 Blood from cases of suspected Enteric Fever:— Agglutination reaction for Typhoid or Para-Typhoid obtained 9 Negative result 10 19 80 Pathological specimens for Enteric Organisms:— Positive result — Negative result 28 28 Sputa from cases of suspected Tuberculosis Tubercle bacilli found 299 Tubercle bacilli not found 1491 1790 Blood from cases of suspected Puerperal Fever:— Positive result 6 Negative result 9 15 Swabs from cases of suspected Gonorrhoea:— Gonococcus found 4 Gonococcus not found 65 69 Examinations of Urine 71 Blood counts 11 Other examinations 18 100 Special examinations of:— Sputa 6 Urine 9 15 Total number of examinations 3370 Public Mortuary.—One hundred and eleven bodies were removed to the Mortuary during 1927, and were admitted as follows:— By order of the Coroner 90 Brought by Police 12 For convenience till funeral 9 111 Ninety-three post-mortem examinations were made and inquests were held in 67 cases. Disinfection.—The following rooms were disinfected and cleansed after infectious disease:— 81 Rooms fumigated after:— Scarlet Fever 362 Diphtheria 355 Measles 28 Phthisis 281 Erysipelas 36 Encephalitis Lethargica 2 Cancer 30 Poliomyelitis 8 Influenza 3 Puerperal Fever and Pyrexia 20 Scabies 6 Enteric Fever 11 Pneumonia 6 Mumps 3 Dysentery 3 Rooms fumigated for Vermin 58 Rooms sprayed 36 Rooms fumigated by request 60 Total 1308 The following articles were disinfected at the Council's Disinfecting Station:— Articles. From private houses. From institutions. Total. Beds 674 2 676 Mattresses 735 54 789 Palliasses 34 — 34 Spring beds 6 — 6 Pillows 1888 102 1990 Cushions 297 12 309 Bolsters 650 4 654 Blankets 2438 225 2663 Sheets 1481 — 1481 Covers 248 — 243 Counterpanes 763 15 778 Curtains 266 — 266 Carpets 274 — 274 Hearth rugs 365 — 365 Articles of clothing 2565 227 2792 Eiderdowns 180 — 180 Sundries 394 54 448 13253 695 13948 82 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 2162 In consequence of infectious disease 909 House-to-house inspections 225 Re-inspections 12942 The following notices, requiring the abatement of nuisances found, were served:— Intimation notices. Statutory notices. Number served. Number complied with up to 31st December, 1927. Number served. Number complied with up to 31st December, 1927. 2073 1890 325 285 The following works were carried out and repairs effected as a result of the action of the Sanitary Inspectors :— Drains tested 1463 Drains relaid 167 Drains repaired 623 Soil pipes renewed 158 Soil pipes repaired 165 Eaves and downspouting repaired 611 Sinks renewed or repaired 309 W.C.s. and flushing apparatus repaired 606 Cisterns cleansed and covered 303 Water supply provided from main 135 Yards and forecourts paved 336 Roofs, chimneys and walls repaired 1347 Dustbins provided 384 Dampness of walls remedied 891 Internal house repairs done 1829 Rooms cleansed 2340 Overcrowding abated 44 Other nuisances abated 895 *This number includes houses reported as insanitary by Tuberculosis Nurses, Health Visitors, etc. 83 Drainage of Buildings.—The following drainage plans were submitted to and approved by the Public Health Committee during 1927:— Plans of drainage of new buildings, including houses (9), shops and flats (6), cottage, school, club, factories, distillery, offices, nursing home, studios, gate house and sub-station, electricity show rooms and garages 40 Additions to existing buildings 40 Reconstructions of the drains of existing buildings 85 The supervision of the above work, with the exception of reconstructions, is in the hands of Inspector A. J. Parsons, the Drainage Inspector. In connection therewith he paid 1,646 visits to works under construction. The following additional matters were dealt with by the Sanitary Inspectors:— Ice cream premises:— Number of inspections 191 Other food premises:— Number of inspections 903 Smoke nuisances:— Complaints 7 Observations 338 Notices served — Number abated 1 During 1927 the seven district sanitary inspectors made 16,229 inspections of dwelling-houses and inspected 2,918 houses. They served 2,073 intimation or preliminary notices and 325 statutory notices. They made 70 inspections of blocks of tenement houses under section 61 of the London County Council (General Powers) Act, 1927, in order to ascertain the adequacy or otherwise of the lighting (natural and artificial) of the staircases. It should be remembered that housing inspection, although occupying more time than any other part of 84 the inspectors' duties, is only one of the questions with which they are concerned. In the course of their work they also carried out 903 inspections of food premises and 191 inspections of ice-cream premises and made 338 smoke observations. Apart from these duties, there are others such as the inspection of markets and food barrows and the supervision of slaughtering and slaughter-houses. Work of the Female Inspector.—The greater part of the work under the Factory and Workshops Act 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 121 11 Food kitchens 225 12 Workshops and workplaces 261 8 Factories 87 2 Infirm and dirty tenants 62 21 85 FACTORIES, WORKSHOPS AND WORKPLACES. I.—Inspection of Factories, Workshops and Workplaces. Inspections made by Sanitary Inspectors. Premises. (1) Number of Inspections. (2) Written notices. (3) Prosecutions. (4) Factories (including factory laundries) 71 — — Workshops (including workshop laundries) 91 — — Workplaces (other than outworkers' premises) 105 25 — Total 267 25 — II.—Defects found in Factories, Workshops and Workplaces. Premises. Number of Defects. No. of Prosecutions. Found. Remedied. Referred to H.M. Inspector (1) (2) (3) (4) (5) Nuisances under Public Health Acts:— Want of ventilation — — — — Want of cleanliness 13 13 — — Overcrowding — — — — Want of drainage of floors — — — — Other nuisances 4 4 — — Sanitary accommodation:— Insufficient 1 1 - - Unsuitable or defective 7 7 - - Not separate for sexes — — - - 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 25 25 — — 86 Rat Destruction. One hundred and fifty-eight complaints were received regarding infestation by rats, and poison baits were laid in the following positions:— Private houses 194 Other premises 22 Sewers 214 The special dustbin traps which were introduced in July, 1926, have accounted for the death of 798 rats, 439 of which were trapped during the year 1927. The amount received by the Council from property owners for the services of the Rat Officer was £9. 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. C. P. Keen, 74, May Street. Failing to comply with nuisance order. Order to abate within 7 days. - - S. A. Berge, 1, Musard Road. Nuisance, 2, Biscay Road. Order to abate within 21 days. - 3 0 J. S. Harman, 50, Castletown Road. Claim for expenses under Housing Act, 1925, re No. 2, Yeldham Rd. Order for payment with interest. - 3 0 R. V. Notley, North Feltham. Nuisance, 32, Yeldham Rd. Withdrawn, work done. - - Do. Nuisance, 38, Yeldham Rd. Do. — — Do. Nuisance, 42, Yeldham Rd. Do. - — Do. Nuisance, 46, Yeldham Rd. Do. - — Do. Nuisance, Do. - — C. Feltham, 48, Yeldham Rd. Nuisance, Do. - - 503, King's Rd., Chelsea. 65, Aspenlea Rd. E. Cook, 31A, Althea St. Nuisance, 31a, Althea St. Do. - - 87 Fulham Civic Week. During Civic Week, which was celebrated from February 5th to 12th, 1927, the Public Health Committee took a stand at the Exhibition in the Fulham Baths. The Exhibition provided an opportunity to the staff to give demonstrations on health subjects, including dietetics, personal cleanliness, cleanliness in connection with food, the dangers of insects and infant and child welfare. The general public were also invited to visit the various institutions in the borough working under or in connection with the Public Health and Maternity and Child Welfare Departments. The amount of health educational work done during the week was most satisfactory and many thousands of people visited the Council's stand. The Flooding in July. An extremely heavy deluge of rain occurred on the afternoon of Monday, 11th July, 1927. This followed a severe thunderstorm and resulted in considerable damage to property. A sad feature of the storm was the death of a little girl aged one year and seven months, owing to drowning; this occurred in a basement in Munster Road. Records taken at the Hammersmith Pumping Station in Chancellor's Road showed that 2.65 inches of rain fell in two hours, and it was estimated that more than a million tons of rain fell in Hammersmith, Fulham, Kensington, parts of Wandsworth and Hampstead, which were the areas chiefly affected by the storm. In Fulham the flooding was most acute in Sands End Ward and in West Kensington, where basements are numerous. The sewers were unable to deal with the large quantity of water and the back pressure of the flood water burst open the manhole covers in many instances, so that flood water containing sewage overflowed into the basements generally through the ventilation openings under the floor or under basement doors; 88 in this way sewage was deposited under the floor boards and water containing sewage passed through the joints between the boards. Carpets, bedding and other contents of the rooms were fouled. In many cases, however, the damage was mainly due to flood water and sewage did not gain access to the premises. In some of the basements, although the flooding was severe, the effects of the flooding were minimised by the fact that the floors were constructed of concrete or stone. Mr. Holden, the Borough Surveyor, reported that only a limited amount of damage was done to some of the wood-paved surfaces which were quickly repaired. After the storm, the Surveyor's men commenced pumping to expedite the removal of the water from the basements. The sanitary inspectors were able to give considerable help and advice to the tenants and arranged for their bedding, carpets and other belongings to be disinfected at the Council's Disinfecting Station. Notices were served on owners in many cases to remove sewage from underneath floor boards, treat the sites with lime and repair the floor boards. A good deal of damage was also done to roofs and ceilings. A large amount of work was done voluntarily by owners who gave considerable help to the tenants. In some cases the owners fitted anti-flood syphons in order to prevent the possibility of sewage entering the premises in the event of a storm occurring in the future, and in other cases replaced wooden basement floors with concrete. Increase of Rent and Mortgage Interest (Restrictions) Act, 1920, Rent and Mortgage Interest Restrictions Act, 1923. Twenty-six 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 1927. 89 Certificates were granted in eight cases and of the remaining eighteen, one did not come within the terms of the Rent Restrictions Act, in another the tenant vacated the premises before the necessary repairs were completed, while in sixteen cases the repairs were carried out at once by the owners so that the issue of certificates was unnecessary. Housing Conditions. Year ending 31 st December, 1927. Number of new houses erected during the year:— (a) Total 128 (b) With State assistance under the Housing Acts — (i) By the local authority — (ii) By other bodies or persons 128 Number of new houses in course of erection 187 1. Unfit dwelling-houses:— (a) Total number of dwelling-houses inspected for Housing defects (under Public Health and Housing Acts) 2693 (b) Number of dwelling-houses which were inspected and recorded under the Housing (Consolidated) Regulations, 1925 225 (c) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil (d) 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 1142 2. Remedy of defects without service of formal notices:— (a) Number of defective dwelling-houses rendered fit in consequence of informal action by the local authority or their officers 748 3. Action under statutory powers:— (A) Proceedings under Section 3 of the Housing Act, 1925:— (a) Number of dwelling-houses in respect of which notices were served requiring repairs 50 (b) Number of dwelling-houses which were rendered fit after service of formal notices:— (i) By owners 28 (ii) By local authority in default of owners — 90 (c) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close — (B) Proceedings under Public Health Acts:— (a) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 319 (b) Number of dwelling houses in which defects were remedied after service of formal notices:— (i) By owners 281 (ii) By local authority in default of owners — (C) Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925:— (a) Number of representations made with a view to the making of Closing Orders — (b) Number of dwelling-houses in respect of which Closing Orders were made — (c) Number of dwelling-houses in respect of which Closing Orders were determined, the dwellinghouses having been rendered fit — (d) Number of dwelling-houses in respect of which demolition orders were made — (e) Number of dwelling-houses demolished in suance of demolition orders — The New Lewis Trust Buildings, Lisgar Terrace. I am indebted to Mr. H. C. Sydney, Secretary of the Samuel Lewis Trust Dwellings for the Poor, for the following particulars regarding these buildings, which are situated on the site previously occupied by the grounds of Otto House. Their erection was commenced in January, 1927, and they were completed on 23rd January, 1928. The flats contain either three or four rooms, one of which is a living-room, in addition to a kitchen, bathroom and W.C. Each flat has a gas copper and a coal-store, which will hold five hundredweights of coal. The rents and rates are as follows:— Three-roomed flats: rent, 10s. 6d.; rates, 2s. 8d. Four-roomed flats: rent 13s.; rates, 3s. 3½d. 91 This scheme has been a great asset to the borough as it has helped to meet the urgent need of the lower wage earners in Fulham for houses of moderate rentals near their places of occupation. In such cases travelling expenses are too much of a drain on the resources of the family. The flats are intended exclusively for people with children and the tenants are Fulham residents with few exceptions. The tenants have now entered into occupation and the present population is 790, consisting of 388 persons over 14 years of age and 402 under that age. The London County Council Estates. Since 1924, 716 Fulham families have been accommodated on the London County Council housing estates. Of this number, 255 were accommodated on recommendation by the Public Health Department of the Borough Council. These were cases either of overcrowding or special hardship. During the year 1927, 475 applications were made to the Public Health Department for housing accommodation and of this number 317 cases were recommended for preferential treatment to the London County Council. During 1927, 92 families were successful in securing accommodation. The County Council estates available for Fulham families are situated as follows:— 1. Becontree Estate, Essex. 2. Downham Estate, Bromley. 3. White Hart Lane Estate, Tottenham. 4. Watling Estate, Edgware. No further applications are being sent for the Castelnau Estate as the number of houses available on this estate for Fulham residents has been exceeded. The rents, plus rates, of the County Council houses vary from 12. 6d. to 24s. per week, and the accommodation varies from two to six rooms. 92 Official circulars were issued during the year 1927 dealing with the following matters:— Tuberculosis :— 31-3-27 771 and Treatment of Tuberculosis. 771A. —12-27 Memo 37T Residential treatment and other Revised. services relating to culous ex-service men. Maternity and Child Welfare:— 9- 5-27 790 Health Visitors. 20- 6-27 802A Registration of Still-births. Infectious Diseases:— 22-12-27 1207 Infectious Diseases (London) ulations, 1927. 28-12-27 826 Cancer VI. Sale of Food and Drugs:— — 1-27 36 Foods. Procedure under Sale of Food and Drugs Acts, etc. 26- 2-27 191 Bakehouses Welfare Order, 1927. 8- 4-27 71855 Public Health (Preservatives, etc., in Food) Amendment Regulations, 1927. 14- 4-27 782 Ditto ditto 21- 9-27 872 Biscuit Factories Welfare Order, 1927. 14-11-27 1093 Public Health (Dried Milk) Amendment Regulations, 1927. 14-11-27 1092 Public Health (Condensed Milk) Amendment Regulations, 1927. 19-11-27 827 Condensed and Dried Milks. Administration:— 17-2-27 759 Public Health (Smoke ment) Act, 1926. 93 CONTENTS. Page Acts, Regulations and Orders dated 1927 relating to food and food premises 77 Ante-natal clinics 24 Babies' Hospital 26 Bacteriological examinations 79 Bakehouses 75 Births and Deaths Registration Act, 1926 9 Births, Notification of 24 Cancer 38 Civic Week 87 Committees, Public Health and Maternity and Child Welfare 3 Circulars of Ministry of Health 92 Day Nursery 28 Deaths, Causes of 15 Disinfection 80 Diseases, Notifiable infectious 31 Dysentery, Outbreak of 69 Drainage of buildings 83 Factory and Workshops Acts 85 Female Inspector, Work of 84 Flooding in July, 1927 87 Food 73 Food preparing places 72 Food (unsound) 75 Food poisoning, Outbreak of 70 Housing 89 Infantile mortality 13 Infant welfare clinics 23 Infectious diseases 31 94 Page Infectious Diseases (London) Regulations, 1927 37 Infectious diseases, Mortality from 32 Introductory 5 Legal proceedings (Sanitary and Housing) 86 Legal proceedings (Adulteration of food) 77 Maternity and Child Welfare 22 Maternity Home 25 Maternal mortality 18 Milk and cream 74 Milk (Special Designations) Order, 1923 75 Milk, Provision of free 29 Mortality among Young Infants and Stillbirths 17 Mortuary 80 Mothers and Children, Home visitation of 25 Nursing, Home 29 Poor Law Relief 30 Principal diseases, Deaths from 11 Rat Destruction 86 Rent Restrictions Act 88 Samples purchased for analysis 76 Sanitary Inspection of the district 82 Slaughterhouses 73 Staff—Public Health and Maternity and Child Welfare Departments 4 Supervision: of Children of pre-school age 23 Tuberculosis 46 Tuberculosis Dispensary 48 Tuberculosis, Report by Dr. Hamilton, Tuberculosis Officer 50 Vaccination 30 Venereal Disease 44 Vital statistics 6