Metropolitan Borough of fulbam. ANNUAL REPORT of the Medical Officer of Health for the year 1932. JOHN SULLIVAN, M B., Ch.B, D.P.H. Medical Officer of Health. Metropolitan Borough of fulbam. ANNUAL REPORT of the Medical Officer of Health for the year 1932. JOHN SULLIVAN, M B , Ch.B, D.P.H. Medical Officer of Health. T. W. Pegg & Sons, Ltd. (T.U.), Walham Green, S. IF.6. 3 Fulbam Borough Council. PUBLIC HEALTH COMMITTEE, 1932. His Worship the Mayor (Alderman W. J. Waldron, J.P.) Ex-office. Chairman: Councillor F. A. Barham. V icc-C hair man : Councillor Dr. T. J. Bokeniiam. Councillor S. T. Cave. Councillor Miss C. Fulford. Mrs. H. L. Cummins. „ G. L. Hodge. „ H. Dodimead. ,, J. S.. Melville. A. G. Everard. „ A. Minute, J.P. A. W. Ford. ,, Mrs. R. H. B. Pavitt. W. Fowell, M.R.S.T. „ Sir T. W. Richardson. Councillor W. J. Stockwell, M.R.S.T. MATERNITY AND CHILD WELFARE COMMITTEE, 1932 His Worship the Mayor (Alderman W. J. Waldron, J.P.) Ex-office. Chairman: Councillor A. Minute, J.P. Vice-Chairman: Councillor Mrs. H. L. Cummins. Councillor Dr. T. J. Bokenham. Councillor G. R. Renton. ,, H. Dodimead. „ Mrs. G. M. Scates. G. L. Hodge. *Mrs. E. Corbin. ,, Mrs. G. M. King. *Mrs. A. Minute. ,, J. S. Melville. *Mrs. E. E. Pritchard. A. Minute, J.P. *Miss C. J. Sketchley. Mrs. R. H. B. Pavitt. *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: *P. L. T. Bennett, M.C., M.R.C.S. (Eng.), L.R.C.P. (Lond.), D.P.H. (Lond.), T.D.D. (Wales). (Tuberculosis Officer and Medical Officer Borough Bacteriological Laboratory), *Ruby Thomson, M.B., Ch.B. (Edin.), D.P.H. (Edin. and Glas.), (Maternity and Child Welfare Officer). *Catharine Ross (Mrs. Colston), M.B., Ch.B. (Glas.), D.P.H. (Glas.). {Part-time), [Resigned 29th February, 1932). *Anna R. Park, M.B., Ch.B., B.A.O., (Belf.), D.P.H. (Belf.), [Appointed 1st March, 1932). Dental Surgeon: *W. E. Dodd, L.D.S. (part-time). Consulting Obstetrician: Alex. Galletly, M.C., M.B., Ch.B. (Edin.), E.R.C.S.E. Public Analyst: Cecil H. Cribb, B.Sc. (Lond.), F.I.C. (part-time). [Died YMh June, J932). William Partridge, F.I.C. (part-time). Public Vaccinators: North District: A. G. Wells, M.R.C.S. (Eng.), L.R.C.P. (Lond.), L.S.A. (part-time). South District: T. Duff Miller, M.D. (Glas.), Ch.B. (Glas.) F.R.F.P.S. [part-time). Vaccination Officer: Hugh Davies. 5 Clerical Staff: A. T. Hurford, Chief Clerk. O. A. Trendell. S. J. Cassiuy. L. G. Brooks. J. U. Dant. W. Swinson. Maternity and Child Welfare: *Miss A. Drury. *Miss W. E. Noble. *Miss G. M. Knight. Senior Sanitary Inspector: *Ciiarles Bristow Jones (Food and Drugs). (Retired 2\)th November, 1932). *Alfred J. Parsons. Sanitary Inspectors: *Frederick H. Manning. *Frederick E. Walsh. (Retired 31st March, 1932). * Arthur S. Jones *(Edgar Drake. * Mrs. M. E. Davies (Retired *Albert E. Clutterbuck 31st March, 1932). *Thomas Henry Robey. *Henry Hutchinson. *Alex W. Gammack (Ap- *Frederick C. Payne (Appointed Food and Drugs pointed 1st April, 1932). Inspector, 30t November, *Mrs. M. E. Raynor (Ap1932). pointed Is/ April, 1932). Health Visitors: 4 5 6 *Mrs. J. Bryning. 4 5 6 *Miss E. Beckett. 1 4 6 *Miss A. Perrett. 4 5 6 *Mrs. J. Granville-Smith. 4 3 8 7 *Miss. D. M. Hayward. 4 5 6 *Miss P. Kaye. 4 5 8 *Miss G. Leach. Tuberculosis Dispensary Staff: Nurses: 4 6 *Miss R. Bowen. 4 5 6 *Miss E. C. Carmichael. 4 *Miss. E. E. Walker. *Miss M. C. Robinson, Bacteriological Assistant and Dispenser. *Miss M. E. Sargent, Clerk and Secretary of the Care Committee. *Miss W. Wright, Clerk (part-time). *Mr. and Mrs. Roberts, Caretakers. 6. Maternity Home: Matron: 4 6 *Miss M. Bustard. Assistant Matron: 4 6 *Miss M. Denman. Disinfection Station: Superintendent: A. V. Williams. Disinfectors: E. J. Eyles, W. Lhaton and G. Passenger. Van Driver: S. Webb. Mortuary Keeper : S. Churchill. Rat Officer: J. Gigner. Housekeeper at Greyhound Road Infant Welfare Centre: *Mrs. B. Gregory. * The Council receives Exchequer grants towards the salaries of these Oflicers. 1 Certified Sanitary Inspector. 5 Health Visitor's Certificate. 2 Food Inspector's Certificate. 6 Certificate of Central Midwives Board. 3 Registered Plumber. 7 Fever Trained. 4 Trained Nurse. 8 Queen's Nurse. 7 Town Hall, Fulham, S.W.G. August, 1933. 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 the sanitary condition of the borough for the year 1932. Staff Changes. Upon the resignation of Dr. Hardy which took effect at the end of 1931, the Council decided to apoint a full-time Assistant Medical Officer to perform the duties carried out by Dr. C. Ross (the part-time Medical Officer) and the Maternity and Child Welfare duties carried out by Dr. Hardy; as stated in my report for 1931 the Council decided that it was unnecessary to appoint a successor so far as Dr. Hardy 's tuberculosis duties were concerned. Dr. Anna R. Park was appointed to the position and commenced her duties on 1st March, Dr. Ross performing the duties until that date with the aid of locum tenens. The Department lost through retirement, the services of two experienced officers in Inspector F. H Manning and Senior Inspector C. B. Jones. These officers had rendered conspicuous service to the late. Vestry and Borough Council for 37½ and 42 years respectively. Mr. F. C. P ayne, who was appointed temporary housing inspector for special surveys under the Housing Act, 1930, for a period of six months ending 24th February, 1932, was re-appointed for another month to finish the surveys and was then taken on to the permanent staff as Housing Inspector in place of Mr. Hutchinson; the latter became District Inspector on the retirement of Mr. Manning. 8 Mrs. Davies, who had been woman inspector for 264 years retired on 31st March and Miss M. E. Raynor was appointed in her place. Mr. C. B. Jones, the Council's l^ood and Drugs Sampling Officer retired on 29th November and Mr. A. W. Gammack, one of the district inspectors, was appointed in his place. Mr. W. C. Turner, who had been acting as temporary inspector during the illness of Mr. Jones, was appointed on 1 st December, as inspector for the district1 vacated by Mr. Gammack, after the position had been advertised. Public Analyst. I regret to record the death of Mr. Cecil H. Cribb, B .Sc., P.I.C., Public Analyst to the Borough for 34 years, on 13th June, 1932. Mr. Cribb during the whole of his service carried out his duties most conscientiously and to the entire satisfaction of the Council. Mr. William Partridge, F.I.C., was appointed acting Public Analyst and was subsequently appointed to the permanent position. I wish to convey my thanks to the members of the staff for their loyal services during the year and to my colleagues in other departments for their willing cooperation. I desire to take this opportunity of thanking the chairmen and members of the Public Health and Maternity and Child Welfare Committees for the valuable support they have given me and I also wish to thank the members of the Voluntary Societies who have been so intimately associated with me in the course of their work. 1 have the honour to be, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, JOHN SULLIVAN, Medical Ojficcr of Health, 9 General Statistics. Area (Acres) 1,706 Population (Census, 1931) 150,928 Population (mid 1932) 149,600 Number of inhabited houses (Census, 1931) 26,245 Rateable Value £1,149,887 Sum represented by a penny rate £4,606 Extracts from Vital Statistics for the Year. Total. Males. Females. Live Births:— Legitimate 2,001 1,024 977 Birth rate per 1,000 Illegitimate 136 65 71 of the estimated resident population, 14.3 Stillbirths:— Legitimate 63 36 27 Kate per 1,000 total Illegitimate 1 1 — (live and stillbirths) births, 29.08 Deaths:— 1,848 924 924 Death rate per 1,000 of the estimated resident population, 12.4 Percentage of deaths occurring in Public Institutions 57.4 Deaths from diseases and accidents of from sepsis 4 Pregnancy and childbirth from other causes 4 Death Rate of Infants under One Year of age:— All infants per 1,000 live births 58 Legitimate infants per 1,000 legitimate live births 54. Illegitimate infants per 1,000 illegitimate live births 117 Deaths from:— Measles (all ages) 26 Whooping Cough (all ages) 12 Diarrhoea (under 2 years of age) 22 10 Population. The census taken during 1931 showed that the population of the borough was 150,928 but the Registrar-General's estimate of the population for the year 1932 was 149,000. This latter figure has been used for the compilation of the various rates mentioned in this report. Marriages. The number of marriages was 1,211 and the marriage rate (the number of marriages per 1,000 of the population) was 8.09. In the preceding years the number of marriages was 1,330 and 1,468 so that there was a decrease in 1932. Births. During the year the live births corrected by the distribution of those occurring in lying-in institutions in the borough to those districts in which the mothers resided and the inclusion of children born to Fulham mothers in institutions outside the borough, numbered 2,137 of whom 1,089 were males and 1,048 were females. The birth rate (the number of live births per 1,000 of the population) was 14.3. The birth rate for the whole of London was 14.2 and for England and Wales 15.3. Stillbirths. The number of stillbirths during 1932 was 04 compared with 70 (lining the previous year. The stillbirths amounted to 29.08 per 1,000 of the total births (live and stillbirths). Illegitimacy. The illegitimate live births numbered 130) (05 males and 71 females) during 1932 as compared with 155 for the previous year and they constituted 0.4 per cent, of the total live births. Natural Increase of the Population. The natural increase of the population, that is to say the excess of the total live births over the deaths, was 289 compared with 424 during 1931. Deaths. During the year ended 31lst December, 1932, 1,509 deaths were registered as having occurred in the borough. Of these 202 were of persons not belonging to the borough while 481 inhabitants of 11 Fulham died outside the borough, chiefly in public institutions. There were, therefore, 1,848 deaths of persons—924 males and 924 females—having their usual residence in Fulham representing an annual rate of 12.4 per thousand of the population. This rate is 0.1 above that of the previous year and l.(i above that of 1930. The following death rates for 1932 are of interest: England and Wales 12.0 London 12.3 Fulham 12.4 Certifications of causes of death. Of the 1,848 deaths belonging to the borough, 1,658 or 89.7 per cent, were certified by registered medical practitioners, 125 or (i.8 per cent, by coroners after inquests, (i() or 3.2 per cent, by coroners without inquests, while 5 cases or 0.3 per cent, were uncertified. Deaths in Public Institutions. Fulham Hospital. In this institution, belonging to the London County Council, there were 664 deaths, of which 612 were of Fulham residents, while 52 were of persons belonging to other districts. Western Hospital, one of the London County Council Infectious Diseases Hospitals, had 146 deaths during the year. Of this number 26 were Fulham residents and 120 were patients admitted from other districts. Deaths of Fulham residents outside the borough. The deaths of Fulham residents in institutions outside the borough numbered 423 and occurred in the following places: — 12 St. George's Hospital 23 West London Hospital 32 Other General Hospitals 85 Children's Hospitals 19 Women's Hospitals 6 Other special Hospitals 29 L.C.C. Infectious Disease Hospitals 14 Public Assistance Hospitals 130 Mental Hospitals 72 Sanatoria 13 423 Of the deaths of Fulliam persons 57.4 per cent, took place in public institutions as follows: Per cent. 742 in Public Assistance Institutions or Hospitals 40.15 40 in Infectious Disease Hospitals 2.16 207 in other Hospitals 11.20 72 in Mental Hospitals 3.89 Zymotic Deaths. The Zymotic Death Kate is that from the principal zymotic or infectious diseases, viz. smallpox, scarlet fever, diphtheria, measles, whoopingcough, diarrhoea and fevers (typhus, enteric, other or doubtful fevers). The mortality from these diseases was higher than in 1931, 73 deaths being due to them as against 39. This increase was due almost entirely to the biennial epidemic of measles, which caused 26 deaths in 1932 whereas only one death was due to measles in 1931. The death rate per 1,000 of the population was 0.49 as compared with 0.25 for 1931. Seasonal Mortality. The mortality in the four quarters of the year under review was as follows. 1932 1931 First quarter 566 639 Second quarter 451 424 Third quarter 365 314 Fourth quarter 466 480 1,848 1,857 13 It will be seen that there is very little difference in the number of deaths during the two years. Causes of Death. These are classified in Table 2, pages 19 & 20. The following table shows the diseases which caused the largest number of deaths: Disease. Males. Females. Both Sexes. Percentage of total deaths. Heart Disease 234 259 493 26.7 Cancer 112 121 233 12.6 Tuberculosis 99 61 160 8.6 Pneumonia 56 62 118 6.4 Chronic and Acute Nephritis 32 35 67 3.6 Cerebral Haemorrage, etc. 21 31 52 2.8 Bronchitis 16 32 48 2.6 Totals 570 601 1171 63.4 It will he seen that heart disease, as in the last three years, heads the list; 493 deaths were certified as due to this cause in 1932 compared with 455 during 1931. Cancer came next with 233 deaths, an increase of live on the previous year. Tuberculosis took third place with 100 deaths as against 169 during 1931. There was a decrease in the mortality from pneumonia, the number falling from 172 to 118. There was a decrease in the deaths from bronchitis, the number being 18 compared with 75 during 1931. The following figures show the number of deaths from the common diseases classified according to the organs of the body affected. Diseases of the organs of circulation caused 609 deaths in 1932 or 32.9 per cent, of the total, including 14 493 from heart disease, 6 from aneurysm and 110 from other circulatory diseases. Including haemorrhage into the brain, the deaths from circulatory diseases were 6(31. There were 314 deaths in 1932 from diseases of the respiratory organs, equal to 10.9 per cent, of the total deaths. This number was made up as follows : Pneumonia 118, Tuberculosis of the lungs 137, Bronchitis 48 and other respiratory diseases 11. A large number of deaths from bronchitis (00.0 per cent.) were in persons over 05 years of age. In the case of deaths from pneumonia 32.2 per cent, were in persons over 65 years of age and 13.5 per cent, were in children under one year of age. Sixty-seven persons died from nephritis and 31 from Influenza (compared with 33 during 1931). Deaths from Cancer in 1932. Males. Females. Total. Carcinoma 102 110 212 Sarcoma 5 5 10 Epithelioma 3 1 4 Not defined 2 5 7 112 121 233 Deaths Classified According to the Organ Affected Cancer of Digestive Organs and Peritoneum 109 (67 males, 42 females) Cancer of Respiratory Organs 16 (11 males, 5 females) Cancer of Breast 29 Cancer of Genito-Urinary Organs, males 13 Cancer of Uterus 29 Cancer of Buccal Cavity and Pharynx 13 (12 males, 1 female) Cancer of other organs 24 ( 9 males, 15 females) 15 Ages at Death of Persons Dying from Cancer in 1932. Age Periods. Males. Females. Total. 0 to 25 years 2 3 5 25 to 35 years — 3 3 35 to 45 years 1 11 12 45 to 55 years 11 20 31 55 to 65 years 40 27 67 65 to 75 years 38 34 72 75 years upwards 20 23 43 112 121 233 From the table showing the principal causes of death it will be seen that one out of every eight deaths in the borough in 1932 was due to Cancer. Infantile Mortality. Of 1,848 deaths of persons of all ages belonging to Fulham during 1932, 124 or 7.8 per cent, occurred in infants under One Year of age. The infantile mortality rate (the number of deaths of infants under One Year of age per 1,000 live births) was 58 as compared with 67 during 1931. The actual number of deaths was 124 compared with 154. The infantile mortality rate for England and Wales was 65 and for London 66. Infantile Mortality Rate in Fulham since 1891. Average for five years. Actual rates for last seven years. 1891-1895 168 1926 64 1896-1900 167 1927 66 1901-1905 144 1928 77 1906-1910 117 1929 69 1911-1915 109 1930 57 1916-1920 92 1931 67 1921-1925 73 1932 58 1926-1930 67 16 The following table shows the birth and infantile mortality rates during the last two years for the various wards in the borough:— Wards. Births and Birth rates. Infantile deaths. Infantile mortality rates. 1932 1931 1932 1931 1932 1931 Baron's Court 139 (9.2) 126 (10.1) 8 16 57 127 Lillie 228 (9.9) 214 (9.1) 23 19 100 89 Walham 215 (15.1) 178 (14.1) 20 34 93 191 Margravine 514 (30.8) 601 (33.7) 19 20 37 33 Munster 433 (12.7) 496 (13.7) 20 22 46 44 Hurlingham 68 (7.6) 51 (5.4) 10 4 147 78 Sands End 214 ( 8.9) 251 (9.7) 20 41 93 163 Town 326 (23.8) 364 (25.8) 4 8 12 22 BOROUGH 2137 (14.3) 2281(15.08) 124 154 58 67 It will be seen from Table III. on pages 21 & 22 that the principal causes of infantile mortality were as follows: Prematurity ... 29 deaths compared with 27 in 1931. Diarrhoea and Enteritis 21 „ „ „ 15 „ „ Pneumonia (all forms) 16 „ „ 3] „ „ Congenital malformations 12 „ ,, ,, 12 „ „ Atrophy, debility and Marasmus 12 „ „ „ 10 „ „ Fifty deaths of infants under four weeks of age occurred in 1932 as compared with 55 during 1931 and 49 during 1930. The following table shows the number of infantile deaths from all causes as compared with infantile deaths from diarrhoea since 1932: Infantile deaths from all causes. Infantile deaths from Diarrhœa. 1923 199 21 1924 214 18 1925 211 36 1926 173 28 1927 162 16 1928 185 50 1929 173 33 1930 136 28 1931 154 15 1932 124 21 17 Maternal Mortality. During the year investigations were made into the causes of death on eight cases of Maternal Mortality and the reports were transmitted to the Maternal Mortality Committee. The following is a list of the cases with the causes of death:— Occupation. Age. Date and Place of death. Cause of death. Wife of a builder's labourer 34 Jan. 22nd, in hospital 1. (a) Eclampsia. (b) Pregnancy. 2. Op. 11.1.32 (Caesarian section). Spinster, domestic servant 24 Jan. 20th, in hospital 1. (a) Broncho-Pneumonia. (b) Influenza. 2. Puerperal sepsis. Wife of a housepainter 32 April 5th, in hospital 1. (a) Anaemia. (b) Hæinorrhage from abortion with retained placenta Spinster, hotel clerk 27 April 25th, in nursing home 1. (a) Cardiac syncope. (b) Pulm. embolism. (c) Confinement and profound chronic anaemia. Spinster, a general servant 21 May 5th, in hospital 1. (a) Eclampsia of pregnancy 2. Acute toxæmic nephritis. Wife of a provision merchant's assistant 29 July 6th, in hospital 1. (a) Puerperal septicaemia, and general peritonitis. (b) Obstructed labour. 2. Caesarian section. Wife of a civil servant 41 Sept. 17th, in hospital 1. (a) Peritonitis. (b) Puerperal septicaemia. (c) Anaemia. 2. Caesarian section Pyelitis. Wife of a milk roundsman 32 Dec. 7th, in hospital. 1. Puerperal septicaemia. 2. Empyema. 18 Table I.—Vital Statistics of the Whole Borough during 1932 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. Of Non. Residents registered in the Borough. Of Residents not registered in the Borough. Under I Year of Age At all Ages. Number. * Rate. Number. * Rate per 1,000 Nett Births. Number. * Rate. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 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 1928 155300 2319 2388 15.4 1548 9.9 128 360 185 77 1780 11.5 1929 153700 2328 2502 16.2 1882 12.2 157 394 173 69 2119 13.7 1930 153700 2226 2366 15.3 1473 9.5 143 343 136 57 1673 10.8 1931 151200 2103 2281 15.08 1532 10.1 107 432 154 67 1857 13.3 1932 149600 1842 2137 14.3 1569 10.5 202 481 124 58 1848 12.4 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. * 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 'hat 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. † "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 I he 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 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) 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. 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 1931: 150,928 19 20 TABLE II. Causes of and Ages at Death during the Year 1932. Nell deaths at the subjoined ages of "Residents," whether occurring within or without the District (a). Deaths, Whether of "Residents" or "NonResidents" Institutions 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 age. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 arid under 15 years. 15 and under 25 years. 25 and under 35 years. 35 and under 45 years. 45 and under 55 years. 55 and under 05 years. 05 and under 75 years. 75 years and upwards. Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. llurllngbam 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) 1843 124 28 45 34 75 76 94 189 300 428 450 480 198 298 201 229 337 134 271 182 Uncertified 5 - - - - - 1 - - - - 4 - 2 - 1 - 2 - - - 1. Typhoid and paratyphoid fevers 1 - - - - - - 1 - - - - - - - - - - - - 1 2. Measles 26 4 9 11 2 - - - - - - - 68 3 4 9 5 1 - 4 - 3. Scarlet Fever 2 - 1 - 1 - - - - - - - 6 - - - 1 - - 1 - 4. Whooping Cough 12 4 6 2 - - - - - - - - 26 - 2 5 - 2 - 2 1 5. Diphtheria 10 - 1 4 4 - - - - - - 1 37 - 3 1 1 - - 4 1 6. Influenza 31 2 - 1 - 2 1 5 5 4 6 5 8 3 3 5 5 4 3 5 3 7. Encephalitis Lethargica 2 - - - - - 1 - 1 - - - - - 1 - - 1 - - - 8. Cerebrospinal fever 5 - - 2 2 1 - - - - - - 5 - 1 1 1 1 - - 1 9. Tuberculosis of respiratory system 137 - 1 - 1 36 25 19 30 15 10 - 58 12 27 18 21 20 7 21 11 10. Other Tuberculous diseases 23 1 - 4 6 7 4 - - - 1 - 15 1 1 3 3 9 - 5 1 11. Syphilis 2 - - - - - - - - 2 - - - - - 1 - 1 - - - 12. General paralysis of the insane 7 - - - - - - - - 4 3 - 4 1 - 2 - 2 - 1 1 13. Cancer, malignant disease 233 - 1 2 1 1 3 12 31 67 72 43 68 29 43 18 22 42 20 36 23 14. Diabetes 23 - - - - 1 1 1 1 1 5 7 15 3 4 - 4 5 1 6 - 15. Cerebral Haemorrhage, etc. 52 - - - - - - - 7 10 16 19 8 7 8 2 8 8 2 11 6 10. Heart Disease 493 - - - 1 5 6 18 38 74 150 201 195 48 72 55 61 87 49 74 47 17. Aneurysm 6 - - - - - - - - 2 4 - 1 1 1 1 1 1 1 - - 18. Other circulatory diseases 110 - - - - - - 1 3 11 46 49 63 15 18 14 10 27 4 10 12 19. Bronchitis 48 3 - 2 - - - - 4 7 11 21 15 3 5 7 7 8 3 7 8 20. Pneumonia (all forms) 118 16 2 9 5 2 4 10 11 21 16 22 43 11 26 13 17 24 4 12 11 21. Other respiratory diseases 11 - 1 1 - - 1 - 1 2 3 2 2 1 3 - 4 1 1 1 - 22. Peptic ulcer 7 - - - - - - - 4 1 1 1 4 2 - - 1 1 - 1 2 23. Diarrhoea, etc. 22 21 1 - - - - - - - - - 14 1 4 3 5 4 2 3 - 24. Appendicitis 17 - - 2 2 2 1 - 3 3 2 2 11 1 2 4 3 3 2 1 1 25. Cirrhosis of Liver 4 - - - - - 1 - 1 - 2 - 4 1 1 - - 1 1 - - 20. Other diseases of liver, etc. 9 - - 1 - - 1 2 2 1 2 - 5 2 1 - 1 2 1 2 - 27. Other digestive diseases 31 3 1 - 1 1 1 3 7 6 2 6 19 1 9 1 3 3 4 5 4 28. Acute and chronic nephritis 67 1 - - - 1 - 1 10 15 28 11 28 4 16 1 10 15 7 6 7 29. Puerperal Sepsis 4 - - - - 1 2 1 - - - - 2 1 1 1 - - - - - 30. Other puerperal causes 4 - - - - 1 3 - - - - - 2 2 - - 1 - 1 - - 31. Congenital debility, premature birth, malformations, etc 61 61 - - - - - - - - - - 27 6 11 7 8 9 8 10 2 32. Senility 40 - - - - - - - - - 5 35 2 7 3 7 6 9 1 4 3 33. Suicide 32 - - - - 1 4 4 7 12 4 - 6 6 4 1 4 10 - 1 5 34. Other violence 62 3 1 1 4 3 7 3 4 13 9 14 22 7 5 5 5 13 6 14 7 35. Other defined causes 136 5 3 3 4 11 10 13 19 23 30 15 56 14 19 14 11 25 6 24 23 36. Causes ill-defined or unknown - - - - - - - - - - - - - - - - - - - - - Total 1848 124 28 45 34 76 76 94 189 300 428 454 840 193 298 202 229 339 134 271 182 a.) All "Tansferable Deaths " ol residents, i.e., of persons resident in the District who have died outside it, are included with the other deaths in columns :—13, and columns 15—22. Transferable deaths of non-residents, i.e., of persons resident elsewhere 11! England and Wales who have died in the District, are in like manner excluded from these columns. for the precisc meaning of the term " transferable deaths " see footnote to Table I. (6) All deaths occurring in institutions for the sick and infirm situated within the district, whether of residents or of non-residents, are entered in column n of Table II. (c) All deaths certified by registered Medical Prhctitioners and all Inquest cases arc classcd as " Certified ' another deaths arc regarded as " Uncertified." 21 22 Table III. Infant Mortality during Year 1932. Nett Deaths from stated causes at various ages under One Year of Age. Netl Deaths under One Year of Residents in the Wards of the Borough. Cause of Death. Under i Week. 1—2 Weeks. 2—3 Weeks. 3—4 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. 6 Months. 6 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under One Year. Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. All Causes Certified 38 7 2 3 50 22 21 14 17 124 8 23 20 19 20 10 20 4 Uncertified - - - - - - - - - - - - - - - - - - 1. Small-pox - - - - - - - - - - - - - - - - - - Chicken-pox - - - - - - - - - - - - - - - - - - 3. Measles — — - — — — — 1 3 4 — 1 2 1 — — — — Scarlet Fever - - - - - - - - - - - - - - - - - - 5. Whooping Cough - — — — — 2 — — 2 4 — 1 2 — — — 1 — 6. Diphtheria and Croup — - - - - - - - - - - - - - - - - - 7. Erysipelas - — — — — 2 1 — — 3 — - 1 - 2 — - — 8. Tuberculous Meningitis - — — — — — — - 1 1 - — — — 1 — - — 9. Abdominal Tuberculosis [a) - - - - - - - - - - - - - - - - - - 10. Disseminated Tuberculosis - - - - - - - - - - - - - - - - - - 11. Other Tuberculous Diseases - - - - - - - - - - - - - - - - - - 12. Meningitis (not Tuberculous! - - - - - 1 - - - 1 - 1 - - - - - - 13. Convulsions - - — - - - - - - - - - - - - - - - 14. Laryngitis - - - — - - - - - - - - - - - - - - 15. Bronchitis 1 — — — 1 — — — 2 3 1 — — 1 — — 1 — 10. Pneumonia (all forms! 1 — - — 1 2 6 5 2 16 - 5 3 3 2 — 2 1 17. Influenza - - — - - - 1 1 - 2 - - 2 - - - - - 18. Diarrhoea 1 — — 1 2 — 6 3 2 13 - 3 1 4 3 1 1 - 19. Enteritis - — — — — — 4 2 2 8 1 1 1 1 1 1 2 — 20. Gastritis - - - - - - - - - - - - - - - - - - 21. Syphilis - - - - - - - - - - - - - - - - - - 22. Rickets - - - - - - - - - - - - - - - - - - 23. Suffocation, overlaying - — — — — - 1 1 — 2 — - - - - - 1 — 24. Injury by Birth 4 — — — 4 1 — — — 5 — 2 1 — 1 1 - — 25. Atelectasis 2 — — — 2 1 — — — 3 1 — — — — — 1 1 20. Congenital Malformations 4 2 1 — 7 5 — — — 12 2 1 — 2 3 1 2 1 27. Premature Birth 21 2 1 2 26 3 — — — 29 2 3 6 5 1 5 6 1 28. Atrophy, Debility and Marasmus 2 2 - — 4 5 1 1 1 12 — 4 — 2 4 1 1 — 29. Other Causes - — - 3 - 1 - 2 6 1 1 - - 2 - 2 - Total 38 7 2 3 50 22 21 14 17 124 8 23 20 19 20 10 20 4 Nett Births in the Year:— Legitimate 2001 Illegitimate 136 Nett Deaths in the Year of:— Legitimate infant 108 Illegitimate infants 10 (a.) Under Abdominal Tuberculosis are included deaths from Tuberculous Peritonitis and Enteritis, and from Tabes Mescnterica. Want of breast milk is included under Atrophy and Debility. Table I.—Vital Statistics of the Whole Borough during 1932 and Ten preceding Years. 23 Infectious Diseases Incidence. Full particulars of all notifiable diseases arranged according to disease, ward and age will be found in Table IV. on page 31. The number of cases of infectious disease notified during 1932 was 4,190 compared with 1,505 in 1931. This large increase was due to the epidemic of Measles which occurred during the year and, excluding this disease, the cases notified were 1,508 as against 1,395 in 1931. The increase in the number of notified cases, apart from Measles, was due to a larger number of Scarlet Fever cases. The notifications of Diphtheria decreased from 2.25 to 177 and those of Scarlet Fever rose from 331 to 543. There was also a decrease in the notifications of primary and influenzal Pneumonia from 275 to 241. Notifications of Erysipelas increased from 86 to 106 and Enteric Fever from 3 to 11, those of Epidemic Diarrhoea fell from 33 to 22. There was a decrease in the number of notifications of Tuberculosis, 311 as compared with 353. The number of cases of infectious disease of the central nervous system were 12 compared with 14 in the previous year; they included eight cases of Cerebro-spinal fever, three of Encephalitis Lethargica and one of Poliomyelitis. Mortality from Infectious Diseases. There were 349 deaths from notifiable infectious diseases in 1932 compared with 392 in 1931. The deaths from Diphtheria were ten compared with nine and Scarlet Fever remained the same at two deaths. The deaths from Tuberculosis fell from 169 to 160 and those due to Pneumonia from 171 to 118. There were 26 deaths from Measles compared with one in 1931. Diseases of the nervous system accounted for eight deaths as against ten during 1931 (Cerebro-spinal fever 5, Encephalitis Lethargica 2 and acute Polio-enceplialitis 24 There were 12 deaths from Whooping Cough compared with seven during 1931 the deaths occurring in the cases of four children under one year of age, six children of one year, one child of two years and one child of three years. Diphtheria. Notification, One hundred and seventy-seven notifications were received during 1932, a decrease of 48 compared with 1931. The attack rate was equal to 1.18 per thousand of the population and the two sexes were affected in the proportion of 87 males to 90 females. The following table shows that most cases occurred in children under ten years of age : 0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 6 to 7 7 to H 8 to 9 9 to 10 10 to 15 15 to 20 20 to 35 35 to 45 15 to 65 65 & up T O T A L. 2 5 21 18 19 14 20 12 5 7 23 10 17 — 3 1 177 The disease was prevalent all the year round, the cases varying from seven in July to 27 in September. The following summary shows the number of notifications received during each month of the year : First Quarter:— January 23 February 20 March 11 Second Quarter:— April12 May 10 June 10 Third Quarter:— July 7 August 12 September 27 Fourth Quarter:— October 19 November 9 December 17 Deaths. Ten deaths were due to Diphtheria, giving a case mortality of 5.65 per cent. and a death rate of 0.06 per thousand of the population at all ages. Two 25 deaths were in males and eight in females. One death occurred in a man aged 79 and the oilier nine were all in children under eight years of age, the ages being as follows : 13/4, 2, 3, 3, 4, 5, 5, 6 and 7 years. Anti-Toxin. During the year medical practitioners were supplied with 376,000 units of anti-toxin. Scarlet Fever. Notification. Five hundred and forty-three cases were notified during the year, an increase of 212 compared with 1931. The attack rate was equal to 3.0 per thousand of the population; more females being affected by the disease than males in the proportion of 294 to 249 cases. As regards the season Scarlet Fever prevailed all the year round, being more prevalent during the last four months of the year. The following figures show the number of notifications received during each month of the year : First Quarter:— January 29 Februarya 16 March 28 Second Quarter:— April 25 May 41 June 44 Third Quarter:— July 29 August 33 September 61 Fourth Quarter:— October 97 November 84 December 56 The ages at which the disease occurred will be seen from the following table : 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 and up TOTAL. 5 26 32 30 56 66 70 33 26 21 84 34 50 10 — — 543 26 Deaths. The two deaths which occurred were in a boy of eleven years and a girl of one year. The death rate per thousand of the population was 0.01 and the case mortality 0.37 per cent. Smallpox. Two cases of smallpox occurred in Fulham during 1932; these were the first cases since 1930 when seven cases were notified. The first case occurred in January in an unemployed wireless mechanic, aged 20 years, who had been working as a temporary porter at Smithfield Market! for 14 days, finishing this work eleven days prior to the appearance of the rash. The second case, which occurred in November, was also in a male, a cabinet-maker, aged 19 years. The source of infection was not traced in this case. Another case was also notified in the person of the fiancee of the first case, but after two days in Hospital the Medical Superintendent certified that she was not suffering from smallpox and the medical practitioner concerned withdrew his notification. During the year 119 contacts living in the borough were kept under observation. Vaccination. Mr. H. Davies, the Vaccination Officer, has supplied me with the following statistics relating to his work : Number of births registered during 1931 2,102 Successfully vaccinated 1,192 Insusceptible of vaccination 6 Unvaccinated on account of conscientious objections made by the parents 542 Died unvaccinated 112 Postponed by medical certificate and unvaccinated on 31st January, 1933 56 27 Removed to other districts and unvaccinated on 31st January, 1933 30 Removed to places unknown 150 Outstanding on 31st January, 1933 14 Number of successful primary vaccination certificates received during 1932 1,331 Number of Conscientious Objection Certi-' ficates received during the year 1932 478 The figures show that 5G.7 per cent. of the infants born in 1931 had been successfully vaccinated by the end of January, 1933. Measles. During the year 2,682 cases of Measles were notified in the borough and 26 deaths occurred from this disease : all except two of the deaths were of children under live years of age. The number of cases and deaths which occurred during each month of the year were as follows : First Quarter:— Cases. Deaths. January 68 February 428 2 March 754 7 Second Quarter:— April 935 10 May 343 3 June 82 2 Third Quarter:— Cases. Deaths. July 32 1 August 19 — September 2 1 Fourth Quarter:— October 3 — November 1 — December 15 — It will be seen from the above figures that the epidemic which commenced in January (there were only 18 cases during the last quarter of 1931) reached its height in April and rapidly declined until it subsided in August. There were 1373 cases in girls and 1309 in boys. Regarding the ages of the children affected the following summary shows that those under five years of age were the chief sufferers : 28 0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 55 65 to up Total 132 279 285 326 439 1121 67 8 22 1 2 — 2682 The case mortality, that is to say the percentage of cases which proved fatal, was 0.97, but the case mortality at the various ages under five years was:— Under 1 year 3.78 1 to 2 years 3.22 2 to 3 years 1.05 3 to 4 years 0.92 4 to 5 years0.91 Children were admitted to the special infectious diseases hospitals of the London County Council, 355 cases being admitted. No difficulty was experienced in obtaining admission to hospitals for these patients, although at the height of the epidemic it was necessary to send patients to the more remote hospitals. Under a special arrangement between the Borough Council and the Fulham District Nursing Association, 210 cases were attended by the District Nurses, who made 2,086 visits to the homes of these patients. As in former years it was impossible for the Council's staff to cope with the home visiting of the patients at the height of the epidemic and the Public Health Committee authorised the employment of two additional Health Visitors, one from 9th February to 24th May and the other from 8th April to 10th May. Convalescent Measles Serum was employed in the case of 17 contacts as a preventive measure with successful results. No attack occurred in 13 of the cases and the attack which occurred in the others was very mild. Enteric Fever. Eleven cases were notified during the year compared with three last year and one death occurred. 29 Cerebro-Spinal Fever. Ten cases were notified during the year but in two the diagnosis was not confirmed, one being a case of tubercular meningitis while the other patient was suffering from Measles. Of the eight definite cases of cerebro-spinal fever, four were in males and four in females. The ages of notified patients varied from ten weeks to 21 years. Four of the cases proved fatal and in addition to these deaths another was reported after a post-mortem examination as having been due to this disease. Puerperal Fever. Eleven cases, the same number as in 1931, were notified, and there were five deaths from puerperal sepsis. The incidence in 1932 was equivalent to 4.99 per thousand of the registered births (live and still-births). The incidence for England and Wales was equal to 3.3 per thousand. Puerperal Pyrexia. Puerperal Pyrexia is defined in the Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations of 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 twentyone days after child-birth or miscarriage in which a temperature of 100.4° Fahrenheit (38° Centigrade) or more has been sustained during a period of 24 hours or has recurred during that period." Thirty-seven cases were notified during 1932 as' compared with 47 during 1931. In addition one case was 30 notified as Puerperal Fever after admission to hospital The incidence per thousand births (live and stillbirths) was equivalent to 1G.8 while that for England and Wales was equal to 8.5. The services of Mr. Alexander Galletly are available for the purpose of consultation with private doctors in cases of Puerperal Fever and Puerperal Pyrexia. Ophthalmia Neonatorum. During the year 28 cases of Ophthalmia Neonatorum were notified compared with 17 during the previous year giving an attack rate of 13.1 per thousand of the registered live births. Through an arrangement between the Borough Council and the District Nursing Association, the services of the District Nurses are available for cases which are under medical treatment in their own homes. During 1932, 49 visits were paid to four such cases. Details regarding the results of the seventeen cases notified during 1932 are given below : Cases Notified. Treated. Vision. Total Blindness. Deaths. Left the Borough. Still receiving treatment. At Home. In Hospital. Impaired. Unimpaired. 28 12 16 2 15 — 2 8 1 General. The Leaflets "Advice on the Occurrence of Infectious Disease" have now been rewritten. They are given to occupiers of houses when a case of notifiable infectious disease occurs in the house. Special leaflets giving instructions regarding preventive measures are handed to householders on the occurrence of acute Polio-myelitis and Cerebro-spinal fever. 31 Table IV.—Cases of Infectious Diseases notified during the Year 1932. 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. Baron's Court Ward. Lillk' 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 2 – – – – – – – 1 1 – – – – – 1 – – – 1 – 2 – Cholera, Plague – – – – – – – – – – – – – – – – – – – – – – – Diphtheria (including Membranous Croup) 177 2 5 21 18 19 58 23 10 17 – 3 1 12 32 25 23 30 17 30 8 172 10 Erysipelas 106 4 2 2 – – – 4 6 18 16 36 16 8 20 9 17 21 10 15 6 81 10 Scarlet Fever 543 5 26 32 30 56 216 84 34 50 10 – – 31 153 85 58 83 34 69 30 519 2 Typhus Fever – – – – – – – – – – – – – – – – – – – – – – Enteric Fever 11 – – – 1 – 2 4 – 3 1 – – – 2 2 2 4 1 – – 10 1 Relapsing Fever, tinued Fever – – – – – – – – – – – – – – – – – – – – – – – Puerperal Fever 11 – – – – – – – – 9 2 – – 1 2 2 1 1 2 2 – 10 5 Puerperal Pyrexia 37 – – – – – – – 2 27 8 – – 6 5 6 2 11 1 6 – 34 – Cerebro-Spinal Meningitis 8 1 1 i 1 – 2 1 – 1 – – – – 2 1 1 1 2 – 1 8 5 Polio-myelitis 1 – – – – – 1 – – – – – – – – – – – – 1 – 1 1 Ophthalmia Neonatorum 28 28 – – – – – – – – – – – 2 4 3 6 4 – 6 3 16 — Tuberculosis of Respiratory System 232 1 – 2 – – 4 2 24 96 34 61 8 25 30 28 21 52 14 38 24 – 135 Non-Pulmonary Tuberculosis 82 2 3 3 5 3 19 11 8 19 3 5 1 9 7 14 14 19 4 13 2 – 23 Measles 2682 132 279 285 326 439 1121 67 8 22 1 2 – 213 474 324 313 620 112 426 200 355 26 Encephalitis Lethargica 3 – – – – – 1 1 1 – – – – 1 1 – 1 – – – – 3 2 Pneumonia 241 2 4 8 2 6 22 11 17 61 38 45 25 15 40 38 37 56 10 33 12 159 107 Diarrhoea 22 16 5 1 – – – – – – – – – 6 4 4 3 2 3 20 22 Malaria 2 – – – – – – – – – – 2 – – – 1 – – – – 1 – – Dysentery 2 – – – 1 – – – – 1 – – – 1 1 – – – – – 1 — Trench Fever – – – – – – – – – – – – – – – – – – – – – – – Total 4190 193 325 355 384 523 1448 208 111 325 113 154 51 324 779 543 500 905 207 642 290 1391 349 32 MATERNITY AND CHILD WELFARE. Report by the Medical Officer in charge of the Maternity and Child Welfare Department (Miss Ruby Thomson, M.B., Ch.B., D.P.H.) on the work ok the department. The year 1932 saw a further step in the unification and development of the Maternity and Child Welfare Department. On the resignation of Dr. Hardy at the end of December, 1931, it was decided that the time had come for the appointment of a full-time Medical Officer to replace the part-time workers. As Dr. Ross (Mrs. Colston) was unable to undertake full-time duties, she resigned her part-time appointment at the end of February. Accordingly, Dr. Anna Park was appointed as Assistant Medical Officer, and assumed duty on 1st March, 1932. She has shared the general work of the Department and has had entire medical charge of the Babies' Hospital. Although from the statistics following it will be seen that the figures referring to visits in the homes arc lower than in 1931, there has been an unusual number of special visits which have tended to take longer than the ordinary routine ones. The number of ante-natal visits has steadily increased; first visits paid to young pregnant women call for the exercise of much tact and patience and take a long time. The increasing number of ante-natal and other reports required by Hospitals and other institutions means a great increase in the work of the Maternity and Child Welfare Clerk. It is her duty to make a precis of the Health Visitor's report, to be forwarded to the institution concerned. This increase in the clinical side of her work makes great inroads into the time which was formerly available for the ordinary routine work; the constant additions to the clerical work of the Department during the last two or three years is a matter which should be noted. The development of relationships 33 between this Department and out-side Authorities and Institutions lias involved a corresponding growth in the clerical work and much of the success of new arrangements is dependent upon the loyal co-operation of the Clerks. I think it right to place on record my appreciation of this. The services of both the Health Visiting and Clerical staff's are frequently given during unofficial hours most cordially and voluntarily. In addition to their ordinary work, the Health Visitors visited (543 cases of Measles, and as a report of those visits has to be entered on two sets of cards, such visits together with the clerical work attached to them, take up a great deal of time. No locum tenens for Health Visitors was provided during the holiday period of 1932, so that approximately the services of one Health Visitor were lost to the Department for six months of the year I am glad to say that we have a very dependable stall of voluntary workers, viz :—Miss Christian Wickham, Mrs. Hell, Mrs. Tait, Mrs. Falcon, Miss Keenlysidc, Miss Sliorto, Miss Dolman and members of the Fulliam Free Church Women's Guild. We are grateful for their devoted services. Health Visitors. We have exceptionally highly trained and experienced women on our Health Visiting staff.. All the Health Visitors are fully trained nurses, and all have the certificate of the Central Midwives' Board in addition to possessing either the Health Visitors' or Sanitary Inspectors' Certificate. Added to these three essential qualifications, several Health Visitors hold qualifications in special branches of nursing, as follows:— One has had a complete Fever training, with special experience in Tuberculosis; one is a Queen's Nurse; a third has had special training in Venereal Disease and in Tropical Diseases; six have had a wide experience in 34 practical Midwifery; one has specialised knowledge of Massage and Actino-Therapy; another was for several years a District Nurse for general and Tuberculosis work. There are seven Health Visitors working in the Department and the scope of their work is indicated by the figures which follow:— First visits to infants under one month 2,182 Re-visits to infants under one month 758 First visits to infants between 1 and 2 months 58 Re-visits do. do. 10,340 First visits to infants between 1 and 2 years 22 Re-visits do. do. 4,646 First visits to infants over 3 years of age 49 Re-visits do. do. 7,177 Visits to cases of Ophthalmia Neonatorum 18 „ Measles 643 „ Diarrhoea 19 „ Pneumonia 21 „ Puerperal Fever 12 „ Puerperal Pyrexia 19 Ante-Natal visits 864 Other visits 94 Each Health Visitor has one-seventh of the Borough as her area, and the work is directed from the Town Hall. The whole Department is controlled by the provisions of the Maternity and Child Welfare Act, 1918, and a large proportion of the work of the Health Visitors is directly dependent on the Notification of Births Act, 1907, as through notifications made under the provisions of that Act information is received of births occurring within the Borough. The Health Visitor calls as soon as the period of attendance by the doctor or midwife has ended, i.e. eleven days after the birth of the child. This is done in all cases, whether the child has been born in an institution or at home. The Health Visitors give advice on the general management of the children: and where there is an infant, the importance of breast feeding is stressed. Anything which can affect the well-being of the home is the concern of the Health Visitor, and mothers are encouraged by them to place their children under regular medical supervision. 35 In spite of all teaching to the contrary, artificial feeding is steadily replacing breast feeding at an alarming rate. The Maternity and Child Welfare staff are constantly urging the desirability of breast feeding, and the Health Visitor sees to it that the mother receives suitable advice as to correct supplementary artificial feeding should the breast fail. Ophthalmia Neonatorum—inflammation of the eyes of the new-born—is a disease which does a great deal of harm to the eyes of new-born infants, who may contract it unless most careful precautions are taken at the time of the confinement. When a case of this kind is notified, the Health Visitor calls immediately. Cases of Puerperal Pyrexia and Fever are also notifiable by law, and here again the Health Visitor visits to offer any advice which may be needed by the family. When a midwife is in charge of a case, any eye discharge occurring in the infant must be notified by her to her local supervising authority, which in London is the London County Council. Such notifications arc forwarded to the Medical Officer of Health, and are handed over to the Health Visitors for home visitation. Measles is a notifiable disease in this Borough, and of late years it has taken an alarming toll of the infant population coining, as it does, as an epidemic every two years. In 1932 we had a severe epidemic. When a child under five years of age is notified as suffering from measles, a Health Visitor calls and advises the mother. During the epidemic of 1932 a special Measles Nurse was appointed to cope with the large numbers, but as has already been mentioned, a great deal of visiting of such cases devolved upon the Health Visitors. Notification of Births. In the year 1932, 2093 births of living children and 17 births of stillborn children were notified. Of these, 208 or 9.7 per cent. were notified by doctors, 1930 or 90.2 36 per cent. by midwives and 2 or 0.1 per cent. by fathers. The stillbirths during 1932 were equal to 2.2 of the notified births. These figures show an increase ol' births over 1931 but a decrease in stillbirths. Maternity and Child Welfare Centres. There are three Maternity and Child Welfare Centres in Fulliam distributed over the Borough, at 90-92, Greyhound Road, 170, Wandsworth Bridge Road and Mel moth Hall, Eustace Road. In addition to my own full-time service, Dr. Ross, Assistant Medical Officer in the Maternity and Child Welfare Department, took certain clinics each week, and assisted in the general administration until 1st March, 1932, when Dr. Anna Park joined the stall'. The total attendances at the Infant Welfare Centres have decreased by 1,237, and the first attendances of children under one year of age represents 52.2 per cent. of the notified live births, as compared with 57.8 per cent. in 1931 and 46.3 per cent. in 1930. This drop in the attendances at the clinics during 1932 may be due, to some extent, to the constant changes in the medical personnel which have occurred during the last two or three years. These changes have unsettled the mothers and been inimical to the work of the Centres. In Fulham we have found that special Toddlers' Clinics were not acceptable to the mothers and it is certainly more satisfactory to consider the mother and her whole family under five years of age together, at least so far as Maternity and Child Welfare work is concerned, so toddlers come to the ordinary clinics. The supervision of the nursing mother is a most important part of the work. Without strict attention to this point, much of the edifice built by the Maternity and Child Welfare Department must fall to the ground. 37 The economic and environmental conditions of the mother to a great extent influence the well-being of her family, and Medical Officers doing this work require always to keep in mind this social side of the work when dealing with the medical aspect. This cannot be too strongly emphasised. The mental care of the mother is as important as her physical when the progress of the family is under consideration. For nearly fourteen years we have had special cards for recording the clinical histories of nursing mothers attending the Infant Welfare Centres. The attendances of such mothers during 1932 were 12,144. The number of clinic sessions during 1932 was lower than in 1931 owing to the fact that the Toddlers' Clinics were dropped, and this accounts for some at least of the decreased attendances of children. The following Table shows the attendances of children at the ordinary Infant Clinics during the year under review:— Clinic, Number of Clinics held. First attendance of babies Total Attendances. Age 0—1 1—2 2—5 0—1 1—2 2—5 92, Greyhound Road 151 493 40 67 5661 1786 1260 170, Wandsworth Bridge Road 145 376 15 41 3887 1449 1114 Melmoth Hall, Eustace Road 97 221 18 20 2649 921 795 TOTALS 393 1090 73 128 12197 4156 3169 Ante-natal Clinics. Three Ante-Natal sessions arc held weekly at the Fulham Centres, and all expectant mothers known to the Health Visiting or Medical staff are urged to place themselves under medical supervision either at the clinics or elsewhere. Any expectant mother in the Borough is entitled to avail herself of the medical and social services of the Ante-Natal clinics, and it is being 38 nised increasingly that the proper supervision of an expectant mother is one of the most important factors in the prevention of Maternal Mortality. It is most important that the fears so often experienced by a pregnant woman should be removed and that her physical condition should be closely observed, in order that any abnormality that may exist or develop during the pregnancy may be suitably treated. When necessary treatment falls outside the scope of the Ante-Natal Clinics, such cases are referred to suitable hospitals or institutions where they can be properly cared for. Every patient attending our Ante-Natal Clinics is visited by a Health Visitor, and advice is given both at the home and at the clinics about the hygiene of pregnancy and the suitable clothing of the mother and necessary garments for the coming child. The clinic doctor satisfies herself that arrangements have been made for the suitable conduct of the confinement, and close cooperation is maintained between her and the doctor or midwife who is to conduct the confinement, and with whom she communicates bv letter when necessary. All cases booked for the Maternity Home are required to attend the Ante-Natal Clinics and one or other member of the Maternity Home staff attends at these sessions. The Health Visitors also visit pregnant women in the Borough who are booked to enter maternity wards in Hospitals. The Almoners send lists of such cases for visitation, and by this means the Department gets into touch with many pregnant women who would otherwise remain unknown. The two Ante-Natal sessions at Greyhound Road Centre are conducted by myself, and the clinic at Wandsworth Bridge Road was conducted by Dr. Ross until 1st March, 1932, when Dr. Park was appointed. The number of attendances at the Ante-Natal Clinics during 1932 has dropped slightly and also the actual number of patients attending. This is possibly due to the opening of a new Ante-Natal Department at 39 Princess Beatrice Hospital. As the Hospital is right on our borders, it naturally takes quite a number of the mothers who would normally attend our Clinics. The following is a record of the work done at the Ante-Natal clinics:— Clinic No. of Sessions. No. of Patients. No. of Attendances. 92, Greyhound Road. 97 447 1345 170, Wandsworth Bridge Road 50 194 798 TOTALS 147 641 2143 The numbers are lower than those for the previous year, but more Hospital beds have been made available within a reasonable distance of the Borough, and Hospital treatment is usually very much cheaper than the fees charged for the Council's Maternity Home. Minor Ailments. We are very careful not to undertake any treatment at the Infant Welfare Centres which should be undertaken by a doctor, midwife or District Nurse. Children requiring treatment that is outside the scope of the work of the Centres are referred to the proper quarter for the attention they may need. The attendances for treatment of minor ailments during 1932 have been as follows:— No. of children attending 214 Attendances made 373 Cases of eye defects in mothers and children are referred to the London County Council Oculist. Children who attend the clinic regularly may attend the London County Council local Treatment Centres, should they be found to be suffering from Impetigo Contagiosa, as no contagious or infectious disease is allowed to attend the clinics. 40 Massage Clinic. The arrangements made for the Massage Centre fell through during the early part of the year after the resignation of Miss Dolman in March on her appointment to a full-time post. In November we were delighted to welcome back Miss Christian Wickham, and since then she has been conducting two massage sessions weekly at Bishop Creighton House. Dental Clinic. At the Dental Clinic every effort is made to secure conservative treatment of the teeth but it is exceedingly difficult to get mothers to attend for this purpose, either for themselves or for their children. It is most disappointing to find that in spite of advice at the clinics much delay usually occurs before proper dental treatment is sought. Mothers receiving treatment 129 Children do. do. 87 Attendances made by mothers 331 do. by children 162 Dentures supplied 15 Patients treated for fillings 30 do. for extractions 140 Miscellaneous (scalings, etc.) 46 Sessions:— Gas 10 Ordinary 38 Home Nursing. Home nursing is provided by the Borough Council for persons requiring such attention and unable to pay for it privately. There are three groups of cases included in the Council's scheme:—Certain illnesses in children under five years of age; certain illnesses in expectant and nursing mothers and certain infectious diseases. A fee of 1/- per patient is paid for each attendance on a case, in the first two groups by the Maternity and Child Welfare Committee and in the third group by the Public Health Committee. 41 The co-operation we receive from Miss Watson, the Superintendent of the District Nurses, is always most cordial and helpful. From the table on page 49 it is very interesting to note the varied types of cases which the District Nurses visit for the Borough Council. Maternity Home. The Fulham Borough Council Maternity Home' is situated at 706, Fulham Road, S.W.6. It has ten beds for patients, with an isolation ward containing one bed. The Home is intended primarily to help mothers whose home circumstances are such that they are unable to have privacy in their own homes. It meets the need of women who are unable to arrange for proper supervision during their first confinement and it is equally an advantage that mothers w ho have large families should have rest dining this trying period. It is unfortunate that more of such mothers do not avail themselves of the opportunities offered for institutional treatment. Frequently the stumbling block is inability to make suitable arrangements for the care of the other children, but we often find that under persuasion these difficulties can be met. For some reason or other the services of Home Helps have not been used in Fulham to the extent that they might be. It seems to be still not quite understood that the Maternity Home is not intended to be used as a Hospital, and that there are no ante-natal beds. The staff from the Maternity Home attend at the Ante-Natal Clinics twice weekly and thus get practical experience in ante-natal work. In addition, the mothers get to know those who will be with them at their confinements. We prepare trained nurses for the certificate of the Central Midwives Board. 42 The following is a record of the work done during the year 1932:— Cases admitted 186 Average duration of stay (days) 14 Number of cases notified as puerperal sepsis — Number of cases notified as puerperal pyrexia — Number of cases notified as ophthalmia neonatorum — Number of cases of infectious disease — Number of infants not entirely breast-fed while in Institution — Number of maternal deaths — Number of foetal deaths:— Still-births 5 Within 14 days of birth 2 The minimum fee is £3 for the fortnight at the Maternity Home and this is the normal duration of treatment. The highest fee charged during 1932 was £6:11:0 for the two weeks and the average fee charged was £4:0:8. The net cost per patient week to the Council for the financial year 1932-33 was £1 :13 :7. Day Nursery. The Fulliam Day Nursery is situated at Eridge House, Fulham Park Road, S.W.G., and is under the control of a Voluntary Committee. The Council makes a grant of £626 per annum to the Day Nursery, in addition to providing the services of myself and Dr. Park as Medical Officers. The institution is visited by one or other of us at least four times weekly. . Children are admitted to the Nursery from six weeks old to live years of age, and the mothers pay a small fee. The Nursery is intended to receive the children of mothers who must go out to work daily, and it is a great advantage to such children to be under trained care instead of being left to the mercy of kindly but often ignorant neighbours. In every case Matron receives a home report of the circumstances of the child, and these reports made by the Health Visitors are of great value to Matron and myself. 43 Breast-feeding is not only encouraged but insisted upon where possible, if only partially. All the feeding of infants is done on the principle oi the use of breast standard milk, and the older children get a well balanced diet. An open-air life is strictly enforced. The following are the figures showing the attendances at the Day Nursery during 1932 : Individual children under 3 years 70 Individual. children over 3 years 20 WHOLE DAYS:— Attendances under 3 years 4189 do. over 3 years 2203 HALF DAYS:— Attendances under 3 years 889 do. over 3 years 215 7496 TOTALS:— Half-days 1104 Whole days 6392 Supply of Milk under the Provisions of the Maternity and Child Welfare Act, 1918. Considerable quantities of dried milk are supplied free to necessitous expectant and nursing mothers and children under three years of age. During 1932 grants of milk were made in 429 cases. During the year under review, the Council altered the scale of income under which parents were able to obtain milk free or at cost price. This alteration made a large number of persons hitherto eligible now ineligible. On the other hand, owing to increased unemployment larger numbers were forced to apply for assistance. By the Regulations of the Ministry of Health the Local Authority is required to ascertain that need actually exists and a special Visitor visits in the homes 44 of applicants and reports on the home circumstances, while the ordinary reports of the Health Visitors are also available for reference. A special Milk SubCommittee of the Maternity and Child Welfare Committee meets every week to consider these reports. The figure for the previous year was £553:7:11 although there were actually more individual applications for assistance during 1932. Milk is also sold at cost-price in cases recommended by the Medical Officers, Health Visitors or any local practitioner or Hospital Medical Officer. During 1932 under this part of the scheme 5,915 lbs. of dried milk were supplied at a cost to the families of £553 :3 :4 as compared with 6,703 lbs. at a cost of ,£634:14:0 during the previous year. It may be noted that the sale of milk has steadily dropped as follows : — 1928 7,896 lbs. 1929 7,432 lbs. 1930 7,294 lbs. 1931 6,703 lbs. 1932 5,915 lbs. I am more than ever convinced that the question of the supply of dried rather than wet milk is of the greatest importance as a factor in the reduction of infant mortality. It is a waste of public money to supply wet milk to houses where it is impossible to keep it in a reasonable condition of purity when there are so many dried milks on the market prepared by the most up-to- The approximate cost of the milk granted free or at less than cost-price during 1932 was:— £ s. d. Dried Milk 410 15 7 Wet Milk 76 18 3 Total 487 13 10 45 date methods. Our practice in Fulham is to keep in stock a full-cream and humanised milk dried by the spray method and a full-cream and humanised milk dried by the roller process. It is found that where one type does not suit a child, the probability is that the other kind will do so. Although the vitamin content of dried milk is somewhat altered, the lighter curd is more easily digested and the lack of vitamins can be made up by the addition of substances which can readily be obtained by the poorest parents. Every mother known to us who is obtaining dried milk either from the Town Hall or from a Chemist is properly instructed by the Health Visitor as to the addition of raw orange or tomato juice to the infant's diet. Experience has proved conclusively that children fed in this way can be reared successfully. As a result of recent research on Anaemia it has been found that certain forms of iron can be incorporated with dried milk. As the condition is so prevalent amongst mothers and babies, we obtained a stock of this modified milk in July and it has been used in the Department to the very great advantage of those who were able to obtain it. Maternal Mortality. The investigations call for by a special memorandum of the Ministry of Health in October, 1928, requiring careful enquiry into the causes of death in all cases in which women have died during pregnancy, at childbirth, or in the puerperium, are conducted by me, as they are intimately connected with the work of the Maternity and Child Welfare Deparment. The annual figure of Maternal Mortality is still high in spite of all that is being done towards prevention. Only constant observation and medical supervision of pregnant women will in time effect satisfactory results in this direction. Every effort is being made by the Fulham Maternity and Child Welfare Department towards this end. 46 The Babies' Hospital. The Babies' Hospital has accommodation for 21 children under five years of age and is under the control of a Voluntary Committee, who receive a grant of £1,417 per annum from the Fulham Borough Council and the services of a Medical Officer. The Hospital is ordinarily intended for cases of malnutrition and children requiring dietetic treatment. The majority of these are cases of marasmus or wasting, but an appreciable number of premature infants requiring special care and nursing are also included. In the case of the larger hospitals the calls on the accommodation are so great that there is often difficulty in keeping dietetic cases king enough in hospital to enable them to derive full benefit, whereas these patients can be treated in the Babies' Hospital as long as is necessary to complete the course of treatment. The number of cases of rickets has diminished very markedly of late years owing to the improved knowledge of feeding among the mothers which has resulted from education in health matters in the welfare centres, schools and elsewhere. A considerable number of children suffering from bronchitis and pneumonia are treated in the hospital from time to time, especially during the winter months. In addition children are admitted for convalescence after minor operations, such as removal of tonsils and adenoids and circumcision, which have been carried out in other hospitals. In all these cases advantage is taken of the facilities for open air treatment on the balcony and in the garden. (rood results have been obtained in the case of infants admitted for test feeding. Here the child is kept under observation as a patient in the hospital while the mother attends at intervals of three or four hours, as arranged, during the day. By means of this detailed observation of the feeds the mother can often be convinced of the possibility of continuing breast f eeding, with great benefit to the infant. 47 On two occasions during the year one of the children developed measles subsequent to admission. Permission was obtained from the parents of the other patients in the hospital to inject measles convalescent serum with the object of preventing them from contracting the disease, with the result that no further cases occurred. This serum is taken from convalescents from measles and its timely use prevented an outbreak which might have been serious in a ward of debilitated infants. Other types of cases which are admitted are shown on the table on the next page. The hospital sustained a serious loss by the death in July, 1932, of Mr. Horace Hutchinson, who was a great friend to the hospital for so many years. Mr. Hutchinson was one of the founders of the hospital and was its first honorary treasurer, retaining this position until 1922. It was entirely owing to his efforts and his power to interest his friends in the work that the present building in Broomhouse Road was acquired for the purpose of a hospital. Mr. Hutchinson's practical interest in the hospital did not cease in 1922 but continued up to the time of his death. He was associated in this work with his wife and the Committee also wish to emphasise their gratitude to Mrs. Hutchinson for her unsparing efforts in raising funds for the maintenance of the hospital and for her untiring work as honorary treasurer. The hospital has been of immense value to the community for many years. Through the co-operation of the medical practitioners in the borough cases of illness which cannot be admitted to the larger Children's hospitals and are unsuitable for treatment at home, are given the benefit of skilled nursing experience. In addition it forms a most important link in the Borough Council welfare scheme for infants and young children. The following table gives an account of the work done during the year:— 48 In Hospital January 1st, 1932 17 Number admitted during the year 142 Average duration of stay (days) 34 Number of cases discharged: (a) In good health 88 (b) Improved 25 (c) No improvement 19 132 Number of deaths 13 Number of babies in hospital, December 31st, 1932 14 The average daily number in the wards during the year was approximately 14.7, the same as in 1931. Reasons for admission of the 142 children were : Adenitis 6 Bronchitis 13 Broncho Pneumonia 5 Cerebral haemorrhage 1 Convulsions 2 Diarrhoea 4 Dieting 5 Dermatitis 2 Dyspepsia 2 Debility 1 Enteritis 2 For observation 1 Gastritis 1 Influenza 1 Lacerated wound of lip 1 Loss of weight 28 Marasmus 9 Malnutrition 4 Mal-development 1 Meningitis 1 Pleurisy 1 Pneumonia 2 Prematurity 1 Pyloric Stenosis 1 Persistent vomiting 3 Rickets 1 Septic finger 1 Vomiting 17 Wasting 17 Post operation, circumcision 5 Post operation, removal of tonsils and adenoids 3 49 Home Nursing by the District Nursing Association. Jan. to Mar. April to June. July to Sept. Oct. to Dec. TOTALS. Cases. Visits. Cases. Visits. Cases. Visits. Cases. Visits. Cases. Visits. Ophthalmia — — 1 18 3 31 — — 4 49 Mammary Abscess 2 55 — — — — 1 5 3 60 Ante-Natal 1 10 — — — — 1 5 2 15 Parturition — — — — 2 31 — — 2 31 Discharging Eyes 10 139 11 143 3 23 6 190 30 495 Pemphigus 5 85 4 75 2 24 — — 11 184 Mastitis 1 6 — — — — — — 1 6 Puerperal Fever — — — — 1 3 — — 1 3 Pneumonia 26 366 10 119 3 43 19 274 58 802 Broncho- Pneumonia 11 166 5 31 4 43 11 135 31 375 Influenza 27 263 3 23 — — 5 43 35 329 Malnutrition — — — — 1 7 — — 1 7 Pleurisy — — — — — — 1 12 1 12 Phlebitis — — — — 1 14 — — 1 14 Otorrhœa — — — — 1 6 — — 1 6 Septic Spots — — — — 1 11 — — 1 11 Diarrhoea — — — — — — 1 10 1 10 Scarlet Fever — — — — 1 4 2 4 3 8 Measles 126 1320 81 738 3 28 — — 210 2086 Chicken Pox — — — — 1 5 3 27 4 32 Totals 209 2410 115 1147 27 273 50 705 401 4535 50 TUBERCULOSIS. During the year under review the Tuberculosis Register has been corrected by the removal of all cases under the headings: Recovered, arrested, diagnosis not confirmed, lost sight of, left the district, or died, and the addition of all new cases notified, in accordance with the Public Health (Tuberculosis) Regulations. The details of these removals and additions are as follows:— Pulmonary: Non-Pulmonary: TOTALS: Males. Females. Males. Females. Number of cases on register at commencement of 1932 Number of cases removed during the year 528 528 288 277 1,621 130 90 29 28 277 398 438 259 249 1,344 Number of cases notified for the first time during 1932 141 95 46 44 326 Number of cases remaining on the Register at the end of 1932 539 533 305 293 1,670 The number of cases notified for the first time during 1932 shown in the above Table includes 314 cases analysed in Table VII. (Page 54) and 12 in Table VIII. (Page 55). The 12 cases are, of course, also included in the 277 cases removed from the Register during the year. In Table IV (Page 31) the notifications received during the year are classified according to the ages of the persons affected and the number of cases notified in each ward of the Borough are also given. 51 Mortality from Tuberculosis. Respiratory System:— 137 deaths 88 males, 49 females. Death rate 0.91 per 1,000, being 0.06 lower than in 1931. 133 notified (97.08 percent.) 4 not notified (2.92 per cent.). Of these four cases, one was notified after death; two died in institutions. Other Tuberculous Diseases:— 23 deaths 11 males, 12 females. Death rate 0.15 per 1,000, being the same rate as in 1931. 15 notified (65.22 percent.) 8 not notified (34.78 per cent. Of these eight cases, one was notified after death; seven died in institutions. Steps are taken in the case of posthumous and nonnotified cases to draw the attention of the practitioner concerned to the omission to notify. Period between Primary Notification and Death. Respiratory System :— Under 1 month 24 (17.91 per cent.) 1-3 months 18 (13.43 per cent.) 3-6 months 16 (11.94 per cent.) 6-12 months 14 (10.45 per cent.) 1-2 years 17 (12.69 per cent.) Over two years 44 (32.84 per cent.) Notified after death 1 ( 0.74 per cent.) Other Tuberculous Diseases- Under 1 month 10 (62.5 per cent.) 1-3 months 1 ( 6.25 per cent.) 3-6 months 6-12 months 1 ( 6.25 per cent.) 1-2 years 1 ( 6.25 per cent.) Over two years 2 (12.5 per cent.) Notified after death 1 ( 6.25 per cent.) 52 DISPENSARY STATISTICS, 1913—1932. TABLE V. Year. New Patients. Attendances at Dispensary. Doctors' Home Visits. Nurses' Home Visits. Suffering from PulmonaryTubercu losis. 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 1928 160 42 26 490 1548 2418 571 4989 1929 158 48 23 436 1411 1834 521 5272 1930 154 25 7 407 1558 1545 427 4532 1931 159 20 7 422 1444 1625 292 4156 1932 143 35 7 380 1329 1521 291 4125 53 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 1928 258 75 114 33 0.73 0.21 1929 279 85 149 24 0.96 0.15 1930 244 52 118 16 0.76 0.10 1931 275 78 146 23 0.97 0.15 1932 236 90 137 23 0.91 0.15 54 TABLE VII.—PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1930. Summary of notifications during the period from 3rd January, 1932 to 31st December, 1932. Age Periods. Formal Notifications. Total Notifications. Primary Notifications. Total (all ages). 0—1. 1—5. 5—10. 10—15. 15—20. 20—25. 25—35. 35—45. 45—55. 55—65. 65 & upwards Pulmonary : Males — 2 2 1 6 19 27 23 31 20 7 138 245 Females 1 — 2 1 18 22 28 11 5 5 1 94 179 Non-Pulmonary : Males 1 11 7 8 4 4 2 2 2 2 — 43 65 Females 1 3 12 3 4 8 5 1 — 1 1 39 56 55 TABLE VIII. NEW CASES OF TUBERCULOSIS COMING TO THE KNOWLEDGE OF THE MEDICAL OFFICER OF HEALTH DURING THE PERIOD, OTHERWISE THAN BY FORMAL NOTIFICATION, (i.e. by post-humous notifications and death Returns from Registrars ) 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 — — 1 3 Females — — — — — — 1 — — — — 1 Non-Pulmonary:— Males — — 2 — — 1 — — — — — 3 Females — — — — 1 — 2 — — — 2 5 56 Report on the work of the Tuberculosis Dispensary for the year 1932 by Dr. P. L. T. bennett, tuberculosis Officer and Medical Officer Borough Bacteriological Laboratory. The work of the Dispensary during the year 1932 has been carried out on similar lines to those of the preceding year. At the end of the year 1931, Dr. G. F. Hardy, the Assistant Tuberculosis Officer, relinquished his post under the Council. He had been acting in this capacity and also as part-time Assistant Medical Officer in the Maternity and Child Welfare Department for many years : his resignation meant the loss of a conscientious officer and pleasant colleague at the Dispensary, where he has been much missed by staff and patients. He carries the good wishes of the entire Dispensary staff in his retirement in Sussex. Holiday duties have been carried out during 1932 by Dr. Miller Vine (late Assistant Medical Officer, Frimley Sanatorium). Miss R. Bowen, Tuberculosis Health Visitor, who returned to duty at the Dispensary in November, 1931 after her serious accident in the previous year, was unfortunately absent on various occasions during the year 1932 owing to ill-health and at the close of the year was absent from duty owing to the same cause. Her duties were carried out most efficiently during these periods by Mrs. Tremeer, Temporary Health Visitor, who has acted previously in a similar capacity on many occasions. Miss M. Wright, part-time clerk, unfortunately had to cease duty on account of appendicitis early in November and was admitted for operation to St. George's Hospital. Whilst waiting for the operation she developed scarlet fever and was at once transferred to the 57 Western Fever Hospital : afterwards returning to St. George's for the operation, and was still absent at the end of the year. During this period, Miss K. Davey, B.A. was appointed part-time clerk. Renovations and Re-decorations. A complete scheme of renovations and re-decorations was carried out at the Dispensary during 1931 and 1932; the greater bulk of the work being done in the year under review. This work took about three weeks to complete during October : however, by making suitable arrangements with the builders, it was not found necessary to close the Dispensary at all, and thus (although the Dispensary Staff had to work under a certain amount of difficulty), there was practically no break in the routine. The Dispensary Time-table:— Monday 10 to 11.30 a.m. Women and young children. 1.45 to 3.0 p.m. School children. Tuesday 10 to 11.30 a.m. Men, old and new cases. 6 to 7.30 p.m. Men and women workers. Wednesday 10 to 11.30 a.m. Women, old and new- cases. Thursday 1.45 to 3.0 p.m. Children, contacts and new cases. Special appointments are also made for new cases, who cannot for some reason or other come up on their proper session times, to be seen at other hours, (chiefly on Friday or Saturday) by arrangement with their doctors. The Tuberculosis Officer sees these patients either at home in consultation or at the Dispensary. Ear, nose and throat cases, which involve special examination are usually seen on Friday or Saturday mornings, as the preparation required is occasionally lengthy and tends to delay other cases during an ordinary session. 58 As might be expected, the Dispensary sessions have been considerably longer this year owing to the fact that one medical officer instead of two has been in attendance. To avoid patients having to wait for a long time, it has been the practice of the Tuberculosis Officer in many cases to specify the hour of appointment for examination on session days. Statistics for 1932. During the year 1932, the number of new cases from ail sources was 505, of which 203 were directly referred by private practitioners and 110 by medical authorities and departments : the remainder having no regular doctor, coming upon their own initiative or on the advice of other patients and friends. The number of patients on the register at the end of the year 1932 totalled 858, a decrease of 45 on the previous year's figures, and accounted for by deaths, transfers and discharges as "recovered" in accordance with the Ministry of Health regulations. In connection with cases discharged it may be noted that in accordance with the Regulations, a classification as "recovered" (formerly "cured") can only be adopted in pulmonary cases if the patient has been in an arrested state for a period of three consecutive years : whilst the term "arrested" is only applicable to those patients who have shewn no indication ol' active disease,—that is "quiescent" for a period of two years. Thus actually if a patient is once notified as suffering from Pulmonary Tuberculosis (unless denotified by or with the consent of the notifying practitioner) he cannot be discharged as "recovered" within a period of five years. These regulations are effective and constant under all authorities, both urban and rural and together with modern Dispensary procedure constitute a uniform and therefore interchangeable Tuberculosis system throughout the country. 59 The number of attendances at the Dispensary during the year was 3583, the number of individuals being 1240 and out of the attendances 3041 were for examination, the remainder being for supervision, advice or "after care" purposes. Notifications for 1932 totalled 190 as against 180 for the previous year, and the number of deaths registered 98. Although some figures are slightly raised in comparison with the previous year,others are less, noticeably the contact attendances which dropped about 27%, partly due to the fact that the actual number of family contacts were considerably less, and partly to indifferance or fear in others of coming up for examination. The Dispensary Staff have, as hitherto, been unrelaxing in their efforts to get contacts to attend but being an entirely voluntary act, it is occasionally very difficult to impress on young and apparently healthy people the advisability of submitting themselves for examination. Dispensary Procedure. Cases attending the Dispensary fall into four groups : (a) Observation cases. Those sent up for diagnosis by medical practitioners or, having no regular medical attendant, coming up on their own initiative. Certain cases of this group are now frequently referred to the Tuberculosis Officer by the District Medical Officers of the Public Assistance Committee. (b) Dispensary Supervision cases. Notified patients who have had various forms of treatment, and whose condition requires periodical examination and supervision at the Dispensary or home by the Tuberculosis Officer. (c) General Supervision cases. Old notified patients in whom the disease is quiescent or arrested, and who only require examination or supervision at fairly lengthy intervals. Working patients, both men and women, come under the last two groups and for these the evening clinics are specially devoted. 60 (d) Domiciliary Treatment cases. These are patients insured under the National Health Insurance Acts, under the care of a Panel Doctor; the latter sending reports every three months to the Tuberculosis Officer on a special form for that purpose. The Panel Doctors act in accordance with regulations of their contract and they can always refer a panel patient to the Tuberculosis Officer at any time for advice or opinion. The Tuberculosis Officer frequently refers patients under this scheme to the Panel Doctor after return from sanatorium, especially when general medical treatment is required : no "routine" treatment by drugs being carried out at the Dispensary, except in very special cases or in an emergency. It may be pointed out at this juncture that very few drugs have any specific action of permanent value in dealing with tuberculosis, medicinal treatment being practically only of palliative nature : a possible exception can perhaps be made in the case of the drug known as "Sanocrysin"—a preparation of Gold—which in many consumptives seems to exert a beneficial action. A patient treated by this method may however shew a very decided idiosyncrasy—'almost amounting in some to poisoning and sanocrysin treatment is therefore carried out preferably at a hospital, where adequate measures can be adopted at once should such a result occur. Sanatorium treatment, if considered advisable, is recommended by the Tuberculosis Officer to the London County Council which is the authority responsible for giving institutional treatment of all kinds-both for medical and surgical cases, the latter usually requiring very lengthy periods away. Special Forms of Treatment. Patients are frequently referred to Brompton Hospital for special treatments, such as Sanocrysin, Artificial Pneumothorax, Oleothorax and other operative measures for putting an affected lung at rest, which is an important factor in assisting nature to promote healing. 61 Close touch is kept with the physicians and X-ray department of Brompton Hospital and all reports from them are noted on the case sheets at the Dispensary. Under arrangements between the Fulliam Borough Council and Brompton Hospital, all cases for X-ray screening and photography are referred to the latter institution : a detailed report by the well-known radiologists, Dr. Stanley Melville and Dr. Rawlinson, being returned to the Tuberculosis Officer together with the X-ray film. This is examined and noted on the casesheets and the film numbered and filed for further use : a series of films at intervals can therefore readily be understood to be of the greatest value in determining progress of the disease when perhaps the patients own condition and physical signs appear to be at variance. In all cases a further report of the X-ray findings is sent to the private practitioner who originally attended the patient. Tuberculosis in Children, Large numbers of children, contacts and otherwise, are referred to the Dispensary. Fortunately, the amount of tuberculosis in an active and virulant state is small, though probably the large majority have had small infections and have become "Tubercularized" during their early years. A severe infection in the infant would probably give rise to fatal disease but a mild "Tubercularization" gives rise to but few symptoms, if any and this is, no doubt, the reason why only comparatively few children shew signs of active disease. Moreover, repeated small doses of infection are probably responsible for the formation of an individual resistance which is strongly protective in later years. Many "slightly infected" children are kept under observation and supervision, and make good progress without specialized treatment. For those who require more active measures, institutional treatment in Sanatoria, Surgical Homes or Convalescent Homes can 62 be provided through the London County Council or the Public Assistance Committee. This will in most of the cases be sufficient to arrest the disease and many of these children arc afterwards sent in to Special schools according to their specific disability. From Fullam and the surrounding Boroughs, notified tuberculous children are referred to the Elizabethan Open-Air School, which is situated in Broomhouse Lane. These little patients are very largely mild gland cases with little or 110 active disease : there are also a few pulmonary cases of doubtful type where "fibrosis" or "scarring" of the lung is all that can be discovered after a period of sanatorium. This school has accommodation for sixty scholars and amongst them are many whose condition has never been sufficiently serious to necessitate their being sent away, or whose parents have been unwilling for them to leave home. These school children are under constant supervision by one of the Tuberculosis Nurses, and the Tuberculosis Officer of the Borough makes a weekly inspection at which a number of the children are examined in rotation, all children being seen at least once every four or five weeks. Classes are held under open-air conditions and when fine, accommodation is provided in two specially constructed canvas shelters built on the playground; whilst in severe weather the children have their classes in the lofty school-hall in the main building. The daily routine is divided into hours of work, rest and exercise under close supervision of the Head-mistress, Miss Clarke, who also controls the diet. The mid-day dinners are excellent, varied and wellcooked and both meals and kitchen are periodically inspected by the Tuberculosis Officer. Each child has also an allowance of milk during the morning and special extra medicaments such as Extract of Malt, Cod-Liver Oil and Malt and Emulsion, Virol etc., are ordered according to individual requirements. 63 Under this regime the children shew decided and in some cases very marked signs of improvement. Treatment by Ultra Violet Rays or artificial Sunlight is not provided under the Borough scheme but certain cases are occasionally sent by the Tuberculosis Officer to Tite Street Hospital, where such treatment is carried out under the supervision of the physician. Home Visits. The number of home visits paid by the Dispensary Staff during 1932 amounted to 4416, of which 291 were made by the Tuberculosis Officer, both for consultative purposes and for home inspection of newly notified cases. Numerous investigations are made and reports submitted by the Tuberculosis Nurses in connection with home conditions and when necessary defects of sanitation etc., are reported to the Medical Officer of Health. The attendance of contacts is invariably urged by the Dispensary Staff at all home visits. co-operation of medical practitioners. It is again a pleasure to report that co-ordination between local doctors and the Dispensary continues to be well maintained and on a very friendly footing. As before the Tuberculosis Officer has always insisted that the interests of private practitioners are properly safegarded. No new cases (having already a doctor in attendance) are seen without a card or letter and all reports on cases referred to the Dispensary are sent by post. It can readily be understood that such good-will and confidence is a factor of the greatest importance in the successful working of the Public Tuberculosis service : all suspected or doubtful early cases are welcomed at the Dispensary, where they can be put under special observation and have X-ray and special tests applied in diagnosis. 64 The numbers sent up during the year under review indicate that the Dispensary continues to hold its position as a consultation centre for Tuberculosis. Bacteriological Examinations. In addition to a large amount of other specialized investigation both bacteriological and pathological, Miss Robinson has carried out in the Borough Laboratory 1141 tests for Tubercle Bacilli. It should be pointed out that the London County Council carry out their own tests lor patients in Eulham Hospital under the present regime, and this has accounted for a slight drop in the laboratory figures during 1932 in this one particular. As, however, it has been decided to test the Dispensary cases rather more frequently in the future, it is probable that the succeeding years' total will be very much increased and the extra testing may be valuable in bringing to light suspected cases of tuberculosis, as well as shewing important variations in the samples from existing notified cases. Institutional Treatment. The London County Council is the authority responsible for the provision of sanatorium and other institutional treatment for notified cases—such patients being recommended to them by the Tuberculosis Officer. Periods of intensive observation are also given in cases of difficult and doubtful diagnosis chiefly at Brompton Hospital in the case of adults, and at High Wood Hospital for children. In the great majority of cases recommendations for observation and treatment are accepted; though it occasionally happens that a heavy waiting list at Headquarters may defer or cause non-acceptance of a recommendation for some special institution. 65 In recommending sanatorium treatment due consideration has to be given to the age, type of disease and mentality of the patient and also whether such treatment away can afford a reasonable prospect of benefit—as in the early and "recoverable" type especially. The problem of dealing satisfactorily with advanced consumption still remains one of great difficulty. Such cases are unsuitable for treatment in sanatoria as the prospects of return to working life are usually remote and in the great majority it is found that anything more than even a temporary degree of recovery is doubtful. London County Council Hospitals and Homes for Advanced cases deal with a certain number of such patients but as nearly all of them wish to return home sooner or later, periods in such institutions are usually only of short duration. When the advanced consumptive returns home the difficulty in obtaining proper segregation and hygiene and adequate nursing attention are disadvantages which have to be faced. Dental Scheme. In 1932 ten persons were recommended for dental treatment under the Borough scheme, eight of whom were to have partial or full dentures. The other two cases were one of repairs to dentures and one of extractions and scaling. Contributions were only asked for in four cases and of these one patient disappeared from the Borough before she received treatment. The Tuberculosis Care Committee. The meetlings of this Committee are held every fourteen days at the Dispensary. Their activities cover a very wide field and are generally speaking concerned with the social welfare of patients and their dependents as well as duties regarding assessments of contributions for treatment. 66 Special mention and thanks should be given to the Charity Organisation Society, who visit and interview all adult cases recommended for institutional treatment under the London County Council. The Tuberculosis Officer wishes to express his deep appreciation and thanks to the Chairman, Secretary and other members of the Care Committee for their most valuable help during the past year. As an illustration of the work carried out by the Care Committee, Miss Sargent has kindly compiled the following cases :— Specimen Cases:— A. first attended the Dispensary in November, 1931, and was at once recommended for institutional treatment and admitted to Brompton before the end of the month. He had been working on his own and his illness left him without resources of any kind but he thought his people would be able to supply him with pocket-money while he was away. However, it was not long before he wrote to the Secretary and asked if any help could be obtained for him as his brother and sister were not in a position to make him any allowance for any length of time. An appeal was made to the National Association for the Prevention of Tuberculosis and met with a generous response. Arrears of rent were paid off and a weekly allowance paid to the patient through the Care Committee. A. was away until December, 1932, and during the whole of the time the Secretary wrote to him every fortnight enclosing a postal order and asking for an acknowledgement. These were very formal at first but gradually lengthened into letters and when at last a vacancy in Papworth was offered to A. the secretary felt she knew him sufficiently well to urge him to accept. The offer, however, was turned down. A. left sanatorium just before Christmas but did not return to Fulham until February. He came, full of gratitude for all the help that had been given him, and then said good-bye as " he had been married two days previously and had moved into another area ! " 67 B. was referred to the Dispensary by her private doctor but no evidence of tuberculosis was found after a period of observation. She was, however, very run down and in need of a thorough change and we referred her to the Charity Organisation Society for convalescence, and at the same time, to the Invalid Kitchen for Dinners. She had the latter until she went away to Bournemouth where the C.O.S. kindly sent her for six weeks, free of charge, and when seen at the Dispensary on her return, she was found to be improved in every way. C. was sent to the Dispensary by his panel doctor: he was still working but had to be advised to rest instead and was very worried indeed as to how his wife and four small children could manage as the only income would be the N.H.I, benefit. Extra nourishment was at once given from the Town Hall and as C. had served for two years in France during the War (though only as a C.2. man) he was referred to the United Services Fund, who gave substantial help while he was still at home; fitted him out with clothing for sanatorium and continued to help the family after he went away. He was still in sanatorium at the end of the year, but, unfortunately, not doing very well. Handicraft Class. The Central Fund for the Industral Welfare of Tuberculous Persons offered to start a Glove-making class at the Dispensary, making themselves responsible for the teacher, the materials and the payments to the class for any gloves made, if a suitable room with heating and lighting could be provided as well as proper tables, a cupboard, scissors, etc. for the use of the class and if arrangements could be made for disinfection of the finished articles. The Borough Council agreed to allow the use of the Dispensary Waiting room on two afternoons a week, with heating and lighting, and the tables, etc., were provided through the kindness of a personal friend of the Secretary. The Class started with a membership of eight on March 2nd, 1932 and during the year twenty women 68 have attended but at no time were there more than thirteen on the roll. Of these twenty, two have returned to full-time employment: two have died: four have lapsed and twelve were on the roll on February 28th, 1933. During the twelve months, forty-seven lessons have been given and total attendances number 361, an average of 7.68 per lesson. In all 152 pairs of gloves have been made and of these 129 pairs have been sold privately and five pairs of dusting gloves have been sent to the Central Fund, leaving only a small stock on hand. £45:0:11 has been paid over to the Central Fund and there is 15/6 outstanding. The class meets every Tuesday afternoon and visitors are welcomed. All kind's of leather gloves (chamois, suede, nappa, hogskin, etc.) are made and orders are most gratefully received. Through the kindness and sympathy of the teacher, Miss Butterworth, the class is a popular one and the patients appear to enjoy their work, whilst the high standard of the gloves made testifies to the excellency of the teaching. Each pair of gloves is sent to the Council's Disinfecting Station for sterilisation and is not handled by the class again, the final pressing being done by Miss Butterworth. Convalescence through the Invalid Children's Aid Association. This Association continues to give very valuable help in dealing with many children who are not found (after observation at the Dispensary) to be suffering from clinically recognisable disease but are debilitated and in special need of a holiday away either in the country or at the seaside. 69 Some of these children are convalescent after whooping-cough, pneumonia and bronchitis, and their home conditions may be unsatisfactory from various causes both financial and environmental. Children, who are close contacts in addition, are undoubtedly far more liable to severe infection at a time when their bodily resistance is at a low level. The work done and help in obtaining convalescent holidays by this fine Association is thus extremely important and their intimate knowledge of the district and economic conditions prevailing as well as personal acquaintance with the families and homes is of the greatest help in dealing with the preventive side of Tuberculosis. Conclusion. For the first time since the Tuberculosis Scheme has been in operation under the Fulliam Borough Council, Dispensary work has been carried out by one Tuberculosis Officer alone, following the resignation of Dr. G. F. Hardy at the end of 1931. This has entailed a certain amount of modification in the detailed routine, and a complete revision of the attendances in all cases. It has been possible to ensure an even more complete "personal"supervision, which with two medical officers was naturally more difficult : although it has obviously meant longer and more arduous clinic hours both for the Tuberculosis Officer and the Tuberculosis Nurses. I would therefore like to put on record my very sincere thanks to both the Clerical and Nursing Staffs at the Dispensary, and to Miss Robinson, the Borough Bacteriological Assistant, for the great help they have invariably rendered in their respective departments. It may be said that, owing largely to their cooperation it was possible to carry on without any appreciable break in the routine and attendances during the period when the renovations were carried out during the autumn. 70 Summary of Statistics, 1932. No. of New Patients:— Insured 264 Uninsured 301 Total 565 No. of Attendances :— Insured 1329 Uninsured 1521 Attendances of Contacts 359 Other attendances 374 Total 3583 No. of patients who have attended, both old and new 1240 No. of Notifications :— Pulmonary 147 Non-pulmonary 43 Total 190 No. of Sputa examined 1141 No. of Physical examinations 3041 No. of Contacts examined 286 No. of Home Visits paid by Doctor 291 Bedside consultations included in above 106 Consultations otherwise 687 No. of Home Visits paid by Nurses 4125 No. of Reports sent to Public Bodies 551 No. of Reports sent to Doctors 758 No. of Letters written 5441 No. of Patients referred to Brompton Hospital 11 For X—ray 130 No. of Notified Patients on Dispensary Books on 31.12.1932 858 No. of Patients sent away into institutions or to the country in 1932 177 71 Table IX. 177 Patients were sent to residential institutions on the recommendation of the Dispensary Medical Officers. (a) 129 by the London County Council:— 50 to Sanatoria. 3 to Colonies. 2 to Convalescent Homes. 74 to Hospitals. Men 14 3 — 46 Women 13 — — 24 Children 23 — 2 4 (b) 29 by the Public Assistance Committee:— 16 to Hospitals. 13 to Sanatoria or Convalescent Homes. Men 8 1 Women 6 — Children 2 12 6 children were sent to Convalescent Homes by the Invalid Children's Aid Association. 1 child was boarded out under the L.C.C.'s Contact Scheme. 7 women received convalescent treatment through the Charity Organisation Society and 5 men through the United Services Fund. Table X. Showing sources of New Cases. 263 were recommended by private doctors. 24 „ „ „ the Medical Officer of Health. 6 „ „ „ the School Medical Authority. 4 „ „ „ the School Authority. 39 „ „ „ Hospitals and Sanatoria. 17 „ „ „ other Dispensaries. 16 „ „ „ the London County Council. 81 „ „ „ the Dispensary Staff. 62 „ „ „ friends. 2 „ „ „ other patients. 47 „ „ „ the Door plate. 4 „ „ „ the Invalid Children's Aid; Association. 565 72 Table XI. New Cases. Pulmonary Tuberculosis. Other Forms. Suspects. NonTuber cular. Percentage Tuberculous. 281 Males 85 18 3 175 36.65 284 Females 58 17 4 205 26.40 565 both sexes 143 35 7 380 31.50 Table XII. Sex and Age of the New Patients for 1932. Under 5 yrs. 5 to 10 yrs. 10 to 15 yrs. 15 to 25 yrs. 25 to 35 yrs. 35 to 45 yrs. 45yrs. and over. All ages. Males 19 40 33 55 44 34 56 281 Females 18 41 27 61 64 35 38 284 Both Sexes 37 81 60 116 108 69 94 565 Table XIII. Diagnosis at Various Age Periods. New Patients. Pulmonary Tuberculosis. Other Forms. Suspects. NonTuber cular. Percentage Tuberculous. Under 5 years - 7 - 30 18.91 Under 10 years 1 8 2 70 11.11 Under 15 years 2 8 - 50 16.66 Under 25 years 40 10 1 65 43.10 Under 85 years 32 - 1 75 29.62 Under 45 years 25 2 2 40 39.13 45 and over 43 — 1 50 45.74 All ages 143 35 7 380 31.50 73 Table XIV. Housing Conditions. Of 166 of the 178 tuberculous patients found in 1932:— 7 lived in the basement. 46 lived on the ground floor. 53 lived on the first floor. 3 lived on the second floor. 2 lived on the third floor. 10 lived on the top floor. 13 lived on more than one floor. 32 lived in the whole house. 166 Table XV. Housing Accommodation. Number of Families occupying One room. Two rooms. Three rooms. Four rooms. Five rooms. Six rooms or more. Patient living alone 12 2 - - - - Patient living with 1 other 6 4 5 1 - 1 2 others 1 5 12 10 2 2 3 „ — 6 13 10 4 3 4 „ — 5 8 5 2 4 5 „ — 2 3 5 4 4 6 „ — 1 2 2 3 — 7 „ — - 4 4 - 1 8 „ 1 1 - 2 2 1 9 „ - - - 1 - - 20 26 47 40 17 16 74 Table XVI. Sleeping Accommodation of 166 Tuberculous Patients The patient slept:— In a separate room in 61 cases. Alone in bed with one other in room in 16 cases. „ 2 others 12 cases „ „ 3 others „ 3 cases „ „ 4 others „ 1 case. „ „ 5 others „ 1 case. In bed with 1 person and no others in room in 48 cases. „ „ „ 1 other „ 12 cases. „ „ „ 2 others „ 9 cases. „ „ 6 others „ 1 case. In bed with 2 persons and no others in room in 1 case. „ „ „ 1 other „ 1 case. 166 cases. Table XVII. Occupations of 87 Men (New Cases) in 1932. l Able seaman. 1 Lavatory attendant. 3 Barmen. 1 Machine operator. 1 Boot repairer. 1 Machine ruler. 2 Brass finishers. 1 Messenger. 1 Carman. 1 Milk roundsman. 3 Carpenters. 1 Musician. 1 Cab washer. 2 Packers. 1 Cashier. 1 Painter. 1 Chauffeur. 1 Petrol Service Station hand. 1 Chocolate refiner. 4 Porters. 9 Clerks. 1 Postman. 1 Civil servant. 1 Printer's labourer. 1 Clock winder. 1 Pharmacist. 1 Coach builder. 1 Repairing whitesmith. 1 Club master. 4 Shop assistants. 3 Decorators. 1 Shop keeper. 1 Electrician's mate. 1 Sorter P.O. 2 Engineers. 1 Stonemason. 1 Estate agent. 1 Stoker. 1 Fireman. 2 Stove fitters. 1 Furniture remover. 1 Tailor. 1 Gate keeper. 1 Tennis coach. 1 Grocer. 1 Traveller. 1 Handy-man. 1 Upholsterer. 1 Joiner. 1 Van driver. 10 Labourers. 2 No occupation. 75 Occupations of 65 Women (New Cases) in 1932 1 Book repairer. 2 Laundry hands. 1 Capper. 1 Machinist. 1 Carpet repairer. 1 Packer. 3 Cashiers. 1 Secretary. 1 Civil servant. 2 Shop assistants. 3 Clerks. 1 Sorter P.O. 2 Charwomen. 1 Student. 3 Dressmakers. 1 Tailoress. 5 Domestics. 1 Valve tester. 1 Factory hand. 2 Waitresses. 1 Glassblower. 6 No occupation. 24 Housewives. Under 15 years of Age. 16 Boys. 10 Girls. 76 GENERAL SANITARY ADMINISTRATION. Bacteriological Examinations. Of the 2,634 specimens sent by doctors during the year, 2,156 were examined at the Council's Laboratory, 114, New King's Road. The remaining 478 specimens were examined by the Clinical Research Association during week-ends, holidays and emergencies. Bacteriological examinations were made during the year as follows:— Material from cases of suspected Diphtheria:— Diphtheria isolated 71 Negative result 1147 Blood from cases of suspected Enteric Fever:— Agglutination reaction for Typhoid or Paratyphoid obtained 3 Negative result 9 Pathological specimens for Enteric Organisms:— Positive result 1 Negative result 7 Sputa from cases of suspected Tuberculosis:— Tubercle bacilli found 219 Tubercle bacilli not found 943 Cases of suspected Gonorrhoea:— Gonococcus found 7 Gonococcus not found 74 Examinations of Urine 85 Blood counts 3 Other examinations 40 Special examinations of urine 25 Total number of examinations 2,634 77 Disinfection. The following rooms were disinfected and cleansed alter infectious disease etc.:— Scarlet Fever 563 Diphtheria 158 Phthisis 203 Erysipelas 72 Smallpox 34 Scabies 38 Cerebro-Spinal Meningitis 9 Whooping cough 2 Cancer 36 Chickenpox 11 Pneumonia 8 Measles 117 Puerperal Fever 6 Puerperal Pyrexia 3 Venereal Disease 3 Encephalitis Lethargica 1 Enteric Fever 9 Tonsilitis 1 Polio-Encephalitis 1 Rooms fumigated for vermin 122 Rooms sprayed 33 Rooms fumigated by request 42 Total 1,472 78 The following articles were disinfected at the Council's Disinfecting Station:— Articles. From private houses. From institutions. Total. Beds 566 - 566 Mattresses 1126 174 1300 Palliasses 7 - 7 Pillows 2212 211 2423 Cushions 288 — 288 Bolsters 643 — 643 Blankets 2895 807 3702 Sheets 1537 184 1721 Covers 265 161 426 Counterpanes 639 19 658 Curtains 23 — 28 Carpets 141 — 141 Hearth rugs 426 — 426 Articles of clothing 3961 1319 5280 Eiderdowns 283 — 233 Sundries 1024 114 1138 16041 2989 19030 Public Mortuary.—One hundred and sixty-three bodies were removed to the Mortuary during 1932, and were admitted as follows:— By order of the Coroner 132 Brought by Police 8 For convenience till funeral 22 By order of Medical Officer of Health 1 163 Ninety-two post-mortem examinations were made and inquests were held in 111 cases. 79 Sanitary Inspection of the District. The ultimate object of sanitary inspection is to promote the health of the inhabitants of the district and to lower the death-rate. The duties of a sanitary inspector are of a very varied character but are mainly in connection with housing, drainage, inspection of food, food premises, workshops, and work-places, and other places where work is done for profit. The inspection of factories is principally the duty of inspectors appointed by the Home Office, but local authorities have also certain functions in factories which are carried out in co-operation with the Factory inspector. During 1932 in order to make the system of inspection more uniform for the borough as a whole a new system of records was inaugurated for the inspections of factories, workshops, workplaces, outworkers' premises, food shops, restaurants and dining rooms, bakehouses, milk shops and dairies and street traders' premises. The following inspections of dwelling-houses were made during the year by the Sanitary Inspectors:— Cause. Inspections. In consequence of complaint 11,014 In consequence of infectious disease 2,502 House-to-house inspection 2,791 Verminous or aged persons 99 Other inspections of dwelling-houses 1,691 The following notices were served in respect of dwelling-houses during the year:— Intimation Notices. Statutory Notices. Number served. Number complied with up to 31st December, 1932. Number served. Number complied with up to 31st December, 1932. 2,736 1,873 617 416 80 The following works were carried out and repairs effected as a result of the action of the Sanitary Inspectors:— Drainage. Drains tested 2,217 Drains cleared 192 Drains repaired 408 Drains relaid 290 Soil and ventilation pipes repaired 71 Soil and ventilation pipes renewed 293 Rain water gutters and pipes repaired or renewed 321 Disused drains excavated 2 W.C.s. Traps cleansed, repaired, etc. 107 W.C. pans renewed 729 W.C. seats repaired or renewed 94 Flushing cisterns repaired 193 Flushing cisterns renewed 62 Additional W.C. accommodation provided 12 Lobbies provided to W.C. apartments 9 Doors to W.C.s repaired and fastenings provided 57 W.C. apartments ventilated 7 Sinks, Sinks provided 70 Baths and Sinks renewed 117 Lavatory Sinks repaired 8 Basins. Sink waste pipes trapped 27 New sink waste pipes provided 265 Sink and bath wastes repaired 95 New bath wastes fitted 84 New baths fitted 78 Lavatory basins fixed 45 Water Drinking water cisterns cleansed and Supply. covered 95 Water supplied from mains 9 Occupied houses provided with a sufficient water supply 5 Water supply pipes and fittings repaired 18 Water supply provided to separate floors 2 81 Cleansing Rooms cleansed 4,063 and Verminous rooms cleansed 302 Internal Decorations and internal house repairs 5,989 work. Fireplaces repaired (nuisance from smoke 84 Kitchen ranges repaired 231 Washing coppers repaired 122 Ventilation provided under floors 107 Dampness remedied 1126 Rooms provided with adequate light and ventilation 55 Ventilated food cupboards provided 3 External Roofs repaired 753 repairs Other external repairs 528 and Accumulations of refuse removed 96 other Dustbins provided 442 nuisances. Yards and forecourts paved and drained 404 Abatement of animals kept in a state of nuisance 33 Urinals of public houses cleansed 2 Urinals of public houses repaired 2 Nuisance from smells abated 6 Other nuisances abated 21 Drainage of Buildings. The following drainage plans were submitted to and approved by the Public Health Committee during 1932:— Plans of drainage of new buildings:— Bungalow 1 Electric sub-stations 4 Garages 2 Shops 2 Lock-up shops 2 Laundry 1 Church Hall 1 Church Army Hostel 1 14 Additions to existing buildings:- Conversion into flats 8 Lavatory accommodation 29 Garages 4 Flats 2 Store 1 Showroom 1 45 Conversion to flats of existing buildings 39 Reconstruction of drains of existing buildings 142 82 The supervision of the work, with the exception of reconstruction, is in the hands of Inspector A. J. Parsons the Council's drainage inspector. In connection therewith he paid 1,411 visits, during the year. Combined Drainage. During the year under review the Council authorised the carrying out of work in connection with Combined Drainage in ten cases. Work of the Female Inspector. The greater part of the work under the Factory and Workshops Act was undertaken by the woman Sanitary Inspector, Miss Raynor. During the year she carried out the following work:— Visits. Notices served. To Factories 159 10 Workshops 137 11 Workplaces 395 39 Outworkers' Premises 382 26 Restaurants, Dining rooms and Eating houses 374 45 Eel and Pie shops ... 13 - Cooked Meat shops 93 - Other food premises 1 - Public conveniences 9 - After Complaint 53 4 Infectious disease enquiries 189 4 Infirm and dirty tenants 46 2 Verminous schoolchildren Other inspections of dwelling- 4 - houses 19 - 83 FACTORIES, WORKSHOPS AND WORKPLACES. (Factory and Workshop Act, 1901.) I. Inspection of Factories, Workshops and Workplaces. Premises. Number of Inspections. Written notices. Prosecutions. (1) (2) (3) (4) Factories (including factory laundries) 553 42 - Workshops (including workshop laundries) 270 17 - Workplaces (other than outworkers' premises) 700 79 - Total 1523 138 II. Defects found in Factories, Workshops and Workplaces. Particulars. Number of Defects Found. Remedied. Referred to H.M. Inspector. No. of Prosecutions. (1) (2) (3) (4) ] Nuisances under the Public Health Acts:— Want of cleanliness 84 84 - - Want of ventilation 3 3 - - Overcrowding — — - - Want of drainage of floors — — - - Other nuisances 141 141 - - Sanitary accommodation:— Insufficient 12 12 - - Unsuitable or defective 45 45 - - Not separate for sexes 2 2 - - Offences under the Factory and Workshops Acts: Illegal occupation of underground bakehouses - — - - 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 8 8 - - Total 295 295 - - Outwork in Unwholesome Premises, Section 108. Nature of Work. instances. Notices served. prosecutions. (1) (2) (3) (4) Wearing Apparel— Making, &c. 26 26 - 84 Food Shops and Food Stalls. All food shops, barrows and stalls and the Fulham Market are kept under careful supervision; and in addition two sanitary inspectors have been on special duty, as in previous years, two evenings a week in connection with these premises. A total of 174 evenings were spent by the inspectors on this special duty. The Merchandise Marks Act, 1926 and the Merchandise Marks (Imported Goods) Orders. The inspections under the Act and Orders were made at the food shops, stalls and barrows at the same time as other food inspections. Prosecutions. During the year two prosecutions were instituted under the above-named Act. In one case the vendor was summoned for failing to indicate the country of origin of imported fresh apples and the summons was dismissed under the P.O. Act on payment of two shillings costs. In the other case, two summons were issued in respect of imported raw tomatoes; on the first summons the defendant was fined two shillings and sixpence and the second summons was withdrawn. Warning Letters. During the year 67 warning letters were issued regarding offences under the Act and Orders. The offences occurred:— In shops 29 On stands 24 On barrows 14 The offences concerned the following articles Currants, sultanas and raisins 12 instances. Apples 21 instances. Tomatoes 36 instances. Slaughterhouses. There are two licensed slaughterhouses in the borough, situate at:— No. 611, Fulham Road. No. 640, King's Road. 85 During the year, Inspector Manning (up to March, 1932) and subsequently Inspector Hutchinson made 35 visits of inspection to these premises. The slaughterhouses, lairs and utensils have been kept in a cleanly condition. The following articles were condemned at the slaughterhouses during the year:— Sheep's lungs 37 pairs. Bullock's liver 14 lbs. Bakehouses. There are 66 registered bakehouses in the borough of which 39 are underground. Inspectors Jones and Gammack made 70 visits and served 17 written notices, principally for the cleansing of the interiors of the bakehouses. Ice Cream. All premises used for the Manufacture, Storage or Sale of ice cream must be registered under section 5 of Part II of the London County Council (General Powers) Act, 1932, but the provision does not apply to premises registered as a factory or workshop or to an hotel, restaurant or club. Any premises previously registered under the Act of 1928 do not require to be re-registered so long as they remain in the same occupation. At the end of 1932, 134 premises were on the register. The registrations were as follows:— Premises registered for the manufacture, storage and sale of ice cream 66 Premises registered for the storage and sale of ice cream 58 Premises registered for the manufacture and storage of ice cream 6 Premises registered only for the manufacture of ice cream 2 Premises registered only for the storage of ice cream 2 134 86 Registration of Premises for the sale of Preserved Food. Under section 5 of Part II of the London County Council (General Powers) Act, 193.2. "Any premises in the district of any sanitary authority used or proposed to be used (ii) for the preparation or manufacture of sausages or potted pressed pickled or preserved meat, fish or other food intended for sale, shall be registered by the owner or occupier or intending occupier thereof with the sanitary authority." This Act only came into force towards the end of the year and no premises were registered before 31st December. Section 5 also prescribes penalties for non-registration of premises and also deals with appeals against a Borough Council's decision to remove registered premises from the register or to refuse to register premises and it also gives a definition of the word "preserved". This section does not apply to any premises used as a club, hotel or restaurant. Unsound Food. The undermentioned articles of food, examined at the request of the owners, were condemned and destroyed during the year:— Turkeys 11 Tinned Plums and Loganberries 7 Fine Oatmeal 4½ lbs. Corned Beef 40 lbs. Butter 11 lbs. Haddocks 5 stone. Cod fillets 16 boxes. Black currants 24 lbs. Apples 2 barrels. Luncheon Tongue 45 tins. Winkles 2 bags. Lettuces 30 Mackerell 2 boxes. Peaches 7 boxes. Samples of Food purchased for Analysis. Particulars of samples purchased for analysis together with the results of the analysis w ill be found on page 126. 87 Proceedings. The following proceedings were taken during 1932 under the Food and Drugs (Adulteration) Act:— Offence. Result. Costs. £ s. d. Selling milk not of the nature, etc., demanded Dismissed - Ditto Dismissed - Ditto Dismissed 2 0 0 Adulteration of butter Withdrawn on payment of costs 2 2 0 Ditto Ditto 2 2 0 Food Poisoning. Under section 7 of the London County Council (General Powers) Act, 1932, medical practitioners are required to notify all cases of food poisoning, whether suspected or definite cases, to the Medical Officer of Health of the Metropolitan Borough in which the patient resides. All medical practitioners in Fulham were notified of the effect of the Act on its coming into force. At one time it was thought that the commonest type of food poisoning was that due to ptomaines but it is now known that food poisoning is most commonly caused by the Salmonella group of bacteria or their toxins, which produce an acute inflammation of the stomach and intestines. The illness commences several hours after food and is usually characterised by vomiting, purging, colicky pains in the abdomen and other symptoms. In order to verify the diagnosis either bacteriological examination of the intestinal evacuations or vomited matter, or examination of the blood is necessary. In mild cases the diagnosis is often made on clinical evidence but this cannot be relied on unless supported by 88 tory examination. A difficulty with which doctors have to contend is that the agglutination test does not usually become positive until at least seven days after the onset of the illness and by that time the patient may have recovered and the doctor may have ceased his attendance The actual source of food poisoning cannot he determined unless some of the food which has been consumed remains for examination and unless this is so the cause can only be presumed. During the latter part of the year after the Act came into operation 14 patients were notified as suffering from this condition. Six of the cases occurred at a wedding party, five at a boarding establishment and the remainder were isolated cases. All were extremely mild and recovered within a few hours or days. Facilities are available for medical practitioners in the Borough for bacteriological and other necessary laboratory examinations and full investigations are made by the Public Health Department regarding the source of infection. I have to acknowledge with thanks the help and advice in food poisoning investigations given by Dr. Scott of the Ministry of Health, who carried out a number of bacteriological tests of specimens submitted to him during the year. 89 Food and Drugs (Adulteration) Act, 1928. This Act requires local authorities to take samples of foods and drugs and one thousand samples are purchased annually in Fulham and submitted to the Council's Public Analyst for analysis. The samples are divided into two classes, viz: "Formal", i.e., those in the purchase of which the requirements of the Act are strictly observed and "Informal" or those in which the Vendor is unaware of the purpose for which the article is purchased. The Table on page 126 gives details ot' all samples purchased and particulars of action taken in cases of adulteration will be found on page Milk. Of 543 samples of milk examined during the year 4 or 0.73% were adulterated or not up to standard, as compared with 0.55 in 1931, 0.7 in 1930, 4.7 in 1929 and 2.5 in 1928. The chemical composition of milk is laid down in the Sale of Milk Regulations, 1901. These Regulations were made by the Board of Agriculture (now the Ministry of Agriculture & Fisheries) under Section 4 of the Sale of Food and Drugs Act, 1899 and fix; the minimum for fat at 3% and milk solids, other than milk fat, at 8.5%. An arrangement exists between the Council and the London County Council for the periodic sampling of milk delivered to the institutions, etc., under their control in this Borough. During the year the following samples were taken and in all cases the milk was found to be genuine. Fulham Hospital 8 Fulham Institution 3 Western Hospital 10 Elizabethan Open-Air School 2 90 Three automatic milk machines (i.e. machines fixed to the doors of milk shops, from which milk is obtainable after trading hours) are operating in the Borough and the samples taken during the year were reported to be genuine. Dairies: These are under the control of the Sampling Officer and in some the type of building used for the storage and bottling of milk was found to be unsuitable. The dairymen are only too anxious to co-operate in endeavouring to give the public clean milk and great improvements have been and are still being made. Public Health (Condensed Milk) Regulations, 1923-1927. During the year five samples of condensed milk were purchased and in each case the labelling, etc., was in accordance with the regulations. Public Health (Preservatives, Etc., in Food) Regulations, 1925-1927. Samples were examined during the year for preservative and no contraventions were reported. Milk and Dairies (Amendment) Act, 1922 and Milk and Dairies Order, 1926. Registration of Dairymen: Section 2 of the Milk and Dairies (Amendment) Act gives local authorities power to refuse to register persons or the premises at which the trade of dairyman is to be carried on. Power is also given to remove persons or premises from the register if the public health is, or is likely to be, endangered by some act or default of the person seeking registration in relation to the quality, storage or distribution of the milk. 91 In October a dairyman who occupied premises in an adjoining Borough made application to be registered as a retail purveyor of milk in this Borough. The usual enquiries were made and in view of the applicant's past record the Public Health Committee decided that he was not a suitable person to carry on the trade in Fulham and his application was accordingly refused. In order that the risk of contamination of milk should be minimised the Council passed a resolution on May 9th, 1923 prohibiting the sale of the following articles in registered milk shops:— Paraffin. Loose pickles. Vinegar (except in sealed bottles). Fish. Meat (of all forms, except when in sealed tins or glass). Fruit. Vegetables. Loose soap. Coals. Coke. Wood (except in bundles not kept in the milk store). Milk (Special Designations) Order, 1923. This order empowers local authorities to grant licences to persons dealing in graded milks and the following licences were issued during 1932:— Number of Licences to sell certified milk 7 Number of supplementary Licences to sell certified milk 1 Number of Licences to sell Grade "A" (Tuberculin Tested) milk 18 Number of supplementary Licences to sell Grade "A" (Tuberculin Tested) milk 1 Number of Licences to bottle and sell Grade "A" (Tuberculin Tested) milk 1 Number of Licences to sell Grade "A" milk 3 Number of Licences to sell Pasteurised milk 14 Number of supplementary Licences to sell Pasteurised milk 1 Number of Licences to Pasteurise milk 1 Number of samples taken in accordance with the instructions of the Ministry of Health Nil 92 There is one pasteurising establishment in the Borough. Under the order there are five special designations applied to milk and the following are the bacteriological standards laid down by the Order:— Type of Milk. Maximum number of bacteria, per c.c. "Certified" 30,000 No Bacillus Coli in 1 /10th. c.c. Grade "A" (T.T.) 200,000 No Bacillus Coli in l/100th. c.c. Grade "A" 200,000 do. Grade "A" (Pasteurised) do. 30,000 No Bacillus Coli in 1 /10th. c.c. Pasteurised 100,000 No standard. Schedule on page 94 gives details of samples taken lor bacteriological examination during 1932. It will be seen that in 110 case was the standard for bacteria, etc., laid down in the Order exceeded and in many instances the results may be regarded as exceptionally good. In addition to sampling the designated milks referred to in the Order, it is customary for the Council's Sampling Officer to purchase for bacteriological examination samples of milk which is sold as "ordinary" and is not therefore subject to a licence. Practically all the milk retailed by Fulham dairymen is pasteurised by the wholesalers although not sold as such by the retailer. Schedule on page 94 gives the results of examinations made of "ordinary" milk and although there is no legal maximum laid down regarding the number of bacteria per cubic centimeter permitted in such milk, in all cases where the number is excessive, the Sampling Officer makes careful investigation in order to ascertain the probable cause of contamination and advises the dairymen. The following are typical cases giving rise to high bacteriological counts and in which assistance has been given:— 93 (a) Failure to rinse the milk bottles in clean cold water after washing in hot soda water. (b) Careless methods of handling milk bottle discs, e.g. discs contaminated on wet bottle-filling racks. (c) Use of worn out, contaminated bottle washing brush. (d) Wiping necks of bottles after washing with cloth which appeared clean but was, in all probability, teeming with bacteria. Artificial Cream Act, 1929. There are no premises in the borough subject to the provisions of this Act. Rag Flock Acts, 1911 and 1928. There are no premises in Fulham at which rag flock is manufactured, used or sold. Increase of Hunt and Mortgage Interest Restrictions Acts. Eleven 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 1932. Certificates were granted in ten cases and one application was withdrawn. Two applications for "Clearance" Certificates were made by owners and granted. The London County Council (General Powers) Act, 1928—Sec. 28. During 1932 seven aged persons were kept under supervision and satisfactory arrangements were made for their care, either in Hospital or in their own homes, without the necessity of applying to the Court for an Order under the Act. 94 95 BACTERIOLOGICAL EXAMINATIONS OF MILK SOLD IN BOTTLES. Date taken. Temperature on arrival at Laboratory. Degrees Centigrade. Number of Bacteria per c.c. B. Coli Test. 48 Hours. Three Days. 1/100th. 1 /1,000th. 1 /10,000th 1/100th. 1 1,000th. 1 /10,000th. Certified Milk— Nov. 24th 14 775 Negative Negative Negative Negative Negative Negative Grade A (T.T.)— Nov. 24th 14 5.533 „ „ „ „ „ „ „ 24 th 14 4,766 „ „ „ „ „ „ „ 24th 14 2.833 „ „ „ „ „ „ „ 29th 26.000 „ „ „ „ „ „ „ 29th 12 6.733 „ „ „ „ „ „ „ 29th 12 5.830 „ „ „ „ „ „ Grade A (Pasteurised)— Nov. 24th 14 916 „ „ „ „ „ „ Pasteurised Milk— Nov. 10th 11 4.766 „ „ „ „ „ „ „ 10th 11 2.800 „ „ „ „ „ „ „ 25 th 14 3,566 „ „ „ „ „ „ Dec. 29th 8 15.733 „ „ „ „ „ „ „ 29th 8 27,000 „ „ „ „ „ „ Sterilised Milk — Dec. 29th 8 270 „ „ „ „ „ „ Ordinary Milk — Nov. 10th 11 14,733 „ „ „ „ „ „ „ 25th 14 43,333 „ „ „ „ „ „ „ 30th 12 9,333 „ „ „ „ „ „ „ 30 th 12 20,666 „ „ „ „ „ „ „ 30th 12 17,066 „ „ „ „ „ „ „ 30 th 12 28,333 „ „ „ „ „ „ Dec. 12th 15 26,000 „ „ „ Positive „ „ „ 14th 15 9,833 „ „ „ Negative „ „ „ 14th 15 27,333 „ „ „ „ „ „ „ 14th 15 36,000 „ „ „ „ „ „ „ 14th 15 18,666 Positive „ „ Positive „ „ „ 14th 15 19,666 Negative „ „ Negative „ „ „ 21st 12 380,000 Positive „ „ Positive „ „ 21st 12 460,000 Negative „ „ Negative Negative „ „ 21st 12 95,666 „ „ Positive „ „ „ 21st 12 139,666 Positive „ „ „ „ „ „ 21st 12 590,000 „ Positive „ „ „ „ 21st 12 49,000 Negative Negative „ Negative Negative „ „ 21st 12 9,133 „ „ „ „ „ „ „ 29th 8 15,333 „ „ „ „ „ „ „ 29th 8 97,333 Positive „ „ Positive „ „ „ 29 th 8 24,666 Negative „ „ „ „ „ „ 29 th 8 30,166 Positive „ „ „ „ „ „ 29th 8 36.666 Negative „ „ Negative „ „ „ 29th 8 80,166 „ „ „ „ „ „ 96 Rat Destruction. The Borough Council employ a Rat Officer who is a whole time employee of the Public Health Department. He attends to complaints regarding rat infestation in the Borough and takes steps necessary for their destruction. He also traces the source of the rats and gives advice regarding the methods necessary to prevent a recurrence of the infestation. One hundred and ninety-four formal complaints regarding infestation by rats were received during the year and 187 premises (including some reported during the previous year) were entirely cleared by the 31st December. Poison baits were laid in the following positions: Private houses 260 Other premises 92 Sewers 1,143 The special dustbin traps in the sewers have accounted for the death of 337 rats during the year and break-back traps and ferrets have accounted for 656 rats. It was found that in 63 or 32.5 per cent. of the new complaints the infestation was due to defective drains. In all these cases the necessary repairs and relaying of the drains have been carried out. The amount received by the Council from property owners for the services of the Rat Officer was, during the year ended 31st March, 1933, £31:13:6, and in addition £5 was credited to the Department for the services of the Rat Officer to other Departments of the Council. During Rat Week in November an intensive effort was made to exterminate rats in sewers and on lands and buildings known to be infested. 97 Legal Proceedings. Proceedings were instituted in the following cases during the year: Offence. Result. Penalty. Costs. £. s. d. £ s. d. Fouling of footpath by dog Dismissed under P.O. Act — 3 0 Ditto Ditto — 3 0 Ditto Ditto — 3 0 Ditto Ditto — 5 0 Ditto Ditto — 5 0 Ditto Ditto — 5 0 Ditto Fined 5 0 — Ditto Dismissed under P.O. Act - 2 0 Ditto Dismissed — — Selling milk from vehicle without having name and address of owner thereon Dismissed under P.O. Act — 2 0 Selling milk without being registered Fined 5 0 0 — Failing to indicate country of origin of imported fresh apples Dismissed under P.O. Act - 2 0 Failing to indicate country of origin of imported tomatoes Fined 2 6 — Nuisance— 57, Orbain Road Order to abate within 28 days — 3 0 Nuisance— 19, Beaumont Road Order to abate within 14 days — 10 0 Nuisance— 198, Munster Road Adjourned sine die-work in hand — — Nuisance— 13, Orbain Road Ditto — — Nuisance— 15, Orbain Road Ditto — — Overcrowding— 304, Lillie Road Adjourned sine die— Nuisance abated — — In addition to the above cases, proceedings were instituted during the year under the Food and Drugs (Adulteration) Act, 1928, particulars of which will be found on page 87. 98 Public Conveniences. The accommodation detailed in my report for 1930 and the general arrangements for the control of the conveniences in the borough have remained unchanged. Public Cleansing. There have been no alterations in the arrangements for the collection and disposal of refuse detailed in my report for 1930. Housing. House inspection is carried out by the Sanitary Inspectors mainly under the Public Health and Housing Acts. Inspections of houses are made under the Public Health Acts irrespective of the amount of rent paid and the social and financial position of the occupants. These inspections are made mainly on complaint or on the occurrence of infectious diseases. The Housing Acts, on the other hand, deal almost exclusively with the housing of the working classes. As people in good financial circumstances are in a position to cater for themselves in procuring satisfactory housing accommodation and maintaining good sanitary conditions, the energies of the staff are mainly directed to working class properties and more especially to housing conditions among the poorer members of the community. Housing is a fundamental factor in relation to health and good housing conditions are second in importance only to diet for the maintenance of health and the prevention of disease. (rood housing conditions, including dry, airy and sunny rooms, sufficient accommodation for sleeping and living purposes, proper facilities for personal cleanliness and washing of clothes as well as for the storage and cooking of food and the cleansing of feeding utensils have a great influence in promoting 99 health, and good drainage and water supply are also essential. Insufficient accommodation, air space and sunlight and defective hygienic conditions, on the other hand, have a deleterious effect on health, vitality and efficiency, and on the mental, moral and physical development of children and adolescents. Diseases such as tuberculosis, rheumatism and the common infectious diseases spread more readily if the home conditions are bad, leading to a high sickness rate and mortality. Inefficiency and increased sickness rate among the working classes reduce the national earning capacity, throwing an increased burden on those in full work, who have to pay higher rates and taxes. The landlord and the tenant are mutually responsible for the conditions which prevail. One cannot help noticing, in any town, marked differences in the appearance of houses in the same street, largely due to variations in the upbringing, habits, education and outlook of the tenants and the degree of encouragement and helpfulness afforded by the landlord. During recent years the public conscience has been stirred regarding housing conditions among the poorer classes and owners of property in Fulham show a much greater desire to carry out improvements and co-operate with the staff of the Public Health Department. Indifferent tenants often improve and take better care of their houses when repairs and redecorations are carried out by the owners. A change for the better in ownership of working class property is often followed by a corresponding improvement in the habits of the tenants. After house to house inspection of a street and improvements have been carried out, the tenants, in the majority of cases, take more interest and pride in their houses and often vie with each other in this respect, adding to the amenities of the houses in various ways. During the last ten years there has been great improvement in the sanitary conditions of working class dwelling houses in the Borough and this has been largely 100 brought about by the work of the Council's staff with the co-operation of owners of property. A perusal of the list of works resulting from sanitary and other notices (page 80) gives an indication of the type and volume of work carried out in one year. It must be remembered that inspections of houses, the service of notices and the supervision of the work resulting from the notices comprise only a part of the duties of the Sanitary Inspectors as they have many other duties such as food inspection, inspection of food premises, inspection of workshops and certain duties in connection with factories. They also give advice on those aspects of domestic hygiene with which their special training and experience make them familiar. The work of the Health Visitors at the Maternity and Child Welfare Centres and their visits to the homes has had a great influence in educating mothers of families regarding personal hygiene and in improving home conditions. It is well known that there is a marked improvement in the personal cleanliness of school children, and the school medical and nursing services have had a great deal to do with this. Chronic infestation by head and body lice, which are indications of gross neglect of personal cleanliness, is now comparatively rare and certain grave diseases which were once spread by these pests are now seldom met with in this country Bugs are unfortunately still prevalent in certain houses. Bugs are very difficult to eradicate as they breed and lay their eggs behind woodwork, in and behind plaster walls and in cracks and crevices in the plaster. Athough much more common in dirty houses they may occur in houses otherwise clean. The question is sometimes raised as to whether the landlord or the tenant has been responsible for the bugs; in many cases previous landlords or tenants were responsible as they failed to take the steps necessary for their eradication. No matter who was originally responsible, 101 bugs cannot be eradicated without the united efforts of all persons concerned. There is no definite proof that bugs cause any particular disease, but judging by analogy it is almost certain that they spread diseases. Overcrowding. Overcrowding was dealt with in my Annual Report for 1930 at some length. According to the Census figures, the population of Fulham fell from 157,937 in 1921 to 150,928 in 1931 and it was estimated at 149,600 for 1932 by the Registrar General. The Registrar General's standard for overcrowding is that a house is overcrowded if there are more than two persons per room. This standard cannot, however, be enforced in a Court of Law and the one usually employed in London is the minimum free air space laid down in the London County Council Byelaws with respect to Houses Divided into Separate Tenements. Bad cases of overcrowding are decidedly less common than they were some years ago. The lowest wage earners suffer the greatest hardship in this respect, especially those with large families of young children. Landlords are often averse to accepting these cases as tenants, as children are sometimes destructive to property and additions to the families are always possible, leading to overcrowding. A great defect in the housing of the working classes in London is that a large proportion of the houses originally intended for one family are now occupied by more than one family and Fulham is no exception in this respect. The Council's Housing Inspector carried out 268 initial and 2,283 re-inspections during 1932, giving a total of 2,551 inspections. One hundred and twenty six houses were added to the register of lodging houses under the London County Council Byelaws during the year. 102 These house to house inspections are of the greatest value and marked improvements in the houses inspected have resulted. The inspections are made under the Public Health and Housing Acts, the Housing (Consolidated) Regulations, 1925 and the London County Council Byelaws with respect to Houses Divided into Separate Tenements, 1925 and 1931. As this work has progressed more and more, better co-operation has been attained between the Public Health Department, owners and occupiers. Many difficulties and misunderstandings have arisen in the course of the work as the byelaws are somewhat complicated and difficult to administer, but consultations between the owners and the staff have had good results in dealing with them. Some owners object to their houses being registered as "Lodging Houses", apparently because they are of opinion that the registration lowers the value of the property and they also dislike the necessity for annual cleansing which is laid down in the byelaws A few owners confuse the terms "Lodging House" and "Common Lodging House" and withdraw their objections when the difference is explained. The majority of the owners offer no objection to registration and a number of those who originally objected now welcome registration. Under the combined effect of the Public Health and Housing Acts and the London County Council Byelaws the responsibility for maintaining lodging houses in a good state of repair, free from nuisance and in a cleanly condition is divided between owners, te nants and lodgers and the Public Health Department have insisted on all three parties carrying out their respective duties. Owners, with few exceptions, have given much assistance. Some of the houses reflect great credit on the owners and occupants but the byelaws are extremely useful in dealing with owners who neglect their propertv and careless, dirty and destructive tenants. 103 The byelaws provide for annual cleansing by owners, tenants and lodgers on or before 30th April and this is an obvious advantage from the sanitary point of view. Leaflets are sent to all three parties in March reminding them of their respective duties and during May and the ensuing months the houses are inspected; if they are in a good state of repair, free from nuisance and in a cleanly condition, no action is necessary, but if this is not the case notices are served. Legal action can be taken if the provisions in the byelaws are not complied with, but this has not been found necessary during 1932. The following table gives the housing statistics in the form desired by the Minister of Health. 1. Inspection of Dwelling-houses during the year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 3,605 (b)Number of inspections made for the purpose 18,097 (2)(a)Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 333 (b)Number of inspections made for the purpose 2,791 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation - (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 2,736 2. Remedy of Dejects during the year without Service of formal Notices:— Number of dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 1,873 3. Action under Statutory Powers during the year:— (a) Proceedings under sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 65 104 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners *82 (b) By Local Authority in default of owners — (b) Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 552 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 334 (b) By Local Authority in default of owners 3 (c) Proceedings under sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made - (2) Number of dwelling-houses demolished in pursuance of Demolition Orders - (d) Proceedings under section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made - (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit - * This figure includes houses regarding which notices were served during the previous year. Fulham Court Estate. The Borough Council's Housing Scheme at Fulham Court consists of 369 flats and 16 lock-up shops, in nine blocks, one block being in four and the others in five storeys. The committee primarily responsible for the initiation and carrying out of the scheme was the Housing Committee under the chairmanship of Sir Thomas Richardson. The erection of the flats on this estate constitutes a big contribution to the housing problem in Fulham. The Architect was Mr. A. F. Holden, M.Inst.C.E., the Borough Engineer and Surveyor. 105 A detailed description of the buildings was given in my annual report for 1930. The first tenants to occupy the flats entered into occupation in June, 1932 and during the year 253 families were accommodated. The flats vary in size from two to five rooms, and the number of fiats of each type with the inclusive rents are as follows:— No. of flats. Rents, including Rates. 2-roomed flats (1 bedroom) 6 12.6 per week. 3-roomed flats (2 bedrooms) 211 15.0 per week. 4-roomed flats (3 bedrooms) 135 17.6 per week. 5-roomed flats (4 bedrooms) 17 20.0 per week. Each of the flats has, in addition to the bedrooms and living room, a kitchenette, bathroom with a washing copper to supply hot water, ventilated larder, W.C. and provision for coals. The living room has a dresser and a combination grate with a fire and oven. Electricity is installed for lighting and the tenants have the choice of gas or electric cookers on hire and may have either gas or electric radiators in the bedrooms. The washing coppers, which will also supply the baths, are, according to the choice of the tenants, either coal fired coppers capable of burning rubbish or gas coppers fitted by the Gas, Light and Coke Co. on hire. The selection of tenents. The Lettings Sub-Committee who were responsible for this arduous task was a Subcommittee of the Housing Committee and Sir Thomas Richardson, the Chairman of the Housing Committee, was its Chairman. The following general principles were laid down by the Borough Council on 26th June, 1929, for guidance in the selection of tenants:— 106 (1) Housing accommodation provided by the Borough Council is intended for persons of the working classes residing in Fulham who are considered as suitable tenants, regard being had to their circumstances and way of life. (2) Preference is given:— (a) to persons displaced by the acquisition of property for clearance or improvement schemes or other public purposes; (b) to persons whose present homes are overcrowded or insanitary or otherwise so ill-adapted to their needs as to cause hardship; (c) to those who served in the War. (3) (a) The amount of accommodation allotted in each case depends upon the reasonable needs of the family, regard being had to the sex and ages of the children and the number of bedrooms required; (b) Not more than two rooms are allotted to a married couple without children, or to two persons of the same sex living together; (c) No person residing alone is accepted as a tenant. Mr. Thomas Brisley was appointed Referencer in order to visit applicants in their own homes and draw up written reports on each application. Mr. Brisley had considerable experience of this work under the London County Council. He commenced duty on the 12th April, 1932 and continued for twelve months; he carried out his work in a very able manner and with great tact. He was attached to the Public Health Department in connection with his duties and this department was primarily responsible for the organisation and carrying out the work of selecting the tenants. The large number of applications (a total of 2,500), visits, enquiries, and record keeping in connection with this duty threw a very large amount of additional work on the existing staff during the year 1932. The application forms and the referencer's reports on the cases were carefully scrutinised by the Medical Officer of Health, who made observations on the merits 107 of each case. The Borough Treasurer also perused the documents in detail before the cases were considered by the Lettings Sub-Committee and made his observations as to the ability or otherwise of the applicants to pay the required rents. The applications were classified into those suitable for two, three, four or live roomed flats, those not recommended, and doubtful cases. They were then brought before the Committee, who were actually responsible for the decisions as to accommodation. Before the tenants were actually accommodated the Borough Treasurer also had to verify the earnings of the applicants. The individual flats were allocated to the successful tenants jointly by the Borough Treasurer and the Medical Officer of Health. Tenants were allocated to flats which were deemed to be sufficient for their reasonable needs, taking into consideration the ages and sexes of the children and the bedroom accommodation required and were not given accommodation in excess of their requirements; the flats containing four or five rooms were therefore reserved for applicants with large families. The main object of the housing scheme is to accommodate families who are either overcrowded or are living under bad housing conditions. Those who are already adequately accommodated and are suffering from no special hardship are not eligible. A point on which the sub-committee lay great stress is that the flats are not intended for families whose incomes are so high that the Council are not justified in providing them with subsidised accommodation; many families with grown-up sons or daughters are able to provide suitable accommodation for themselves. Families with low incomes are given preferential consideration provided they can pay the necessary rents. Unfortunately, however, many applicants have had to be refused accommodation because their incomes were so low that the rentals, added to other necessary expenses, would be too much of a drain on their resources. If such families were accepted they 108 would have to go short of food or adequate clothing in order to pay the rents. The main reasons given by the applicants to justify their applications were: (i) overcrowding. (ii) lack of sleeping accommodation for the separation of the sexes. (iii) illness ascribed to bad housing conditions. (iv) living in underground rooms. (v) rent so high that the applicants could not afford the necessities of life. Every endeavour has been made to provide accommodation only for those in real need of it who were likely to make good tenants. On account of the large number of applications, however, many deserving applicants had to be refused. The sanitary condition of the premises occupied by tenants who were accommodated in Fulham Court was enquired into by the sanitary inspectors and appropriate action was taken when necessary. In cases of overcrowding letters were sent to the owner or other person responsible for the letting of the rooms, requesting them not to re-let in such a way as to cause a repetition of the overcrowding. It was found on subsequent visiting by the inspectors that the landlords had in many cases given the vacated rooms to existing tenants and, up to the present, no cases of overcrowding have been found in the vacated rooms. London County Council Estates. Since October, 1924, fifteen houses out of every thousand erected on London County Council Estates have been allocated to Fulham residents recommended by the Medical Officer of Health of the borough. 109 Families are accommodated on these estates both on the recommendation of the Medical Officers of Health of the various boroughs and on application direct to the County Council. The following table shows the number of families accommodated on the various estates since October, 1924:— Estate. Accommodated on recommendation by the Fulham Borough Council. Accommodated on applying direct to the London County Council. Total Fulham families accommodated. EAST HILL. Wandsworth. 12 35 47 WATLING, Middlesex. 137 83 220 DOWNHAM, Kent. 54 20 74 *BECONTREE, Essex. 99 383 482 *ST. HELIER, Morden. 73 135 208 BROXHOLME HOUSE, Fulham. 1 39 40 TON, CASTELNAU, CENTRAL LONDON, Etc. 104 347 451 TOTALS: 480 1042 1522 * Estates marked thus are still available for Fulham residents. During the year 1932, 37 applications were made to the Public Health Department of the Borough Council for accommodation on the London County Council Estates and were dealt with as follows:— 110 26 families were recommended to the County Council for preferential treatment; 6 cases upon enquiry proved unsuitable for recommendation, and 5 applicants decided that the estates available were not suitable for them on account of the distance from their places of employment. During 1932 eighteen families were successful in securing accommodation as a result of recommendations from the Public Health Department. It will be noticed that the number of applications made to the Public Health Department dropped considerably during 1932 (from 1(38 in 1931 to 37 in 1932). This drop is, however, explained by the fact that during the major part of 1932 the Fulham Court flats were available and families desiring other housing accommodation were loth to apply for an estate outside London when there was a chance of obtaining a flat in Fulham. Health Propaganda. Owing to the need for economy no provision was made in the annual estimates by the Public Health Committee for Health Propaganda and it was not possible to arrange for lectures or special displays. The work of the Medical Officers and Health Visitors of the Maternity and Child Welfare Department is largely concerned with giving advice on the promotion of health and fitness. The same principles are adopted by the Tuberculosis Officer and the Dispensary Nurses in the course of their duties. The Sanitary Inspectors also give advice on sanitary questions, which are of importance in the prevention of illness. The following leaflets are available for the public free of cost and are in considerable demand: 1ll "How to keep Fit (including the choice of a rational diet)." "Some useful hints on household hygiene." "The Prevention and Treatment of Tuberculosis." "The Prevention and Treatment of Bronchitis." "The Ante-Natal Clinics for Expectant Mothers." "The Care and Feeding of Infants." "Cancer." "Measles." "The Prevention and Treatment of Influenza." "Summer Diarrhoea in Infants." " Summer Time and Tired Children." " Rat Destruction." The British Social Hygiene Council, as in former years, continued their propaganda against Venereal Diseases and for the education of young people in sex matters. A useful part of the Council's work consists in giving Cinema Lectures to parents containing suggestions as to the best methods of passing on to their children instruction on reproduction. The following list shows the number of lectures and cinema displays given by the Council in this borough during the year: Single Lectures Date. Place. Speaker. Film. Attendance. Public Meetings— Oct. 24th Central Library Dr. Feldman Deferred Payment 100 „ 25th Baths (men 100) Dr. Forgan John Smith 400 „ 24th Baths Miss Swaisland — 40 540 Oben Air— May 4th Walham Grove Mr. Harris - 75 Mr. Buckler June 1st Walham Grove Mr. Harris - 200 Mr. Buckler Sept. 7th Walham Grove Mr. Harris - 250 525 112 Date. Place, Speaker. Film. Attendance. Unemployed Centres— Mar. 9th Langford Hall Mr. Buckler - 150 „ 14th Langford Hall Mr. Buckler Deferred Payment 350 500 Women— Jan. 25th St. John's Church Miss Dugdale Gift of Life 80 Sept. 7th Munster Park Co-op. Guild Miss Dugdale Irresponsibles 50 Oct. 26th Bishop Creighton House Miss Dugdale How to Tell 20 Nov. 30th St. John's Fellowship Miss Dugdale - 40 Dec. 8th Church of Christ Miss Dugdale How to Tell 150 340 Young Women— Mar. 13th Church of Christ Miss Dugdale Growing Up 25 Sept. 19th Church of Christ Miss Dugdale Ways of Life 45 70 Courses of Lectures Young Men— November—3 lectures—Public Course at Everington Street School. Lecturer: Dr. Feldman. Film: Gift of Life Average attendance 25 Young Women November—3 lectures—Public Course at Everington Street School. Lecturers: Miss Dugdale, Dr. R. Turner. Films: Gift of Life, Our Bodies, Irresponsibles Average attendance 18 January and February—3 lectures at Church of Christ. Lecturer: Miss Dugdale. Films: Gift of Life, Our Minds, Our Bodies Average attendance 20 38 ANALYSIS Total No. of lectures 24 Total attendance 2,038 Medical Examination of Council Employees. During the year 1932, the medical staff of the department made examinations of 30 persons as to their physical fitness to enter the Council's service, or their ability to continue their work owing to ill-health 113 Public Health Legislation. The following is a list of the Public Health Acts, Orders, Regulations and Byelaws under which the work of the Public Health Department is carried on I have compiled this list as a guide to the staff in carrying out their duties. ACTS OF PARLIAMENT. Local Government Acts, 1871 to 1929. Ministry of Health Act, 1919. Ministry of Agriculture & Fisheries Act3, 1889 to 1919. Municipal Corporations Act, 1882. London Government Act, 1899. Vaccination Acts, 1867 to 1907. Merchandise Marks Acts, 1887 to 1926. Metropolis Management Acts, 1855 to 1899. Sale of Food and Drugs Act, 1875 (Repealed except Sections 30, 31 & 36). Sale of Horse Flesh, etc., Regulations Act, 1889. Public Health (London) Act, 1891. Cleansing of Persons Act, 1897. Housing Acts, 1885 to 1930. London County Council (General Powers) Acts, 1890 to 1932. Small Dwellings Acquisition Acts, 1899 to 1923. Increase of Rent & Mortgage Interest (Restrictions) Acts, 1920 to 1925. Public Health (Smoke Abatement) Act, 1926. Factory & Workshop Acts, 1901 and 1907. Rag Flock Acts, 1911 & 1928. Public Health (Regulations as to Food) Act, 1907. Milk & Dairies (Consolidation) Act, 1915. This Act is in force except section 9 and the third schedule which are repealed and embodied in sections 21 and 29 and the second schedule of the Food & Drugs (Adulteration) Act, 1928. Rats & Mice Destruction Act, 1919. Public Health (Officers) Act, 1921. Only section 7 is in force in London. Public Health (Tuberculosis) Act, 1921. Milk & Dairies (Amendment) Act, 1922. Food & Drugs (Adulteration) Act, 1928. Agricultural Produce (Grading & Marking) Acts, 1928 & 1931. Artificial Cream Act, 1929. 114 ORDERS MADE BY GOVERNMENT DEPARTMENTS AND ORDERS IN COUNCIL. ORDER: MADE BY: UNDER: Order making regulations as to Competency of Public Analysts, 1900. Local Government Board. Sale of Food & Drugs Acts, 1875 to 1899. Order as to registration of manufactories of, and premises of Wholesale Dealers in Margarine & Margarine Cheese, 1900. Local Government Board. Margarine Act, 1887. Sale of Food & Drugs Act, 1899. Order as to registration of Butter Factories, and of manufactories of, and premises of Wholesale Dealers in MilkBlended Butter, 1907. Local Government Board. Margarine Act, 1887. Sale of Food & Drugs Act, 1899. Butter & Margarine Act, 1907. Diphtheria Antitoxin (London) Order, 1910. Local Government Board. Public Health (London) Act, 1891, Section 77. Destruction of Rats Order, 1910. Local Government Board. Public Health Acts, 1875, 1891 & 1896. Home Work Orders, 1911, 1912 and 1913. Home Secretary. Factory & Workshop Act, 1901. Part III, article 7 (a) and (c) Sale of Food Order, 1921. except where it applies to bacon, ham and lard. Part VI, articles 18 (a) and (c), 23 and 25. Board of Trade. Ministry of Health (Continuance) Act, 1920. Ministry of Food (Cessation) Order, 1921. Ministry of Health (Factories & Workshops — Transfer of Powers) Order, 1921. H.M. The King, on advice of Privy Council. Ministry of Health Act, 1919, Section 3. Milk (Special Designations) Order, 1923. Minister of Health. Milk & Dairies (Amendment) Act, 1922, Sec. 3. Milk & Dairies Order, 1926. Minister of Health with the cdncurrence of Minister of Agriculture & Fisheries. Milk & Dairies (Consolidation) Act, 1915, Sees. 1 & 2 &c. 115 ORDER: MADE BY: UNDER: Merchandise Marks (Imported Goods) Orders:— H.M. The King, on advice of Merchandise Marks Act, 1926, Sec. 2. Imported Honey & Imported Fresh Apples, No. 3 Order, 1928. Imported Currants, Sultanas, Raisins, Eggs in Shell, Dried Eggs and Oat Products, No. 5 Order, 1928. Imported Raw Tomatoes, No. 4 Order, 1929. Imported Malt Products, No. 5 Order, 1930. Imported Frozen or Chilled Salmon and Imported Frozen or Chilled Sea Trout. No. 8 Order, 1931. Imported Butter, No. 1 Order, 1932. Privy Council. Dangerous Drugs (Hospital Exemption) Order, 1929. Home Secretary. Dangerous Drugs Act, 1920. This Order applies only to Fulham. Dangerous Drugs (Consolidation) Regulations. Sanitary Officers Order, 1926. Minister of Health. All powers enabling him in any Statute. Vaccination Order, 1930. Minister of Health. Vaccination Acts, 1867 to 1907. REGULATIONS MADE BY GOVERNMENT DEPARTMENTS. REGULATION: MADE BY: UNDER: Sale of Milk Regulations, 1901 and 1912. J Board of Agriculture & Fisheries. Sale of Food & Drugs Act, 1899, Section 4. Sale of Butter Regulations, 1902. Board of Agriculture & Fisheries. Sale of Food & Drugs Act, 1899, Section 4. Rag Flock Regulations, 1912. Local Government Board. Rag Flock Act, 1911. Public Health (Shell Fish) Regulations, 1915. Local Government Board. Public Health (Regulations as to Food) Act, 1907. Public Health (Small-pox Prevention) Regulations, 1917. Local Government Board. Public Health Acts, 1875, 1891 & 1896. 116 REGULATION: MADE BY: UNDER: Public Health (Condensed Milk) Regulations, 1923 and 1927. Minister of Health. Public Health Acts, 1875, 1891 & 1896. Public Health (Dried Milk) Regulations, 1923 and 1927. Minister of Health. Public Health (Regulations as to Food) Act, 1907. Milk & Dairies (Amendment) Act, 1922. Public Health (Meat) Regulations, 1924. Minister of Health. Public Health (Regulations as to Food) Act, 1907. Public Health (Preservatives, etc., in Food) Regulations, 1925 to 1927. Minister of Health. Public Health Acts, 1875, 1891 & 1896. Public Health (Regulations as to Food) Act, 1907. Public Health (Prevention of Tuberculosis) Regulations, 1925. Minister of Health. — ditto. — Housing (Consolidated) Regulations, 1925 & 1932. Minister of Health. Housing Acts, 1925 & 1930. Public Health (Tuberculosis) Regulations, 1930. Minister of Health. Public Health Acts, 1875, 1891 & 1896. Local Government (Qualifications of Medical Officers & Health Visitors) Regulations, 1930. Minister of Health. Local Government Act, 1929, Section 59. Parrots (Prohibition of Imports) Regulations, 1930. Minister of Health. Public Health Acts, 1875 and 1896 and Public Health (London) Act, 1891. Housing Acts (Form of Orders Notices) Regulations, 1932. Minister of Health. Housing Act, 1930, Section 57. Agricultural Produce (Grading & Marking) Regulations. Minister of Agriculture & Fisheries. Agricultural Produce (Grading & Marking) Acts, 1928 and 1931. These Regulations have been made regarding the following articles:— Apples and Pears, 1928. Beef, 1929. Wheat Flour, 1929; Malt Flour & Malt Extract, 1929; Potatoes, 1929. Eggs, 1930; Broccoli, 1930; Glasshousegrown Tomatoes & Cucumbers, 1930; Strawberries, 1930 ; Canned Fruits, Peas and Beans, 1930; Cherries, 1930; and Dressed Poultry, 1930. Honey, 1932; Plums, 1932; Cider, 1932; Bottled Fruits (Various Fruits), 1932; Bottled Vegetables (Various), 1932. 117 The Agricultural Produce (Grading & Marking) (General) Regulations, re the National Mark Committee, were made in 1928. For list of regulations on notification of infectious diseases see special list. No canal boats are registered in Fulham under the Canal Boats Regulations, 1878 and 1925 (made by the Minister of Health under the Canal Boats Act, 1877). REGULATIONS AS TO NOTIFIABLE INFECTIOUS DISEASES. 1. The following diseases must be notified to the Medical Officer of Health in Fulham under the Public Health (London) Act, 1891, sec. 55:— Smallpox, cholera, diphtheria, membranous croup, erysipelas, scarlatina (or scarlet fever) and the fevers known by any of the following names:— Typhus, typhoid or enteric (including paratyphoid), relapsing, continued and puerperal. 2. The Local Government Board or the Ministry of Health have made regulations under the Public Health Acts relating to the compulsory notification and other matters as follows:— Public Health (Cerebro-Spinal Fever & Acute Poliomyelitis) Regulations, 1912 and 1919. Public Health (Acute Encephalitis Lethargica and Acute Polio-encephalitis) Regulations, 1918 and 1919. Public Health (Puerperal Fever & Puerperal Pyrexia) Regulations, 1926 and 1928. Public Health (Ophthalmia Neonatorum) Regulations, 1926 & 1928. Infectious Diseases (London) Regulations, 1927, (regarding malaria, dysentery, acute primary pneumonia and acute influenzal pneumonia). Metropolitan Borough of Fulham (Measles) Regulations, 1920. Public Health (Tuberculosis) Regulations, 1930. 3. Epidemic diarrhœa in children under five years of age must be notified in Fulham in accordance with the Regulations made by the Borough Council in 1919 under section 55 of the Public Health (London) Act, 1891. 4. Cases of lead, phosphorus, arsenical or mercurial poisoning or of anthrax must be notified by medical practitioners to the Chief Factory Inspector, Home Office, London, under the Factory & Workshop Act, 1901. 118 In accordance with orders made by the Ministry of Agriculture & Fisheries under the Diseases of Animals Acts, 1894 to 1927, cases of anthrax, glanders, farcy and rabies (hydrophobia,) in animals coming to the knowledge of the Veterinary Inspectors of the County Council are notifiable to the Medical Officer of the Borough Council of the district in which the animal is or was. LONDON COUNTY COUNCIL BYELAWS enforced by the Public Health Department of the Borough Council. Drainage and Deposit of Drainage Plans, 1929. (under Metropolis Management Act, 1855, sec. 202, and Metropolis Management Act Amendment (Byelaws) Act, 1899.) Water Closets, Earth Closets and Privies, 1930. (under Public Health (London) Act, 1891, sec. 39 (i) and London County Council (General Powers) Act, 1928, sec. 24.) Ashpits, 1893 and 1913. (under sec. 39, Public Health (London) Act, 1891.) Receptacles for Dung, 1893, 1904 and 1913. (under sec. 39, Public Health (London) Act, 1891.) Closing and Filling of Cesspools and Privies, 1893. (under sec. 16 (ii) of the Public Health (London) Act, 1891.) Removal and disposal of House and other Refuse, 1893. (under sec. 16 (ii) of the Public Health (London) Act, 1891.) Removal of faecal and offensive matter by road, 1901. (under sec. 16 (ii) of the Public Health (London) Act, 1891.) Conveyance of Carcases of Dead Horses through streets, 1905. under L.C.C. (General Powers) Act, 1903, sec. 54.) Offensive Businesses:— (under sec. 19 (4), Public Health (London) Act, 1891.) Fat Melter or Fat Extractor, 1907. Knacker, 1907. Gut Scraper and Gut Maker or Catgut Manufacturer, 1907. Glue and Size Manufacturer, 1907. Tripe Boiler, 1907. Bone Boiler, Manure Manufacturer, or Tallow Melter, 1907. Soap Boiler, 1907. Dresser of Fish Skins, 1907. Fellmonger, 1907. Dresser of Fur Skins, 1922. Slaughterer of Poultry, 1923. 119 Byelaws made under the London County Council (General Powers) Act, 1908, sec. 9, regulating business of:— Vendor of Fried Fish, 1913. Fish Curer, 1913. Rag and Bone Dealer, 1923-1928. Slaughterhouses, 1891. (under Slaughterhouses, &c. (Metropolis) Act, 1874 and Local Government Act, 1888.) Slaughterhouses, 1923. (under Public Health (London) Act, 1891.) Houses Divided into Separate Tenements, 1925 and 1931. (under Public Health (London) Act, 1891, and Housing Act, 1925, sec. 6.) Byelaw regulating the emission of smoke, 1931. (under sec. 2, Public Health (Smoke Abatement) Act, 1926. ) BYELAWS made by the FULHAM VESTRY and the FULHAM BOROUGH COUNCIL which are administered by the Public Health Department. For the prevention of nuisances arising from any snow, ice, salt, dust, ashes, rubbish, offal, carrion, fish or filth or other matter or thing in any street, 1893. Made under the Public Health (London) Act, 1891, sec. 16 (i). For preventing nuisances arising from any offensive matter running out of any manufactory, brewery, slaughterhouse, knacker's yard, butcher's or fishmonger's shop or dunghill into any uncovered place whether or not surrounded by a fence, 1893. — ditto. — For the preventing of the keeping of animals on any premises in such place or manner as to be a nuisance or injurious or dangerous to health, 1893. — ditto. — As to the paving of yards and open spaces in connection with dwellinghouses, 1893. — ditto. — With respect to the keeping of waterclosets supplied with sufficient water for their effective action, 1893. Made under sec. 39 (ii) Public Health (London) Act, 1891. 120 For securing the cleanliness and freedom from pollution of tanks, cisterns and other receptacles used for storing of water used or likely to be used by man for drinking or domestic purposes, or for manufacturing drink for the use of man, 1893. Made under sec. 50, Public Health (London) Act, 1891. As to the decent conduct of persons using the public lavatories and sanitary conveniences within the borough, 1902. Made under sec. 45 (i), Public Health (London) Act, 1891. Tents, vans, sheds, etc., 1924. Made under Housing of the Working Classes Act, 1885, sec. 9 (ii). Nuisances by dogs, 1926. Municipal Corporations Act, 1882, sec. 23, the Local Government Act, 1888, sec. 16, and Local Government Act, 1899, sec. 5. RULES AND REGULATIONS made by the Borough Council and administered by the Public Health Department. Mortuary Regulations as to: (1) Deposit of Bodies (under sec. 90 (i) of Public Health (London) Act, 1891. (2) Duties of Mortuary Keeper. Management of Public Conveniences (under sec. 45 (i) of the Public Health (London) Act, 1891). Underground Rooms. (under Housing & Town Planning Act, &c., 1909, sec. 17 (7).) Keeping of Poultry, 1925. (worked in conjunction with Public Health (London) Act, 1891.) Regulations regarding the notification of Epidemic Diarrhoea in Children under five years of age, 1919. (made under sec. 55, Public Health (London) Act, 1891.) 121 New Legislation, Circulars and Memoranda from the Ministry of Health during 1932. London County Council (General Powers) Act, 1932. Merchandise Marks (Imported Goods) No. 1 Order, 1932, dated 17th March, 1932—Imported Butter. Housing Consolidated Amendment Regulations, 1932, dated 11th August, 1932. Circular 1243 dated 21st March, 1932, enclosing: Memorandum on the Criticism and Improvement of Diets and on Diets in Poor Law Children's Homes. Circular Letter M.S. 1492, dated 12th May, 1932, from the Ministry of Agriculture & Fisheries, explaining the provisions of the Agriculture Produce (Grading and Marking) Acts, 1928 and 1931, as they affect local authorities. Memorandum 161/Med. dated 25th May, 1932—Precautions against shock from Electro-Medical Apparatus. Circular 1285, dated 29th August, 1932, enclosing Med. 164/M.C.W.—Maternal Mortality Investigations. Circular 1290, dated 27th October, 1932—Nutrition. Letter from Sir Geo. Newman, dated 25th February, 1932— Bacteriological investigation with reference to Puerperal Sepsis. 122 Report of Acting Public Analyst, Wm. Partridge, F.I.C., for Six Months ended 31st December, 1932. During the period named 549 samples of food and drugs were submitted for analysis by officials having the powers of sampling officers for the Metropolitan Borough of Fulliam. This fotal was constituted as follows Milk 282, Skimmed milk 1, Condensed Skimmed milk (sweetened) 5, Cream 13, Butter 78, Margarine 22, Cheese 9, Lard 13, Dripping 3, Shredded Suet 3, Bread (j, Flour 3, Sago 1, Custard powder 2, Sponge cake 3, Pepper 6, Cayenne pepper 6, Pepper compound 1, Mustard 1, Vinegar 2, Malt vinegar 1, Sugar 4, Icing sugar 3, Honey 2, Jam 4, Tea 3, Coffee 1, Coffee and chicory 2, Coffee extract with chicory 3, Cocoa 2, Whisky 5, Brandy 3, Gin 2, Non-alcoholic wines 3, Lime juice cordial 1, Lemon squash 3, Lemonade powder 1, Table jelly 2, Mincemeat 3, Dried fruit 6, Glace cherries 3, Confectionery 6, Preserved sausages 2, Meat pies 4, Fish paste 2, Tinned peas 3, Tinned beans 4, Gravy thickening 1, Compound syrup of figs 2, California syrup of figs 1, Olive oii 2, Castor oil 2, Camphorated oil 1, Sal volatile 1, Tincture of iodine 1. The varieties of articles in this table number 55, showing a wide range to have been covered, which in a lull year would be still further enlarged. In the desire to use the Food and Drugs (Adulteration) Act, 1928 to the fullest advantage both from the aspects of effect on health, protection against poison, and nutrition of consumers, every month some fresh item, after due consider- ation, is investigated, so that it rests at this : that no article considered by the Medical Officer of Health and myself (the Public Analyst) as requiring analysis is overlooked in our scheme. The slightest inference that the Act can be of use in our Borough in any way is promptly followed up; commonly a simple and innocent explanation of any anxiety follows, but in other cases the Medical Officer of Health is provided with information which means better health and greater benefit for Fulliam. 123 Of the 549 samples, 20 were returned as adulterated; this yields a Percentage of Adulteration of 3.64. Of the adulterated samples 3 consisted of Milk, 11 of Butter, 3 of Margarine, and 1 each of Bread, Cayenne pepper and Canned beans. Milk, its cleanliness, freedom from adulteration and quality, is a vital factor in public health. It is one of the cheapest foods and besides actual nutriment is expected to contain other characters (vitamins) that are desirable, sometimes essential, for the maintenance of health. The average composition of milk was — fat 3.58%, solids not fat 8.81%. During the last six months of the year milk is of better quality than during the first six months, so that these figures are higher than would obtain in a full year. It is satisfactory to record that out of 28.2 samples only 3 were adulterated; in other words the percentage of adulteration for milk was 1.06. The three samples of adulterated milk all showed small deficiencies: namely, 4%, 3% and 1% respectively of added water. It is within the bounds of possibility that the producer or vendor of each of these was quite ignorant of the presence of water. Milk is taken from the cows in a hurry and all through handling there is nothing but rush to get it to the consumer as soon as possible. Utensils after rinsing or cleaning are often left damp with water and leaks in coolers (most frequent of all innocent sources of added water) all add to the quota of watered milk. Unless negligence or carelessness of this description, rare though they be, is the subject of comment, however, even though the amount of added water in a sample is small, the effect is that the customer is getting water when he pays for milk; whereas if the attention of vendors is directed to small deficiencies of this description improvement generally follows. One sample of milk was dirty, but, on analysis, the dirt was found to be rust from rusty churns. By far the most striking feature of the half year's work has been the proportion of adulterated samples of butter and margarine. Eleven out of 78 samples of 124 butter were unsatisfactory, while margarine yielded three adulterated samples out of 22. Two samples of butter were so badly decomposed as to be unfit for food* and nine samples exceeded the standard for water allowed by the Butter Regulations (16%). To put it bluntly, butter of good farmhouse or dairy quality with 9% to 12% of water is purchased in bulk by certain firms, who add further water up to an amount just low enough to prevent prosecution. All the same good quality butter is obtainable in the Borough as 15 samples contained water in amounts between 11% and 14%. Such butter's keep better than wet ones, and do not develop the moulds and other discolourations that are very common on water-loaded butters to-day. The average moisture in butter was 15.13% and in Margarine it was 14.75%. Lard was invariably of reasonably fresh quality, and not only free from rancidity but capable of being kept for an appreciable time in a house without spoiling. The average amount of Free Fatty Acids was 0.51%, the range being from 0.36% to 0.72%. A sample of Bread, submitted to the Medical Officer of Health by a Fulham resident, that was the subject of a Certificate of Adulteration, was decomposing. It had a sour smell and in addition was the subject of incipient mouldiness. I duly certified that in 24 hours the mould alone would render the bread unfit for use by man, horse or poultry. A substantial amount of information and also suggestions were supplied to assist the bakers in preventing any recurrence. It is a point, if not of duty then of neighbourliness, that whenever objections of innocent cause are discovered, as much assistance as possible should be generously given to the unwitting offender, when this can be done without prejudice to consumers. Subsequent loaves from the same vendor proved entirely satisfactory. * The remainder of the stock was surrendered by the vendor and destroyed. SAMPLES PURCHASED FOR ANALYSIS DURING 1932. Article. Number of Samples. Total Samples Analysed. Total Samples Adulterated. Percentage of Adulteration. Taken officially | Adulterated. Taken unofficially. Adulterated. Milk 537 6 543 4 0.74 Machine-skimmed Milk (condensed) — — 5 — 5 — — Skimmed Milk 1 — — — 1 — — Cream — — 13 — 13 — — Butter 5 — 134 7 139 11 7.91 Margarine 2 1 20 2 22 3 13.64 — — 14 — 14 — — Lard — — 23 — 23 — — Beef Dripping — — 9 — 9 — — Olive Oil — — 5 — 5 — — Tea — — 3 — 3 — — Coffee — — 3 — 3 — — Cocoa — — 7 — 7 — — Coffee Extract with Chicory — — 3 — 3 — — Coffee and Chicory — — — — — — — Mustard — — 9 — 9 — — Peppier — — 11 — 11 — — Cayenne Pepper 1 — 10 1 11 1 9.09 Pepper Compound — — 1 — 1 — — Flowers of Sulphur — — 3 — 3 — — Magnesium Oxide — — — — — — 100.00 Black Draught — — — 1 4 — 25.00 Turpentine Liniment — — — 2 5 — 40.00 Castor Oil — — — — 2 — — Epsom Salts — — 3 — 3 — — Ground Ginger — — 3 — 3 — — Tincture of Iodine — — 1 — 1 — — Sal Volatile — 1 — 1 — — Californian Syrup of Figs — — 1 — 1 — — Compound Syrup of Figs — — — 2 — — Camphorated Oil — — 3 — 3 — — Malt Vinegar — — 1 — 1 — — Vinegar — — 2 — 2 — — Demerera Sugar — — 2 — 2 — — Icing Sugar — — 3 — 3 — — sugar — 4 4 — — Confectionery — — 10 — 10 — — Meat Pies — — 7 — 7 — — Mincemeat — — — — 3 — — Shredded Suet — — 3 — 3 — — Preserved Sausages — — 6 — 6 — — Self-raising Flour — — 10 — 10 — — Arrowroot — — 3 — 3 — — Gravy Thick — — 1 1 — — Bread 2 — — 1 6 1 16.67 Sago — — — — 1 — — Custard Powder — — 2 — 2 — — Table Jelly — — 2 2 — — Lemonade Powder — — 1 — 1 — — Fruit Squashes — — 3 — 3 — — Lime Juice Cordial — — 1 — 1 — — Lemon & Orange Squash — — 3 — 3 — — Non-alcoholic Wines — — 6 — 0 — — Brandy — — 3 — 3 — — Whiskey 1 — 12 1 13 1 7.69 — — 2 — 2 — — Gin — — 6 — 6 — — Jam — — 2 — 2 — — Fish Paste — — 7 — 7 — — Tinned Peas — — 5 — 5 — — Tinned Beans 1 — 3 1 — 1 25.00 Dried Fruit — — — — — — — Glace Cherries — — 3 — 3 — — Sponge Cake — — 6 — 6 — — Totals 550 9 451 20 1001 29 2.89 127 A sample of Condensed Machine-Skimmed Milk came under notice because of a fishy smell. This fishy smell was due to some fish-product being taken by the contributing cows. It was impossible from the analysis to say whether they had got it in the form of fish meal as food or of cod-liver oil as medicine. Either source would be quite in accordance with modern handling of cattle and the purchaser would suffer no damage. Fishy odours due to various types of food, not only for cows but also for stock being prepared for the butcher, for pigs, and for poultry, are receiving considerable attention from agricultural experts and discrimination in selection of both fish meal and cod-liver oil is reducing the incidence of the fishy taint. Instances of what is probably misunderstanding 011 the part of vendors occur from time to time; thus in a sample of Cayenne Pepper, 89% of the article was exhausted of its valuable principles. Such exhausted cayenne is commonly sold for feeding canaries but it is not the quality to which a human consumer is entitled. Attention was given to Canned Beans, in which haricot beans are packed in tomato sauce with pork (generally a small amount), because of the presence of boric acid in some imported articles (two canned in England were quite free from borates). This matter was gone into very thoroughly during consultations with the Medical Officer of Health and was left with the possible explanation that the boric acid might have been absorbed from the soil by the growing bean plants. There was no instance during the six months where objectionable or illegal colouring matters or significant amounts of poisonous metals were present. There are many other points 011 which comment could be made if desired. 128 CONTENTS. PAGK. Aged and Infirm Persons 93 Babies' Hospital 46 Bacteriological Examinations 76 Bakehouses 85 Cancer 14 Combined Drainage 82 Committees, Public Health and Maternity and Child Welfare 3 Deaths, Causes of 19 Disinfection 77 Drainage of Buildings 81 Factory and Workshops Acts 83 Female Inspector, Work of 82 Food Poisoning, Cases of 87 Food (unsound) 86 General Statistics 9 Health Propaganda 110 Home Nursing 49 Housing Conditions 98 Housing Estates 104 Ice Cream, Registration of Premises 86 Infantile Mortality 15 and 21 Infectious Diseases 23 Introduction 7 Legal Proceedings (Adulteration of Food) 87 Legal Proceedings (Sanitary and Housing) 97 Maternity and Child Welfare, Report by Dr. R. Thomson:— 32 Home Visitation 34 Notification of Births 35 129 PAGE. Maternity and Child Welfare Centres 36 Ante-Natal Clinics 37 Minor Ailments 39 Home Nursing 40 Massage , 40 Maternity Home 41 Day Nursery 42 Provision of Milk 43 Maternal Mortality 45 Maternal Mortality 17 Medical Examination of Employees 112 Milk Purveyors 90 Milk, Bacteriological Examination of 94 Miik (Special Designations) Order, 1923 91 Mortuary 78 Overcrowding 101 Preserved Food, Registration of Premises 86 Principle Diseases, Deaths from 19 Public Analyst's Report 122 Public Conveniences 98 Public Health Legislation 113 Rag Flock Acts . 93 Rat Destruction 96 Rent Restrictions Acts 93 Samples purchased for Analysis 126 Sanitary Inspection of the District 79 Slaughterhouses 85 Staff—Public Health and Maternity and Child Welfare Departments 4 Tuberculosis 50 Tuberculosis Report by Dr. P. L. T. Bennett:— 56 130 PAGE Statistics 58 Dispensary Procedure 59 Treatment, Special 60 Tuberculosis in Children 61 Home Visits 63 Institutional Treatment 64 Care Committee 65 Handicraft Class 67 Summary of Statistics 70 Vaccination 26 Vital Statistics 18