Metropolitan Borough of Fulham- ANNUAL REPORT of the Medical Officer of Health for the Year 1936- 77-75 FUL Metropolitan Borough of Fulham- ANNUAL REPORT of the Medical Officer of Health for the Year 1936- JOHN ALEXANDER SCOTT, M-D-, M-R-C-S-, L-R-C-P-, D-P-H-, Medical Officer of Health- CONTENTS- Lists of Committees concerned with work of the Department- 4 Staff of Public Health Department- 5 Section 1:—Statistics and Social Conditions of the area- 9 „ 2:—General Provision of Health Services for the area- 24 „ 3:—Sanitary circumstances of the area- 41 „ 4:—Housing- 58 „ 5:—Inspection and Supervision of Food- 67 „ 6:—Prevalence and Control over Infectious and other Diseases- 85 Index 125 Clearance Areas Keir Hardie House (Photographs) End of Section 4 3 Public Health Department, To the Mayor, Aldermen and Councillors Town Hall, of the Metropolitan Borough of Fulham- FULHAM, S-W-6- July, 1937- Mr- Mayor, Ladies and Gentlemen, I have the honour to submit the Annual Report on the health and sanitary conditions of the Borough for the year 1936- The year has been a reasonably healthy one, the most outstanding epidemiological event being the biennial outbreak of measles- The outbreak is dealt with in Section VI of the Report, the very low mortality being particularly noteworthy- I dealt at some length last year with the effect of the trend of the birth rate on the future population and the vital statistics- In the light of the comments then made the slight increase in the rate this year is therefore satisfactory- Housing work has proceeded vigorously throughout the year and Clearance Orders have been confirmed by the Ministry for areas in Field Road, Carnwath Road, Sotheron Road, Buckler's Alley, Lanfrey Place and Hawes Buildings- In addition to these, intensive preparatory work for the Avenues Redevelopment Area has been completed- I have devoted -particular attention to the analysis of the results of the overcrowding survey, the subject being discussed in Section IV of the Report- Staff Changes- Mr- W- E- Dodd, parttime Dental Surgeon to the Maternity & Child Welfare Department, resigned his appointment in February and Mr- D- K- Gaskill was appointed to the vacancy- Changes among the clerical staff include the resignation of Mr- E- Thompson, consequent upon his obtaining an appointment under the London County Council as a temporary Sanitary Inspector and the transfer of Mr- A- E- R- Scott to the position of temporary Sanitary Inspector in October- To fill the vacancies created by these resignations, two junior clerks were appointed, the other clerks being promoted to more responsible work- In June, Mr- Swinson was designated as housing administrative assistant to deal with the work involved in Clearance and Redevelopment Areas under consideration by the Council and an additional junior clerk was appointed to take over part of his general Public Health routine work- Mr- A- E- Clutterbuck, Senior Sanitary Inspector, retired on superannuation on May 31st, after 34 years of efficient and effective service, and Mr- E- Drake was promoted to the position of Senior Sanitary Inspector- To fill the vacancy of district inspector Mr- E- H- Jenkins was appointed- Mr- J- H- Crabtree resigned in May, on securing an appointment under the Holborn Borough Council, and Mr- J- W- Campbell was appointed as district inspector- In October three temporary Sanitary Inspectors were appointed to release members of the permanent inspectorial staff for duties in connection with Clearance Areas and the Overcrowding Survey under the Housing Act, 1936- On April 1st three additional Health Visitors commenced duty, Miss P- M- Bucknell, Miss A- S- Clark and Miss A- G- Fox- It is a pleasure to express my thanks to the staff for their highly efficient work, and to the Committees for their interest and support during a year that has seen the initiation of many improvements in the public health services of the Borough- I have the honour to be, Mr- Mayor, Ladies and Gentlemen, Your obedient Servant, J- A- SCOTT, Medical Officer of Health- 4 Fulham Borough Council PUBLIC HEALTH COMMITTEE, 1936-37- His Worship the Mayor (Alderman C- Lancaster, J-P-, L-C-C-) Ex-Officio- Chairman: Councillor Miss A- Gilliatt- ViceChairman: Councillor J- H- Ward- Alderman R- M- Gentry, J-P- Councillor Mrs- E- E- Hollingbery- Councillor S- F- J- Ballantyne- „ Mrs- F- Laski- R- A- Bender- ,, Mrs- J- Marsh- Dr- T- J- Bokenham- ,, J- S- Melville- P- E- Coleman- ,, Mrs- E- M- Rankin- ,, L- F- Dew- ,, Miss C- J- SketchleyH- Dodimead- MATERNITY AND CHILD WELFARE COMMITTEE, 193637- His Worship the Mayor (Alderman C- I ancaster, J-P-, L-C-C-) ExOfficio- Chairman: Councillor Mrs- J- Marsh- ViceChairman: Councillor Mrs- E- M- Rankin- Councillor H- Dodimead- Councillor Miss C- J- SketchleyMrs- E- E- Hollingbery- „ G- A- Thesiger- „ Mrs- F- Laski- * Miss S- Baber- „ Mrs- N- M- Phillips- * Mrs- R- M- French- „ Miss K- I- Pottle- * Mrs- E- M- Rae- „ W- Rankin- * Mrs- E- N- Vanderhook- * Miss C- M- L- Wickham- * Coopted Members- STAFF- Medical Officer of Health: John Alexander Scott, M-D-, M-R-C-S-, L-R-C-P-, D-P-H- (Liverpool)- Deputy Medical Officer 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)- Clinical Tuberculosis Officer and Medical Officer Borough Bacteriological Laboratory)- Assistant Medical Officers of Health: *Ruby Thomson, M-B-, Ch-B- (Edin-), D-P-H- (Edin- and Glas-), (Maternity and Child Welfare Officer)- Helena E- Barrett, B-A-, M-B-, Ch-B-, B-A-O- (N-U-I-)-, D-P-H- (Edin- and Glas-)- Edith M- P- Wilson, B-Ch-, (Camb-), M-R-C-S- (Eng-), L-R-C-P- (Lond-), (part-time)- Medical Officer, Gynaecological Clinic: Lynette Hemmant, M-A- (Camb-), M-R-C-S- (Eng-), L-R-C-P- (Lond-), (part time)- Consulting Obstetrician: Alex- Galletly, M-C-, M-B-, Ch-B- (Edin-), F-R-C-S-E- Medical Officer, Diphtheria Immunisation Clinic: Guy W- J- Bousfield, M-D-, (Lond-), M-B-, B-S- (parttime)- 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)- Dental Surgeon: *W- E- Dodd, L-D-S- (parttime)- (Resigned 31st January, 1936) *D- Gaskill, L-D-S-, R-C-S- (Eng-) (part-time)- (Appointed 1st February, 1936)- Public Analyst: Thomas McLachlan, A-C-G-F-C-, F-I-C- (part-time)- Vaccination Officer: Hugh Davies- Clerical Staff: A- T- Hurford, Chief Clerk- O- A- Lrendell, O-P-A- (Lond-)- E- J- Sharp- E- Thompson (Resigned 29th August, 1936)- S- Firsht- w- Swinson, (Housing Assistant)- J- Pasco (Appointed 4th August, 1936)- A- E- R- Scott (Reigned 5th October, 1936)- C- J- Guy (-Appointed 17th August, 1936)L- Burrows- J- E- Burton (Appointed 12th October, 1936)- 1 temporary shorthand-typist- 6 Maternity and Child Welfare: *Miss A- Drury- *Miss E- G- Goodrum- *Miss I- M- Buckingham- *Miss R- Barter- Senior Sanitary Inspector: * Albert E- Clutterbuck (Retired 31st May, 1936J*Edgar Drake (From 1st June, 1936)- Sanitary Inspectors: * Edgar Drake (promoted 1st June, 1936)- 12 *Thomas Henry Robey- 18 9 *Charles J- Price- 12 *Alex- W- Gammack- 12 * Joseph H- R- Crabtree- {Sampling Officer)- (Resigned 31st May, 1936)- 12 *frederick E- Walsh- 1 2 *L- G- Brooks- 12 *Arthur S- Jones- 1 4 5 6 *Miss Ellen H- Sexton- 15 *Henry Hutchinson- 1 2 *Eric H- Jenkins- 12 *Frederick C- Payne- (Appointed 1st May, 1936)- 12 3 *wilfred C- Turner- 1 2 *James W Campbell- (Appointed 29th June, 1936)- Health Visitors : 4 s e *mrs j Bryning- 4 5 6 7 8 *miss e y Thomas- 4 6 6 8 *miss £ Beckett- u68 *Miss N- Milburn- 4 6 6 7 *mjss 13 m Hayward- 4 8 6 *Miss P- M- Bucknell- Appointed 4 6 6 *]yiiss q Leach- 4 5 0 *Miss A- S- Clark- 1st April, 4 6 e *miss p Kaye- 4 5 0 *Miss A- G- Fox- 1936- (Infant Life Protection Visitor)- 1 4 6 *Miss A- Perrett- Tuberculosis Dispensary Staff: Nurses : 4 *Miss E- E- Walker- 4 6 e *MISS E- C- Carmichael- 4 b 6 *Miss E- M- Pretty- *Miss M- C- Robinson, Bacteriological Assistant and Dispenser*Miss M- E- Sargent, Clerk and Secretary of the Care Committee*Miss Grimstone, Clerk (parttime)- *Mr- and Mrs- Roberts, Caretakers- Maternity Home: Matron: 4 6 *Miss M- Bustard- Assistant Matron: 4 6*Miss M- Denman- 7 Disinfecting Station: Superintendent: A- V- Williams- Disinfectors: E- J- Eyles, W- Leaton, T- G- Martin- Van Driver: John Barks- Mortuary Keeper: S- Churchill- Rat Officer: J- Gigner- Housekeepers Infant Welfare Centres : Greyhound Road: *Mrs- B- Gregory- Wandsworth Bridge Road: *Mrs- M- B- Sexton- *The Council receives Exchequer grants towards the salaries of these Officers- 1 Certified Sanitary Inspector- 6 Certificate of Central Midwives Board- 2 Food Inspector's Certificate- 7 Fever Trained- 3 Smoke Abatement Certificate- 8 Queen's Nurse- 4 Trained Nurse- 9 Associate Member of Institute of 5 Health Visitor's Certificate- Sanitary Engineers- Section I- STATISTICS AND SOCIAL CONDITIONS OF THE AREA- 9 GENERAL STATISTICS- Area (acres) 1,706 Population (census 1931) 150,928 Population (mid 1936) 141,300 Number of inhabited houses (census 1931) 26,245 Rateable Value at 31st December, 1936 £1,327,199 Sum represented by a penny rate £5,138 EXTRACTS FROM VITAL STATISTICS FOR THE YEAR- LIVE BIRTHS:— Total- Males- Females- Legitimate 2,006 1,028 978 Birth rate per 1,000 Illegitimate 105 52 53 of the estimated population 14-9 STILLBIRTHS:— Legitimate 52 33 19 Rate per 1,000 total Illegitimate 3 2 1 (live and still) births 25-4 DEATHS:— 1,786 928 858 Death rate per 1,000 of the estimated population, crude rate 12-6 adjusted rate 12-7 Percentage of deaths occurring in public institutions 60-9 Rate per 1,000 total (live and still) Deaths- births- Deaths from disease and accidents of From sepsis 2 0-92 pregnancy and childbirth From other causes 2 0-92 Total 4 1-85 Death rate of Infants under One Year of Age:— All infants per 1,000 live births 64 Legitimate infants per 1,000 live births 61 Illegitimate infants per 1,000 illegitimate live births 124 Deaths from:— Cancer (all ages) 250 Measles (all ages) 14 Whooping cough (all ages) 6 Diarrhoea (under two years of age) 22 10 SOCIAL CONDITIONS- UNEMPLOYMENT- The Manager of the Local Employment Exchange has kindly supplied me with the following particulars relating to the number of persons registered as unemployed:— October, 1936- January, 1937- Adult males 1,836 2,339 Adult females 571 602 Juvenile males -22 37 Juvenile females 26 32 Totals 2,455 3,010 These show a considerable decrease compared with the corresponding periods for last year, especially in the number of males, both adult and juvenile- The figures for the females are approximately the same for October but substantially lower for January- LOCAL INDUSTRIES- The main local industries are the borough electrical power station, the gas works, a distillery, a sugar refinery, printing works, oil and petrol depots, transport and other distributive trades- A table of occupations was printed in the Annual Report for 1935- COMMENTS ON THE VITAL STATISTICS- POPULATION- The Census taken during 1931 showed that the population of the borough was 150,928 but the RegistrarGeneral's estimate of the population for the year 1936 was 141,300- This latter figure has been used for the compilation of the various rates mentioned in this report- Despite a natural increase (excess of births over deaths) of 325, the RegistrarGeneral estimates a decrease of 2,300 in the population from mid 1935 to mid 1936- MARRIAGES- The number of marriages during 1936 was 1,385 and the marriage rate (the number of marriages per 1,000 of the population) was 9-80- In the previous year the number of marriages was 1,479 and the rate was 10-29- BIRTHS- During the year the live births, corrected by the distribution of those occurring in lyingin 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 2,111, of whom 1,080 were males and 1,031 were females- The birth rate (the number of live births per 1,000 of the population) was 14-9 an increase of 1-1 compared with 1935- The birth rate tor the Metropolis was 13-6 and for England and Wales 14-8- 11 STILLBIRTHS- The number of stillbirths during 1936 was 55 compared with 65 during the previous yearThe stillbirths amounted to 25-4 per 1,000 of the total births (live and stillbirths)- The corresponding rate for England and Wales was 39-73- On the basis of stillbirths per 1,000 of the population, the local rate is 0-39 as againsit 0-61 nationally and 0-45 in the administrative county- ILLEGITIMACY- The illegitimate live births numbered 105 (52 males and 53 females) during 1930 compared with 103 for the previous year and constituted 4-9 per cent- of the total live births- DEATHS- During the year ended December 31st, 1930, 1,480 deaths were registered as having occurred in the borough- Of these, 230 were of persons not belonging to the borough, while 530 inhabitants of Eulham died outside the borough, chiefly in public institutions- There were, therefore 1,786 deaths of persons, 928 males and 858 females, having their usual residence in Eulham, representing an annual crude death rate of 12-6 per 1,000 of the population- This rate is 1-0% above that of the previous year- The death rate for England and Wales was 12-1 and for London 12-3- The "Comparability Factor" remains unchanged at 1-01 and the adjusted death rate is, therefore, 12-7- CERTIFICATION OF CAUSES OF DEATH- Of the 1,786 deaths belonging to the borough, 1,643 or 91-99 per cent-, were certified by registered medical practitioners; 75 or 4-20 per cent-, by coroners after inquests; 67 or 3-75 per cent-, by coroners without inquests, while 1 case or 0-06 per cent- was uncertified- DEATHS IN PUBLIC INSTITUTIONS- Of the deaths of Eulham persons 60-9 per cent, took place in Public Institutions- The distribution of these institutional deaths according to the type of institution was as follows:— per cent- 781 in Public Assistance Hospitals or Institutions 71-8 29 in Infectious Disease Hospitals 2-7 222 in Other Hospitals 20-4 55 in Mental Hospitals 5-1 FULHAM HOSPITAL- In this institution belonging to the London County Council there were 677 deaths of which 594 were of Fulham residents and 83 of persons residing in other districts- WESTERN HOSPITAL- This hospital, the only London County Council Infectious Disease Hospital in the borough, had 150 deaths during the year and of this number 21 were of Fulham residents while the remaining 129 were of patients admitted from other districts- 12 DEATHS OF FULHAM RESIDENTS OUTSIDE THE BOROUGH- The deaths of Fulham residents outside the borough numbered 530 and occurred in the following places:— St- George's Hospital 41 West London Hospital 24 Princess Beatrice Hospital 26 Other General Hospitals 63 Children's Hospitals 15 Women's Hospitals 7 Other Special Hospitals 31 L-C-C- Infectious Disease Hospitals 8 L-C-C- Hospitals and Institutions 187 Mental Hospitals 55 Sanatoria 15 Nursing Homes and elsewhere 58 530 ZYMOTIC DEATHS- The Zymotic death rate is that from the principal zymotic or infectious diseases, viz:— smallpox, scarlet fever, diphtheria, measles, whooping cough, epidemic diarrhoea and fevers (typhus, enteric, other or doubtful fevers)- The mortality from these diseases was higher than in 1935, 53 deaths being due to them as against 36- The death rate per 1,000 of the population was 0-38 compared with 0-25 for 1935- The increase was due to the number of deaths from measles (14 against nil)- SEASONAL MORTALITY- The number of deaths in each of the four quarters of the year was as follows: 1936 1935 First quarter 560 462 Second quarter 414 413 Third quarter 328 384 Fourth quarter 484 403 1,786 1,662 13 CAUSES OF DEATH- These are classified in Table 5, pages 19 and 20- The following table shows the number of deaths from the six commonest causes:— Disease No- of Persons Males- Females- Percentage of total deaths Death Rate per 1,000s inhabitant Heart Disease 470 208 262 26 32 3 33 Cancer 250 135 115 13 99 1 77 Respiratory diseases 213 109 104 11 93 1 51 Tuberculosis (all forms) 120 81 39 6 72 085 Cerebral haemorrhage 70 28 42 392 0 49 Chronic and acute nephritis 55 34 21 3 08 039 TOTALS 1,178 595 583 65 96 8 34 It will be seen that heart disease, as in the last seven years, heads the list; 470 deaths were due to this cause compared with 479 during 1935- Sex distribution of these deaths was 208 males and 262 females- Of the total no less than 426 occurred in persons over the age of 55 years- Cancer came next as in the last 3 years with 250 deaths, an increase of 32 on the previous year; 195 were in persons over 55- Pneumonia, bronchitis and other respiratory diseases together caused 213 deaths- The age distribution is less marked in these deaths, deaths taking place in every age group though with a preponderance in the groups aged 45 and over- Tuberculosis caused 120 deaths, of which 107 (73 males and 34 females) were from pulmonary tuberculosis- The death rate from pulmonary tuberculosis is 0-76 as compared with the national rate of 0-58- The prevention of this disease depends in the main upon good nutrition and good environmental conditions, the cure upon early diagnosis- The steady year by year fall in mortality from this cause is one of the most satisfactory achievements of public health and social work- Cerebral haemorrhage is again a disease of the elderly, only 10 of the 70 deaths occurring under the age of 55- Influenza caused 16 deaths compared with 24 in 1935- INFANTILE MORTALITY- Of the 1,786 deaths of persons of all ages belonging to the Borough, 136 or 7-61 per cent-, occurred in infants under one year of age- 14 The Infantile Mortality Rate (the number of deaths of infants under 1 year of age per 1,000 live births) was 64 as compared with 51 during 1935. The actual number of deaths was 136 compared with 100. The Infantile Mortality Rate for England and Wales was 59 and for London 66. INFANTILE MORTALITY RATE IN FULHAM SINCE 1891. Average for 5 years. Actual rate for the last 9 years. 1891-1895 168 1928 77 1896-1900 167 1929 69 1901-1905 144 1930 57 1906-1910 117 1931 67 1911-1915 109 1932 58 1916-1920 92 1933 65 1921-1925 73 1934 59 1926-1930 67 1935 51 1931-1935 60 1936 64 The following table shows the births, infantile mortality, and death rates during the last two years for the various wards in the borough. TABLE 1. Wards Birth Birth Rates Infantile deaths Infantile Mortality Rates General Death Rates 1936 1935 1936 1935 1936 1935 1936 1935 1936 1935 Baron's Court 198 185 13 1 12 .9 14 9 71 49 13.9 13.9 Lillie 323 308 15 .2 14 .1 24 21 74 68 11.8 9.9 Walham 281 269 20 .9 20 .2 19 16 67 59 12.7 13.7 Margravine 236 198 14.3 12 .2 24 11 102 56 15.3 11.5 Munster 478 431 15.1 12 .9 23 20 48 46 11.6 10.9 Hurlingham 91 105 10.8 12 .3 11 4 121 38 12.6 11.7 Sands End 319 314 14 .1 13 .8 14 9 44 29 11.7 10.2 Town 185 179 14.3 13 .4 7 10 38 56 14 .2 13.9 BOROUGH 2111 1989 14.9 13 .8 136 100 64 51 12.6 11.6 The principal causes of infantile mortality were as follows:— Prematurity 28 deaths compared with 22 in 1935. Pneumonia (all forms) 27 deaths compared with 13 in 1935. Diarrhoea and Enteritis 19 deaths compared with 13 in 1935. The increased pneumonia deaths are associated with the measles epidemic which occurred in the spring. 55 deaths (40.4 per cent., of all deaths under one year of age) occurred in infants under 4 weeks of age as compared with 42 in 1935 and 46 in 1934. 15 MATERNAL MORTALITY- The Maternal Mortality rate of 1-85 per 1,000 total births compares favourably with the similar rate for England and Wales, namely 3-81- This rate is usually low in London and the South compared with the country as a whole- The following is a list of the maternal deaths together with the causes:— Occupation- Age- Date and place of death- Cause of Death- Wife of Caterer's Watchman- 37 16th February— Hospital- Haemorrhage following abortion at three months; fifth pregnancy- Wife of Commercial Motor Driver- 32 9th May— Hospital- Purulent BronchoPneumonia following miscarriage of first pregnancy at about three months—not due to interference- Wife of Advertising Copy Writer- 37 16th June— Nursing Home- 1- (a) Pulmonary Embolism, (b) Placenta Praevia- Wife of a Clerk- 31 13th July— Hospital- 1- (a) Peritonitis- (b) Pelvic abscess, sloughing round ligament- Placenta accreta. 16 Table '2-—Vital Statistics of the Borough during 1936 and Ten preceding Years- Year- Population Estimated to Middle of each Year- Occurring in the Borough- Births- Total Deaths Registered in the Borough- Transferable Deaths- • Nett Deaths the Bo Belonging to rough- Nett Deaths uxder Nett Deaths under Zymotic Death Rate (Influenza included)- Nett. Of Non Residents registered in the Borough- Of Residents not registered in the Borough- At all Ages- Under 1 Year of Age- One Year- Five Years- Number- Rate- Number- Rate- Number- Rate per 1,000 Nett Births- Percentage of Total Nett Deaths- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 l5 1926 164,300 2,691 2,670 162 1,578 168 373 1,783 108 173 64 97 158 071 1927 161,900 2,356 2,444 151 1,588 121 366 1,833 113 162 66 88 123 054 1928 155,300 2,319 2,388 154 1,548 128 360 1,780 115 185 77 104 144 073 1929 153,700 2,328 2,502 162 1,882 157 394 2,119 137 173 69 82 135 078 1930 153,700 2,226 2,366 153 1,473 143 343 1,673 108 136 57 81 134 068 1931 151,200 2,103 2,281 1508 1,532 107 432 1,857 133 154 67 83 107 048 1932 149,600 1,842 2,137 143 1,569 202 481 1,848 124 124 58 67 107 069 1933 148,200 1,579 1,938 1308 1,531 143 538 1,926 130 126 65 65 89 089 1934 145,400 1,592 1,996 137 1,531 206 507 1,832 126 118 59 64 109 074 1935 143,600 1,653 1,989 138 1,353 129 438 1,662 116 100 51 602 76 042 1936 141,300 1,576 2,111 149 1,486 230 530 1,786 126 136 64 761 969 049 17 TABLE 3. STATISTICS 1901-1936. Year- Population. Structurally separate Dwellings (Census). Number of Private Families (Census). Average size of Family (Census). Birth Rate. Death Rate. Infant Mortality Rate. Pulmonary Tuber culosisRate 1901 137,289 (Census) 19,007 32,137 4-27 33.2 15.8 152 1.35 1902 143,102 — — — 32.9 17.1 148 1.38 1903 147,780 — — — 32.5 13.9 127 1.34 1904 152,482 — — — 32.2 15.4 153 1.43 1905 150,210 — — — 30.5 15.1 145 1.23 1900 149,520 — — — 31.9 14.8 136 1.14 1907 150,070 — — — 30.6 14.6 122 1.23 1908 151,059 — — — 31.1 14.2 115 1.22 1909 152,501 — — — 28.2 13.9 108 1.30 1910 153,100 — — — 28.1 12.5 107 1.07 1911 153,284 (Census) 20,737 36,432 4.13 26.9 14.5 126 1.45 1912 155,402 — — — 27.1 13.6 94 1.30 1913 157,117 — — — 26.9 12.7 96 1.34 1914 157,303 — — — 26.4 13.6 113 1.32 1915 153,101 — — — 24.3 15.2 115 1.29 1916 149,428 — — — 23.1 13.3 88 1.41 1917 145,180 — — — 18.4 13.7 109 1.32 1918 143,211 — — — 16.7 17.4 107 1.45 1919 152,543 — — — 18.6 12.2 83 1.01 1920 158,021 — — — 27.2 11.5 74 6.89 1921 157,944 (Census) 20,030 40,436 382 22.1 11.7 83 6.96 1922 159,500 — — 20.3 12.1 69 1.02 1923 101,000 — — — 19.3 10.5 64 6.92 1924 103,100 — — — 18.2 11.1 72 6.80 1925 103,700 — — — 16.9 10.7 76 6.92 1920 104,300 - — — 16.2 10.8 64 6.98 1927 101,900 - — — 15.1 11.3 66 6.77 1928 155,300 - — — 15.4 11.5 77 6.73 1929 153,700 - — — 16.2 13.7 69 6.90 1930 153,700 - — — 15.3 10.8 57 6.76 1931 150,928 (Census) 20,738 43,153 338 15.08 13.3 67 6.97 1932 149,000 - — — 14.3 12.4 58 6.91 1933 148,200 - — — 13.08 13.6 65 6.85 1934 145,400 - — — 13.7 12.6 59 6.77 1935 143,000 - — — 13.8 11.6 51 .78 1930 141,300 - - — 14.9 12.6 64 6.76 18 TABLE 4.—VITAL STATISTICS OF LONDON BOROUGHS, 1936. Borough. Estimated Resident Population (mid1936). Live Births Rate per 1,000 Population. Death Rate per 1,000 Population. Infantile Mortality Rate per 1,000 Live Births- Crude. Adjusted. WEST DISTRICTS- Paddington 139,200 13.8 12.98 12.81 72.0 Kensington 176,100 12.7 12.5 11.7 73.0 Hammersmith 127,700 15.1 12.5 12.9 60.0 FULHAM 141,300 14.9 12.6 12.7 64.0 Chelsea 56,500 11.3 13.7 11.6 53.0 Westminster 124,100 8.5 11.1 11.4 65.8 NORTH DISTRICTS- St- Marylebone 92,400 9.8 12.6 12.5 75.0 Hampstead 90,700 10.4 10.2 9.6 65.8 St- Pancras 183,900 13.0 13.5 13.8 79.0 Islington 304,100 15.24 12.44 12.56 61.0 Stoke Newington 50,350 13.7 11.4 10.9 44.6 Hackney 209,100 14.4 12.0 12.6 62.9 CENTRAL DISTRICTS- Holborn 34,850 8.29 11.99 12.83 62.0 Finsbury 60,800 13.8 14.0 15.3 81.0 City of London 9,100 7.5 11.4 12.65 147.0 EAST DISTRICTS- Shoreditch 85,400 14.9 12.8 14.1 75.0 Bethnal Green 96,900 13.5 12.7 14.3 98.0 Stepney 207,800 14.7 12.6 14.7 100.09 Poplar 140,300 15.0 12.5 13.8 72.0 SOUTH DISTRICTS- Southwark 152,200 14.8 13.1 — 59.0 Bermondsey 100,400 15.4 12.8 14.6 60.0 Lambeth 277,500 13.9 12.5 12.4 59.0 Battersea 145,500 14.63 13.06 12.93 59.21 Wandsworth 343,000 11.46 11.79 10.96 58.0 Camberwell 229,300 13.93 12.64 12.64 58.86 Deptford 98,900 15.7 12.2 12.6 50.0 Greenwich 95,900 13.82 11.36 11.58 49.0 Lewisham 224,000 13.0 10.8 10.9 55.0 Woolwich 146,500 13.8 11.2 11.8 59.0 LONDON, Administrative County 4,141,100 13.6 12.3 — 66.0 ENGLAND AND WALES 14.8 12.1 — 59.0 19 20 Table 5. Causes of and Ages at Death during the Year 1936. Nell deaths at the subjoined ages of "Residents," whether occurring within or without the District. totals deatjs, wheather of "Residents " or "non-residents" in Institutions in the district. Nett deaths at all ages of "Residents" in the Wards of the Borough, wherever occurring. Causes of Death. All aged Under 1 year. 1 and under 2 yean. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 35 years. 35 and under 45 years. 45 and under 55 yean. 65 and under 65 yean. 65 and under 75 yean 75 yean and upwards. Baron's Court Ward. Lille Ward. Walbam Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 All Causes Certified 1785 136 21 15 33 51 65 92 153 309 415 495 957 199 248 170 242 372 105 265 184 Uncertified 1 — — — — — - — - — — 1 — — — — — - 1 — - 1. Typhoid and paratyphoid fevers 3 - - - - 1 - - - 2 - - 3 - 1 - - — — 1 1 2. Measles 14 3 6 2 3 - - - - - - - 46 — 3 4 2 1 — 3 1 3. Scarlet Fever 1 - - - 1 — — — — — —- - 7 — 1 — — — — - — 4. Whooping Cough 6 1 1 3 — — — — — — — 1 33 2 1 — — — 1 2 — 5. Diphtheria 10 1 1 2 6 — — — — — — - 32 2 2 - 2 4 - - — 6. Influenza 16 - - - - - 1 1 2 5 2 5 — 2 2 - 2 3 1 4 2 7. Encephalitis Lethargica 2 — — — — — — 1 1 — — — 1 1 - - - - - 1 — 8. Cerebro-spinal fever 2 2 - - - - - - - - - - 1 - - - - 1 1 - - 9. Tuberculosis of respiratory system 107 — — — 1 22 24 18 19 13 8 2 44 8 15 15 14 21 3 20 11 10. Other Tuberculous diseases 13 1 — 1 1 1 2 2 1 1 2 1 8 3 2 — 1 5 1 1 — 11. Syphilis 7 1 — — 1 — 1 — 3 1 — — 1 2 — — 2 1 — 2 — 12 General paralysis of the insane 8 — — — — — — 2 1 4 1 — 4 2 2 1 — 1 - 1 1 13. Cancer, malignant disease 250 — — — — 3 — 21 31 65 83 47 170 24 36 29 27 53 15 38 28 14. Diabetes 20 — — — — — — — 2 1 11 6 8 3 3 2 4 4 1 2 1 15. Cerebral Haemorrhage, etc. 70 — — — — — — 2 8 11 26 33 40 9 12 6 7 12 7 7 10 16. Heart Disease 470 — — — 2 3 2 14 23 72 142 212 186 46 64 38 64 94 33 75 56 17. Aneurysm 6 — — — — — — - — 4 1 1 — - — 2 — 3 — 1 — 18 Other circulatory diseases 105 — — — — — 2 1 5 21 27 49 37 15 12 8 14 22 8 13 13 10. Bronchitis 62 7 1 — — — — - 2 7 13 32 21 4 8 7 12 14 2 9 6 20. Pneumonia (all forms) 135 27 7 2 — 4 4 6 15 29 16 25 78 19 15 18 19 30 12 13 9 21. Other respiratory diseases 16 — — — — 1 2 — 3 6 2 2 8 2 4 — 1 4 2 2 1 22. Peptic ulcer 24 — — — — - 2 2 5 5 8 2 11 1 5 1 2 7 - 5 3 23. Diarrhoea, etc. 22 19 2 — — - 1 - — — — — 41 2 3 4 3 4 - 4 2 24. Appendicitis 12 — — — 2 1 2 1 — 2 2 2 8 — — 1 1 2 - 6 2 25. Cirrhosis of Liver 6 — — — — - — 1 1 2 1 1 2 — 3 - 1 - 1 - 1 26. Other diseases of liver, etc 7 - - - - - - - 1 2 4 - 2 2 — - 2 - - 2 1 27. Other digestive diseases 26 1 — 1 1 2 1 2 3 6 4 5 11 2 3 4 7 3 1 5 1 28 Acute and chronic nephritis 55 — — — 3 — 5 — 7 14 17 9 21 11 5 2 7 14 2 8 6 29. Puerperal Sepsis 2 — — — — — 2 — — — — — 1 - - - - - - 1 1 30 Other puerperal causes 2 — — — — — — 2 — — — — 1 1 — - - 1 - - - 31. Congenital debility, premature birth, malformations, etc 66 66 _ - - - - - - - - - 29 6 14 3 17 13 4 6 3 32. Senility 35 — — — — — — — — — 6 29 17 5 7 2 4 7 2 5 3 33. Suicide 8 — — — — — 3 1 2 2 — - — 2 - 3' - 1 - 2 - 34. Other violence 48 2 2 1 5 3 5 3 2 12 6 7 20 7 4 9 9 10 1 8 - 36. Other defined causes 150 5 1 3 7 10 6 12 16 22 33 35 65 10 21 11 18 37 8 18 21 30. Causes ill-defined or unknown - - - - - - - - - - - - - - - - - - - - - Total 1786 136 21 15 33 51 65 92 153 309 415 496 957 199 248 170 242 372 106 265 184 21 22 Table 6. Infant Mortality during Year 1936. Nett Deaths from slated causes at various ages under One Year ot Age. Nett Deaths under One Year in Wards. Causes of Death. Under 1 Week. 1—2 Weeks. 1—3 Weeks. 3—4 Weeks. Total under 4 Weeks. 4 Weeks and under Months and under 6 Months. 6 Months and under 9 Months and under Total Deaths under One Year. Baron's Court Ward. Lille Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. All Causes Certified 40 4 5 6 55 26 27 16 12 136 14 24 19 24 23 11 14 7 Uncertified - - - - - - - - - - - - - - - - - - 1. Small-pox - - - - - - - - - - - - - - - - - - 2. Chicken-pox - - - - - - - - - - - - - - - - - - 3. Measles — — — — — — — 1 2 3 - 1 1 1 - - - - 4. Scarlet Fever - - - - - - - - - - - - - - - - - - 5. Whooping Cough — - — — — — - - 1 1 — 1 - - - - - - 6. Diphtheria and Croup — — — - — — — 1 — 1 — 1 — — — — — — 7. Erysipelas - - - - - - - - - - - - - - - - - - 8. Tuberculous Meningitis — - — — — — — — - — — — — — — — — 9. Abdominal Tuberculosis - - - - - - - - - - - - - - - - - - 10. Other Tuberculous Diseases - - - - - - 1 - - 1 - - - 1 - - - - 11. Meningitis (not Tuberculous) - — - — — — 2 - 2 4 - — - 1 1 2 - - 12. convulsions - - - - - - - - - - - - - - - - - - 13. Laryngitis - - - - - - - - - - - - - - - - - - 14. Bronchitis and Pneumonia 3 - 2 2 7 5 9 8 4 33 4 3 5 5 5 5 3 3 15. Influenza - - - - - - - - - - - - - - - - - - 16. Gastro-Entcritis and Diarrhoea — — — — — 7 5 4 3 19 2 3 4 3 3 - 3 1 17. Syphilis - - - 1 1 - - - - 1 - - - - - - 1 - 18. Rickets - - - - - - - - - - - - - - - - - - 19. Suffocation, overlaying - - - - - - - - - - - - - - - - - - 20. Injury by Birth 8 1 — — 9 - - - - 9 3 2 - - 1 1 2 — 21. Atelectasis 4 — — — 4 - 1 - - 5 1 2 1 - - 1 - - 22. Congenital Malformations 6 —| — — 6 4 2 - - 12 3 3 1 2 1 - - 2 23. Premature Birth, Debility and Marasmus, etc. 15 3 - 3 21 5 2 - - 28 1 6 2 11 4 1 2 1 24. Other Causes 4 — 3 — 7 5 5 2 — 19 — 2 5 — 8 1 3 — Total 40 4 5 6 55 26 27 16 2 136 14 24 19 24 23 11 14 7 Section II. GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. 24 STAFF. A full list of the staff of the Health Department appears at the beginning of this report. LABORATORY FACILITIES. The Council's Laboratory is situated at the Dispensary, 114, New King's Road. It is equipped for all routine bacteriological work and during the year 3,330 specimens were examined. Arrangements have also been made with the Clinical Research Association for the examination of specimens during week-ends, holidays and emergencies, 454 specimens being reported on during the year. The following classification details the specimens examined:— Material from cases of suspected Diphtheria:— Diphtheria isolated 86 Negative Result 1,684 1,770 Blood from cases of Enteric Fever:— Agglutination reaction for Typhoid or Para- Typhoid obtained 1 Negative Result 4 5 Pathological Specimens for Enteric Organisms:— Positive result — Negative result 12 12 Sputa from cases of suspected Tuberculosis: — Tubercle bacilli found 340 Tubercle bacilli not found 1,342 1,682 Swabs from suspected Gonorrhoea: — Gonococcus found 2 Gonococcus not found 76 78 Examinations of Urine 92 Blood Counts 2 Throat Swabs, Haemolytic Streps, etc. 60 Examinations of Ice Cream 20 Examinations of Water 8 Other Examinations 21 Special Examinations of:— Sputa 9 Urine 25 34 Total Number of Examinations 3,784 AMBULANCE FACILITIES. This service is under the control of the London County Council, a depot being situated in the Borough at the Western Hospital, Seagrave Road. 25 NURSING IN THE HOME. Certain types of cases requiring home nursing treatment are visited on behalf of the Council by the Fulham District Nursing Association at a cost of one shilling per visit. A table showing the number and type of visits is given below. The District Nursing Association employs twelve full-time nurses and besides nursing cases in tluir own homes provides attendance and home visits in connection with the School Treatment Centres at Bagley's Lane and Bishop Creighton House. A treatment room is also available at the headquarters of the local Association. TABLE 7. HOME NURSING BY THE FULHAM NURSING ASSOCIATION ON BEHALF OF THE FULHAM BOROUGH COUNCIL, 1030. Illness. Jan. to Mar. April to June . July to Sept.. Oct. to Dec. TOTALS Cases Visits Cases Visits Cases Visits Cases Visits Cases Visits ()phthalmia Neonatorum — - - - 3 78 1 3 4 81 Mammary Abscess and Inflamed Breasts 3 37 1 4 4 53 - - 8 94 Ante-Natal 7 47 2 15 5 65 3 20 17 147 Post Parturition — — 7 122 2 12 3 75 12 209 Discharging Eyes 17 187 15 209 8 93 7 74 47 563 Mastitis 5 44 3 10 7 59 6 115 21 234 Wet Cord 15 119 6 55 2 35 1 16 24 225 Prematurity 1 7 — — - - 2 36 3 43 Otorrhcea — — 1 5 3 47 5 37 9 89 Menorrhagia — — — — - - 1 7 1 7 Diarrhoea — — 2 23 - - - - 2 23 Constipation 1 7 2 8 - - 4 23 7 38 Debility 11 73 3 12 - - 1 4 15 89 Worms 1 5 3 19 1 8 - - 5 32 Conjunctivitis - — 1 46 - - - - 1 46 Thrush 6 29 1 13 - - - - 7 42 Sore Buttocks 1 13 - - 1 4 - - 2 17 Pemphigus — — 2 29 - - 1 7 3 36 Pneumonia 19 231 9 141 11 168 22 309 61 849 Broncho-pneumonia 26 305 3 52 - - 26 565 55 982 Influenza 7 99 3 24 - - 11 103 21 226 Pleurisy 1 8 - - - - - - 1 8 Chicken Pox 1 17 1 5 - - - - 2 22 Scarlet Fever — - 1 5 - - 1 4 2 9 Diphtheria — - 1 2 - - - - 1 2 Whooping Cough — - - — 2 28 - - 2 28 Tuberculosis — - - — — - 10 298 10 298 Measles 35 435 36 375 1 9 - - 72 819 Erysipelas — — — 2 4 - - 2 4 Enteritis — — 1 14 - - 1 10 2 24 Septic Spots — — 4 42 2 20 - - 6 62 Burns 2 15 - - - - 2 14 4 29 Abscess of Arm 1 4 - - - - - - 1 4 Rash - - 1 9 - - - - 1 9 Rhinitis - - 1 8 - - - - 1 8 Thrombosis - - - - 1 3 - - 1 3 Bleeding after teeth extraction - - - - 1 3 - - 1 3 Eczema - - - - 1 11 - - 1 11 Stomatitis - - - - 1 6 - - 1 6 Boils - - — — - - 2 20 2 20 TOTALS 100 1,742 110 1,253 58 706 110 1,740 438 5,441 26 CLINIC AND TREATMENT CENTRES. The following is the list of clinics in the borough. There are, in addition, school treatment centres controlled by Voluntary Committees at Bagley's Lane and Bishop Creighton House, Lillie Road. Clinics. Address. Hours. Provided by. ANTE-NATAL 90 2, Greyhound Road. Mondays—2 p.m. Fridays—10.30 a.m. Borough Council. 170, Wandsworth Bridge Road. Fridays—2 p.m. ditto. INFANT WELFARE 90/2, Greyhound Road. Wednesdays and Thursdays— 10.30 a.m. and 2 p.m. Tuesday—10.30 a.m. ditto. 170, Wandsworth Bridge Road. Mondays, Tuesdays and Wednesdays—2 p.m. ditto. Melmoth Hall, Eustace Road. Tuesdays and Thursdays—2 p.m. ditto. TODDLERS 170, Wandsworth Bridge Road. Tuesdays—11 a.m. ditto. BREAST FEEDING 90/2, Greyhound Road Thursdays—2 p.m. ditto. DENTAL (expectant and nursing mothers and children under 5 years) 90/2, Greyhound Road. Fridays—2 p.m. ditto. GYNAECOLOGICAL 90/2, Greyhound Road. ( Tuesdays—2 p.m. ditto. MASSAGE Bishop Creighton House, Lillie Road. Fridays—9.20 a.m. Voluntary. TUBERCULOSIS DISPENSARY 114, New King's Road. Mondays—10 to 11.30 a.m. (Women and young children). Mondays—1.45 to 3 p.m. (School children). Tuesdays—10 to 11.30 a.m. (Men—old and new cases). Tuesdays—6 to 7.30 p.m. (Men and Women workers). Wednesdays—10 to 11.30 a.m. (Women—old and new cases). Thursdays—1.45 to 3 p.m. (Children—old and new cases). Borough Council. DIPHTHERIA IMMUNISATION 170, Wandsworth Bridge Road. Thursdays—2 p.m. ditto. 27 HOSPITALS. (a) GENERAL: There are no voluntary general hospitals in the borough, the needs of the district in this respect being fully met by Fulham Hospital, which is under the control of the London County Council Public Health Committee and has 555 beds (410 for medical, 64 for surgical, 12 for maternity, 10 for V.D., 19 for isolation, 14 for psychiatric, 22 for tuberculosis cases and 4 for sick members of the staff). Of these beds, 73 are reserved for children. (b) CHILDREN AND INFANTS: The Fulham Babies' Hospital is controlled by a voluntary committee, an annual grant being made by the Borough Council, who also provide the medical staff. It contains 21 beds and during the year admitted 121 patients, the average daily number of beds occupied being 12.9. This hospital works in the closest co-operation with the child welfare service and renders particularly valuable services in dealing with cases of difficult nutrition. (c) INFECTIOUS DISEASES: There is one hospital for infectious diseases in the borough, the Western Hospital, Seagrave Road, which is under the control of the London County Council and contains 479 beds. HEALTH PROPAGANDA. During the early part of the year a series of five lectures, all illustrated with films was given at the Central Library:— Date. Title of Lecture. Lecturer. February 17th Prevention of Diphtheria. Dr. Scott. March 2nd A Housing Evil—the Bed Bug. Dr. Scott. March 16th Social Hygiene (for Men). Dr. Scott. April 6th Tuberculosis and its Prevention. Dr. Bennett. April 20th Social Hygiene (for Women). Dr. N. Dancy. In addition three lectures on Diphtheria, all illustrated with the film "The Empty Bed," were given at various halls in the Borough: — March 23rd at St. James' Church Hall. November 12th at Princess Beatrice Social Centre. December 17th at Bishop Creighton House. 28 The British Social Hygiene Council have continued their propaganda work in the Borough and, besides assisting at the two lectures at the Central Library, held the following meetings during the year: — SINGLE LECTURES. Date. Place. Speaker. Film. Attendance. OPEN-AIR MEETINGS. June 10th Walharn Grove Captain Buckler. - 20 July 8th Walham Grove Captain Buckler. - 30 September 16th. Walharn Grove Captain Buckler. - 60 110 MEN. February 17th Sh'ell-Mex. Mr. Lucas Phillips. Trial for Marriage. 330 March 11th British Vacuum Cleaner Co. Mr. Lucas Phillips. Any livening affer work. 150 September 7th A.M.B Club. Captain Buckler. — 50 September 8th Munster Roatd Social Club Captain Buckler. — 50 580 WOMEN. March 4th. British Vacuum Cleaner Co. Miss Bennett Growing Up. 90 COURSES OF LECTURES. November 26th, December 3rd, December 10th.—Course of 3 lectures at Princess Beatrice Welfare Centre. Speaker Mrs M. C. Hume. Average Attendance 50 ANALYSIS. Total No. of Meetings :— 11 Total Attendance 830. 29 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 of the Department. The work of the Maternity and Child Welfare Department has been considerably extended during the year 1936. Dr. Barrett acted for me until 13th January, when 1 resumed duty. Dr. Louise Matheson, however, continued to attend some of the Infant Welfare sessions until Easter, when I undertook full duty. To meet the necessity for extra medical work at the clinics, Dr. Edith Wilson, who had previously acted as a locum tenens in the Department, was appointed in November to act as Medical Officer at one Infant Welfare session weekly at Eustace i i. . Road clinic. In May, the Council decided to inaugurate a gynaecological clinic at Greyhound Road on one afternoon weekly. To this clinic any married woman in the district may go when in need of any advice on the diseases peculiar to women; and the Medical Officer advises medically, or on birth control, according to the necessities of the case and with due regard to conditions laid down by the Ministry of Health in a memorandum on the subject. Dr. Lynette Hemmant was appointed to be Medical Officer for this clinic. An investigation was commenced in Fulham in August on the nutrition of expectant and nursing mothers attending Greyhound Road clinic. We were fortunate in obtaining the voluntary services of Dr. Lilli Meyer-Wedell, late of Hamburg, for the scientific side of the work, while 1 do the clinical work. Dr. Meyer-Wedell has spent an aggregate of approximately eighteen hours in the Borough every week doing this work, attending at Greyhound Road, or at the Maternity Home when her patients were there. Work of this kind is being undertaken in different parts of the country; and the information obtained will be of great value to future Maternity and Child Welfare arrangements throughout the country. Mr. Dodd who had been dental surgeon in the department for several years retired in January and his place was taken by Mr D. K. Gaskill, L.D.S. HEALTH VISITORS. In April three additions were made to the Health Visiting staff, so that there are now ten Health Visitors, each of whom is responsible for visiting one-tenth of the Borough. The more highly trained the Health Visitor, and the more vivid her personality, the more effective is the work of Maternity and Child Welfare in any area. The first contact of the majority of mothers with Public Health activities is usually made through the Health Visitors. As; the Health Visitor has no "right of entry" into any house, it, in a large measure, depends upon her persuasive powers as to whether or not the mothers in her district keep their children under regular medical supervision. It should be mentioned that little difficulty is encountered locally in getting into any house. The Health Visitors come and go as friends of the family, and they are appealed to for advice on very many subjects. The qualifications, training and special experience of the Health Visitors were fully described in last year's Report. 30 The whole department is controlled by the provisions of the Maternity and Child Welfare Act, 1918, and the Public Health (London) Act, 1936; and a large proportion of the work of the Health Visitors is directly dependent on the Notification of Births Acts, 1907 and 1915, which make compulsory the notification of every birth to the Medical Officer of Health within thirty-six hours. The Health Visitor calls as soon as the period of attendance by the doctor or midwife has ended. Advice is given on the general management of all children under five years of age, and where there is an infant the importance of breast-feeding is stressed. Anything which may affect the well-being of the home is a concern of the Health Visitor; and mothers are encouraged to place their children under regular medical supervision, through the Welfare Centres or otherwise. 'ihe question of the importance of breast-feeding is continually urged in the home and at the clinic; and yet there is a large proportion of mothers who, for no physical reason, persist m putting their babies on artificial foods. There may be many contributory causes for this; but it is a matter which gives rise to grave concern on the part of the Maternity and Child Welfare staff. The Health Visitors visit all cases of ophthalmia neonatorum, puerperal fever and puerperal pyrexia; all cases of measles (which is notifiable in this Borough) in children under the age of five years; all antenatal cases brought to oar notice; cases of pneumonia in children under five ^ears; and epidemic diarrhoea;—and give such advice in these cases as may be desirable. The Health Visitors also visit pregnant women in the Borough who are booked to enter maternity wards of hospitals. The hospital Almoners send lists of such cases; and by this means the department gets into touch with many pregnant women who would otherwise remain unknown. The following table illustrates the wide scope of their work:— Visits to cases of stillbirths 25 First visits to infants under one month 1,851 Re-visits to infants under one month 562 First visits to infants aged one to twelve months 108 Re-visits to infants aged one to twelve months 7,540 First visits to infants aged one to two years 63 Re-visits to infants aged one to two years 4,455 First visits to infants aged two to five years 88 Re-visits to infants aged two to five years 9,595 Visits to children over five years of age:— Removal from Infant Welfare Register 257 Measles 144 Convalescent Homes 50 Throat swabs, etc. 29 Diphtheria Immunisation Clinic 32 First visits to Antenatal cases 1,432 Re-visits to Antenatal cases 1,078 Visits to Puerperal Fever cases 10 Visits to Puerperal Pyrexia cases 19 Enquiries concerning maternal deaths and other visits 8 Total Effective Visits 27,346 "No replies" 4,152 Total Visits 31,498 31 ANALYSIS OF SPECIAL VISITS TO INFANTS UNDER FIVE YEARS OF AGE. Measles 737 Ophthalmia Neonatorum 20 Pneumonia 20 Epidemic Diarrhœa 3 Chicken Pox 9 Whooping Cough 1 In addition to their work in the homes, the Health Visitors systematically attend at the various Centres during the medical sessions for the control and management of the clinics. INFANT LIFE PROTECTION VISITOR. In April, 1933, under an Order of the Minister of Health, the supervision of all fostermothers in Fulham was transferred from the London County Council to the Borough Council. Fvery foster-mother in the Borough is now required to be approved as such by the Council as the local authority. At the end of the year there were 87 foster-mothers with 116 children in their care. The Infant Life Protection Visitor paid 1605 visits to foster-mothers and inspected 1991 children at such visits. In addition 231 special visits were made and 567 visits were made to cases of measles. There was a scarcity of foster-mothers during the year. The Department would be glad to hear of suitable candidates for approval as foster-mothers, as there are more applications for their services than can be met. The duties of the Infant Protection Visitor are closely associated with those of the Health Visitors, and foster-mothers are urged to bring their charges to the Infant Welfare Centres, that they may be under regular medical supervision. Close co-operation is also maintained between the Infant Life Protection Visitor and the School Authorities, as her duties relate to children between birth and the age of nine years. The Visitor possesses the "right of entry," and may visit at night as well as by day, when necessary. The Maternity and Child Welfare Department also maintains touch with the National Society for the Prevention of Cruelty to Children. NOTIFICATIONS OF BIRTH. The Birth Rate was again slightly higher last year (14.9 compared with 13.8 in 1935). Under the Notification of Births Acts, "2078 births were notified to the Department during the year, oi which 52 were stillborn. The number of births notified by midwives was 1902, and by doctors and parents 176. The stillbirths equalled 2.6 per cent, of the notified births. MATERNITY AND CHILD WELFARE CENTRES. There are three Maternity and Child Welfare Centres in the Borough, viz:—90/92, Greyhound Road; 170, Wandsworth Bridge Road; and at Melmoth Hall, Eustace Road; all of which are attended by the Medical Officers in this Department. The times of the sessions are detailed on page 26. The total attendances at the clinics increased by 3,325, and the first attendances of children under one year of age represented 56 per cent, ol the notified live births. 32 The following table shows the attendances at the Infant Clinics during the year 1936: — Clinic. Number of Clinics held. First attendance of babies Total Attendances. Age in years 0—1 1—5 0—1 1—5 92, Greyhound Road 257 557 92 7722 *4389 170, Wandsworth Bridge Road 148 331 52 4810 2507 Melmoth Hall, Eustace Road 95 256 60 4075 2387 TOTALS 500 1144 204 16607 9283 * Includes attendances made by Toddlers at special clinic (402)—47 sessions. In 1935 the experiment was tried of issuing dried milk during the clinic sessions at the Greyhound Road Centre for mothers in that district, instead of at the Town Hall. The experiment proved successful, and was instituted at all the clinics, so that no milk is now issued at the Town Hall. This system is not entirely without disadvantages, but it is working well. As all mothers buying milk at cost price now attend the Centres, children are brought for medical supervision who might otherwise remain without it. The percentage of children under the age of one year attending the clinics is still far below what it ought to be; and we know that a great proportion of those children who do not attend the clinics have no medical supervision except in illness. The area of the Borough is such that, with the Infant Welfare Centres situated as they are, no mother has a very great distance to walk with her child in order to attend at a Centre; and it would be well for the Borough if mothers realised the importance of medical supervision for the apparently healthy child. Fewer defects would remain to be detected when the children are compulsorily examined by the Education Authorities, and less curative treatment would be required during school life. Here as elsewhere, prevention is better than cure. The General Practitioner has neither time nor opportunity for this work; whereas, on the other hand, the clinics are not concerned with the treatment of sick children. Again I would stress that supervision of the pregnant and nursing mother is the foundation o' the whole edifice of Maternity and Child Welfare work. In Fulham since 1919 special cards have been used at the clinics for recording the history of nursing mothers, while pregnant women attend at separate sessions. Upon the mother depends greatly the contentment and well-being of the family, and at the Centres great emphasis is laid on this point. The presence in the Borough of open spaces such as Eelbrook Common, Parson's Green, the Recreation Ground, South Park and Bishop's Park, definitely contributes towards the same end. The organised games which have been continued in the Parks during the year are a means of reassuring the mothers of their children's safety and happiness while away from school and out of their sight. Legislation continues to extend the boundaries of Maternity and Child Welfare work, and the Maternity and Child Welfare Staff never seems big enough to meet all the demands. I should like to place on record my deep appreciation of the loyal services of both the Health Visiting and the Clerical staffs. 33 I am glad that the clinics still retain the generous services of our Voluntary Workers, some of whom have attended regularly for many years, and to them we would express our sincere gratitude; they help to ensure the smooth running of the clinic sessions. The members of the Fulham Free Church Women's Guild continue to provide tea and biscuits at a nominal cost for mothers attending the Centres, and their services are much appreciated. Three antenatal sessions are held each week, a morning and an afternoon session at Greyhound Road conducted by myself, and an afternoon session at Wandsworth Bridge Road conducted by Dr. Barrett. The public mind is becoming yearly more conscious of the importance of regular medical supervision of pregnancy, and the demand for this, and for the hospitalisation of labour, increases; but there is much to be done yet to spread tho conviction that every pregnant woman should have medical supervision from early pregnancy, whether she intends to have the services of a doctor at the actual confinement or not. The accidents and risks of child birth are every year greater than they should be, and pregnant women can do so much to reduce this risk if they will only obtain for themselves proper antenatal supervision. The antenatal clinics are intended primarily for supervision with a view to the occurrence of a safe confinement. It is the duty of Medical Officers of antenatal clinics to satisfy themselves that any abnormalities are known and provided against, and that ever}' woman attending has made suitable arrangements for the proper conduct of her confinement. A close co-operation h maintained between the clinics and the doctors or midwives concerned with all cases; and v.ritten reports are sent when necessary. All patients who are booked for their confinements in the Council's Maternity Home are required to attend at the antenatal clinics. It will be seen from the following table that the actual number of new patients attending has considerably increased from 1935. Quite a number, however, make only a single attendance, on account of their being referred to hospitals and attending the antenatal clinics there; others are sent by hospitals to obtain grants of milk or dinners, and since such patients continue under the observation of the hospital doctors, only one attendance may be registered. It does not seem to be understood as widely as it should be, that any expectant mother in the Borough who is attending an antenatal department of a hospital may attend as well the Borough antenatal clinics to avail herself of the various activities of the Fulham antenatal clinics. ANTENATAL CLINICS. The following is a record of the work done at the antenatal clinics during 1936:— Clinic No. of Sessions. No. of New Patients. Total No. of Attendances. 92, Greyhound Road. 97 290 401 1736 170, Wandsworth Bridge Road 50 147 177 890 TOTALS 147 437 578 2626 34 It may be mentioned here that a stock of maternity outfits is maintained at the Town Hall and Centres. Each parcel contains all sterilised dressings, etc., likely to be required for use at a confinement in a private house, and may be obtained by any expectant mother or midwife at a cost of four shillings. OPHTHALMIA NEONATORUM. Ophthalmia Neonatorum—infiamation in 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 at the time of birth unless careful precautions are taken. When a midwife is in charge of a case, any eye discharge occurring in the infant is required to be notified by her to her local supervising authority, which in London is the London County Council; she must also call in a doctor who, if necessary, notifies the Medical Officer of Health. When a case of this kind is notified, the Health Visitor calls immediately, and any necessary treatment is arranged for. EYE AND SKIN DEFECTS. Cases of eye defects in mothers and children are dealt with by the London County Council oculist, and this is a convenience to the mothers. Children who attend the clinics regularly are referred to the London County Council local School Treatment Centres, when they are found to be suffering from any skin condition requiring attention. No contagious or infectious disease is allowed in the clinics. MASSAGE CLINIC. Cordial appreciation and thanks are again due to Miss Christian Wickham, for her continued help in carrying out massage treatment which is undertaken, as previously, two mornings each week at Bishop Creighton House. DENTAL CLINIC. One dental session is held weekly at Greyhound Road, and work is increasing slowly but surely. During the year the Council gave dental assistance in 26 cases, in some instances giving completely free dentures to clinic mothers. During the year 290 new cases attended, making 967 total attendances; 207 extractions and 25 fillings were carried out, 32 dentures also being supplied. 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 one shilling per visit 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. 35 Miss Watson has been succeeded as Superintendent of the District Nurses by Miss Browning, her Chief Assistant, and to both I would express thanks for their loyal co-operation and assistance in the work of the Department. 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. No antenatal beds are provided. The primary purpose of the Home is to ensure that mothers whose own homes arc not suitable or convenient for their confinements should have such privacy and proper attention as is desirable. It may be mentioned here that a new Maternity Home and Health Centre is in course of erection at Parson's Green, and this will greatly extend the possibilities of the work of this Department. The Council's arrangements for this are already well in hand, and will be described in next year's Report. The new Maternity Home will be provided with antenatal beds—a welcome addition to our present facilities. The Staff from the Maternity Home attend at the antenatal clinics to receive their practical training in antenatal work. The Maternity Home is recognised as a training school by the Central Midwives Board, and trained nurses are prepared for the certificate of that Board. The following is a record of the work done at the Maternity Home during 1936: — Cases admitted 225 Average duration of stay (days) 14 Number of cases notified as Puerperal Pyrexia 1 Number of cases notified as Ophthalmia Neonatorum 3 Number of cases of Infectious disease - Number of infants not entirely breast-fed while in the institution — Number of maternal deaths — Number of foetal deaths (stillborn or within ten days of birth) 7 The highest fee charged during 1936/37 was £9: 10: 0d., for the two weeks, and the average fee charged was €3: 9: 3d. The cost per patient per week to the Council before deduction of patients' fees was £3: 14: 5d., for the financial year 1936/37. DAY NURSERY. The Fulham Day Nursery is situated at Eridge House, Fulham Park Road, S.W.6, 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 thr- services of myself and the Assistant Medical Officer for Maternity and Child Welfare as Medical Officers. The institution is visited by one or other of us five times weekly Children are admitted to the Nursery between the ages of six weeks and five years; 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. 36 In every case the Matron receives a home report of the circumstances of the child; and these reports made by the Health Visitors are most useful. Breast-feeding is not only encouraged, but insisted upon where possible, if only partially. All the feeding of infants is done on the principle of the use of breast standard milk, and the older children get a well balanced diet. An open-air life is rigidly followed; and an old army hut in the garden makes it possible for the children to be out of doors in winter and summer, although they are never allowed out when there is fog. The Day Nursery is affiliated to the National Society of Day Nurseries, 117, Piccadilly, W.l. Ciiris of over sixteen are received for a year's training. After examination certificates of proficiency are granted by the National Society. Some of the girls become children's nursery nurses, and others proceed to hospital training. The following are the figures showing the attendances at the Day Nursery during 1936: — Individual children under 3 years 113 Individual children over 3 years 16 WHOLE DAYS:— Attendances under 3 years 5050 Attendances over 3 years 1594 6644 HALF DAYS: — Attendances under 3 years 1300 Attendances over 3 years 139 1439 8083 Average number of attendances per day 30.7 SUPPLY OF MILK. Under the provisions of the Maternity and Child Welfare Act, 1918, milk may be supplied free to necessitous nursing and expectant mothers and to children under three years of age. In certain circumstances also milk is granted to children between the ages of three and five years. The Local Authority is required by the regulations of the Ministry of Health to ascertain that need actually exists; and a special Visitor visits the homes of applicants and reports on the home circumstances, while the ordinary reports of the Health Visitors are also available for reference. A special Milk Sub-Committee of the Maternity and Child Welfare Committee meets every week to consider applications and make grants. The approximate cost of the milk granted free or at less than cost price during 1936 was: — Dried milk £459 18 6 Wet milk £246 1 8 £705 19 9 37 Milk is also sold at cost price in cases recommeded by the Medical Officers, Health Visitors or any local practitioner or hospital Medical Officer. During 193G under this part of the scheme 5,958 lbs. of dried milk were supplied at a cosi to the families of £570: 18: 6d., as compared with 5071 lbs. at a cost of £401 10s. lOd. during the previous year. Under the arrangements made with the Public Assistance Committee of the London County Council, dried milk is given in exchange for relief tickets in certain cases; and during the year 290 lbs. of dried milk were so issued at a cost to the Committee of £24: 9: 4d. The Borough Council supplies a full-cream or humanised dried milk prepared by the spray method and similar preparations dried by the roller process. It is found that where one type of milk does not suit a child, almost invariably the other form will prove digestible. The digestibility of either form of dried milk is greater than that of wet milk. The heating of milk in the process of drying somwhat alters the vitamin-content of it; but this is easily and completely made good by the addition of a small quantity of fresh fruit juice daily to the infant's food. Every mother whose infant is receiving dried milk at the clinics is carefully and repeatedly instructed by the doctor:;-, and health visitors in reference to this matter. Experience confirms me in views I have expressed strongly in previous Reports, that dried milk and not wet milk should be supplied practically exclusively in the Infant Welfare clinics; and this is my personal practice in the sessions that I myself conduct. My reason for this attitude is that it is difficult in any circumstances to maintain fresh milk in a pure condition. In the absence of proper precautions there is a continuous liability to the contamination of wet milk by dust and flies carrying germs of disease, such, for instance, as cause the diarrhoea of young infants, so frequently fatal. The probability of such dangerous contamination is greatly less when dried milk is used. Another consideration that weighs with me is, that the composition of cow's milk differs from that of human milk; and the modification necessary to render it a suitable food for human infants cannot be looked for in the circumstances of many of those attending the clinics. I am of the opinion that the reduction of infant mortality in this Borough and throughout the country, especially in the large cities, has been to some extent contributed to by the wider use of dried milk and the consequent elimination of some of the causes of illness in very young children. Still another consideration may be referred to; the curd formed in the stomach from milk made from the dried powder is lighter and more easily digested than that resulting from the ingestion of wet milk. Experience has proved conclusively that children fed on dried milk with the addition of a little fresh fruit juice, as above described, can be reared successfully. Medical research has proved the importance of a due regard to the question of anaemia in the mothers and babies of this country. For many years we have met this necessity by distributing dried milk powder with which a mild preparation of iron has been incorporated or by using Iron and Ammonia Citrate tablets. CHARITABLE ORGANISATIONS. The Charity Organisation Society, the Invalid Children's Aid Association and the Invalid Kitchens of London have continued their helpful co-operation. The last-named conducts its local activities at Bishop Creighton House. 38 Dinners are provided also by the Council at the Centre at 170, Wandsworth Bridge Road, the food being prepared on the premises by the housekeeper. In this way, both the north and the south parts of the Borough have equal facilities for the supply of dinners, as the arrangement with the Invalid Kitchens of London to supply dinners at the cost of the Council still continues at Bishop Creighton House. Each year the Women's Holiday Fund sends away for a fortnight many mothers who would otherwise be unable to get away from home responsibilities. The women who are thus sent to the country or to the seaside are expected to contribute to the cost as they may be able. They begin to save from the early spring for these holidays, and the joy of anticipation adds to the value of the holiday itself. MATERNAL MORTALITY. The Maternity and Child Welfare Department investigates all cases in which women have died during pregnancy, at childbirth or during the puerperium. Details of maternal deaths are given on page 15. 39 BABIES' HOSPITAL. The Fulham Babies' Hosptial is under the control of a Voluntary Committee on which the Borough Council is represented. The type of ease in which the hospital is mainly interested is that in which there are nutritional difficulties, but rickets, pneumonia, bronchitis, anaemia and certain post-operative conditions are also treated. The hospital is an invaluable adjunct to the child welfare services at whose request the majority of the children are admitted, and has been an important factor in reducing infant mortality. The medical staff is provided from the medical officers of the Borough Council. The medical statistics for 1936 were as follows: — Cases admitted: 121. Clinic cases 99 General Practitioners 22—this number includes 5 from other districts. Average daily number in Hospital 12.9 Average duration of stay 38.9 days. In Hospital January 1st nil—closed for fumigation. In Hospital December 31st 14 Reasons for admission: Anaemia 3 Injury to knee 1 Bronchitis 9 Indigestion 1 Broncho Pneumonia 7 Loss of weight 13 Bronchial Catarrh 13 Marasmus 10 Constipation 2 Otitis Media 2 Diarrhoea 3 Prematurity 5 Debility 5 Pleurisy 1 Dermatitis 1 Pneumonia 1 Enteritis 1 Rickets 5 For observation 7 Spina Bifida 1 For dieting 11 Septic Umbilicus 1 For weaning 1 Test feeding 8 Gastro Enteritis 1 Vomiting 6 Gastritis 1 After Tonsilectomy 1 Discharges: Deaths: In good health 65 Broncho Pneumonia 2 Improved 24 Prematurity 3 No improvement 9 Gastro Enteritis 1 Spina Bifida 1 Total 98 Septicaemia 1 Marasmus 1 (Three of these cases were in Hospital for less than 24 hours). Discharged on account of infectious diseases: Measles 2 Diphtheria 1 Section III. SANITARY CIRCUMSTANCES OF THE AREA. 41 RIVERS AND STREAMS. No action to check pollution was necessary during the year. CLOSET ACCOMMODATION. All closets are of the water carriage type There are no closets of the conservancy or wastewater type in the area. There is, however, a sad deficiency of the "sufficient" water closet accommodation of the Housing Acts. In an urban community this can only be reasonably interpreted as meaning one W.C. per family, a standard which is far from being realised locally. PUBLIC CLEANSING. REFUSE COLLECTION. Reluse collection is carried out by means of mechanical transport at an economic cost and with a general fieedom from complaints. The Council endeavour to keep the type of vehicle engaged on the collection as up-to-date as circumstances will permit, and latterly have purchased four vehicles with enclosed bodies of the barrier type, which are giving every satisfaction not only to the Department, but to the residents generally; further vehicles of this type will, no doubt, be purchased in the near future when renewals become necessary. Generally the House Refuse is collected once weekly, but extra collections are made in the case of public buildings, large blocks of flats and other premises where special circumstances arise. The Council has recently inaugurated the "Container" system of storage and collection in connection with ills Housing Estates, whereby a daily collection is given. The system works very satisfactorily and is being adopted by the London County Council in respect of Hospitals and Schools under their control. Owners of certain large blocks of residential flats in the Borough are also considering the scheme. There are still a few ash pits in the Borough, but these are gradually being abolished as opportunities occur. Special attention is given tr the maintenance of the dustbins to see that these are kept in serviceable condition. DISPOSAL. Practically the whole of the House and Trade Refuse collected in the Borough continues to be disposed of at the Refuse Destructor in a satisfactory and economical manner. The volume of Refuse dealt with has increased out of proportion to the tonnage, and it assumed this is due to the increasing substitution of gas and electric fires in place of solid fuel fires, and so curtailing facilities for burning Refuse on the premises. 42 SCAVENGING AND WATERING. Practically all the streets in the Borough rcceive daily attention and the more important thoroughfares are swept several times daily; mechanical watering vehicles are employed in the summer and gullies are mechanically cleansed by a modern machine. SANITARY INSPECTION OF THE AREA. During the year the staff numbered one senior inspector responsible for all new drainage work, ten district inspectors, one woman inspector and one food and drugs inspector. In November, three temporary inspectors were appointed to release three of the permanent staff for house-to-house inspection of a proposed re-development area and afterwards to release the staff in turn for work in connection with the Overcrowding Survey under the Housing Act, 1930. DWELLING HOUSES. The following table shows the number and nature of inspections carried out by the . sanitary inspectors during the year. TABLE 8. DWELLING HOUSES. COMPLAINTS. Houses inspected for first time 3,416 Re-inspections 14,147 Intimations served 2,630 do. complied with 1,984 INFECTIOUS DISEASES. Houses inspected for lirst time 1,397 Re-inspections 839 Intimations served 217 do. complied with 119 HOUSE TO HOUSE INSPECTIONS. Houses inspected for first time 703 Re-inspections 5,252 Intimations served 581 do. complied with 575 STATUTORY NOTICES. Number served under: — Public Health Act 649 Housing Acts 79 Metropolis Management Acts 146 L.C.C. (G.P.) Acts 24 Number complied with:— " Public Health Act 396 Housing Acts 67 Metropolis Management Acts 79 L.C.C. (G.P.) Acts 6 RENT RESTRICTION ACT CERTIFICATES. Number of applications 12 Number of inspections made 15 Number of reports to M.O.H. 7 HOUSES LET IN LODGINGS BYELAWS. Annual Cleansing Inspections 12 Intimations served 10 do. complied with 10 43 DRAINAGE. Drains tested 4,569 Inspections of work carried out under Notice 6,724 Number of Notices received of voluntary work 344 Inspections of work carried out voluntarily 3,290 Inspections of Sewer Re-Construction work 76 INFIRM AND DIRTY TENANTS. First inspections 151 Re-inspections 119 Notices served 1 FACTORIES. FACTORIES, INCLUDING FACTORY LAUNDRIES. Inspections 557 Intimation Notices served 22 do. complied with 4 Statutory Notices served 2 do. complied with 3 WORKSHOPS, INCLUDING WORKSHOP LAUNDRIES. Inspections 202 Intimation Notices served 9 do. complied with 3 WORKPLACES. Inspections 260 Intimation Notices served 19 do. complied with 6 Statutory Notices served 1 do. complied with 5 OUTWORKERS' PREMISES. Inspections 125 Intimation notices served ... 1 SMOKE ABATEMENT ACT. Complaints received 5 Observations made 53 Intimation Notices served 2 do. complied with 1 FOOD PREMISES. Number of inspections to:— Food Factories 11 Milkshops and Dairies 453 Restaurants 55 Dining Rooms and Eating Houses 126 Eel and Pie Shops 9 Slaughter Houses 47 Butchers' Shops 183 Fried Fish Shops 45 Fish Shops 33 Fish Curing Premises 26 Greengrocers'or Fruiterers' Premises 93 Ice Cream Premises 65 44 Stallholders' Storage Premises 30 Cooked Meat Shops 12 Licensed Premises 92 Other Food Premises 192 N umber of Intimation Notices served 32 do. do. do. complied with 11 EVENINGS ON MARKET DUTY 79 OTHER INSPECTIONS PHARMACY AND POISONS ACT. Number of inspections 526 SHOPS ACT. Number of inspections 388 Number of Intimation Notices served 32 Number of Intimation Notices complied with 11 Number of Statutory Notices served 2 Number of Statutory Notices complied with 3 Inspections of Common Lodging Houses ... 13 Inspections of Public Conveniences 112 Inspections in connection with Housing applications 284 Inspections in connection with Underground Room Survey 41 Houses in Clearance Areas 805 Supervision of disinfestation prior to entry to Council flats 62 Inspections in connection with " Bath Room survey " 32 Inspections in connection with noise, coal dust and effluvia nuisances 44 Enquiries regarding suspected cases of food poisoning 42 Miscellaneous visits 20 In addition the inspectors made 2,003 ineftectual visits (i.e. cases in which no reply was obtained). SUMMARY. Cause of Inspection. First inspections. Reinspections. Total inspections. In consequence of Complaint 3,410 14,147 17,563 In consequence of Infectious Disease 1 397 839 2,236 House to House Inspections 703 2,552 3,255 Houses in Clearance Areas 257 548 805 Annual Cleansing Inspections - 12 12 Verminous or Aped Persons 151 119 270 Rent Restriction Act Applications 15 — 15 Totals 5,939 18,217 24,156 45 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, 1930. Number served. Number complied with up to 31st December, 1930. 3,438 2,688 898 548 REPAIRS EFFECTED. The following works were carried out and repairs effected as a result of the action of the sanitary inspectors: — TABLE 9. DRAINAGE. Drains cleared 202 Drains repaired 276 Drains relaid 366 Soil and ventilation pipes repaired 78 Soil and ventilation pipes renewed 18 New Soil and ventilation pipes provided 98 Rain water gutters and pipes repaired and renewed 467 Drains sealed off 13 Disused drains excavated 1 Fresh Air inlet 62 WATER CLOSETS. Traps cleansed, repaired, etc. 420 Pans renewed 602 Seats repaired or renewed 406 Flushing cisterns repaired 351 Flushing cisterns renewed 14 Additional W.C. accommodation provided 15 Lobbies provided to W.C. apartments 3 Fastenings provided to doors, and doors repaired 123 W.C. apartments ventilated 55 SINKS, BATHS AND LAVATORY BASINS. Sinks provided 80 Sinks renewed 336 Sinks repaired 40 Sink waste pipes trapped 431 New sink waste pipes provided 186 Sink and Bath wastes repaired 156 New baths fitted 66 New lavatory basins fitted 100 New bath and lavatory wastes fitted 36 Baths cleansed 3 WATER SUPPLY. Drinking water cisterns cleansed, etc., 129 Water supplied from mains 16 Occupied house provided with a sufficient supply 25 Water supply pipes and fittings repaired 65 Water supply provided to separate floors 25 46 CLEANSING AND INTERNAL WORK. Rooms cleansed 4946 Verminous rooms cleansed 444 Decorations and internal house repairs 7992 Fireplaces repaired (nuisances from smoke, etc.) 472 Kitchen ranges repaired or renewed (for cooking purposes) 467 Washing coppers repaired or renewed 205 Ventilation provided under floors 173 Dampness remedied 1854 Staircases provided with adequate light and ventilation 137 Rooms provided with adequate light and ventilation 33 Ventilated food cupboards provided 69 EXTERNAL REPAIRS AND OTHER NUISANCES. Roofs repaired 1068 Other external repairs 719 Accumulation of refuse removed 104 Dustbins provided 421 Yards and forecourts paved and drained 487 Abatement of nuisance from animals 10 Urinals in Public Houses cleansed and repaired 2 Urinals in factories cleansed and repaired 4 Rat runs traced ... 33 DRAINACE OF BUILDINGS. The following drainage plans were submitted to and approved by the Public Health Committee during 1936. New Buildings:— Maternity Home, Parson's Green 1 Public Convenience 1 Children's lavatory, Eelbrook Common 1 Fulham Power Station 2 Public House 1 Earl's Court car park 2 Block of Flats (private) 2 Borough Council Flats 2 Electricity Transformer Station 1 Chemical Works 1 14 Additions to existing buildings 19 Conversion to Hats of existing buildings 17 Reconstruction of existing buildings 209 The supervision of the work with the exception of re-construction is in the hands of the COnncil's senior inspector. The following summaries his work in connection with drainage:— Visits to new drainage 770 Visits to extensions of existing drainage work 251 Visits to reconstruction work 230 1,257 Drains tested 1,159 Old drains sealed off 3 COMBINED DRAINACE. During the year the Council authorised the carrying out of work in connection with combined drainage in live cases. 47 LEGAL PROCEEDINGS. TABLE 10. Proceedings were instituted in the following cases during the year:— Address Offence. Result. 109, Estcourt Road Nuisance Order to abate within 7 days and £2 2s. Od. costs. 109, Estcourt Road do. £7 7s. Od. line. 49, Lindrop Street do. Work done before hearing. 49a, Lindrop Street do. Order to abate and £3 3s. Od. costs. 501, Fulham Road do. Dismissed under P.O. Act. 56, Tournay Road do. Withdrawn upon payment of 5s. 0d. Work done before hearing. 56, Tournay Road do. Withdrawn upon payment of costs. 106, Waterford Road Appeal against closing order on front basement room Appeal withdrawn. 13, Lillie Road Obstruction of M.O.H. in the performance of his duties Fined £1 0s. Od. and £2 2s. Od. costs. 13, Lillie Road Obstruction of sanitary inspector Walsh in the performance of his duties. Fined £1 0s. Od. 13, Lillie Road Failure to give information required under Housing Act. Fined £2 0s. Od. 13, Lillie Road do. j Fined £5 0s. Od. 45, Crefeld Road { Nuisance from overcrowding Order to abate within 21 days. 34, Darlan Road • Nuisance Order to abate nuisance within 2H days. Fined £5 0s. Od. and £2 2s. Od. costs. 17, Purcell Crescent do. Summons withdrawn. Work done. 17, Purcell Crescent do. Fined £2 0s. Od. 39, Greyhound Road Failure to comply with drainage notice Fined £2 0s. Od. and £3 3s. Od. costs. William Hyam, 2, Riverbank, Beafont Road, Stan more, Middlesex. Carriage of offensive matter through London. Fined £1 0s. Od. William Hvam, 2, Riverbank, Beafont Road, Stanmore, Middlesex. do. do. 48 ATMOSPHERIC POLLUTION RECORD. APL. MAY JUNE JULY AUG. SEPT. OCT. NOV. DEC. JAN. FEB. MAR. 1936 - 1937. Covering an area within ½ mile radius of Fulham Power Station. The similarity of these curves is striking. It can be assumed that the lowest recorded pollution occurring in July roughly indicates the normal industrial pollution in that area. The peaks corresponding with the cold damp weather of November are almost entirely due to domestic pollution; the ration being about 3 to 1. (The April reading for Station 4 seems to be exceptional.) 40 SMOKE ABATEMENT. During the year live complaints regarding smoke nuisance were received and 52 observations on chimneys were made by sanitary inspectors; in two cases intimation notices were served on the owners to abate the nuisance. No legal proceedings were necessary during the year. ATMOSPHERIC POLLUTION AND THE NEW POWER STATION. Since the last annual report, the new Fulham Power Station has come into operation, a potential source of enormous atmospheric pollution, with an incredible total flue gas discharge rate of 330,000 cubic feet per minute. To ascertain the sulphur activity in the atmosphere, five test points using lead peroxide cylinders have been set up on a circle approximately ½ mile radius, it being indicated as the result of experiments that the worst ground conditions occur at a distance of eight to ten chimney heights away, in this case between 2,400 to 3,000 feet. A graph showing the pollution record at these five points is reproduced on page 48. The results obtained at these points compare favourably with those from three other positions in London. It is difficult to trace any correlation between these results and the Fulham Power Station, but the seasonal fluctuation indicates considerable pollution from domestic sources. For the proper interpretation of these results it is necessary to take into consideration wind direction and the installation of a recording wind indicator on the Station roof is a practical requirement. During the Inquiry prior to the extension of the Station a limit for Sulphur emission of 0.03 grains per cubic foot (equivalent to 50 parts per million) was suggested, but by the adoption of a new flue gas cleaning system of the lime treated non-effluent water type, an exceptionally high rate of sulphur elimination has been obtained, the average figure being as low as 0.007 grains per cubic foot (12 p.m.) Interesting and probably unique experimental apparatus for continuously recording the acidity due to the soluble oxides of sulphur and nitrogen in the flue gases has been installed at the base of each shaft. Dust can be said to be non-existent in the effluent gases, the residual being an extremely small percentage of particles approaching the size of, and behaving like gaseous molecules, practically impossible to eliminate. The overall efficiency of the flue gas washing system, for sulphur grit and dust extraction, is of the order of 99.5 per cent. Some nuisance arises from the "attempted" burning of wet debris collected from the intake screens of the condenser cooling water and another method of disposal is indicated; its removal as trade refuse would meet the case. It is only when results such as the above are achieved and maintained that Electricity has any claim to being a clean fuel, it being remembered that the original plant allowed sulphur to be discharged into the atmosphere. RAG FLOCK. The sale and use of Rag Flock are nov; regulated by Section 136 of the Public Health (London) Act, 1936, which repeals the Rag Flock Acts of 1911 and 1928. 50 The Regulations made by the Ministry of Health in 1912 continue in force and prohibit the sale or use of unclean flock manufactured from rags in making any article of upholstery, cushions, bedding, etc., and provide that when not less than 40 grams of flock are thoroughly washed with distilled water at a temperature below 25°C., the chlorine must not exceed 30 parts per 100,000 of flock. This standard ensures a certain degree of cleanliness. During 1930, four samples of rag flock were taken with the following results:— Sample No. Parts of Chlorine per 100,000 of flock. R.F. 1 15 „ 2 4 „ 3 2.5 „ 4 26.5 PUBLIC BATHS AND WASH-HOUSES. The swimming baths and wash-houses are at present being rebuilt and when complete in about September 1937 will provide a first class men's bath, a first class ladies' bath and a bath for mixed bathing, together with 16 first class and 41 second class slipper baths for men; and 10 first class and 15 second class slipper baths for women; 4 foam baths for women will also be provided. The wash-houses will contain 12 compartments. In June samples of water were taken from a private open air swimming pool in the Borough and submitted for bacteriological and chemical analysis. The reports gave the following figures: — Parts per Grains per (1) Chemical. 100,000 gallon. Solids in suspension nil. nil. Total solids (dried at 120°C.)in solution 43.0 30.1 Combined chlorine ... G.GO 4.62 Equivalent to NaCl. 10.89 7.62 Nitric nitrogen (Nitrates) 0.16 0.11 Nitrous nitrogen (Nitrites) nil. nil. Amrnoniacal nitrogen 0.0068 0.0048 Albuminoid nitrogen 0.0100 0.0070 Oxygen absorbed in 4 hours at 27°C. ... 0.064 0.045 (2) liacterioloeical. Average number of organisms producing visible colonies on gelatine plates, incubated at 20°—22°C. for 3 days. 9 per c.c. Average number of organisms producing visible colonies on agar plates incubated at 37.5°C. for 2 days ... 2 per c.c. B. Coli ... not found in 100 c.c. Streptococci not found in 30 c.c 51 These excellent results show how pure swimming bath water can be kept under continuous filtration process. MORTUARY. The Mortuary provides cold chambers for the accommodation of eight bodies, two in each compartment. One compartment is entirely isolated from the general body of the chamber, so that two bodies of infectious cases can be accommodated separately. There is also a postmortem room with modern equipment. During the year 192 bodies were removed to the Mortuary and were admitted as follows:— By order of the Coroner 118 For convenience till funeral 74 192 There were 73 post-mortems made and inquests were held in 45 cases. PUBLIC CONVENIENCES. The following tables show the existing accommodation in Public Conveniences in the Borough. Under the control of the Public Health Department. Convenience. Date erected. Men. Women. Total W.C.s. Free W.C.s. Urinal Stalls. Wash Basins. Total W.C.s. Free W.C.s. Wash Basins. WALHAM GREEN (enlarged in 1930) 1895 7 2 14 4 8 2 2 GIBB'S GREEN 1900 4 1 9 2 4 1 2 L1LLIE ROAD 1905 3 1 4 2 3 1 2 EELBROOK COMMON 1929 4 1 9 - 4 1 - PUTNEY BRIDGE 1934 5 1 11 2 7 1 2 WYFOLD ROAD 1936 2 2 4 1 3 3 1 EFFIE ROAD (for men only) 1903 4 1 8 2 - - - Total 29 9 59 13 29 9 9 52 Under the control of the Borough Surveyor's Department. SOUTH PARK: Lodge, Clancarty ltd. 1903 1 1 3 - 3 1 2 Lodgo, Hugon Rd. 1903 2 2 3 - 3 2 - BISHOPS PARK: Prvor's Bank Paviln. 1896 3 1 3 - 3 1 1 Chalet by Bandstand (Women's enlarged 1931). 1905 2 1 4 - 5 2 2 Total 8 5 13 - 14 6 5 Total for the Borough 37 14 72 13 43 15 14 The Conveniences under the control of the Public Health Department are open from 8 a.m. to 12 midnight on weekdays, and on Sundays from 10 a.m. to 10 p.m. The hours of those in the Parks are regulated by the hours of opening and closing of the Parks. INCREASE OF RENT AND MORTGAGE INTEREST (RESTRICTIONS) ACTS, 1920—1933. During 1936 twelve applications for certificates under the above-named Acts as to the fitness of the houses for habitation were received and in eight cases issued; in the other four cases the applications were withdrawn. In addition one application that the work specified in a certificate had been carried out was received from the owner of the premises and a "Clearance Certificate" issued. REMOVAL OF ACED, INFIRM AND PHYSICALLY INCAPACITATED PERSONS. Sec. 224 of the Public Health (London) Act, 19:10 continues the power formerly contained in one of the London County Council (General Powers) Acts, for the Council to apply to a Magistrate for an order for the compulsory removal of aged, infirm or physically incapacitated persons living under insanitary conditions, to a hospital or institution. During the year it was only necessary to apply for one order and the application was granted. In addition, however, the Council's Woman Sanitary Inspector was able to persuade twenty persons to enter hospital voluntarily and she also kept thirty-six other cases under observation but it was not necessary to have them removed to hospital. RAT REPRESSION AND DESTRUCTION. The Borough Council employs a Rat Officer who is a whole time employee of the Public Health Department. He attends to complaints regarding rat and mice infestation in the Borough and takes steps necessary for their destruction. He also traces the manner in which the rats have pained entry to the premises and gives advice regarding the methods necessary to prevent a recurrence of the trouble. In all cases the Rat Officer works in close co-operation with the sanitary inspectors. During the year 134 formal complaints regarding infestation by rats were received and 1.775 visits were made to dwelling houses and 519 visits to business premises in the Borough. In addition 680 visits to sewers in all parts of the Borough were made. 53 Out of the 134 formal complaints investigated, in 79 instances or 58.96 per cent. the rats gained admission to the premises owing to defective drains. The type of drainage defect was: Defective drains under premises 42 Defective connections under footway 36 Direct from sewers 1 Rats were caught as follows during the year:— In cage traps in sewers 138 In dustbin traps in sewers 219 By ferrets and break-back traps in premises 323 Under footways 135 The amount received by the Council from property owners tor the services ot the Rat Officer during the year ended 31st March, 1937, was £26 5s. and, in addition, £5 was credited to the department for the services of the Rat Officer to other departments of the Council. NATIONAL RAT WEEK. During National Rat Week held from November 4th to 9th the Rat Officer paid special attention to the sewers in the Borough, and laid 16,500 baits in the stunt ends of 12 pipe sewers which are known to harbour rats in 112 streets. While, of course, it is difficult to to estimate the number of rats destroyed as a result of this action, it is satisfactory to note that the majority of the baits were taken. A circular letter pointing out the need for the destruction of rats and giving advice concerning this, was circulated to all factories and large workshops in the Borough with a request that it should be displayed on the staff notice boards. A copy was also sent to the three newspapers circulating in the Borough. A number of posters from the Ministry of Agriculture and Fisheries were purchased and exhibited on the Council's vehicles and outside public buildings during the week. NUISANCE FROM PIGEONS. Section 121 of the Public Health (London) Act, 1936, continues the power of the Council tc abate or mitigate any nuisance caused by pigecns having no owner, subject to the consent of the owner of the land or buildings upon which the birds congregate. During the year special traps were set up on the roof of a private house, the Fulham Hospital and the Town Hall. As a result of this action 110 pigeons were caught and killed. SHOP ACT, 1934. During the year, the sanitary inspectors made 388 inspections of shops under the abovenamed Act in connection with ventilation, temperature and sanitary conveniences. Thirty-two intimation and two statutory notices were served regarding these matters and five certificates under Section 10 of the Act exempting shops from the provision of sanitary conveniences were issued. All the certificates were issued on the ground of restricted accommodation making it impossible for the conveniences to be provided or. the premises. In three cases, the use of water closet compartments as sculleries was discontinued, and in six cases water closet accommodation was provided as the result of action by the sanitary inspectors. 54 INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. TABLE 11. Premises. Number of Inspections. Written Notices. Occupiers prosecuted. (1) (2) (3) (4) Factories (including factory laundries) 557 73 - Workshops (including workshop laundries) 202 10 - Workplaces (other than outworkers' premises) 260 21 - Total 1,019 104 - DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. TABLE 12. Particulars. Number of defects. Number of offences in respect of which Prosecutions were instituted. Found. Remedied. Referred to H.M. Inspector. (1) (2) (3) (4) (5) Nuisances under the Public Health Acts:— Want of cleanliness 35 35 - - Want of ventilation 11 11 - - Overcrowding - - - - Want of drainage of floors 3 3 - - Other nuisances ... 20 20 - - Sanitary accommodation insufficient 4 4 - - unsuitable or defective 15 15 - - not separate for sexes 4 4 - - Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouses (s. 101) - - - - Other offences (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921.) 14 14 - - Total 106 106 - - 55 HOME WORK DONE BY OUTWORKERS. In certain industries specified in the Home Work Orders made by the Home Secretary, if work is given out by employers or contractors to be done in private houses, the workers are known as Outworkers and the premises in which they work are subject to inspection by the Sanitary Inspectors of the Borough Council. In Fulham this duty is carried out by the Woman Sanitary Inspector. The object of the inspections is to prevent such work being done in unwholesome premises or in houses in which infectious diseases are present. The following table gives the number of Outworkers' premises in the Borough, the nature or the work carried on and the classification of the Outworkers' premises into factories, workshops and workplaces:— Nature of Work. Nature of Premises. Total. Factories Workshops. Workplaces. Wearing Apparel 5 10 44 59 Bootmaking 1 - 40 41 Miscellaneous 1 1 20 22 Totals 7 11 104 122 OUTWORK IN UNWHOLESOME PREMISES. Nature of Work. Instances. Notices served. Prosecutions. Boot Making 3 3 - Wearing Apparel 5 - - Totals 8 3 - TOTAL INSPECTIONS. ]Premises. Male Inspectors. Woman Inspector. Total. Factories 408 149 557 Workshops 65 137 202 Workplaces 90 170 260 Outworkers' Premises - 125 125 Totals 563 581 1,144 Section IV. HOUSING. 58 GENERAL. A general description of the growth of the Borough, of the occupations of the residents and the number of dwellings and families in the Borough, and an analysis of the 1931 Census in its bearing on housing, was given in last year's Report. OVERCROWDING. The information revealed by the preliminary overcrowding survey was fully described in last year's Report. The detailed measurement of over 20,000 working class houses is now in progress and sufficient information has been accumulated to throw some rather depressing light on the standards of overcrowding laid down by the Act. These standards are as follows:— TABLE II. Where the floor area is Permitted number of persons (a) 110 sq. ft. or more 2 (b) 90 sq. ft. or more, but less than 110 sq. ft. 1½ (c) 70 sq. ft. or more, but less than 90 sq. ft. l (d) 50 sq. ft. or more, but less than 70 sq. ft. ½ (e) under 50 sq. ft. Nil The maximum permitted number of persons per house is that determined by applying these two tables. Thus, for example, a three roomed house in which each of the rooms were between 70 and 90 sq. ft., would accommodate three persons only; a similar house in which all the rooms exceeded 110 sq. ft., would accommodate five presons, not six, subject to the modification determined by the age of the persons. The Act provides that in measuring a house for the purpose of estimating the "permitted number" the area of the living room shall be taken into account. In cottage property inhabited by one family and where a scullery in addition to a living room is available, this inclusion, though regrettable, may not have very serious consequences. In London, where the majority of working class houses are now occupied by two on more families, the inclusion of the living room TABLE I. Where a house consists of Permitted number of persons (a) one room 2 (b) two rooms 3 (c) three rooms 5 (d) four rooms 7½ (e) five or more rooms 10 with an additional two in respect of each room in excess of five. 59 in ascertaining the "permitted number" becomes much more serious in its effects. Houses of this type may or may not have a common scullery on the ground floor, but the living room on the first floor has always to be used as a scullery, and all food, etc., stored in it. The rooms are usually of small size, so small that in many instances cooking stoves are erected on the landing outside the living room. Every room in a dwelling of this type is therefore used to the maximum and it has not been possible to exclude any room on the grounds that it was a scullery. The survey results of 1,054 houses have been specially analysed with a view to throwing light on the present occupation and the maximum possible occupation allowable by the standards ot the Housing Acts. These results can only be described as startling and are set out in the following table:— TABLE 13. (i) Structurally separate dwellings surveyed 24,502 (ii) Population in "equivalent units 115,422 (ii) Number of structurally separate dwellings, Census 1931 26,738 (iv) Actual population, Census 1931 150,928 (v) Population in "equivalent units", Census 1931 140,639 (vi) Number of houses analysed 1,054 (vii) Percentage of working class houses analysed 4.3% (viii) "Equivalent population" in houses analysed 5,518½ (ix) "Permitted number" applicable to houses analysed 11,177½ (x) "Permitted number" applicable to all dwellings surveyed, on basis of the 1,054 especially analysed 259,840 (xi) "Permitted number" applicable to all dwellings surveyed, on basis of the 1,054 especially analysed, with allowance for a kitchen/living room 186,557 TABLE 14. (i) Number of occupied rooms in Fulham, Census 1931 139,943 (ii) "Equivalent units" per room, Census 1931 1.004 (iii) "Equivalent units" per room applicable to all dwellings, on basis of the 1,054 especially analysed 1.85 (iv) Re-housing standard, persons per room 1.5 Streets containing the 1,054 houses especially analysed. Allestree Road Vernon Street Biscay Road Anselm Road Stamford Road Chesson Road Ewald Road Edenvale Street Seddlescombe Road Mimosa Street Epple Road Lindrop Street Claybrook Road St. Dunstan's Road Avonmore Road 60 It will be noted that the houses analysed amount to 4.3% of the total working class dwellings surveyed, that they actually contain a population reckoned as "equivalent units" of 5,518½, and that the "permitted number" applicable is no less than 11,177½ i.e. more than double the existing number. If the kitchen/living rooms had been excluded in calculating the permitted number "for these dwellings, the total permitted population in terms of" equivalent units" would amount to 8,025½. A calculation has been made of the "permitted number" for all the working class houses in the Borough on the basis of the information revealed by the analysis of these 1,054 representative houses. This amounts to no less than 259,840, as compared with an actual population at the Census of 1931 of 140,639 "equivalent units." The exclusion of the kitchen/living rooms in calculating the "permitted number" would have reduced this potential maximum population of the working class houses of the Borough, to 186,557. Most house owners have now been supplied with the "permitted number" for inclusion in the rent books of their tenants, the "appointed day," after which fresh overcrowding becomes an offence in the Borough, being 1st July, 1937. It has been an encouraging, if unusual, experience to receive from them many grumbles and protests at what they regard as an unreasonably high figure for the dwellings which they own. It has been pointed out to the Department by owners on many occasions that tenants' knowledge of the maximum "permitted number" may lead to undesireable sub-letting. Consideration of these figures will show that the present overcrowding standards can only be of a temporary nature. Low as they undoubtedly are they have already revealed the fact that more than 1,700 families are overcrowded, and will need the provision of larger houses. Even that provision will not be easy within the circumscribed area of the Borough. This rather pessimistic review should perhaps conclude with a reminder that the re-housing standards which the Council have to apply are better than the overcrowding standards, and allow a maximum occupation of Council dwellings of 1.5 persons per room. The revealed maximum "permitted number," flrom the 1,054 houses analysed, works out as 1.85 "equivalent units" per room. 61 LONDON COUNTY COUNCIL ESTATES. During the year 1936, 29 families were allotted houses on London County Council Estates on the recommendation of the Public Health Department, in addition to other families applying direct to the County Council. The following table shows the number of families accommodated on the various Estates:— TABLE 15. Estate. Accommodated on recommendation by the Fulham Borough Council. Accommodated on applying direct to the London Countv Council. Total Fulham families accommodated. EAST HILL, Wandsworth. 14 40 54 WATLING, Middlesex. 139 86 225 DOWNHAM, Kent. 54 20 74 BECONTREE, Essex. 109 450 559 ST. HELIER, Morden. 136 292 428 HANWELL. 6 15 21 BROXHOLME HOUSE, Fulham. 1 46 47 ROEHAMPTON, CASTELNAU, CENTRAL LONDON, Etc. /- 150 541 691 TOTALS: 609 1490 2099 During the year 110 applications were made to the Public Health Department of the Borough for accommodation on the London County Council Estates and were dealt with as follows:— 81 families were recommended to the County Council for preferential consideration; five of them subsequently refused the accommodation which was offered. 29 families proved upon enquiry to be unsuitable for recommendation, but 12 of those applications were forwarded to the London County Council for inclusion in the ordinary list "of applicants. In addition 34 applicants made enquiries but did not return their application forms or notify the Department of their reasons for not doing so. 62 HOUSING WORK DURING 1936. A summary of the housing work carried out during the year is given on pages 42—44. HOUSE-TO-HOUSE INSPECTION. Details of house-to-house inspections carried out during the year will be found in the following table which gives the housing statistics in the form desired by the Minister of Health. TABLE 16. 1. (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 5,939 (b) Number of inspections made for the purpose 24,156 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 960 (b) Number of inspections made for the purpose 4,060 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 257 (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 3,438 2. Remedy of Defects 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 2,688 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 79 (2) Number of dwelling-houses which were rendered fit after service of formal notice:— (a) by owners 67 (b) by Local Authority in default of owners 10 (b) Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 649 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) by owners 396 (b) by Local Authority in default of owners - 63 (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 (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 54 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or rooms having been rendered fit - LONDON COUNTY COUNCIL BYE-LAWS WITH RESPECT TO HOUSES DIVIDED INTO SEPARATE TENEMENTS. During the year 10 notices were served on tenants and owners regarding failure to carry out the provisions of the Bye-laws. UNDERGROUND ROOMS. During the year Closing Orders were made by the Council in respect of 54 underground rooms which did not comply with the Regulations. The Orders were made under Section 20 of the Housing Act, 1930, as amended and extended by Section 84 of the 1935 Act, which prohibits the use of the rooms for human habitation. CLEARANCE AREAS. During the early part of the year a careful survey of the Borough was made to ascertain which houses were unfit for human habitation in accordance with the Clearance Area Sections of the Housing Acts. A definite programme was formulated and 7 Areas, involving 88 houses and 131 families were represented by me and the following Clearance Orders subsequently made:— Field Road Area (No. 1), Field Road Area (No. 2), Mulgrave Road Area, Lanfrey Place Area and Hawes Buildings Area, on the 24th June, 1936, and Carnwath Road Area, Sotheron Road Area and Gorleston Street Area, on the 22nd July, 1936. Formal notices were forwarded to the London County Council as required by Section 16 (5) of the Housing Act, 1930, and the County Council intimated that they themselves intended to deal with the Gorleston Street Area, which adjoins their Avonmore Road School. A Public Enquiry was held by the Minister of Health into the Council's application for confirmation of the above orders during the month of November and the C learance Orders were confirmed on the 27th April, 1937, with the exception of three houses in the Carnwath Road Area. 64 Some photographs illustrating typical conditions met with in the Clearance Areas in the Borough are reproduced at the end of this section, together with a phonograph showing the type of flats which have been erected by the Borough Council to re-house families displaced by the slum clearance programme. DEMOLITIONS UNDER PART 2, HOUSING ACT, 1930. Two houses were demolished in consequence of Orders made by the Council during the year. COMMON LODGING HOUSE. There is one Common Lodging House in the Borough, accommodating 36 men, and the Inspector made 13 inspections of the premises during the year. DISINFESTATION. During the year the household effects of 22 families were disinfested by the H.C.N, process prior to transfer to new dwellings from slum clearance areas. The bedding was taken to the Fulham Disinfecting Station and treated by steam before delivery to the new flat. All woodwork from condemned houses in the Clearance Areas was burnt on the site and all other building materials were treated before removal. For the treatment of infested premises, the usual procedure is to have the room stripped of all woodwork and then fumigated by means of sulphur candles. In some cases where fumigation w as inconvenient the rooms were sprayed with a formalin or other solution or tenants were allowed the use of a spray filled with solution on paying a deposit of 2s. 6d., which was refunded when the spray was returned. A total of 78 issues of such sprays were made during the course of the year. During the year 342 rooms were fumigated or sprayed on account of vermin. THE VITAL STATISTICS OF WORKING CLASS FLATS. Unfit houses produce ill-health, particularly of a respiratory character. This cannot always be shown in figures, but it is of interest to examine the vital statistics of the fairly stable populations living in modern blocks of working class flats. The influence of good nutrition on these statistics has been strikingly shown by Dr McGonigle, of Stockton-on-Tees, in his comparison of the vital statistics of a re-housed slum population before and after re-housing with a similar population living under continued bad housing conditions. KEIR HARDIE HOUSE, FULHAM PALACE ROAD. (RE—HOUSING). TYPICAL VIEWS IN CLEARANCE AREAS. 65 Dr. McGonigle showed conclusively that where the family income per head is low, good housing alone will not prevent ill-health. Fortunately, these considerations do not apply to the statistics of the working class flats given in the following table:— TABLE 17. Fulliam Borough. Fulliam Court. Lewis Trust, S.W.6. Lewis Trust, W.14. Peabody Buildings. Population:— (a) Total 141,300 2,010 1,356 762 598 (b) Under 10 16,291 577 388 202 67 (c) Per cent, under 10 11.5 28.7 28.6 26.5 11.2 Births 2,111 21 12 2 4 Birth Rate 14.9 10.4 8.8 2.6 6.7 Deaths:- (a) Total 1,786 6 5 3 4 (b) Under 10 191 1 1 2 - (c) Under 1 136 1 1 - - Total Death Rate (crude) 12.6 3.0 3.7 3.9 6.7 Death Rate under 10 on population under 10 11.1 1.8 2.6 9.9 - Infant Mortality Rate 64 48 83 - - Diphtheria, No. of Cases:— (a) Total 179 4 3 4 - (b) Under 10 138 4 3 4 - Attack rate per 1,000:— (a) Total 2.6 2.0 2.2 5.3 - (6) Under 10 8.5 6.9 7.7 19.8 - Scarlet Fever. No of Cases:- (a) Total 323 13 3 1 1 (b) Under 10 223 11 1 - - Attack rate per 1,000:— (a) Total 2.3 6.5 2.2 1.3 1.7 (6) Under 10 13.7 19.1 2.6 - - Section V. INSPECTION AND SUPERVISION OF FOOD. 67 MILK. During the year 1030, 500 samples of milk (including two of machine-skimmed milk) were purchased by Inspector Gammack and submitted to the Council's Public Analyst for chemical analysis. Of these, 243 were purchased from milk vendors in the streets during the early hours of the morning, 01 were taken at the early morning delivery to hospitals, etc., in the Borough which are under the control of the London County Council and 96 were purchased on Sundays and public holidays, three of the latter (Nos. 287, 288 and 347) being adulterated. Six, or 1.00% of the 500 samples of milk examined, were reported as adulterated and the following table gives details of the results of the analyses of the samples and the action taken:— TABLE 18. Sample No. Result of Analysis. Action taken. Result. 287 1.4% added water 13.7% deficient in fat Prosecution Fined £10 0s. 0d., costs £3 3s. 0d. 288 5.5% deficient in fat Prosecution Dismissed under P.O. Act on payment of £2 2s. 0d. costs. 291 347 36.6% deficient in fat 56.6% deficient in fat Milk brought to Town Hall by member of public. Further samples purchased from same dairyman reported to be genuine. Evidence of agent who purchased milk for sampling officer too unreliable to justify legal proceedings. Dairyman refused registration as retail purveyor of milk in Fulham by Public Health Committee. 552 2% deficient in fat ... Vendor cautioned. 646 Contained:—2.99% Fat, 8.57% Solids not fat. Vendor's attention drawn to result of analysis. Note:—The vendors of samples Nos. 287 and 288 were formerly registered as dairymen in Fulham but have now discontinued trading and the vendor of sample No. 347 who was registered in Hampstead was refused registration as a retail purveyor of milk in Fulham. 68 Particulars of the number and percentage of adulterated samples of milk for the years 1928 to 1936 inclusive are given in the following table:— TABLE 19. SAMPLES OF MILK ADULTERATED. Year. 1928 1929 1930 1931 1932 1933 1934 1935 1936 No. examined 591 565 548 540 543 641 554 580 566 No. adulterated 15 28 4 3 4 18 6 2 6 Percentage of adulteration 2.5 4.7 0.7 0.55 0.74 2.8 1. 1 0.3 1.06 As in previous years, samples of milk were taken in course of delivery to the hospitals, institution and schools in the Borough which a re under the control of the London County Council. The following were taken during 1936 and no adulterations were reported. TABLE 20. Institution. Samples taken for Chemical Analysis. Bacteriological Examination. Fulham Hospital 23 18 Fulham Institution 6 6 Western Hospital 30 18 Elizabethan Open Air School 2 2 L.C.C. Schools 29 31 AUTOMATIC MILK MACHINES. There are in the Borough three automatic milk machines fixed to the doors of registered niilkshops from which milk is obtainable after ordinary trading hours. During the year under review ten samples were purchased from these machines for chemical analysis and in all cases the milk was genuine. 69 COMPOSITION OF MILK SAMPLES. The following table gives the monthly average composition of all samples of milk (excluding machine-skimmed milk) taken during 1936, and it is satisfactory to note that the quality of the milk supplied in Fulham is well maintained and compares very favourably with the standards of the Ministry of Agriculture and Fisheries: — TABLE 21. Month. No. of Samples. Fat. Solids not Fat. Remarks. January ... 48 3 -57% 8 -89% February 48 3 -42% 8 -86% March 51 3 -44% 8-77% Including 3 adulterated samples. April ' 51 3 -42% 8-71% May 54 3 -42% 8-77% M I »» >» June 52 3-51% 8 -94% July 36 3 -58% 8-81% >> 1 »» II August ... 39 3 -60% 8 -73% »» 1 l» 1) September 44 3 -59% 8 -84% October ... 46 3 -94% 8 -93% November 49 3 -90% 8 -88% December 46 3 -80% 8 -77% 564 3 -59% 8 -82% Legal Standards ... ... 3 -00% 8 -50% Average composition of normal cow's milk ... ... 3-7% 8 -9% MILK AND DAIRIES (AMENDMENT) ACT, 1922, AND MILK AND DAIRIES ORDER, 1926. Article 6 of the Milk and Dairies Order, 1926, requires local authorities to keep registers of dairymen and dairy premises; while Section 2 (1) of the Milk and Dairies (Amendment) Act, 1922, gives the Council power to refuse to enter any person's name on the register of retailers of milk and dairies if they are satisfied that the public health is, or is likely to be, endangered by any act or default of t!he person in relation to the quality, storage or distribution of the milk. During the year under review, a dairyman—Albert James Martin—who occupied registered premises in the Borough of Hampstead, applied for registration as a retail purveyor of milk in Imlham. The application was regarded with suspicion and careful enquiries revealed the fact that this man had been convicted of many offences under the Acts and Orders relative to milk. It was from this man that sample No. 347 referred to in Table lb, was purchased. The applicant 70 was given notice, as required by Section 2 of the Milk and Daires (Amendment) Act, 1922, to appear before the Public Health Committee to show cause why his application for registration should not be refused but he failed to attend the meeting and discontinued retailing milk in the Borough. No contraventions of Article 31 (2) of the Milk and Dairies Order, 11)26, which requires that the bottling of milk shall be carried out only on registered premises were reported during the year under review. This is due in large measure, to the fact that very few dairymen carry " loose " milk in hand-cans or churns. There were on the register at the end of 1936, 107 dairymen occupying 107 registered dairies within the Borough. In addition, there were 29 dairymen retailing milk in Fulham from premises situated and registered in adjoining districts. The following are details of the changes which took place during 1936: — No of Dairymen on the Register: — No. on Register at 31st December 1035 112 No. who transferred their business or discontinued selling milk during the year 1036 13 99 No. of Registrations granted during 1036 8 No. on Register at 31st December 1036 107 The sale of milk in properly closed and unopened receptacles from premises not registered as a dairy has been held to make it compulsory for such shopkeepers to be registered as dairymen. The expression "dairy" as defined in the Milk and Dairies (Consolidation) Act, 1015, includes "a milk store, milk shop, or other place from which milk is supplied on, or for, sale or in which" milk is kept or used for the purpose of sale or manufacture into butter, cheese, dried milk or condensed milk for sale and in the case of a purveyor of milk who does not occupy any premises for the sale of milk, includes the place where he keeps the vessels used by him for the sale of milk, but does not include a shop from which milk is not supplied otherwise than in the properly closed and unopened receptacles in which it was delivered to the shop, or a shop or other place in which milk is sold for consumption on the premises only." The expression "dairyman" includes any occupier of a dairy or any purveyor of milk and the expression " purveyor of milk " includes a seller of milk, whether wholesale or by retail. During 1936, registration as purveyors of milk in properly closed and unopened receptacles was granted to seventeen persons and there arc now 162 names on the Register. INSPECTION AND SUPERVISION OF DAIRIES AND MILKSHOPS. During the year under review, the Sampling Officer made 451 visits to dairies and milkshops and served 10 written notices and in addition gave many verbal intimations of defects noted during his inspections. 71 Every dairy in the Borough in which milk bottle washing and filling is carried out is now provided with means for sterilizing vessels, bottles, etc. Milk and Dairies (Consolidation) Act 1915—Section 4. This section empowers local authorities to stop the supply of milk from any dairy if such milk causes, or is likely to cause, tuberculosis. During 1936, it was not necessary to take any action under this Section. Similarly, there was no evidence that milk sold in the Borough was infected by persons suffering from infectious diseases, so that no action was taken under Article 18 of the Milk and Dairies Order, 1926. MILK (SPECIAL DESIGNATIONS) ORDER, 1936. The licences granted by the Borough Council during 1936 were as follows: — Number of Licences to sell Certified Milk 8 Number of supplementary Licences to sell Certified Milk 2 Number of Licences to sell Grade A (Tuberculin Tested) Milk 34 Number of Supplementary Licences to sell Grade A (Tuberculin Tested) Milk 3 Number of Licences to sell Grade A (Pasteurised) Milk Number of Supplementary Licences to sell Grade A (Pasteurised) Milk 1 Number of Licences to sell Pasteurised Milk 36 Number of Supplementary Licences to sell Pasteurised Milk 5 Number of samples taken in accordance with the instructions of the Ministry of Health 4 BACTERIOLOGICAL EXAMINATION OF MILK. The Milk (Special Designations) Order, 1936, which came into operation on 1st June, 1936, repealed the Milk (Special Designations) Orders, 1923 and 1934. The new Order simplifies, to some extent, the nomenclature of designated milks, the new grades being as follows: — (a) Tuberculin Tested Milk. This is milk from tuberculin tested herds and takes the place of " Certified " and " Grade A (Tuberculin Tested)" which were recognised by the old order. The word " Pasteurised " may be added to the designation " Tuberculin Tested " if the appropriate conditions have been complied with, or the word " Certified " if the milk is bottled at the place of production. (b) Accredited Milk is raw milk from cows which have passed a veterinary examination; it is bottled on the farm or elsewhere and is identical with that previously designated " Grade A." 72 It cannot be treated by heat and still retain its designation. If bottled at the place of production the words " Farm Bottled " may be added to the designation. (c) Pasteurised, Milk is milk which has been pasteurised by being heated to a temperature of between 140°F and l50°F for at least 30 minutes and then immediately cooled to a temperature of not more than 55°F. It will be noted that there are therefore now six designations applicable to milk, and these, together with details of the bacteriological standards prescribed by the new order, are as follows: — Designation. Bacteriological standard. 1. Tuberculin Tested Milk This milk must not; decolourise 2. Tuberculin Tested Milk methylene blue within 4½ hours if the (certified). sample is taken between 1st May and 3. Accredited Milk 31st October, or within 5½ hours if 4. Accredited Milk (Farm taken between 1st November and bottled) 30th April. It must not contain B. Coli in 1/100th millilitre. 5. Tuberculin Tested Milk Must not contain more than 30,000 (Pasteurised). bacteria per millilitre. G. Pasteurised Milk Must not contain more than 100,000 bacteria per millilitre. In addition to the bacterial plate count, the Ministry of Health recommend that the Phosphate test should also be applied to milk which is sold under the designation "Pasteurised." By this test, it is possible to detect even relatively small errors in pasteurisation technique. e.g. heating the milk at 143°F instead of 145°F, or heating for 20 minutes instead of 30 minutes, or the addition of as little as 0.3% of raw milk to the pasteurised bulk. Several important changes are laid down in the new Order, and as will be observed from the above, the plate count for raw milks is no longer recognised. Other amendments are (a) the term "bottle" includes any container of a capacity not exceeding one quart and of a type approved by the licensing authority; thus cartons may now be used for designated milks; (b) the cap used for closing the bottle need not bear the day of production of the milk, and (c) the licensing authority may dispense with the payment of licence fees. During the year under review, 105 samples of graded milk, 27 of ungraded and 6 of raw milk were purchased by the Sampling Officer for bacteriological examination. Forty-six of the samples were purchased from milk vendors in the streets in the early hours of the morning and 44 were taken at the early morning delivery to the hospitals, etc., in the Borough which are controlled by the London County Council. Of the total of 138 samples examined 41 were especially tested by animal inoculation for the presence of tubercle bacilli under Section 5 of the Milk and Dairies (Amendment) Act, 1922, and in none of the samples so examined was tubercle bacilli detected. 73 The following table gives the number of the various types of milk examined: — TABLE 22. Type of Milk. Examination Made. Bacteriological Count only. Bacteriological count and Animal inoculaton for tubercle bacilli. Certified 6 — Tuberculin Tested 3 — Grade A (Tuberculin Tested) 7 5 Tuberculin Tested (Pasteurised) 1 1 Grade A (Pasteurised) 3 — Pasteurised 85 21 Ordinary 25 9 Carton 2 1 Raw 6 4 Totals 138 41 Certified Milk and Tuberculin Tested Milk Of the nine samples examined, four were taken at the request of the Ministry of Health, one of which was reported to contain 86,500 bacteria per c.c., the legal maximum under the 1923 Order being 30,000. The matter was dealt with by the Ministry. Grade A (Tuberculin Tested) Milk. Seven samples were examined during 1936 and the average bacterial count was 18,071 per c.c.—well below the legal maximum of 200,000 bacteria pel c.c. Tuberculin Tested Milk (Pasteurised). One sample taken and reported to contain 1,820 bacteria per c.c.—legal maximum 30,000 per c.c. Grade A (Pasteurised) Milk. The results of three samples examined were excellent, the bacterial counts being respectively 260, 280 and 1,560 per c.c. Pasteurised Milk. A maximum of 100,000 bacteria per c.c. was prescribed for this milk by the Order of 1923 and none of the 85 samples examined during 1936 was reported to contain bacteria in excess of this standard, the lowest count being 690 and the highest 43,000 bacteria per c.c. Ordinary Milk. This is milk which has beer treated by heat although not sold under the designation "Pasteurised." There is of course, no bacteriological standard for such milk, and it is satisfactory to record that the lowest count was reported to be 8,860 bacteria per c.c., and the highest 111,660 per c.c., while the average for the 25 samples examined was 41,777 bacteria per c.c. In addition to the above, six samples of raw milk and two of carton milk were examined bacteriologically and satisfactory reports received. 74 FOOD AND DRUGS—ADULTERATION, ETC. During the year, one thousand articles of food and drugs were purchased by Inspector Gammack in his capacity as sampling officer and were submitted to the Public Analyst for analysis. The samples were taken under the Food and: Drugs (Adulteration) Act, 1928, and other Acts, Regulations and Orders relating to foodstuffs. Of these, 26 or 2.6% were adversely reported upon and full details of the adulterated samples will be found in Table 18 (milk) and Table 24 (other articles). The usual practice of reporting all adulterated samples to the Public Health Committee was continued during 1936 and the appropriate action taken. In the table which follows will be found details of the number and percentage ot adulterated samples of all articles of food during the years 1928 to 1936 inclusive. TABLE 23. SAMPLES OF ALL FOOD (INCLUDING MILK) REPORTED AS ADULTERATED ON CHEMICAL ANALYSIS. Year. 1928 1929 1930 1931 1932 1933 1934 1935 1930 No. examined 1,000 1,000 1,000 1,000 1,001 1,000 1,000 1,002 1,000 No. adulterated 31 44 40 22 29 35 43 40 26 Percentage of adulteration 3.1 4.4 4.0 2.2 2.89 3.5 4.3 3 .99 2 .6 During 1936, one sample of tinned crab and one of tinned salmon were purchased by the Sampling Officer and submitted to the Clinical Research Association for examination for the presence of organisms of the food poisoning (Salmonella) group, but in neither sample were food poisoning or other micro-organisms of importance found. PUBLIC HEALTH (CONDENSED MILK) REGULATIONS, 1923 & 1927 AND PUBLIC HEALTH (DRIED MILK) REGULATIONS, 1923 & 1927. Ten samples of condensed milk were purchased during 1936 and in all cases the milk, labelling of tins, etc, were in accordance with the Regulations. 75 PUBLIC HEALTH (PRESERVATIVES, ETC., IN FOOD) REGULATIONS, 1925—1927. During the year under review samples were examined for the presence of preservative and no contraventions were reported. For a detailed report on the result of the analysis of food and drug samples see the report oi the Council's Public Analyst on pages 80—83. TABLE 24. DETAILS OF ACTION TAKEN IN CONNECTION WITH SAMPLES (EXCLUDING MILK) REPORTED TO BE ADULTERATED OR NOT IN ACCORDANCE WITH PRESCRIBED STANDARDS. Sample No. Article. Result of Analysis. Action taken. 235 Butter 1 % excess water Vendor cautioned. 236 Butter 1 % excess water Vendor cautioned. 238 Ground Nutmegs Contained 4% St. Vincent Arrowroot Informal sample—see 246. 246 Ground Nutmegs Contained 2% St. Vincent Arrowroot Vendor cautioned. 281 Powdered Rhubarb Contained 3 % excess of ash Vendor's attention drawn to matter. 312 Malt Vinegar Consisted of artificial vinegar Vendor cautioned. 559 Gelatin Contained l/30th grain of arsenic per pound. Informal sample—see 634. Vendors attention drawn to matter. 568 Allspice Consisted of pickling spice Vendor's attention drawn to matter. 582 Black Draught Contained 32% excess magnesium sulphate. Vendor cautioned. 634 Gelatin Contained l/30th grain of arsenic per pound Vendor cautioned and remainder of stock collected by wholesalers. 731 Tinned Sild Contained 2.5 grains of tin per lb. Remainder of stock—4,704 tins—surrendered. 733 Tinned Sild Contained 2.2 grains of tin per lb. 734 Tinned Sild Contained 2.8 grains of tin per lb. 735 Tinned Sild Contained 2.2 grains of tin per lb. 736 Tinned Sild Contained 3.5 grains of tin per lb. 737 Tinned Sild Contained 2.8 grains of tin per lb. 752 Gin Contained 0.9% by weight excessive water. Vendor cautioned. 753 Gin Contained 0.5% by weight excessive water. Vendor cautioned. 764 Vinegar Was 12% deficient in Acetic acid Vendor cautioned. 940 Shredded Suet Contained 20% rice starch—15% only allowed. Vendor cautioned. INSPECTION OF BAKEHOUSES AND BAKERS' SHOPS. At the end of 1936 there were 61 registered bakehouses in the Borough of which 33 were underground. Of the 01 bakehouses 49 are factories and 12 are workshops; in addition there are 13 retail bakers' shops in the Borough without bakehouses attached. During 1930, 313 visits were made and 51 notices served, principally for the limewashing and cleansing of the interior of bakehouses. In addition a large amount of cleansing is carried out as the result of verbal intimation to the occupiers. 76 INSPECTION OF MEAT AND OTHER FOODS AND OF FOOD PREMISES. This is extremely important for the health of the community. The inspections are made for many reasons, but principally: — (1) To ensure that articles of food are sound, wholesome, free from disease and fit for the food of man. (2) That the premises are in good sanitary condition and clean. (3) That the persons engaged in food occupations are clean in their persons and free from disease and that they carry out their duties in a hygienic and wholesome manner. The public can assist materially by encouraging clean food shops and discouraging any that are not obviously clean and hygienic. The following table shows the number of inspections of the various types of food premises: — Milk shops and dairies 453 Ice Cream premises 65 Butchers' shops 183 Fish shops 33 Fried fish shops 45 Fish curing premises 26 Greengrocers' and Fruiterers' Premises 93 Cooked meat shops 12 Eel and Pie shops 9 Dining rooms and eating rooms 126 Restaurants 55 Licensed Premises 92 Street Traders' Storage Premises 30 Slaughter Houses 47 Factory Bakehouses 283 Workshop Bakehouses 18 Workplace Bakehouses 12 Bakers' shops 53 Food factories other than those included above 11 Other food premises 139 1,785 The inspection of food shops and of food is carried out by the District Inspectors as well as by the Sampling Officer. Two inspectors are on duty two evenings a week inspecting the North End Road Market, the Fulham Market and other street markets in addition to shops. All the male Inspectors take their turn with this duty. SLAUGHTER-HOUSE. There is now one licensed slaughter-house in the Borough, and the following is a summary of the work performed in connection with these premises during the year: — Animals Slaughtered 179 sheep. Visits to slaughterhouse 47 Meat condemned 1 liver (2 lbs.) abcess. 4 prs. lungs abcess. 2 prs. lungs strongylosis. 77 PREMISES USED FOR THE PREPARATION OF FOOD. On and after October, 1936, the powers formerly exercised under the London County Council (General Powers) Act of 1932, with regard to the registration of premises used for the manufacture, storage or sale of ice cream and for the preparation of certain specified articles of food, have been exercised under Section 187 of the Public Health (London) Act, 1936. At the end of 1936 there were 118 premises on the Register relating to the preparation of preserved foods and 227 premises on the Register relating to the manufacture or sale of ice cream under the following headings: Premises registered for manufacture, storage and sale of ice cream 93 Premises registered for storage and sale of ice cream 120 Premises registered for the manufacture and storage of ice cream 10 Premises registered only for the manufacture of ice cream 4 227 UNSOUND FOOD. The undermentioned articles of food examined at the request of the owners were condemns destroyed during the year: — Tomatoes 180 lbs. Potatoes 10 cwt. Chilled beef 159 lbs. Bacon 61 lbs. Nougat 5 bars. Smoked fillets 7 lbs. Tinned herrings 194 tins. Cod 1 Winkles 5 bags. Onions 34 bags. Corned beef 122 tins. Shredded wheat 4 pkts. Tinned ham 8 tins. Crab dressing 14 tins. Cod fillets 4 boxes. Honey 3 pots. Skate 105 lbs. Evaporated milk 17 tins. Lemon curd 1 pot. "Cremo" oats 5 pkts. Tinned salmon 8 tins. Baked beans 3 tins. Tomato puree 3 tins. Cream 2 tins. Sardines 2 tins. Oranges 2 Tinned pilchards 3 tins. Wheatschop 1 Tinned bristling 2 tins. Peas 2 tins. Syrup 2 tins. Anchovy Paste 2 jars. Gelatine roll 2 tins. Tinned fruit 38 tins. No food was seized as unfit for consumption. PUBLIC HEALTH (IMPORTED FOOD) REGULATIONS, 1925. One notification was received from the Port of London Sanitary Authority under these Regulations relating to bags of damaged sugar. The sugar was inspected and seen in the process of refining by one of the sanitary inspectors. 78 THE PHARMACY AND POISONS ACT, 1933, THE POISONS RULES, 1935. This Act, together with the Rules made under it, came into full effect on 1st May, 1936, and by it all the existing legislation relating to the sale etc., Of poisons was repealed. The law relating to the sale, supply, storage and transport of poisons has been considerably revised and the Act establishes a Poisons Board with the duty of preparing a list of the substances to which the Act is to apply. This list known as the Poisons List, was confirmed by the Home Office on 21st December, 1935, and consists of two parts. In Part I are those substances, the sale of which is restricted to the premises of "authorised sellers of poisons," i.e. chemists and pharmacists, and in Part II are those poisons in common use which may be sold from premises of "authorised sellers" and also "listed sellers of poisons," i.e. shop-keepers other than chemists, provided the name of the person and the address of the premises are entered in a list kept by the local authority of the area in which the poisons are sold. The principal changes in the law are: — 1. The sale of certain poisonous preparations used in agriculture and horticulture (not arsenical weed killers) is now permitted to any trader who is registered with the local authority. '2. Traders so registered are now permitted to sell carbolic disinfectant containing up to 60% of phenols. Formerly the sale of liquids containing more than 3% of phenols was restricted to chemists' shops. 3. The sale of ammonia of over 5% strength, sulphuric acid, nitric acid, potassium quadroxalate (salts of lemon), hydrochloric acid (spirits of salts) and of disinfectants containing less than 3% of phenols which has hitherto been unrestricted except for requirements in regard to labelling arid form of bottle, is now restricted to authorised sellers and listed sellers of poisons only. 4. The sale of potasium hydroxide (caustic potash) and sodium hydroxide (caustic soda) it, controlled for the first time and may only be sold by authorised and listed sellers of poisons. 5. The only poisons which listed sellers are permitted to retail from " bulk " (i.e. repack) are ammonia, hydrochloric acid, nitric acid, potassium quadroxalate and sulphuric acid. All other Part II Poisons may be sold by listed sellers only in closed containers as closed by the manufacturer or wholesaler from whom they have been obtained. 0. The sale of Part II poisons must be effected on the premises specified in the local authority's list and the previous practice of hawking carbolic disinfectants from barrows, becomes, therefore, illegal. No poison may be sold from an automatic machine. It is the duty of the Pharmaceutical Society of Great Britain to secure compliance by authorised sellers of poisons with the provisions of the Act and Rules and local authorities control listed sellers of poisons and other persons not being authorised sellers of poisons. 79 A fee of 7s. 6d. is payable to the local authority by every person for entry of his name in the list in respect of each set of premises on which he is entitled to sell poisons and thereafter an annual fee of 5s. is payable for the retention of his name on the list for each set of premises. The local authority is empowered to refuse to enter, or to remove from the register, the name of any person who fails to pay the prescribed fee or who, in the opinion of the authority is, for any reason relating either to himself or to his premises, not fit to be on the list. There is right of appeal against the decision of the local authority. At the end of 1936, there were 98 names on the Register of Listed Sellers of Part II poisons and Inspector Gammack, who is carrying out the provisions of the Act in Fulham, made 526 visits to premises during the year. Under the Act, local authorities are empowered to take samples of poisonous substances for examination and during 1936 two articles were purchased and submitted to the Council's Public Analyst. 80 REPORT OF THE PUBLIC ANALYST. (Mr. Thomas McLachlan, A.C.G.F.C., F.I.C.). It is satisfactory to note that the percentage of adulteration (2.6%) during the year under review is less than it has been for many years in Fulham, and would have been still lower (2.0%) if it had not been for a complaint regarding tinned fish, to which reference will be made later. Of a total of 566 samples of milk and skimmed milk, six only (1.06%) were reported as adulterated. An informal sample submitted to the Medical Officer of Health as being "bad" was found to be 36% deficient in fat, but as this had been taken from the bottom of a jug, the probability was that the person making the complaint had poured off most of the fat with the creamy layer. A formal sample taken in the course of delivery from the vendor was found to be satisfactory. Another sample was found to contain 1.4% of added water and to be 13.7% deficient in fat. A third sample was over 50% deficient in fat, and in this case the application for a licence to sell milk in Fulham was refused. The other three samples were slightly deficient in fat. Of a total of 364 samples of foods, other than milk, beers, or spirits, 16 (or 4.4%) were reported as adulterated. Two samples of butter were found to contain 1% of excessive water. It is found in general that good butter usually only contains about 12—14% of water, so that the Regulation requiring butter not to contain more that 16% of water is not too stringent. One sample of shredded suet was found to contain 20% of rice starch. At Christmas time the charge made for suet is 1s. per lb., and with the ground rice at approximately one-sixth this price it will be seen that the addition of more than 15% of starch is definitely fraudulent. Two samples of ground nutmeg, one informal and the other a formal sample from the same vendor, were found to contain a small quantity of St. Vincent arrowroot. Inspection of the vendor's premises showed that various spices, starches, etc., were kept in a chest of drawers, and that products leaked from one drawer into another. In one case, where the inspector asked for allspice, he was supplied with pickling spice. Allspice is the popular name for pimento, a small berry which looks rather like black pepper, and although it is used in pickling spice and for flavouring pickles, it should not be confounded with pickling spice, which is composed of a mixture of various spices. As a result of the Spanish Civil War there was a shortage of almonds at the beginning of the season, and consequently a tendency to supply substitutes Mixtures sold definitely as substitutes are a simple matter with which to deal; but powders made from ground apricot kernels require considerable care in their examination. In no case was any sample submitted by the inspector found to be other than genuine ground almonds. In other parts of the country there have also been several complaints about the presence ot magnesium carbonate in ground white pepper, but none was detected in any sample examined in Fulham. At one time it was considered necessary to add some substance to pepper in order to facilitate grinding, but millers have now overcome this difficulty, so that it is a matter of argument as to whether such additions should be permissible or not. In the opinion of your analyst it would be an advantage to have a standing Committee at the Ministry of 81 Health which could arbitrate in such matters and guide analysts and manufacturers, rather than make it necessary for these cases to be decided in Court. Of the five samples of gelatine submitted, two were found to contain excessive quantities of arsenic. Arsenic is sometimes used in the treatment of hides, either as a preservative or for dehairing them, and scraps from the leather industry are used for the preparation of gelatine. It is claimed by many experts that the use of arsenic for these purposes is unnecessary; but it is certain that any hide which has been treated with arsenic should be discarded and not passed on for the purposes of making food products. Owing to a complaint from a neighbouring borough that tins of sild, emanating from a wholesale store in the Borough contained an excessive amount of tin, 14 tins were examined, and of these G were found to contain from 2.2—3.5 grains of tin per lb. All the tins were found to be corroded on the inside, and the whole batch was condemned. One sample of malt vinegar was found to consist of artificial vinegar. Of the 20 samples of beers and spirits, 2 samples of gin were found to contain an excessive amount of water. The Food and Drugs (Adulteration) Act, 1928, requires that no spirits shall be sold which are less than 35% under proof. Owing to the desire of publicans and their wholesalers to obtain the maximum profit on spirits, there is a growing tendency to dilute them to as nearly 35% under proof as possible, with the result that the amount of water is sometimes just above the limit. The quality of drugs examined this year is superior to that of the last few years, and it is to be hoped that this improvement will be maintained. Only two out of fifty samples of drugs were reported against. These were a sample of Black Draught, which contained an excess of Epsom salts to the extent of 35%, and of powdered rhubarb where the ash was 18% as compared with the maximum of 15% permitted by the British Pharmacopoeia. A sample of sulphur ointment containing 10.9% of sulphur was reported genuine, although the Pharmacopoeia formula demands 10.0% only. In cases such as these it must be borne in mind that the active ingredient may be less expensive than the ointment base, and that there may be a tendency to err on the side of allowing too much of a drug in consequence. With the advent of the New Year the Addendum, 1936, to the British Pharmacopoeia, 1932, will come into operation, and will make some of the tests more reliable and simpler in manipulation than formerly. At the same time, tests such as those requiring cod-liver oil to be examined for vitamin activity by means of the spectrum absorption test for Vitamin A and by biological assay in the case of Vitamin D will tend to result in increased, rather than decreased, possibilties of controlling important drug-foods. The beginning of the New Year also marks the introduction of the methylene-blue test for Tuberculin-Tested milk and for Accredited milk instead of the former method of making bacteriological plate counts. 82 TABLE 25—SAMPLES ANALYSED, 1936. Number of Samples. Article. Taken F ormallv. Adulterated. Taken Informally. Adulterated. Total Samples Analysed. Total Samples Adulterated. Percentage of Adulteration. Milk 562 5 2 1 564 6 1.1 Skimmed Milk 2 — — - 2 - - Condensed Machine- - skimmed Milk — — 10 - 10 - - Cream 5 — 6 - 11 - - Butter 69 2 6 - 75 2 2.7 Margarine 13 — — - 13 — — Cheese 6 — — - 0 — — Lard 19 — — - 19 — — Shortening 1 — — - 1 — — Dripping 3 — — - 3 — — Suet 5 1 1 - 6 1 16.7 Tea 6 — 2 - 8 — — Popper 5 — — - 5 — — Cayenne Popper 4 — — - 4 — — Ground Ginger 6 — — - 6 — — Ground Nutmeg 2 1 2 1 4 2 50.0 Mixed Spice — — 3 - 3 — — Pimento (Allspice) — — 4 1 4 1 25.0 Mint Sauce — — 4 4 — — Ground Almonds 6 — — - 6 — — Demerara Sugar 11 — — - 11 — — Dried Fruits 22 5 5 - 27 — — Mincemeat 5 2 2 - 7 — Butter Beans — 5 5 - 5 — — Dried Peas — 5 5 - 5 — Flour 4 — — - 4 — — Self-raising Flour — 3 3 - 3 — — Oaks 3 1 1 - 4 — — Arrowroot — 4 4 - 4 — — Oatmeal — 4 4 - 4 — — Rice 4 3 3 - 7 — — Sago Tapioca 2 1 1 - 3 — — 3 — 1 - 4 — — Gelatine 1 1 4 1 5 2 40.0 Sausages 17 — 2 - 19 — — Preserved Sausages 7 — — - 7 — Corned Beef 3 — — - 3 — — Moat Pies and Rolls 5 — — - 5 — — Tinned Fish 2 — 14 6 16 6 37.5 Non-Alcoholic Wine and Cordials 9 — 2 — 11 — — Fruit Cordial Powders 4 — — — 4 — — Malt Vinegar 11 1 — — 11 1 9.1 Vinegar 7 1 — — 7 1 14 .3 Ale 5 — — — 5 — - Brandy 5 — — — 5 — Gin 4 •> — — 4 2 50.0 Rum 4 — _ — 4 — Whisky 2 — — — 2 — — Bicarbonate of Soda — — 4 4 — Black Draught — — 4 1 4 1 25.0 Boric Ointment 2 — — 2 Camphorated Oil — — 7 — 7 — Epsom Salts 4 ~~~ — —— 4 —• — continued. 83 Number of Samples. [Article. Taken Formally. Adulterated. Taken Informally. Adulterated. Total Samples Analysed. Total Samples Adulterated. Percentage of Adulteration. Flowers of Sulphur 4 4 - Liquorice Powder — - 2 - 2 - - Parrish's Food — - 4 4 - Rhubarb (Powdered) — - 3 1 3 1 33.5 Sulphur Ointment 7 - — - 7 - Sal Volatile 3 — - 3 Senna (Powdered) — - 3 - 3 - Zinc Ointment 3 - — - 3 - - Totals 877 14 123 12 1000 26 2.6 Section VI. PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. 85 TABLE 26. TABLE SHOWING THE AGE AND WARD DISTRIBUTION OF THE CASES OF INFECTIOUS DISEASES NOTIFIED DURING 1936. Notifiable Diseases. Number of Cases Notified. Total Cases Notified in each Ward of the Borough. At Ages—Years. Baron's Court Ward. Lillie Ward. ( Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. Total cases removed to Hospital. Deaths. D.N.C. At all Ages. 0—1. 1—2. 2—3. 3—4. 4—5. 5—10. 10—15. 15—20. 20—35. 35—45. 45—65. 65 and upwards. Smallpox - - - - - - - - - - - - - - - - - - - - - - - - Cholera, Plague — — — — — - - - - - - - - - - - - - - - - - - - Diphtheria 179 3 11 7 14 17 86 14 10 12 3 2 - 6 31 32 30 40 5 24 179 10 24 - Erysipelas 63 1 2 - - - 3 ?. 3 6 8 23 15 3 6 16 8 9 5 10 6 40 - - Scarlet Fever 323 4 11 27 22 38 121 31 19 33 7 8 2 23 45 58 39 62 22 46 28 307 - — Typhus Fever - - - - - - - - - - - - - - - - - - - - - - - - Enteric Fever 16 - 1 1 - 1 1 - 1 6 2 3 - 2 5 1 1 2 - 2 3 16 3 — Relapsing Fever, Continued Fever - - - - - - - - - - - - - - - - - - - - - - - - Puerperal Fever 6 - - - - - - - - 5 1 - - 2 - 2 1 - - - - — — — Puerperal Pyrexia 25 - - - - - - - - 21 4 - - - - - - — - — 1 6 2 — Cerebro-Spinal Meningitis 4 3 - - - - 1 - - - - - - 6 5 2 2 7 - 1 - 24 — — Polio-myelitis 4 - - - - - 2 1 - 1 - - - 1 - - 1 - - 1 1 4 2 — Ophthalmia Neonatorum Tuberculosis of 13 13 — — — — - - — - - - - 2 3 2 3 2 — 1 i 1 8 — — Respiratory System Non-Pulmonary 208 1 — — — — 5 2 15 80 29 61 15 20 33 24 26 32 18 35 20 — 107 - Tuberculosis 35 2 2 2 1 5 3 8 3 9 - - - - - - - - - - - - Measles 2875 132 297 306 350 514 1164 55 23 33 3 2 2 6 7 1 4 8 1 4 4 — 13 — Encephalitis Lethargica - - - - - - - - - - - 1 - 1 38 630 404 200 629 118 496 210 419 14 5 Pneumonia 226 11 5 8 7 10 31 9 11 43 22 44 25 12 39 26 29 57 20 24 19 - 2 — Diarrhoea 6 2 3 - 1 - - - - - - - - - - - - - - - - - 133 — Malaria - - - - - - - - - - - - - - 1 1 1 2 — 1 — 4 22 — Dysentery 7 — 5 - - - - - - - - - - 1 1 1 2 - — 2 — 7 — — Irench Fever — — — — — — — — — - — - — - - - - — — - — - — - Totals 3990 172 337 349 396 582 1420 119 85 248 79 144 59 222 806 620 347 851 190 649 305 1016 309 44 8 6 TABLE 27. MONTHLY DISTRIBUTION OF INFECTIOUS DISEASE. Notifiable Disease. January February March April May June July August September October November December Totals. Pneumonia 39 19 34 17 23 8 9 7 8 23 12 27 226 Scarlet Fever 19 20 29 26 41 45 26 12 24 23 30 28 323 Diphtheria 21 27 14 16 10 11 8 10 17 20 15 10 179 Puerperal Fever — — — 1 — 1 1 — - - - 3 6 Puerperal Pyrexia 1 1 1 2 — — 2 2 5 4 4 3 25 Erysipelas 14 5 5 5 5 4 6 3 1 3 7 5 63 Ophthalmia Neonatorum 1 1 1 5 — - 1 - 2 1 1 13 Cerebro-Spinal Meningitis 2 — — — — - — — 1 - 1 4 Enteric Fever — — 1 1 4 2 3 1 3 1 16 Polio-myelitis - - 1 3 - ___ 4 Encephalitis Lethargica — — — — — — — — — - - Measles 54 440 1222 782 245 86 23 5 10 - 3 5 2875 Dysentery 1 — 4 — — — — — - - 2 7 Epidemic Diarrhoea — — — 1 — 4 — — - - - 1 6 Totals 152 513 1311 856 328 161 79 41 74 75 73 84 3747 TABLE 28. COMPARATIVE STATEMENT OF NOTIFIABLE INFECTIOUS DISEASES, 1930-1930. 1930 1931 1932 1933 1934 1935 1936 Scarlet Fever 595 331 543 720 691 317 323 Pneumonia 207 275 241 203 180 139 226 Diphtheria 402 225 177 185 473 375 179 Erysipelas 74 86 106 104 117 56 63 Puerperal Fever 17 11 11 11 4 6 6 Puerperal Pyrexia 33 47 37 27 37 28 25 Enteric Fever 13 3 11 5 4 10 16 Ophthalmia Neonatorum 19 17 28 15 15 11 13 Cerebro-Spinal Meningitis 2 9 8 5 6 1 4 Encephalitis Lethargica 2 1 3 — 1 2 - Polio-myelitis 3 4 1 2 2 3 4 Measles 2526 110 2682 163 2967 41 2875 Epidemic Diarrhoea 31 33 22 13 14 4 6 Dysentery — — 2 —. 1 4 7 Smallpox 7 - — — — — - Totals 3931 1152 3872 1453 4512 997 3747 87 88 TABLE 20. NUMBER OF CASES OF INFECTIOUS DISEASE NOTIFIED FROM 1900-1936 INCLUSIVE. 1900 1901 1002 1003 1004 1005 1000 1907 1008 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1020 1921 1022 1923 1924 1925 1926 1927 1028 1929 1030 1931 1932 1033 1934 1935 1936 Small-Pox 9 16 94 11 - - - - - - - - - - - 7 - - - - - - 2 - - - - - 1 - 7 - 2 - - - - 552 600 552 404 294 779 674 668 596 511 354 384 484 766 1,042 621 286 234 228 371 930 961 626 466 360 398 311 360 416 489 595 331 543 720 691 317 323 Diphtheria 641 644 420 293 302 286 403 604 400 322 257 311 231 270 272 271 312 237 206 336 623 579 438 277 259 276 345 390 359 370 402 225 177 185 473 37 5 179 Typhoid Fever 02 133 74 SO 30 56 45 58 39 41 18 38 26 34 40 14 5 11 15 6 25 7 16 3 7 10 8 11 41 2 13 ll 5 4 10 16 154 132 121 115 131 143 141 128 127 115 115 115 115 121 152 89 73 50 45 75 102 92 94 76 92 74 77 58 81 78 74 86 104 117 Cholera — 1 — — — — — — — !— 106 104 117 56 63 Cerebro-Spinal Meningitis — — - - — — — 3 4 3 7 3 2 5 1 20 12 20 8 9 5 4 1 2 2 3 4 7 4 5 2 9 8 5 6 - - Polio myelitis — — - — — — - — — .— 1 5 2 — - 3 5 2 2 2 2 2 5 7 3 7 3 3 5 3 1 9 2 3 4 Ophthalmia Neonatorum — — - - — — — — — — — 15 13 23 55 47 49 57 44 47 40 30 33 22 27 32 29 33 38 32 19 17 28 15 15 11 13 Measles Notifiable from 1st January, 1916 — — — — — - - — — - 751 2,021 1592 615 942 396 2438 1,951 1,692 589 3700 463 2099 948 2526 110 2682 163 2,967 41 2875 Encephalitis Lethargica Notifiable from 1st January. 1919 - - - - - - - - - - - - - 6 2 7 3 2 21 10 12 5 2 5 2 1 3 - 2 - Pneumonia Notifiable from 1st March. 1919 1— — 199 108 215 300 218 326 320 288 310 297 345 207 275 241 203 180 139 226 — - - - - - - - - - - - - - 83 51 140 17 79 40 70 50 18 60 36 31 33 22 13 14 4 6 Puerperal Fever 9 7 7 10 8 24 17 15 17 34 20 23 30 19 33 24 22 15 12 35 32 27 31 32 26 21 15 16 16 23 17 11 11 11 4 6 6 Puerperal Pyroxia Notifiable from 1st October. 1926 - - - - - - - - - - - - - - - - - - - - - - - 51 33 37 27 37 28 25 Trench Fever Notifiable from 1st March, 1919 - - - - - Dysentery - Notifiable from 1st March. 1919 - - - - — - - - - - - - - 9 - 2 - - - - - 6 1 2 - - - Malaria - - - - - - - - - - - - - - 104 20 9 1 1 3 - - 1 4 - 2 — 2 1 - - - Totals 1,457 1,533 1,277 922 774 1,288 1,280 1,476 1,183 1,026 771 890 906 1,240 1,595 1,093 1,513 2,650 2,152 1,898 2,972 2,474 4,003 3,134 2,862 1,806 4,858 1,700 3,473 2,391 3,933 1,152 3,876 1,454 4512 997 3747 TABLE 30. NUMBER OF DEATHS FROM THE SEVEN PRINCIPAL ZYMOTIC DISEASES DURING 1900-1936 INCLUSIVE. 1900 1901 1902 1003 1004 1905 1906 1907 1908 1909 1010 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1023 1024 1025 1026 1027 1028 1020 1030 1931 1932 1033 1934 1935 1936 - 3 13 - - - - - - - - - - - - 3 - - - - - - 1 - - - - - - - - - - - - - - Measles 80 37 168 62 64 85 53 69 71 74 15 64 65 49 31 121 18 75 46 14 24 2 41 23 20 2 47 - 15 10 27 1 26 2 31 — 14 Scarlet Fever 23 20 19 8 4 23 18 14 17 10 7 6 0 4 21 17 5 4 4 5 9 15 12 3 4 1 2 3 2 2 2 6 1 - 1 Diphtheria 65 48 51 24 24 24 33 38 32 39 14 27 15 15 23 27 20 16 12 32 44 43 33 20 11 11 14 11 13 10 19 9 10 8 30 12 10 Whooping Cough 76 65 48 58 82 31 76 34 48 60 28 45 27 43 32 22 58 4 17 30 26 14 14 35 6 8 12 25 5 7 12 14 7 5 6 Typhoid Fever 19 22 9 16 6 10 13 8 10 4 2 8 S 8 9 4 1 2 5 9 4 1 4 - 1 - - 2 1 - 1 2 1 - 1 — 3 Diarrhcea (and Enteritis under 2 years) 181 199 140 165 235 202 275 115 130 105 74 211 34 100 127 81 64 71 60 44 36 71 27 25 22 36 30 10 53 35 34 15 22 20 18 19 22 Totals 422 405 465 323 391 426 423 319 294 280 222 344 173 203 254 304 140 190 185 101 134 162 144 87 82 87 101 41 96 83 88 36 73 50 88 36 56 Zymotic Death Rate 3.17 2.93 3.25 2.19 2.57 2.73 2.66 2.00 1.94 1.83 1.45 2.25 1.12 1.28 1.62 2.00 0.90 1.31 1.29 0.66 0.88 1.30 0.93 0.53 0.50 0.53 0.60 0.20 0.60 0.50 0.57 0.25 0.49 0.33 0.61 0.25 0.38 90 DIPHTHERIA. During the year 179 cases were notified compared with 375 the previous year, the attack rate being 1.3 per 1,000 of the population compared with 2.6. My anticipation that the incidence of this disease was waning has been fully borne out. All cases were removed to hospital for treatment; 10 deaths occurred, the fatality rate being 5.0 per cent., as compared with 3.2 per cent., last year. The age distribution of the cases is shown in Table 26(page 85). DIPHTHERIA ANTITOXIN. This is available to practitioners upon request at the Public Health Department. During the year 44 issues, each of 8,000 units, were made. Since October, besides the usual packing that has been in use for several years, a special packing with the serum already in a " syringe " has been stocked and 9 issues were made. DIPHTHERIA IMMUNISATION. No. of Clinic Sessions held 47 New cases treated 582 Total attendances of old and new cases 3,129 Average attendance 66.5 Primary Schick Test. Positive 503 Negative 78 Not tested 1 582 Posterior Schick Test. Positive 79 Negative 491 Not read 8 578 Post Schick Test. Positive 2 Negative13 15 Inoculations. With T.A.F 576 With A.P.T. (1) 221 With A.P.T. (2) 194 With A.P.T. (3) 124 1,115 Discontinued treatment 16 Transferred to other districts 5 Certificates of immunity issued ,491 91 TABLE 31. SUMMARY OF INOCULATIONS WITH T.A.F. Age Group Primary Schick. Inoculations. Posterior Schick. Transferred to other areas. Discontinued treatment. Positive Negative Not read 1st 2nd 3rd 4th 5th Positive Negative Not read 6/12 — 1 15 - - 15 15 15 - - 2 13 - - - 1 — 2 21 — 1 21 21 21 - 1 2 18 1 - 1 2—3 19 1 — 19 19 19 1 1 2 18 - 3—4 14 1 1 13 13 13 1 1 1 12 2 1 3 4 — 5 19 — — 19 19 19 — - 1 18 - 5 — 6 16 3 - 16 16 16 2 1 2 17 - - - 6—7 11 — - 11 11 11 1 1 1 10 - - - 7—8 14 - - 14 14 14 1 1 2 12 - - - 8—9 9 3 - 9 9 9 — - - 11 1 - - 9 — 10 10 3 1 10 10 10 - - 1 12 - - - 10 — 11 3 5 - 3 3 3 — - - 8 - - - 11 — 12 2 4 — 2 2 2 - - 6 - - - 12 — 13 6 2 — 6 6 6 - - - 8 - - - 13 — 14 2 2 — 2 9 2 - - - 4 - - - 14 — 15 1 — — 1 1 1 - - - 1 - - - 15 and upwards 3 2 - 3 3 8 - - — 5 — — — TOTALS 165 26 3 164 164 164 6 6 14 171 4 1 4 194 504 92 TABLE 32. SUMMARY OF INOCULATIONS WITH ONE INJECTION OF A.P.T. Age Group Primary Schick. Inoculations. Posterior Schick. Transferred to other areas. Discontinued treatment. Positive Negative Not read 1st 2nd 3rd Positive Negative Not read 6/12 — 1 5 1 - 5 - - 1 5 - - - 1 — 2 28 1 — 28 — — 3 25 - — 1 2 — 3 27 1 — 27 — — 3 23 - i 1 3 — 4 34 1 — 34 — — 2 31 - — 2 4 — 5 33 5 — 33 — — 8 29 1 — — 5 — 6 22 — — 22 — — — 18 1 i 2 6 — 7 25 3 — 25 — — 4 24 - — — 7 — 8 11 4 — 12 — — 2 11 - — 2 8 — 9 13 4 — 13 — — 4 13 - — — 9 — 10 4 3 — 4 — — 1 6 - — — 10 — 11 5 3 — 5 — — — 8 - — - 11 — 12 6 3 — 6 — — 1 7 - — 1 12 — 13 4 2 — 4 — — — 6 - — — 13 — 14 2 2 — 2 — — — 4 - — — 14 — 15 - 2 — 1 — — — 4 - — — 15 and upwards - 8 — - — — — 6 - - 2 TOTALS 221 43 — 221 - — 29 220 2 2 11 264 264 CO CO TABLE 33. SUMMARY OF INOCULATIONS WITH TWO INJECTIONS OF A.P.T. Age Group Primary Schick. Inoculations. Posterior Schick. Transferred to other areas. ntinued treatment. Positive Negative Not read 1st 2nd Positive Negative Not read 6/12 — 1 1 - - 1 1 - 1 - - - 1 — 2 17 — — 15 15 - 12 1 — 4 2 — 3 12 — — 11 11 - 11 - - 1 3 — 4 10 1 — 10 10 - 8 - - 3 4 — 5 9 — — 9 9 1 7 - - 1 6 — 6 13 1 — 13 13 1 13 - - - 6 — 7 14 2 — 15 15 1 15 - - - 7 — 8 11 1 — 11 11 - 12 - - - 8 — 9 3 — — 2 2 - 2 - - 1 9—10 3 4 — 3 3 - 7 - - - 10 — 11 2 1 — 2 2 - 3 - - - 11 — 12 2 2 — 2 2 - 4 - - - 12 — 13 2 — — 2 2 - 2 - - - 13 — 14 1 1 — 1 1 - 2 - - - 14 — 15 — - - - - - - - 15 and upwards - - — - — - — - — — TOTALS 100 13 — 97 97 3 99 1 - 10 113 113 j TABLE 34. SUMMARY OF INJECTIONS WITH MIXED PROPHYLACTICS (T.A.F. & A.P.T.). Age Group Primary Schick. Posterior Schick. T.A.F. A.P.T. Positive Negative Not read Positive Negative Not read 1st 2nd 3rd 1st 2nd 3rd 6/12 1 2 1 – 3 – – 2 2 2 3 2 – 1 2 4 — — 4 — 1 2 1 1 5 5 3 2 3 4 — — 4 — — 2 2 2 4 2 2 3 4 3 1 — 4 — — — — — 4 3 3 4 5 6 1 — 7 — — 2 2 9 7 7 6 5 6 3 — — 3 — — 2 2 2 3 3 1 6 7 4 1 — 5 — — 1 1 1 5 5 3 7 8 4 — — 3 — — 2 2 1 4 3 2 8 9 7 — — 7 — — 3 3 3 7 7 4 9 10 3 — — 3 — — 2 2 2 2 2 1 10 11 3 — — 3 — — 3 3 3 3 3 11 12 3 — — 3 — — 0 2 o 2 3 1 12 13 — — — — — — — — — – – 13 14 1 — — 1 — — 1 1 1 1 1 14 15 — — — — — — , 15 and upwards 1 – – 1 — — 1 1 1 1 1 – TOTALS 48 4 — 51 – 1 25 22 25 51 47 24 <J4 95 SCARLET FEVER. There were 323 cases during the year compared with 310 in 1935. The attack rate was 2.3 per cent., compared with 2.2 in the previous year. The age distribution and seasonal incidence are shown in Tables 26 and 27 at the beginning of this section. 307 cases were hospitalised and one death occurred. MEASLES EPIDEMIC. Circumstances for the investigation of outbreaks of measles are particularly favourable in Fulham as the disease has been notifiable in the Borough since 1910. The disease was, at that time, made compulsorily notifiable throughout the country, but, owing to the apparent inffectiveness of notification in checking epidemics, the procedure was generally abandoned a few years later, and notification is now at the discretion of the local authority. The difficulty of control arises from the fact that the rash does not appear until the fourth day of the disease, whereas infectivity is most marked before the rash appears and the diagnosis is made. Epidemics occur in London with remarkable regularity every two years; thus in Fulham the present epidemic gave rise to 2,804 cases up to July 10th this year. Compared with that, only 41 cases occurred in the whole of 1935, but during the 1934 epidemic there were again 2,907 cases. The London County Council have recently modified their system of control of measles epidemics in order that cases should be diagnosed more promptly and any requisite treatment provided; thus contacts are no longer excluded from school but, on the occurrence of cases in a class, the class and then the school, is specially visited and the children regularly examined. Measles in school children runs, on the whole a beneficent course, but in young children under five is apt to be a dangerous disease, the most common complication being inflammation of the lungs in one form or another. The disease is also apt to leave damaged structures behind it, the eyes and ears, in particular, being liable to suffer. A prolonged condition of debility predisposing, in undernourished children, to tuberculosis, is also not uncommon. There are some 1,508 children under five attending London County Council and nonprovided schools in the Borough of Fulham. It was, therefore, of some public health moment to determine whether the London County Council's system of control, involving continued attendance of these children at school during an epidemic, was likely to give rise to more chance of infection than existed amongst children of three and four, who did not attend school, but whose brothers and sisters did attend. The opportunity furnished by the present epidemic was taken to determine whether school attendance of children under five did in fact, lead to increased risks of infection. The outbreak began towards the end of January and the notifications, by February 8th, had reached 12 or 13 daily. The peak of the epidemic was reached about March 28th—that is, about the 13th week of the outbreak. Notifications, for two weeks in advance of this date and for a week after, numbered about 50 daily. The outbreak ended towards the end of June after a duration of, approximately, 28 weeks. Spasmodic cases continued to occur during July. 96 In all, 2,864 cases were notified during the epidemic, of which, 1,713 were in children under the age of five, 1,100 in children between 5 and 15, and 51 in people over 15. A summary of the figures of the outbreak is appended. It will be noticed from this summary that the attack rate in children under five is more than three times as high as that of children over five Eleven deaths occurred in children under five, as compared with three in children over five, none of these affecting children of 3 and 4 attending school. Considering the extent of the epidemic, these numbers are remarkably low, as will be evident from the 31 deaths which occurred in the 1934 outbreak. In the 1,508 children under five attending school, 400 cases occurred, giving an attack rate of 305 per thousand. In the 2..344 children aged 3 and 4, not attending school, 489 cases occurred, giving an attack rate of 208 per thousand. It is a little difficult to assess the significance of this difference in the attack rates in two groups of children of similar environment, one group of which attend school, the ather remaining at home. There is no doubt that some of the children remaining at home will be the eldest in the family and, therefore, will not come into contact with school children either at home or in the school. No estimate of the number of children to whom this applies has been formulated, but, on the whole, it seems reasonable to assume that a difference of one hundred per thousand in the attack rate is partly accounted for by the increased risk of school contact with the disease. Although no deaths from measles occurred amongst children aged 3 to 4 attending school, the seriousness of the disease in children under five warrants further investigations of the effect of school attendance on the incidence of the disease in this group. 1 have no doubt of the wisdom, from the personal and from the public health point of view, of postponing measles wherever possible, until after the age of five years. Confirmatory evidence on the lines of the Fulham figures would to my mind, justify a revision of the London County Council scheme of control in so far as children under five are affected. Definite proof of increased risk of infection would warrant the exclusion of all children under five during epidemic periods. All population figures quoted in the various age groups, with the exception of the figures of children under five attending school, which were supplied direct by the London County Council's Education Officer, are taken on the 1931 Census. They are not, therefore, literally accurate for 1930, but completely accurate figures are not available, and the effect on the rates quoted, which adjustment would produce, would not, in any case, be significant. TABLE 35. MEASLES EPIDEMIC, 1930. Population. Total population (mid 1935) 143,000 Children under 5 (Census 1931) 9,894 Children aged 5 to 15 (Census 1931) 21,454 Children aged 3 to 4 (Census 1931) 3,852 Children aged 3 to 4 attending school 1,508 Children aged 3 to 4 not attending school 2,344 97 Number of cases. Total number of cases of measles 2,864 Number of cases aged 0 to 4 1,713 Number of cases aged 5 to 15 1,100 Number of cases aged 3 to 4 attending school 400 Number of cases aged 3 to 4 not attending school 489 Attack Rate. Attack rate for whole population ... 19.95 per 1,000 Attack rate in children aged 0 to 4 173.1 „ j y Attack rate in children aged 5 to 14 51.2 „ i > Attack rate in children aged 3 to 4 attending school 305. »t Attack rate in children aged 3 to 4 not attending school 208.6 it »* Fatality Rate. Fatality rate all cases (%) <.. 0.45 Deaths in children 0 to 4 ... 11 Fatality rate in children 0 to 4 (%) 0.04 Deaths in children 5 to 15 3 Fatality rate in children 5 to 15 (%) 0.27 TABLE 36 ALL CASES—AGE GROUP. 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-15 15-20 20-35 35-45 45-65 65+ Total 123 292 349 339 610 468 393 138 52 23 26 23 27 — 1 — 2,864 98 FATAL CASES. Age at death. Under 1 1-2 2-3 3-4 4-5 5-6 6-7 Total No. of deaths 3 5 1 2 – 1 2 14 99 ENTERIC FEVER. Sixteen cases were notified compared with 10 during the ,previous year ; three deaths occurred. Two of these cases and one of the deaths arose from the Bournemouth and Poole outbreak. CEREBROSPINAL MENINGITIS. Four cases occurred during the year—three being of infants under 1 year of age and one of a child aged 5 years. Two of the cases died. PUERPERAL FEVER. Six cases were notified and there were two deaths from puerperal sepsis. The incidence was equal to 2.8 per 1,000 of the registered births (live and still). All the cases occurred in Fulham Hospital. PUERPERAL PYREXIA. Twenty-five cases were notified during 1936 compared with 20 during the previous year. The incidence per 1,000 registered births (live and still) was 11.5 compared with 12.7. CONSULTANT. The services of Mr. Alexander Galletly are available for the purpose of consultation with private practitioners in cases of Puerperal Fever and Puerperal Pyrexia cases and also for difficult obstetric cases. During the year no request was made for his services. OPHTHALMIA NEONATORUM. During the year thirteen cases of ophthalmia neonatorum were notified compared with 11 during the previous year giving an attack rate of 0.2 per 1,000 of the registered live births. 1 hrough an arrangement between the Borough Council and the Fulham District Nursing Association the services of the District Nurses are available for cases which are under medical treatment in their own homes. During 1936, there were 81 visits to 4 such cases. The following tableshows the place of treatment and the result of the 13 cases: — Cases notified 13 Treated at Home 5 Treated in Hospital 8 Vision Impaired — Vision Unimpaired 9 Total Blindness — Deaths 1 Left the Borough (condition not known) 3 100 NON-NOTIFIABLE INFECTIOUS DISEASES. During 1030 the Woman Sanitary Inspector paid visits to cases of non-notifiable infectious diseases as follows: — Chicken pox 60 Whooping Cough 145 Mumps 35 Suspicious cases (sore throats, spots, etc.) 65 305 These visits are paid to ascertain that the children are not suffering from any notifiable infectious disease and that they are receiving adequate medical and nursing attention. Information as to the cases is received daily from the Head Teachers of the schools in the Borough on Form 84. The table on page *25 shows inter alia the number of non-notifiable infectious disease cases which were visited by the Fulham District Nursing Association on behalf of the Borough Council. CANCER. The 250 deaths classified as Cancer occurred as follows: — TABLE 37. Organ Affected. Total. Males. Females. Digestive Organs and Peritoneum 124 77 47 Respiratory Organs 36 26 10 Buccal cavity and Pharynx 12 8 4 Breast 16 — 16 Uterus 30 — 30 Genito-Urinary Organs (males) 17 17 — Other Organs 15 7 8 Totals 250 135 115 Classification. Total. Males. Females. Carcinoma 244 131 113 Sarcoma 4 4 — Epithelioma 2 — 2 Not defined – – – Totals 250 131 115 101 The ages of death of persons dying from Cancer were: — TABLE 38. Age periods. Total. Males. Females. 0-25 years 3 1 2 25-35 years — — — 35 -45 years 21 11 10 45-55 years 31 17 14 55-65 years 65 40 25 65-75 years 83 44 39 75 years upwards 47 22 25 Totals 250 135 115 From the table showing the principal causes of death it will be seen that one out of every seven deaths in the Borough during 1936 was due to Cancer. The death rate from the disease was 1.77 per 1,000 compared with 1.62 for England and Wales. The yearly death-rates from Cancer since 1920 are as follows: — 1920 1.19 1928 1.38 1921 1.32 1929 1.53 1922 1.27 1930 1.57 1923 1.31 1931 1.51 1924 1.35 1932 1.57 1925 1.20 1933 1.62 1926 1.59 1934 1.86 1927 1.36 1935 1.52 1936 1.77 PREVENTION OF BLINDNESS. No action was taken under Section 66 of the Public Health Act, 1925. TUBERCULOSIS. No action was taken under the Public Health (Prevention of Tuberculosis) Regulations, 1925 (relating to persons suffering from pulmonary tuberculosis employed in the milk trade) or under Section 62 of the Public Health Act, 1925, (relating to the compulsory removal to a hospital of persons suffering from tuberculosis). 102 TUBERCULOSIS REGISTER. 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: Males. Females. Males. Females. TOTALS: Number of cases on Register at commencement of 1936 581 585 306 306 1,778 Number of cases removed during the year 121 88 25 19 253 460 497 281 287 1,525 Number of cases notified for the first time during the year 131 88 18 22 259 Number of cases remaining on Register at end of year 591 585 299 309 1,784 The number of cases notified for the first time during the year includes 243 cases analysed in Table 41, page 106 and 16 cases in Table 42, page 107; these 16 cases are, of course, also included in the 253 cases removed from the Register during the year. In Table 26, page 85, 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 is also given. MORTALITY FROM TUBERCULOSIS. Respiratory system: 107 Deaths 73 males, 34 females. Death rate 0.76 per 1,000, being 0.02 lower than in the previous year. 93 notified (86.92 per cent.). 14 not notified (13.08 per cent.). Of these 14 cases 7 died in institutions and 3 were notified after death. Other Tuberculous Diseases'. 13 Deaths 7 males, 6 females. Death rate 0.09 per 1,000, being 0.03 lower than in the previous year. 7 notified (53.85 per cent.). 6 not notified (46.15 per cent.). Of these 6 cases 1 died in an institution. 103 PERIOD BETWEEN PRIMARY NOTIFICATION AND DEATH. Respiratory system: Under 1 month 10 (17.20 per cent.) 1—3 months 8 ( 8.GO per cent.) 3—G months 11 (11.83 per cent.) 6-12 months 12 (12.90 per cent.) 1 2 years 14 (15.06 per cent.) Over two years 32 (34.41 per cent.) Other 'tuberculous Diseases: Under 1 month 3 (42.85 per cent.) 1—3 months 1 (14.29 per cent.) 8—6 months — 6-12 months 1 (14.29 per cent.) 1—2 years 2 (28.57 percent.) Over two years — DISPENSARY STATISTICS, 1913—1936. TABLE 39 Year. New Patients. Attendances at Dispensary. Doctors' Home Visits. Nurses' Home Visits. Suffering from Pulmonary Tuberculosis. Suffering from other forms of Tuberculosis. Doubtful Cases. NonTuberculous Cases. Insured. Uninsured. 1913 324 86 323 429 2361 11967 2175 1517 1914 203 45 261 361 2276 8084 2385 2547 1915 174 28 260 323 1171 5568 1910 2918 1916 225 13 311 200 852 5954 1079 2828 1917 286 13 349 329 1052 6528 1141 2789 1918 235 14 201 478 1223 8465 1435 2317 1919 221 50 251 281 1444 8116 1724 4043 1920 142 37 239 342 1850 6713 2004 4989 1921 116 23 163 344 2074 5387 2217 5640 1922 155 35 13 888 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 2448 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 1933 161 14 — 331 1312 1916 409 3936 1934 172 25 6 338 1265 2262 435 3895 1935 144 21 12 _ _ 328 1232 1871 448 3857 1936 158 11 18 386 1164 2321 426 3655 104 TABLE 40. Year. Notifications. Deaths. Death-Rate. Pulmonary. Other forms of Tuberculosis. Pulmonary. Other forms of Tuberculosis. Pulmonary. Other forms of Tuberculosis. 1918 765 289 215 49 1.34 0.81 1914 531 164 207 45 1.82 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 76 158 31 0.96 0.19 1922 272 113 168 33 1.02 0.20 1923 819 155 149 32 0.92 0.19 1924 270 126 129 33 0.80 0.20 1925 279 114 151 22 0.92 0.13 1926 812 122 161 17 0.98 0.10 1927 251 95 126 21 0.77 0.13 1928 258 75 114 38 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 1933 219 38 126 14 0.85 0.09 1934 258 33 112 20 0.77 0.14 1935 185 55 112 17 0.78 0.12 1936 219 40 107 13 0.76 0.09 105 TABLE 41.—PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1930. Summary of notifications during the period from ls£ January, 1936 to 31 st December, 1936. Age Periods. Formal Notifications. Number of Primary Notifications ot new cases of Tuberculosis. Total Notifications. 0—1. 1—5. 5—10. 10—15. 15—20. 20—25. 25—35. 35—45. 45—55. 55—65. 65 & upwards Total (all ages). Pulmonary : Males — — 2 — 10 15 21 19 27 20 10 124 210 Females 1 — 3 2 5 20 24 10 11 3 5 84 144 Non-Pulmonary : Males 1 2 2 3 — 1 2 2 1 — 2 16 22 Females 1 . 3 3 2 3 2 3 1 1 — — 19 29 Totals 3 5 10 7 18 38 50 32 40 23 17 243 406 106 TABLE 42. New Cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the period, otherwise than by formal notification. 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 — — – — — — 2 — 8 1 1 7 Females — — — 1 — — 1 — 1 – 1 4 Non-Pulmonary:— Males — – — — — — 1 — — 1 — 2 Females — — — — — — 1 — — – 2 3 Totals — — — 1 — — 5 — 4 2 4 16 108 TUBERCULOSIS. REPORT FOR THE YEAR 1936. By Dr. P. L. T. BENNETT, Clinical Tuberculosis Officer and Medical Officer, Borough Bacteriological Laboratory. There has been no change either of Staff or of the routine at the Tuberculosis Dispensary during the year. A summary of tuberculosis statistics is given at the end of this report. The figures, tfiough slightly increased from the previous year as a whole do not call for any particular comment; and it should be pointed out that the slight increase in the number of suspected cases sent for examination and the few more notifications do nc-i imply that the disease is on the increase. The investigation of statistical returns in other areas show similar yearly variations, and most of such returns, studied over a period of years, show a very decided decline both in mortality and incidence. Therefore, in endeavouring to make any deductions, a period of years should be taken, rather than any particular year—always bearing in mind that the campaign against tuberculosis cannot be a spectacular one showing immediate results. There still exists a great deal of misconception in the lay mind as to what tuberculosis is, and how the national campaign against its ravages is conducted. A brief description of the disease and its history, and the present measures adopted for the furtherance of its control by the State, may therefore be helpful. A definition of tuberculosis. Tuberculosis is a disease due to a specific micro-organism, it may be acute or chronic in type; and is infectious within certain limits an! under certain conditions, the incubation period being extremely variable, varying (according to individual factors) from weeks to years. • The causative organism. A minute, rod-shaped bacillus, believed to be of the fungoid or mould group: it is readily demonstrated in pathological material (sputum, discharges, excreta, etc.) by a process of staining known as the "Ziehl Neelsen" method—an investigation which is carried out very extensively in the Borough Laboratory. Tubercle bacilli capable of causing disease in man, are derived from the sputum, discharges or excreta of consumptive individuals; and from the milk (or flesh) of diseased cattle. Tuberculous milk is responsible for a large proportion of the bone and joint tuberculosis in children, and may give rise to fatal disease. 109 Bacilli are killed by exposure to direct sunlight, by the usual disinfectants, and by boiling: but survive outside the body for long periods in conditions of damp, dirt, and bad ventilation. Promiscuous spitting, especially inside buildings or vehicles, may be a particularly potent source of infection: for the sputum of a consumptive is often heavily laden with virulent micro-organisms, which are liberated into the surrounding air as the former dries up. Predisposing factors. Modern investigation has disproved the hereditary theory of tuberculosis—in other words, it is not handed down as an unwelcome legacy from parents to children: though there may exist in some families a disposition or weakness towards the disease. The subject is thus bound up with the fact of infection—almost universal in civilised communities—and a bodily resistance in the individual, which is sufficient to overcome the invasion by tubercle bacilli in the great majority of persons. This resistance, however, is largely influenced by other factors, and one can broadly state that any circumstance which tends to lower bodily health at the same time lowers resistance to disease. Illness, excessive fatigue, anxiety states, toxaemic conditions or prolonged fevers all tend tc- lower vitality, and therefore lower resistance to tuberculosis, giving rise to a particular state in the individual that favours the multiplication of micro-organisms which may gain entry. In 1933 there was conducted (under the auspices of the National Association for the Prevention of Tuberculosis) an extensive investigation into the causal factors of tuberculosis in two large industrial areas in the north of England—these two areas showing a particularly high tuberculosis incidence and mortality rate. The result of this enquiry was of the greatest importance as it showed that poverty, leading to under-nourishmenit and over-crowding, was a marked feature in both areas. Under-nourishment (especially in essentials such as fresh milk and fats) lowers bodily vitality and hence resistance: whilst over-crowding with all its accompanying faults of defective hygiene, lack of fresh air, and other insanitary conditions, favours the chances for continuous and perhaps heavy infection. Certain trades which involve the inhalation of special forms of mineral dust are characterized by a peculiar condition of the lung tissue (known as librosis) due to continuous irritation: and this is often complicated by infective processes such as tuberculosis. In the female subject, pregnancy and prolonged lactation may sufficiently lower resistance in certain cases, so that tubercular infection already implanted may become activated. There are certain other factors, racial, sociological and climatic, which have been considered to have a bearing on this subject, but are largely a matter of controversy and space forbids any discussion on them. Historical. Proof of the cxisitence of tuberculosis can be traced back to remote antiquity, for evidences of its ravages have been seen in mummies from Egyptian tombs. 110 Hippocrates, a celebrated Greek physician about B.C. 400, gave a very good clinical picture of consumption and its treatment; whilst Galen, A.D. 130, recognised that it was an infectious complaint—an opinion which was also held by the Arabian, Avicenna, A.D. 1037. The early treatment of consumption, judged by the writings of these old-time doctors, appeared to have been conducted on sound lines, and in some fundamental principals viz., fresh air, rest, sunshine, adequate and good dietary (milk and fats), was much the same as is carried out nowadays in Sanatoria: whilst the drug Creosote was used in those days, as it is now. Although the cause of tuberculosis during the middle ages was in a large degree considered to be due either to " curses or visitations evil eye, witchcraft, or to " miasma from the East one finds that a definite view as to its infectivity was constant in foreign countries: whilst in England it was regarded rather as " hereditary " than infectious—a belief which held sway until within comparatively recent times. It was not until numerous experiments, carried out by Klencke, Villemin, I3urdon-Sanderson, Chaveau and Klebs, Cohnheim and others had shown its infectious nature that this erroneous theory fell into disrepute: and the crowning discovery of the causative micro-organism by Robert Koch in 1832 set the seal on all the extensive experimental work which had been done during the previous fifty years. Just as Laennec's teachings in Paris at the beginning of the 19th century laid the foundations of modern methods of clinical examination (particularly the use of the stethoscope), so did Koch's discovery of the tubercle bacillus revolutionize our treatment of the disease and methods of prevention. The outlook in the early part of the 19th century was extremely pessimistic, and the writings of such well-known novelists as Charles Dickens, Samuel Warren and Charlotte Bronte give us a clear indication how dread the disease was in popular estimation, and how slight was the chance of recovery considered to be in those times. Control and prevention of tuberculosis. Hospitals for consumption existed as far back as 1814, but rather focussed attention on clinical aspects of the disease and symptomatic treatment, than on preventive measures such as segregation. In 1840, George Bodington stressed the benefits of open-air treatment accompanied by proper feeding and graduated exercises; but his teaching and theories were disregarded in this country. Abroad, however, they were accepted and promptly acted upon with the result that Sanatoria and treatment on similar lines were established in Germany, Switzerland and America. The excellent results of sanatorium treatment thus conducted no doubt influenced public attention in this country; and after Koch's epoch-making discovery, more energetic measures were instituted. To Sir Robert Philip is due the honour for the foundation in Edinburgh of the first tuberculosis dispensary system in the British Isles in 1887. In England, charitable enterprise was responsible for the inauguration of the Paddington Dispensary for the Prevention of Consumption in 1909; followed in 1910 by the St. Marylebone Dispensary and in 1911 by the Fulham Dispensary. By 1911 fourteen Sanitary Authorities had provided Dispensaries in their areas; and in fifty other districts voluntary establishments had been founded. It will be seen that the theory of hereditary tuberculosis has now given place to one of direct infectivity: and Public Health Regulations. 1912, set the official seal on the evidence of Ill the latter, by enacting that all cases of tuberculosis should be at once notified to the district Mcdical Officer of Health. In 1911 "sanatorium benefit" was included as one of the provisions of the National Health Insurance, but it was realized that any scheme dealing with tuberculosis should be made available for the whole community, and not mereiy for insured persons; so in the Public Health (Prevention and Treatment of Disease) Act, 1913, effect was given to recommendations urged by the Local Government Board on County Councils and County Borough Councils to provide necessary facilities for diagnosis and treatment lor all, with a promise of 50% net grant on approved expenditure. In 1921, "Sanatorium Benefit" ceased to be a benefit under National Health Insurance; and the Public Health (Tuberculosis) Act, 1921, required all County and County Borough Councils to make adequate arrangements for tuberculous persons—and also permitted them to assist in after-care schemes. So far, no hint of any compulsory measure in dealing with the disease is seen (with the exception of the onus of notification by the doctor): but in the Public Health Act, 1925, power was given to the authorities to apply to court for Orders to remove to institutions, under certain specified circumstances, tuberculous persons likely to be a danger to the community from the point of view of infection. By the Public Health (Prevention of Tuberculosis) Regulations, 1925, employment of persons suffering from phthisis—or tuberculosis of the respiratory organs—was prohibited in various branches of the milk trade. All the earlier regulations (notification, etc.) were consolidated in the Public Health (Tuberculosis) Regulations, 1930: and the Local Government Act, 1929, simplified institutional treatment by handing over care of those tuberculous persons (formerly in hospitals controlled by the Guardians) to the local authorities for tuberculous schemes, hence removing the disadvantage of dual control. In 1919, the Local Government Board was replaced by the Ministry of Health and the latter institution has had an important influence upon the prevention and treatment of the disease. Health Services were co-ordinated and a special medical department in the Ministry was organised to deal solely with tuberculosis. Certain memoranda 37T and 37T (revised) were issued in 1925 and 1930 by the Ministry of Health formulating a comprehensive and uniform system of records for use throughout all Dispensaries. The system of record and procedure is now adopted universally in England and Wales and has proved to be most efficacious in dealing with the tuberculous population, many of whom are not permanently resident in one district but move away for various reasons. Returns of all dispensary work are furnished yearly to the Minister of Health and to the Chief Medical Officer of the Local Authority for tuberculosis, by the Medical Officer of Health of the Borough. (Within the administrative County of London, this Local Authority is, of course, the London County Council). In addition to the above, an optional return can also be submitted dealing with the after histories of patients. This is designed to arrive at some conclusion as to the value of the tuberculosis service in relation to prolongation of life or cure of the disease. 112 Further regulations and circulars have been issued by the London County Council covering all phases of tuberculosis procedure and administration including after-care; and this authority is now responsible for a block grant towards the cost of the service in each metropolitan area. The Tuberculosis Dispensary. All notified cases occurring in an area are nominally under the supervision of the Dispensary, although many cases may have been notified by a hospital physician and attend his out-patient department, only coming to the Dispensary if specially instructed to do so. The sources of new patients coming to the Dispensary are various, as a glance at the heading in the summary will show, but the majority are directly referred by private doctors. It has always been a matter of satisfaction that the local doctors have to such a large extent availed themselves of the dispensary service—especially in view of the fact that patients could be equally well referred to any one of the five hospitals (one of which is world famous for consumption and other chest diseases) within easy reach of the Borough. A spirit of most friendly co-operation has been maintained between the dispensary service 2nd the general practitioners, and I feel that this is an important factor in the fight against the disease, from both present and future standpoints. { A specialist Service has without doubt its place in the state scheme, but team work is essential if there is to be any real success: and perhaps the most important point is the acquisition of the patient at a stage before the disease has had time to ravage beyond repair. The private doctor is much more likely to see the patient before anyone else and can advise further investigation (sputum tests, X-ray, etc.) if there is any suspicion: and this investigation is willingly carried out by the Tuberculosis Officer until the diagnosis is definitely cleared up one way or another. It should, however, be emphasized that no compulsion can be brought to bear on any patient to be examined, tested, X-rayed or treated: thus all attendances are entirely voluntary. There is no provision for coercive measures in any act or regulation yet in force—with the exception of removal to Hospital (already quoted) in the Public Health Act, 1925. Considering that tuberculosis is a notifiable disease just as scarlet fever, diphtheria and small-pox are (amongst many others) and that stringent powers are available for the control of the latter, there would appear to be a case for the operation of similar powers in the case of a disease which is so much more fatal, and whose economic and sociological effects are so much more pronounced and permanent. Under the present system too much is left 'to voluntary acquiescence on the part of patients and contacts; and although statistics show a marked decline during the past sixty years, the possibility of having nearly reached a "low-water" mark in this respect must be visualized. Dispensary procedure. Patients attending the Dispensary are grouped and classified according to the type and stage of their disease, whether actively infectious or not, and if quiescence or arrest is reached. A patient is said to be quiescent if there are no signs or symptoms of active disease, but only those which might be shown by a healed lesion, and whose sputum, if any, is free from tubercle bacilli, 113 If this stage of quiescence is maintained without relapse for two consecutive years, the patient is " arrested ", and if remaining so for three years the name can be removed from the registers as recovered. In addition to notified cases, there are, of course, many persons, adult and child, who are under observation as suspects or as contacts. During this period frequent examinations and tests are made, and X-rays are carried out under arrangements made between the Borough Council and Brompton Hospital. The great importance of X-rays as an adjunct to dispensary work is nowadays universally recognised. All doubtful cases require radiography, and as many others as possible, because it is sometimes very difficult to assess the amount of damage done to a lung by purely external means, or to be certain that no fresh deposits of disease are being formed. In previous annual reports mention has been made of Mantoux tuberculin tests carried out on children and it will be remembered that a positive reaction does not necessarily imply that disease was present, but that infection with the micro-organism has at some t<me previously occurred, giving rise to tuberculin sensitiveness. Conversely, however, the absence of such a reaction would demonstrate (in the great majority of cases) that no infection had taken place and, therefore, there could not be disease present—a very important fact from the diagnostic standpoint in an otherwise suspicious case. Mention has already been made of the co-operation with medical practitioners, with whom constant touch is kept concerning their patients: but the Dispensary is equally in touch with other Health Services, the School Medical Service and with the Public Assistance Committee and hospitals. Treatment. Sanatorium is still the best basic form of treatment for tuberculosis—the complete rest, fresh air, feeding and hygiene having a natural tendency for the promotion of healing. When the toxaemia has thus been overcome, graduated exercises stabilize the condition and help to render patients as fit as can be expected to return home and carry on. It should be pointed out that patients have to be selected for sanatorium treatment—which would not be suitable for all, either from the point of view that the disease might be too advanced and a stay in sanatorium only filling an otherwise useful bed to no advantage; or the age of the patient might militate against such open-air treatment especially in winter time, or if complicated by much bronchitis. I here are other forms of treatment which are often used in combination with sanatorium. •va) Surgical measures, all designed to give rest tc the damaged lung, such as artificial pneumothorax and refills, phrenic evulsions and more rarely thoracoplasty. (b) Injections of gold salts and tuberculins, (c) Heliotherapy, in the form especially of ultra-violet rays and Finsen Light. All these forms of treatment are arranged through the Dispensary, the cost of special treatment being borne by the Borough Council whilst provision of sanatorium treatment under the L.C.C. is free. I he Elizabethan Open Air School (L.C.C.) caters for f>0 children, who are notified for gland, at Nominal and other forms of non-infective tuberculosis, and who are in a state of quiescence or arrest. 114 Contact children, especially those of debilitated type, whose condition is likely to be strengthened against disease, can also be referred to the School. Under open air conditions of schooling, adequate rest hours, special supervision and feeding up, these children appear to do very well, and there have been but few relapses to active disease. Breakfasts, consisting of porridge, fried, bread, scrambled eggs, or fish cake, together with bread and butter and jam, are provided; also mid-day meals with a varied and ample dietary consisting of fresh and stewed meat, two vegetables and pudding, with fresh fruit and lemonade. In addition to those meals the usual ration of fresh milk is given daily to each child; and in certain cases cod liver oil and malt, Irradex, Haliverol, or Virol are prescribed as well. Contact children can also be referred to the L.C.C. for boarding out under their Contact Scheme, if they are in danger of being infected with tuberculosis, or if a parent or parents are receiving residential treatment and adequate arrangements for their care cannot otherwise be made. After Care. After patients have been discharged from sanatorium or hospital, they return home to conditions which in many cases are unchanged, and have to face the prospect of competing in the Labour Market for work with all and sundr, It can readily be conceived then, that this period is a critical one, and unfortunately many patients, if not the great majority, sooner or later relapse. The prognosis in this disease depends on many things, but on nothing more vitally than the economic and sociological facjtor. It is with a view to endeavouring to ameliorate these hard times following treatment in sanatorium, etc., that After Care Committees have been organised as part of the machinery of the Tuberculosis Dispensary Service. The functions of Care Committees are comprehensive. The economic position of the family of every patient is considered, and advice and assistance rendered, as far as possible, with a view to enabling the family to adjust their circumstances to the new conditions in order to maintain their economic independence, and to allow the fullest possible advantage to be derived from the medical treatment given. Care Committees also carry out, after investigation, recommendations for dental work, including the provision of dentures, and also in connection with the supply of essential clothing and boots in order that patients may be able to benefit from residential treatment. All recommendations for extra nourishment pass through the Care Committee to the Medical Officer of Health, and in this connection grants of extra nourishment to 74 patients were made during the year. I would like to place on record my appreciation of the services of the Chairman, Vice-Chairman and other members of the Care Committee and of the Secretary for their valuable work during the year, and in this connection would specially wish to thank the Invalid Children's Aid Association and the Charity Organisation Society for very special help given freely at all times. 115 To illustrate the scope of the work of the Committee, the Secretary, Miss Sargent, has kindly selected specimen cases which are here appended: — Specimen Cases:— A. Was first seen at Brompton Hospital and recommended for sanatorium treatment. He was a waiter and actually working at the time but his earnings were very low and he looked ill and under-nourished. He had a wife and two small children (one a baby in arms); the rent was high and payments on furniture still further reduced the amount available for food. As A. came from Scotland, he was referred to the Royal Scottish Corporation for assistance which was given during the whole period of his treatment in sanatorium: extra nourishment was given from the Town Hall until he went away: an outfit of clothing was granted by the London County Council, and a fortunate encounter provided the money to pay off the whole of the amount owing on the furniture. On his return from sanatorium, A. was able to sign on the Labour Exchange, and the National Association granted an allowance for four weeks whilst he was looking for suitable work. He was not very fortunate at first and only had odd days, but just as he felt at the end of his resources and had agreed to apply for Public Assistance, he obtained work in the country and is holding his job. B. Was in Fulham Hospital when we first heard of him early in the year. He was notified and was given a period in sanatorium, and at first it seemed as if no help was required as he had no dependants and his insurance benefit more than covered the rent of his fiat. Before he was discharged, however, his insurance had dropped to half and this was not sufficient tc meet his expenses. The Public Assistance Committee were not able to help while the patient was in sanatorium as he had not been in receipt of Relief before his admission to Hospital. We referred the case to the Charity Organisation Society, one of whose visitors went to see B. in sanatorium and they agreed to co-operate with the Care Committee in keeping on the flat until he should be discharged, when i: would be possible for him to apply for Public Assistance should he not be able to work. Actually, when B. came home he arranged to move out to Ealing and the flat was given up, the move being paid for by the Charity Organisation Society and the Care Committee. C. Came to the Dispensary in the spring and was at once recommended for sanatorium treatment. He had been off work for some months and was only eligible for 9/National Health Insurance owing to arrears of stamps. His father had been ill for many months and was only on disablement benefit, bu': had gone to Manchester to a brother's, where he hoped eventually to find light work. The only other source of income was the rent of a cottage in the country which brought in 9/a week. Extra nourishment was given from the Town Hall and help was obtained from the Soldiers' Sailors' and Airmen's Families' Association, which continued help until the father was actually in work and able to send a little home. When the patient was discharged in the autumn, extra nourishment was again given and as there seemed a prospect of a light job materialising for him near Manchester and the family wanted to be re-united, they were helped to move north by the Charity Organisation Society, the Care Committee paying up the arrears of insurance stamps so as to keep C. in benefit. 116 The Gloving Class. Thirty-seven lessons were given during the year and tctal attendances numbered two hundred and twenty-six. The numbers in the class varied a good deal: there is now only one or the original class attending but several of the more recently joined members have attained a high degree of proficiency and there is usually a beginner. The outstanding event for the class was a Sale which was held in the Dispensary on October 13th, when the Mayor and Mayoress were present and showed much interest in the display of gloves and in the class itself. £14: 14: 9 was taken at the sale together with a large number of orders. During the year and including the Sale, gloves to the value of £42: 3: 3 were disposed of through the agency of the Committee, besides those which were sold direct by the Central Fund which continues to be financially responsible for the class. Conclusion. In the foregoing an attempt has been made to give a brief account of the history and present day control of tuberculosis. Reference has been made to the decline in mortality rates during the past sixty years, and a glance at the dispensary statistics during the past few years is sufficient to indicate that Fulham is nc exception to the general rule. At the same time it must be confessed that our past statistics are somewhat misleading— and there may be still some who are unduly impressed with large figures, judging departmental value quantitatively rather than qualitatively. 1 should like to point out that large numbers—as representing work done in a department dealing specially with tuberculosis, do not necessarily indicate efficiency—rather otherwise; for excessive numbers defeat their own ends and individual care, so specially needed in this disease, suffers in the struggle to attain imposing annual returns. Tuberculosis work, whether examination, supervision or after-care, cannot be rushed: nor can large numbers be properly dealt with at clinics, as there is a limit to one's critical faculties. There are so many factors which musit be; thought of if any good is to be expected—and the mental attitude of the patient has also to be carefully considered. Sanatorium, institutional or dther treatment is not likely to do much good if a patient is worried all the time with private and home anxieties. It is well, however, to guard against undue optimism because there has been this continued decline. The epidemiology of tuberculosis is but imperfectly understood at the present time; and although excellent work is being carried out in the country and the Borough with regard to better housing and nutrition, I do not for one minute think this ;s going to "wipe out' tuberculosis when there are so many hidden sources of infection, and where public ignorance, sentiment or deficiencies in the present scheme, prevent more satisfactory measures being taken in those already known. Two important factors make themselves continuously felt in opposition to our control of the disease viz.: (A) the unjust " stigma " which is so often more potent in that it is usually indirectly expressed. (B) Fear of the inevitable re-adjustment of all private life (often accompanied by more or less financial crash or loss of employment) which may ensue on a diagnosis of consumption being made. 117 These two conditions are in themselves quite, sufficient to inhibit some (who might otherwise be quite willing) from presenting themselves for early examination on the appearance of (possibly) suspicious symptoms, or as contacts of others. In fact the patient already notified may feel that the only way to " get a chance " in life is to move away to a new locality leaving no trace, and hope for the best: and this is undoubtedly what does happen at times. Though it is very unsatisfactory, both for the community and from the administrative standpoint, one cannot but feel sympathy for these people: to have the complaint is bad enough without being as it were penalised by loss of work and break-up of home life. Whilst criticism can usually be directed against any particular system, it is, however, very difficult to indicate how a more efficient and comprehensive scheme could be evolved without further legislation and a re-organisation of the present one, together with greater public education on the subject. The disease is a fatal one and the cost of it heavy from whatever aspect it is considered; and any changes which would give the State a more efficient control should be welcomed. To all who have worked during the past year in the Tuberculosis Dispensary; Miss Sargent and her assistant, Miss Grimstone, in the Clerical Department; Miss Robinson, Bacteriological Assistant, of whom special mention must be made for her care and skill in carrying cut Mantoux tests and keeping records of same in addition to her other work in the laboratory: to the Tuberculosis Health Visitors for their success in getting contacts—sometimes an almost superhuman task; and to Dr. Crowe, who acted as locum tenens tuberculosis officer during holiday periods, I wish to express my appreciation and thanks. TABLE 43. MANTOUX TESTS. (1) Total number of injections given:— 1—10,000 dilution 270 1—1,000 dilution Tota 1 028 1—100 dilution 168 ) (2) Total number of Positive Reactions-. 1—10,000 dilution 00 or 24.44% 1—1,000 dilution 7 or 3.08% 1—100 dilution 17 or 10.11% Total 90 or 14.33% (3) Number of those who received test:— For the first 199 (82+ : 117—) For the second 29 ( 2+ : 27—) For the third 31 ( 3+ : 28—) For the fourth 11 ( 3+ : 8—) Total 270 Examinations for tubercle bacilli in laboratory No. of sputa examinations 1079 (339 + : 1340—) No. of urine examinations 11 No. of faeces examinations 11 Special Treatments: Artificial pneumo-thorax refills 610 at a cost of £320 Finsen Light 85 ,, ,, ,, ,, £21: 5: 0. Ultra violet light 2 ,, ,, ,, ,, 5.0. 118 Dental Treatment: Fourteen persons were referred for treatment but of these one withdrew. Of the remaining thirteen, ten were recommended for extractions and dentures, two for repairs to dentures and one for extraction. Extra Nourishment'. Seventy-four patients were recommended for grants of extra nourishment for varying periods of from two weeks to three months. SUMMARY OF STATISTICS, 1936. No. of New Patients'.— Insured 234 Uninsured 339 Total 573 No. of Attendances:— Insured 1164 Uninsured 2321 Attendances of Contacts 796 Other Attendances 828 Total 5109 Attendances in Gloving Class 226 No. of patients who have attended, both old and new 1224 No. of Notifications:— Pulmonary 161 Non-pulmonary 13 Total 174 No. of Sputa examined 1679 No. of Physical Examinations 2638 No. of Contacts examined 267 No. of Home Visits paid by Doctor 426 Bedside Consultations included in above 230 Consultations otherwise 725 No. of Home Visits paid by Nurses 3655 No. of Reports sent to Public Bodies 573 No. of reports sent to Doctors 758 No. of Letters written 5388 No. of Patients referred to Brompton Hospital 3 For X-ray 420 119 No. of Notified cases on Dispensary Books on 31.12.36 703 No. of Patients sent away into institutions or to the country in 1936 164 TABLE 44. 164 Patients were sent to residential institutions on the recommendation of the Dispensary Medical Officers. (a) 108 by the London County Council Public Health Department:— 34 to Sanatoria. 2 to Colonies. 6 to Convalescent Homes. 66 to Hospitals. Men 18 2 1 31 Women 16 — — 25 Children — — 5 10 (b) 15 by the Public Assistance Committee:— 6 to Hospitals. 9 to Sanatoria or Convalescent Homes. Men 3 1 Women 1 - Children 2 8 16 Children were sent to Convalescent Homes by the Invalid Children's Aid Association. 11 Children were boarded out under the Contact Scheme. 5 Children went away through the Children's Country Holiday Fund. 6 Women and 3 Children were sent away by the Charity Organisation Society. TABLE 45. Showing sources of New Cases. 229 were recommended by private doctors. 32 „ „ ,, the Medical Officer of Health. 8 ,, ,, ,, the School Medical Authorities 1 was ,, ,, the School Authorities. 112 23 were ,, ,, Hospitals and Sanatoria. „ „ ,, other Dispensaries. 3 ,, ,, ,, the London County Council. 123 „ „ ,, the Dispensary Staff. 3 ,, ,, ,, friends. 27 „ ,, ,, the doorplate. 6 „ „ ,, the Invalid Children's Aid Association. 4 ,, ,, ,, Bishop Creighton House. 1 was ,, ,, the Army Authorities. 1 „ „ ,, Soldiers & Sailors Help Society. 578 120 TABLE 46. New Cases. Pulmonary Tuberculosis. Other Forms. Suspects. NonTuber cular. Percentage Tubercular. 268 Males 93 4 9 162 36.19 305 Females 65 7 9 224 23.60 573 both sexes 158 11 18 386 29.49 TABLE 47. Sex and Age of the New Patients for 1936. Under 5 yrs. 5 to 10 vrs. 10 to 15 yrs. 15 to 25 yrs. 25 to 35 yrs. 35 to 45 yrs. 45yrs. and over. All ages. Males 15 48 30 51 41 27 56 268 Females 24 39 30 72 74 32 34 305 Both Sexes 39 87 60 123 115 59 90 573 TABLE 48. Diagnosis at various Age Periods. New Patients. Pulmonary Tuberculosis. Other Forms. Suspects. NonTuber cular. Percentage Tubercular. Under 5 years 3 36 00.00 Under 10 years 2 1 3 81 3.44 Under 15 years 1 4 — 55 8.33 Under 25 years 43 1 3 76 35.77 Under 35 years 44 4 4 63 41.73 Under 45 years 22 1 3 83 38.98 45 and over 46 — 2 42 51.11 All ages 158 11 18 386 29.49 121 TABLE 49. Housing Conditions. Of 159 of the 174 tuberculous patients found in 1930:— 5 lived in the basement. 41 lived on the ground floor. 42 lived on the first floor. 19 lived on the second floor. 2 lived on the third floor. 14 lived on the top floor. 10 lived on more than one floor. 26 lived in the whole house. TABLE 50. Housing Accommodation. Number of Families occupying One room. Two rooms. Three rooms. Four rooms. Five rooms. Six rooms or more. Patient living alone Patient living with 12 2 3 — — — 1 other 4 7 8 4 — 2 2 others 2 3 20 10 1 1 3 „ 1 2 18 13 9 4 4 „ — - 5 8 3 2 5 ,, — — 5 2 1 2 6 „ — — 1 — — 3 7 „ - - - - - - 8 ,, - - - - - 1 19 14 60 37 14 15 TABLE 51. Sleeping Accommodation of 159 Tuberculous Patients. The patient slept:— In a separate room in 61 cases. Alone in bed with one other in room in 14 cases. Alone in bed with two others in room in 5 cases. Alone in bed with three others in room in 1 case. In bed with one person and no others in room in 59 cases. In bed with one person and one other in room in 14 cases. In bed with one person and two others in room in 4 cases. In bed with two persons and no others in room in 1 case. 122 TABLE 52. Occupations of 94 Men (New Cases) in 1930. 1 Advertiser. 1 Milk Roundsman. 1 Barman. 8 Motor Drivers. 2 Boot repairers. 1 Motor Tyre Builder 1 Builder. 1 Musician. 1 Canvasser. 2 Painters. 1 Carman. 1 Pastry Cutter. 1 Carpenter. 1 Pedlar. 6 Clerks. 1 Pipe Maker. 1 Commercial Artist. 2 Plumbers. 1 Coal Porter. 2 Postmen. 1 Convenience Attendant. 1 Relieving Officer. 1 Domestic. 2 Salesmen. 1 Electrician. 1 Sheet Metal Worker. 4 Engineers. 1 Ship Steward. 2 Factory Hands. 6 Shop Assistants. 1 French Polisher. 6 Shopkeepers. 1 Furniture Remover. 1 Soldier. 2 Gardeners. 1 Stoker. 3 Hall Porters. 3 Students. 1 Haulage Contractor. 1 Upholsterer. 1 Hotel Valet. 1 Waiter. 1 Insurance Agent. 1 Warehouseman. 8 Labourers. 1 Well sinker. 1 Mason. 1 Window Dresser. 1 Messenger. 2 No occupation. Occupations of 67 Women (New Cases) in 1980. 1 Actress. 2 Hospital Nurses. 1 Bedding Cutter. 28 Housewives. 1 Braille Copier. 4 Laundry Hands. 8 Clerks. 1 Manageress. 1 Dancer. 3 Shop Assistants. 9 Domestics. 1 Traveller. 4 Factory Hands. 2 Waitresses. 1 Handbag Maker. Under 15 years of age. 3 Boys. 5 Girls. VACCINATION. Mr. H. Davies, the Vaccination Officer, has supplied me with the following figures relating to his work:— Number of births registered during 1935 1656 Successfully vaccinated 910 Insusceptible of vaccination — Unvaccinated on account of conscientious objections made by the parents 421 Died unvaccinated 66 123 Postponed by medical certificate and unvaccinated on 3lst January, 1937 42 Removed to other districts and unvaccinated on 31st January, 1937 69 Removed to places unknown 134 Outstanding on 31st January, 1937 14 Number of successful primary vaccination certificates received during 1936 1160 Number of Conscientious Objection Certificates received during 1936 427 The figures show that 55 per cent, of the infants born in 1935 had been successfully vaccinated by the end of January, 1937. DISINFECTION. The following rooms were disinfected and cleansed after Infectious Diseases, etc.:— TABLE 53. Scarlet Fever 291 Diphtheria 168 Measles 44 Encephalitis Lethargica 1 Erysipelas 47 Ophthalmia Neonatorum 1 Tuberculosis 171 Puerperal Pyrexia 1 Vermin 342 Cancer 12 Cerebro-Spinal Meningitis 7 Poliomyelitis 2 School Class rooms after Diphtheria 5 Ditto. after Scarlet Fever 16 Chicken Pox 5 Whooping Cough 2 Enteric Fever 10 Infantile Paralysis 3 By request 21 Maternity Home 28 Day Nursery 42 Babies' Hospital 1 Infant Welfare Clinics 25 Library 4 1,249 124 The following articles were disinfected at the Council's Disinfecting Station:— TABLE 54. Articles. From private houses. From institutions. Total. Beds 434 - 434 Mattresses 929 67 996 Palliasses 9 — 9 Spring beds 1 — 1 Pillows 2151 103 2254 Cushions 326 — 326 Bolsters 616 — 616 Blankets 2168 305 2473 Sheets 1321 78 1399 Covers 325 — 325 Counterpanes 663 — 663 Curtains 3 — 3 Carpets 26 — 26 Hearth rugs 254 — 254 Clothing 2892 584 3476 Eiderdowns 322 — 322 Sundries 660 4 664 13101 1137 14238 125 INDEX. Pages Aged and Infirm Persons 52 Ambulance Facilities 24 Atmospheric Pollution and New Power Station 48, 49 Babies' Hospital 27, 39 Bacteriological Examinations 24 Bakehouses and Bakers' Shops, Inspection of 75 Cancer 100, 101 Certification of Causes of Death 19, 20 Clearance Areas 63, 64 Clinic and Treatment Centres 26 Closet Accommodation 41 Combined Drainage 46 Committees, Public Health and Maternity and Child Welfare 4 Common Lodging House 64 Deaths, Causes of 13, 19, 20 Deaths of Fulham Residents outside the Borough 12 Deaths in Public Institutions 11 Demolitions under Part 2, Housing Act, 1930 64 Diphtheria 90 Diphtheria—Antitoxin 90 Diphtheria Immunisation 90-94 Disinfection 123, 124 Disinfestation 64 Drainage of Buildings 46 Dwelling Houses 42, 43 Extracts from Vital Statistics 9 Factories, Workshops and Workplaces 43, 54 Food and Drugs, Adulteration 74 Food and Food Premises, Inspection of 43, 44, 76 Food, Unsound 77 General Statistics 9 Health Propaganda 27 Home Nursing 25 Hospitals 27 House-to-House Inspection 62 63 Housing 58-65 General 58 Overcrowding—Survey and Standards of Accommodation 58-60 Rehousing of Overcrowded Families 61 London County Council Estates 61 Houses divided into Separate Tenements 63 Underground rooms 63 Ice Cream, Registration of Premises 77 Infantile Mortality 13, 14, 21, 22, Infectious Diseases 85-99 Infectious Diseases, Non-notifiable 100 Introduction 3 126 Pages Laboratory Facilities 24 Legal Proceedings (Adulteration of Food) 67 „ „ (Sanitary and Housing) 47 Markets 44 Maternity and Child Welfare (Report by Dr. Ruby Thomson) 29 Antenatal Clinics 33 Charitable Organisations 37, 38 Day Nursery 35, 36 Dental Clinic 34 Eye and Skin Defects 34 Health Visitors 29, 30 Home Nursing 25, 34, 35 Home Visitations 30 Infant Life Protection 31 Maternity and Child Welfare Centres 31-33 Massage Clinic 34 Maternity Home 35 Maternity Mortality 15, 38 Notification of Births 31 Provision of Milk 32, 36, 37 Measles Epidemic 95-98 Milk, Automatic Milk Machines 68 Milk, Bacteriological Examinations of 71-73 Milk, Examination of 67, 68 Milk, Inspection and Supervision of Dairies and Milkshops 70, 71 Milk Purveyors 70 Milk Samples, Composition of 69 Milk and Dairies (Amendment) Act, 1922, and Milk and Dairies Order, 1926 69, 70 Milk (Special Designations) Order, 1936 71 Mortuary 51 National Rat Week 53 Nuisances from Pigeons 53 Outworkers 55 Overcrowding 58-60 Pharmacy and Poisons Act, 1933 78, 79 Poisons Rules, 1935 78, 79 Prevention of Blindness 101 Preserved Food, Registration of Premises 77 Public Analyst, Report of 80-83 Public Baths and Washhouses 50 Public Cleansing 41, 42 Public Conveniences 51, 52 Public Health (Condensed Milk) Regulations, 1923 and 1927 74 Public Health (Dried Milk) Regulations, 1923 and 1927 74 Public Health (Imported Food) Regulations, 1925 77 Public Health (Preservatives, etc., in food) Regulations, 1925 and 1927 75 Rag Flock Acts, 1911-1928 49, 50 Rat Repression and Destruction 52, 53 127 Pages Rent Restrictions Acts, 1920-1933 52 Refuse Collection and Disposal 41 Repairs effected 45 Rivers and Streams 41 Samples purchased for Analysis 82, 83 Sanitary Inspection of Area 42 Scavenging and Street Watering 42 Scarlet Fever 95 Seasonal Mortality 12 Shops Act, 1934 44, 53 Slaughter House 76 Smoke Abatement 49 Social Conditions 10 Staff—Public Health and Maternity and Child Welfare Departments 5-7 Statistics, 1901-1936 17 Summary of Sanitary Inspections 44-46 Tuberculosis 101 Tuberculosis Dispensary, Report by Dr. P. L. T. Bennett 108 Bacteriological Department 117 Care Committee 114, 115 Contacts 114 Control and Prevention of Tuberculosis 110, 111 Dental Treatment 114, 118 Dispensary Statistics 104 Extra Nourishment 114 Handicraft Class 116 Home Visits 118 Mantoux Test 117 Mortality from Tuberculosis 102 Open-air School 113, 114 Register 102 Sanatorium Treatment 119 Special Treatment 113, 114, 117 Summary of Statistics—Tables 104-107, 118-122 X-Ray Examinations 113, 118 Notifications, 1913-1936 105 New Cases, 1936 106, 107 Underground Rooms 63 Vaccination 122 Vital Statistics for the Borough 16 „ „ of London Boroughs, 1936 18 „ „ of Working-Class Flats 64, 65 „ „ comments on 10 1901-1936 17 Zymotic Deaths 12, 87-89 T. W. PEGO & SONS, LTD., Printers (T.U.), EFFIE ROAD, WALHAM GREKN, LONDON, S.W.6.