Metropolitan Borough of Fulham. ANNUAL REPORT of the Medical Officer of Health for the Year 1937. 77.75 FUL Metropolitan Borough of Fulham. ANNUAL REPORT of the Medical Officer of Health for the Year 1937. 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 7 Staff of Public Health Department 8 Section 1:—Statistics and Social Conditions of the area 11 „ 2:—General Provision of Health Services for the area 27 „ 3:—Sanitary circumstances of the area 45 „ 4:—Housing 61 „ 5:-Inspection and Supervision of Food 69 „ 6:- Prevalence of and Control over Infectious and other Diseases 83 Index 111 3 Public Health Department, Town Hall, Fulham, S.W. 6. July, 1938. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Fulham. Mr. Mayor, Ladies and Gentlemen, I have the honour to submit the Annual Report on the health and sanitary conditions of the Borough for the year 1937. "The Mortality still is, as it always was, greater in towns than in the country. But the difference has diminished in an extraordinary degree. There is the best reason to believe that the annual mortality of Manchester, about the middle of the last century, was one in twenty-eight. It is now reckoned at one in forty-five. In Glasgow and Leeds a similar improvement has taken place. Nay, the rate of mortality in those three great capitals of the manufacturing districts is now considerably less than it was, fifty years ago, over England and Wales, taken together, open country and all. We might with some plausibility maintain that the people live longer because they are better fed, better lodged, better clothed, and better attended in sickness. ..." Despite the modern ring of these sentiments, Macaulay wrote them in 1830,* and whilst the passage of one hundred years has modified the slightly self-satisfied attitude underlying them, it has not diminished their validity. The annual mortality of Manchester and the other great towns to which he refers is now about one in eighty, but further improvements in housing, nutrition and medical science have rather revealed further deficiencies to be met than pointed to the achievement of perfection. (Incidentally, not the least of these deficiencies is the ugliness produced by industrialisation, on which Southey's criticisms led to Macaulay's thunder.) Nutrition and housing remain the basic public health problems and in the former field much significant work is being undertaken. That of the National Birthday Trust and the Research Committee of the Joint Committee of Midwifery Organisations deserves special mention. It was devoted, in particular, to the problem of maternal mortality, and commenced in the Rhondda Valley in 1934, being subsequently extended to other distressed areas in South Wales and on the North East coast. The early work concentrated on providing improved midwifery facilities, both personal and environmental, and insofar as the maternal mortality rate was an index of its effect, was without result. The provision, however, of certain forms of nourishment rich in vitamin content, in addition to the milk supply and supervision already given, reduced the maternal mortality rate to one quarter, not only of the earlier figures, but of the concurrent figures in non-assisted women in the same area. It also produced a 50 per cent. reduction in the still-birth and neo-natal death rates. Puerperal sepsis, which usually causes as many deaths as other puerperal causes, practically disappeared from the 'fed' group. This work, baldly summarised here from the accounts given of it by Lady Williams in "Public Health," is still continuing, and the Medical Research Council are observing it officially. It was undertaken in a group whose income per head per week, after rent, etc. was met, was less than four shillings; it is not yet possible to evaluate its statistical significance; but it clearly calls for repetition on a very wide scale and pari passu it is probably applicable to groups whose income is higher. Equally, it may affect local authority policy on maternity homes. However socially desirable these may be, they may prove a poor alternative to the provision of adequate nourishment with the additional disadvantage of being a more expensive one. Should choice be necessary, good food and poor housing may be, in maternity as in life generally, superior to bad food and good housing, though there is no intrinsic reason why both should not be good. * Essay on Southey's Colloquies on Society. 4 The problem of nutrition has continued to receive keen attention locally and Dr. Meyer-Wedell's work on the blood-picture in pregnant women is now approaching the stage when a report will be possible. A share in the nutrition and dietary survey organised by Sir John Boyd Orr has also been secured and should furnish valuable comparative information. The vital statistics of the Borough exhibit no significant changes. Epidemiological events of interest were the expected epidemic of measles towards the end of the year, and the epidemics of dysentery and catarrhal jaundice which are described in Section VI of the report. One fatal case of Typhoid Fever, contracted in Croydon, by a resident of that district, also occurred in the Borough. Babies' Hospital Although the transfer of the Babies' Hospital to the Borough Council was not completed until April 1st, 1938, this is the appropriate place to record it. The war work undertaken in Fulham by Mrs. Horace Hutchinson provided the stimulus for her and a group of friends headed by her husband, Mrs. Bessemer Wright and the late Dr. Jackson, then Medical Officer of Health, to found this hospital in 1915. The hospital has not lacked many generous friends, but it was in a very real sense the creation of Mrs. Hutchinson, and the intimation of her inevitable retirement from the post of Honorary Treasurer led me, as Chairman of the Committee of the Hospital, to press the convictions which have led to its official adoption by the Council. From 1913-1917, the infant mortality rate in Fulham averaged about 110. It is now about 60. It is no exaggeration to state that the nursing of sick babies in the twenty-one beds of the hospital has made a significant contribution to this fall. I have not the slightest idea of, or interest in, the capital value of this generous gift, in which many have participated, but as Medical Officer of Health I feel a lively satisfaction that the continuance of the work of the hospital is assured. That security will in the long run prove the most acceptable thanks to those who for twenty-three years undertook such valuable work. Maternity Home and Clinic.—I have elsewhere described the opening of the new maternity home and clinic at Parson's Green as marking a milestone on the local road of maternity and child welfare progress. A special handbook giving a full description of the building was issued on the occasion of the opening and a brief description is given in Section II of this report. This is the first ad hoc building for maternity and child welfare work erected by the Council and its success is evidenced not only by the slightly envious congratulations of many professional visitors, but, much more so, by the unexpectedly heavy use by the public both of the clinics and the maternity beds. Whilst improvements are easily possible in the older child welfare centres, the Council are aware that the most urgent need for the maternity and child welfare work of the borough is a centre to serve the Baron's Court and Lillie Wards. When it is possible to meet this need, the geographical distribution of the four centres which will then exist will be admirable. Housing.—The present year witnessed a further decisive step in the Council's plans to deal with the Avenues re-development area. A Ministry of Health Inquiry into three clearance areas in this area, containing 169 houses and housing 392 families was held in March. The Minister confirmed the Orders relating to all the houses except two. Appeals to the High Court against one Order were made by two owners of a substantial number of the houses. In one case, the appeal was withdrawn before the hearing and, in the other, dismissed by the judge. Welfare Adviser (Housing).—An interesting whole-time appointment grew out of the excellent work undertaken by the Council's Woman Sanitary Inspector amongst the tenants re-housed at Keir Hardie and Carnwath Houses. The transition to a Council flat would in some cases have resulted in a failure to make adequate use, or to take adequate care, of the new facilities but for Miss Sexton's firm and tactful guidance. The need for the extension of this work to all the Council's estates was appreciated by the Council and led to the appointment described in Section IV. Vaccination.—The policy of compulsory vaccination in infancy has recently received critical scrutiny from many medical officers of wide experience. Provided that the underlying biological truths are not lost sight of, periodic assessment of the best method of their routine application, in an environment which may have changed, is obviously desirable. 5 It is common knowledge that the occurrence of one case of inflammation of the central nervous system in every thirty thousand people vaccinated in the last fifteen years or so led to official reexamination of the method of preparing and applying vaccine lymph. As a result, the traditional four scarifications were reduced to one. The widespread occurrence in this country of mild smallpox which appears to be a genuine variant of the classical disease, breeding true, the traditional objection in certain parts of the country to compulsory vaccination, the prominence given on the official vaccination form to, and the ease with which, exemption can be secured, the absence of genuine Eastern smallpox (still a dread and fatal malady, sporadically imported), together with the rare occurrence of vaccinal encephalitis alluded to in the previous paragraph, clearly furnish grounds for re-examination of the established ritual of vaccination. They furnish in the opinion of many experienced observers, grounds for a change in policy and for a belief that vigorous supervision and vaccination of contacts of cases of the disease would control smallpox with more efficiency and economy. Here clearly is the dominating factor in determining policy. Vaccination does one thing and one thing only, namely, if applied before contact or within a certain limited period after contact, it prevents smallpox. The rapidity of modern communications not only allows the easier importation of smallpox, either active or incubating, but gives immediate knowledge, even foreknowledge, of its arrival. There is, therefore, a prima facie basis for the view that the isolation and supervision of these sporadic cases and the prompt vaccination of every contact will stamp out the disease. I am not personally convinced that these facts justify a change in policy. Smallpox, like most other infectious diseases, is in natural conditions a disease of infancy and childhood. There is no need to reproduce here the figures which show the undoubted effect of universal vaccination in reducing the incidence of smallpox and in changing it to a disease of later life. The latter effect is, of course, due to the fact that full immunity from vaccination persists only for about seven years, and exposure after this time, in the absence of re-vaccination, may lead to an attack. Such figures have been often reproduced, arc well known and are unchallengeable. Equally certain is the fact that universal vaccination and re-vaccination, as on the Continent, diminishes the seriousness of smallpox to the point at which sporadic cases can be nursed without concern in a block attached to an ordinary fever, or even a general hospital. The difficulty of an ad hoc policy of vaccination appears to me to be that of control of contacts. Every medical officer is familiar, either by personal experience or by tradition, with the tramp, with ambulant smallpox, who scatters infection in his peregrinations. Large liners bring hundreds of passengers who disperse to the four corners of the land, to tour daily, during a precious leisure, from place to place. Post-contact vaccination in these cases, with the difficulty of ascertaining precisely when exposure began and ended, will not always prevent an attack; compulsory powers of segregation will merely be an incentive to concealment and escape, and knowledge of daily destination is not always obtainable. Even when obtainable, medical officers and sanitary inspectors are not available in every hamlet. I recently had the temporary supervision of four Australians who had for at least two weeks been in continuing contact on shipboard with serious cases of typhoid fever. The trip to England was to them the event of a lifetime and any interference with their liberty, owing to contact with any sickness, would have been intolerable. Before the incubation period was over, they scattered to unknown addresses in known places, warning me of their intention in advance. Communication with the local medical officer of health was clearly valueless, but I could fortunately rely on their intelligent co-operation on the appearance in themselves of the slightest sign of illness. It is not a flight of fancy to substitute smallpox for typhoid fever and to visualise an exact duplication of this incident. A train journey, a visit to a cinema or cricket match, any one of a thousand normal occupations during the three days preceding the appearance of a smallpox eruption opens up weary vistas of unsuccessful contact ascertainment, supervision and vaccination. Nor can the possibility of illicit entry by aeroplane be ignored in the consideration of this subject 6 It would be a thousand pities if the first and most brilliant application of the method of preventive inoculation, a method which has given rise, in due course, to immunisation against diphtheria, typhoid, plague and other diseases, which has saved hundreds of thousands of lives and prevented untold human misery, should be jettisoned for any procedure which has not received the most thorough examination and most cautious experimental application. Vaccination prevents smallpox. Smallpox is still worth preventing and no surer method of doing it has yet been devised than universal infant vaccination and periodic re-vaccination. Nature may yet choose to illustrate tragically that vaccination in infancy is no longer universal. Staff Changes.—The department during the year lost the services of Miss Beckett, health visitor, Mr. Davies, Vaccination Officer, and Mr. Drake, senior sanitary inspector, all of whom retired on superannuation on May 31st, after long and distinguished service. The filling of Mr. Davies's post gave rise to some internal re-organisation, Mr. Hurford, Chief Clerk, being also appointed Vaccination Officer, and an additional junior clerk being appointed. The opening of the new Maternity Home led to the appointment, in addition to the staff transferred, of a Resident Medical Officer, Sister, resident porter, a cook, maids and cleaners. A nurse for the Ultra Violet Light Department, an additional health visitor and an additional clerk were appointed to meet clinic needs. The Overcrowding Survey continued during the year, the following temporary staff being appointed for varying periods: three temporary sanitary inspectors, six survey assistants, three clerks and one shorthand-typist. Preventive medicine can to-day reasonably claim to be a science but the application of any science to human beings becomes an art. My third annual report on the health of Fulham is the appropriate place to thank my colleagues in the Health Department, not only for their kindly reception of my own ideas about the way things should be done, but also for their unobtrusive and plentiful supplying of local knowledge. The resultant team work has, I think contributed materially to the achievement of our object: the spread of knowledge about health and the fostering of conditions in which health is possible. To my colleagues, the heads of other Council departments, I am also indebted for very real co-operation, as also to the constructive interest of members of the Council in general and of the Chairmen and members of the public health, maternity and child welfare and housing committees in particular. I have the honour to be, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, J. A. SCOTT, Medical Officer of Health. 7 Fulham Borough Council. PUBLIC HEALTH COMMITTEE, 1937-38 His Worship the Mayor (Councillor T. M. Cox, J.P.) Ex-Officio Chairman: Councillor Miss A. Gilliatt. Vice-Chairman: Alderman H. M. Gentry, J.P. Alderman Mrs. E. M. Rankin. Councillor T. Harper. Councillor S. F. J. Ballantynf. „ J. T. Horton. „ Miss N. Black. „ Mrs. F. LaskI. „ P. E. Coleman. „ Mrs. J. Marsh. E. J. P. Cussen. „ J. S. Melville. „ H. Dodimead. „ Miss C. J. Sketchley. MATERNITY AND CHILD WELFARE COMMITTEE, 1937-33 His Worship the Mayor (Councillor T. M. Cox. J.P.) Ex-Officio Chairman: Councillor Mrs. J. Marsh. Vice-Chairman: Alderman Mrs. E. M. Rankin. Alderman J. C. J. Dickinson, J.P. Councillor Miss C. J. Sketchley. Councillor Mrs. H. B. M. Andrews. „ J. Vincent-Hill. „ H. Dodimead. *Miss S. Baber. „ J. T. Horton. *Mrs. E. E. Hollingbery. „ C. W. Ironside, *Mrs. E. M. Rae. (died 6.1.38). Mrs. F. Laski. *Mrs. E. N. Vanderhook. Miss K. L Pottle. *Miss C. M. L. Wickham. * Co-opted Members. 8 STAFF OF PUBLIC HEALTH DEPARTMENT. 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.) (Assistant Maternity and Child Welfare Officer.) Edith M. P. Wilson, B.Ch. (Camb.), M.R.C.S. (Eng.), L.R.C.P. (Lond.) (part-time). (Resigned 31st May, 1937.) (Maternity and Child Welfare Officer.) 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. (part-time). Public Vaccinators: North District: A. G. Wells, M.R.C.S. (Eng.), L.R.C.P. (Lond.), L.S.A. (part-time). South District: T. Duff Miller, M.D. (Glas.), Ch.B. (Glas.), F.R.F.P.S. (part-time). Dental Surgeon: D. Gaskill, L.D.S., R.C.S. (Eng.) (part-time). Public Analyst: Thomas McLachlan, A.C.G.F.C., F.I.C. (part-time). 9 Clerical Staff: A. T. Hurford, Chief Clerk and Vaccination Officer. O. A. Trendell, D.P.A. (Lond.) Miss R. Barter. (Assistant Vaccination Officer.) S. Firsht. W. Swinson (Housing Assistant). J. Pasco. Miss A. Drury. C. J. Guy. Miss E. G. Goodrum. J. E. Burton. L. Burrows. Miss D. Wanneli. (appointed 7th June, 1937). Miss I. M. Buckingham. Mrs. D. Myers (appointed 7th June, 1937). E. J. Sharp. F. Crane (appointed 7th June, 1937). Senior Sanitary Inspector: 1 Edgar Drake (retired 31st May, 1937). 12 Thomas Henry Robey (from 1st June, 1937). Sanitary Inspectors: 12 Thomas Henry Robey (to 1st June, 1937). 129 Charles J. Price. 12 Alex. W. Gammack (Sampling Officer). 12 L. G. Brooks. 12 Frederick E. Walsh. 1456 Miss Ellen H. Sexton. 12 Arthur S. Jones. 12 Eric H. Jenkins. 12 Henry Hutchinson. 12 James W. Campbell. 12 Frederick C. Payne. 12 George E. Hardy (appointed 123 Wilfred C. Turner. 1st June, 1937). Rat Officer: J. Gigner. Health Visitors: 456 Mrs. J. Bryning. 456 Miss P. N. Bucknell. 4 5 6 8 Miss E. Beckett (retired 31st May, 1937) 4 5 6 Miss A. S. Clark. 4567 D. M. HAYWARD. 456 * Miss A.G. FOX. 4 5 6 Miss G. Leach. 4 5 6 Miss F. MacDonald (appointed 4 5 6 Miss P. Kaye. 1st June. 1937). 45678 Miss E. V. Thomas. 4 5 6 Miss E. Moore (appointed 4568 Miss N. Milburn. 18th October, 1937). Infant Life Protection Visitor: 14 6 Miss A. Perrett. Tuberculosis Dispensary: Nurses: 4 Miss E. E. Walker. 4 5 6 Miss E. C. Carmichael. 4 5 6 Miss E. M. Pretty. Miss M. C. Robinson, Bacteriological Assistant and Dispenser. Miss M. E. Sargent, Clerk and Secretary of the Cure Committee. Miss Grimstone, Clerk (part-time). 10 Maternity Home: Resident Medical Officer: Dr. Wallace Freeborn, M.B., Ch.M. (Sydney), M.C.O.G. Matron: Miss M. Bustard. Three Sisters. One Resident Porter. Three Staff Nurses. Domestic Staff. Ultra Violet Light Clinic: Nurse-in-charge: Miss Studdart, C.S.M.G. (appointed 15th November, 1937). Disinfecting Station: Superintendent: A. V. Williams. Three Disinfectors. One Van Driver. Mortuary Keeper: S. Churchill. 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 Sanitary Engineers. 5 Health Visitor's Certificate. Section I STATISTICS AND SOCIAL CONDITIONS OF THE AREA 12 GENERAL STATISTICS Area (acres) 1,706 Population (census 1931) 150,928 Population (mid 1937) 138,900 Number of inhabited houses (census 1931) 26,245 Rateable Value at 31st December, 1937 £1,333,270 Sum represented by a penny rate £5,377 EXTRACTS FROM VITAL STATISTICS FOR THE YEAR LIVE BIRTHS:- Total. Males. Females. Legitimate 1,798 891 907 Birth rate per 1,000 of the estimated population, 13.9 Illegitimate 135 74 61 STILLBIRTHS Legitimate 59 25 34 Rate per 1,000 total (live and still) births, 30.6 Illegitimate 2 1 1 DEATHS 1,817 908 909 Death rate per 1,000 of the estimated population: Crude rate 13.1 Adjusted rate 13.2 Percentage of deaths occurring in public institutions 64.06 Deaths. Rate per 1,000 total (live and still) births. Deaths from disease and accidents of pregnancy and childbirth From sepsis - — From other causes 6 3.01 Death rate of Infants under One Year of Age:— All infants per 1,000 live births 56 Legitimate infants per 1,000 legitimate live births 57 Illegitimate infants per 1,000 illegitimate live births 67 Deaths from:— Cancer (all ages) 241 Measles (all ages) 2 Whooping cough (all ages) 7 Diarrhœa (under two years of age) 30 13 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, 1937. January, 1938. Adult males 1,979 2,914 Adult females 591 995 Juvenile males 62 65 Juvenile females 46 54 Totals 2,678 4,028 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 depôts, transport and other distributive trades. A table of occupations was printed in my 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 Registrar-General's estimate of the population for the year 1937 was 138,900. 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 116. the Registrar-General estimates a decrease of 2,400 in the population from mid 1936 to mid 1937. Emigration and immigration in the London area are very complex, but local knowledge of housing applications, of empty properties and of overcrowding, rather suggest an under-estimate on the part of the Registrar-General. A quinquennial census offers many advantages in this and in other directions. MARRIAGES. The number of marriages during 1937 was 1,340, and the marriage rate (the number of marriages per 1,000 of the population) was 9.65; in the previous year the number of marriages was 1,385 and the rate 9.80. BIRTHS. During the year the live births, corrected by the distribution of those occurring in lying-in institutions in the borough to those districts in which the mothers resided, and the inclusion of children born to Fulham mothers in institutions outside the borough, numbered 1,933, of whom 965 were males and 968 were females. The birth rate (the number of live births per 1,000 of the population) was 13.9, a decrease of 1.0 compared with 1936. The birth rate for the Metropolis was 13.4, and for England and Wales 14.9. 14 STILLBIRTHS. The number of stillbirths during 1937 was 61 compared with 55 during the previous year. The stillbirths amounted to 30.6 per 1,000 of the total births (live and stillbirths). The corresponding rate for England and Wales was 39.04. On the basis of stillbirths per 1,000 of the population the local rate is 0.44 as against 0.60 nationally and 0.46 in the administrative county. ILLEGITIMACY. The illegitimate live births numbered 135 (74 males and 61 females) during 1937 compared with 105 for the previous year, and constituted 6.9 per cent. of the total live births. DEATHS. During the year ended December 31st, 1937, 1,518 deaths were registered as having occurred in the borough. Of these, 220 were of persons not belonging to the borough, while 519 inhabitants of Fulham died outside the borough, chiefly in public institutions. There were, therefore, 1,817 deaths of persons, 908 males and 909 females, having their usual residence in Fulham, representing an annual crude death rate of 13.1 per 1,000 of the population. This rate is 0.5 above that of the previous year. The death rate for England and Wales was 12.4, and for London 12.5. The "Comparability Factor" remains unchanged at 1.01, and the adjusted death rate is, therefore, 13.2. CERTIFICATION OF CAUSES OF DEATH. Of the 1,817 deaths belonging to the borough, 1,619 or 89.11 per cent., were certified by registered medical practitioners; 110 or 6.05 per cent. by coroners after inquests, and 88 or 4.84 per cent. by coroners without inquests. DEATHS IN PUBLIC INSTITUTIONS. Of the deaths of Fulham persons 64-06 per cent, took place in Public Institutions. The distribution of these institutional deaths according to the type of institution was as follows :— Per cent. 887 in Public Assistance Hospitals or Institutions... ... 76-20 28 in Infectious Disease Hospitals ... ... ... ... 2-41 181 in other Hospitals ... ... ... ... ... ... 15-55 68 in Mental Hospitals ... ... ... ... ... 5-84 FULHAM HOSPITAL. In this institution belonging to the London County Council there were 809 deaths, of which 690 were of Fulham residents and 119 of persons residing in other districts. WESTERN HOSPITAL. This hospital, the only London County Council Infectious Disease Hospital in the borough, had 90 deaths during the year, and of this number 14 were of Fulham residents, while the remaining 76 were of patients admitted from other districts. 15 DEATHS OF FULHAM RESIDENTS OUTSIDE THE BOROUGH The deaths of Fulham residents outside the borough numbered 519, and occurred in the following places:— St. George's Hospital 21 West London Hospital 19 Princess Beatrice Hospital 20 Other General Hospitals 79 Children's Hospitals 18 Women's Hospitals 4 Other Special Hospitals 16 L.C.C. Infectious Disease Hospitals 14 L.C.C. Hospitals and Institutions 197 Mental Hospitals 68 Sanatoria 4 Nursing Homes and elsewhere 59 519 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 lower than in 1936. 47 deaths being due to them as against 53. The death rate per 1.000 of the population was 0-34 compared with 0*38 for 1936. SEASONAL MORTALITY The number of deaths in each of the four quarters of the year was as follows :— 1937 1936 First quarter 658 560 Second quarter 373 414 Third quarter 339 328 Fourth quarter 447 484 1,817 1,786 CAUSES OF DEATH These are classified in Table 6, pages 23 and 24. 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 1,000 inhabitants. Heart disease 509 235 274 28 .01 3.66 Cancer 241 122 119 13.27 1.74 Respiratory diseases 186 107 79 10.24 1.34 Tuberculosis (all forms) 118 67 51 6.49 0.85 Cerebral hæmorrhage 93 43 50 5.12 0.67 Influenza 69 21 48 3.79 0.49 Totals 1.218 595 621 66.92 8.75 16 It will be seen that heart disease, as in the last eight years, heads the list; 509 deaths were due to this cause compared with 470 during 1936. Sex distribution of these deaths was 235 males and 274 females. Of the total, no less than 454 occurred in persons over the age of 55 years. Cancer came next, as in the last four years, with 241 deaths, a decrease of 9 on the previous year; 179 were in persons over 55. Pneumonia, bronchitis and other respiratory diseases together caused 186 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 118 deaths, of which 108 (63 males and 45 females) were from pulmonary tuberculosis. The death rate from pulmonary tuberculosis is 0.78 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 hæmorrhage is again a disease of the elderly, only 6 of the 93 deaths occurring under the age of 55. Influenza caused 69 deaths compared with 16 in 1936; 10 of the deaths being in persons under 45 years of age. INFANTILE MORTALITY Of the 1817 deaths of persons of all ages belonging to the Borough, 109 or 5.99 per cent., occurred in infants under one year of age, compared with 136 or 7.61 per cent. in the previous year. The Infantile Mortality Rate (the number of deaths of infants under one year of age per 1,000 live births) was 56, as compared with 64 during 1936. The Infantile Mortality Rate for England and Wales was 58, and for London 60. INFANTILE MORTALITY RATE IN FULHAM SINCE 1891. Average for 5 years. Actual rate for the last 10 years. 1891-1.895 168 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 1937 56 The following table shows the births, infantile mortality and death rates during the last two years for the various wards in the Borough. 17 TABLE 1 Wards. Births. Birth Rates. Infantile Deaths. Infantile Mortality Rates. General Death Rates. 1937 1936 1937 1936 1937 1936 1937 1936 1937 1936 Baron's Court 177 198 12.5 13.1 10 14 56 71 14.0 13.9 Lillie 331 323 15.8 15.2 20 24 60 74 12.9 11.8 Walham 238 281 18.0 20.9 16 19 67 67 13.9 12.7 Margravine 217 236 13.9 14.3 15 24 69 102 13.1 15.3 Munster 362 478 11.4 | 15.1 20 23 55 48 12.8 11.6 Hurlingham 95 91 11.4 10.8 3 11 31 121 11.8 12.6 Sands End 314 319 14.1 14.1 17 14 54 44 12.6 11.7 Town 199 185 15.7 14.3 8 7 40 38 13.9 14.2 BOROUGH 1,933 2,111 13.9 14.9 109 136 56 64 13.1 12.6 The principal causes of infantile mortality were as follows:- Prematurity 31 deaths compared with 28 in 1936. Pneumonia (all forms) 13 deaths compared with 27 in 1936. Diarrhoea and Enteritis 29 deaths compared with 19 in 1936. Forty-one deaths (36.7 per cent., of all deaths under one year of age) occurred in infants under four weeks of age as compared with 55 in 1936 and 42 in 1935. MATERNAL MORTALITY The Maternal Mortality rate of 3.01 per 1.000 total births com pares with a rate for England and Wales of 3.11. 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 a Provision Merchant's Manager. 23 5th May, 1937 Hospital. 1. (a) Eclampsia. (b) Partus 2/5/37. Wife of an Electrician. 27 13th July Hospital. Syncope. Respiratory failure and massive collapse of lungs during gas, oxygen and ether anæsthesia induced for the purpose of instrumental delivery. Misadventure. Spinster. 28 31st July Hospital. 1. (a) Pulmonary Embolism. (Post puerperal.) Spinster. 26 22nd October Hospital. 1. (a) Post Parturn Eclampsia. Wife of a Coal Porter. 39 2nd December Hospital. Bi-lateral pyelonephritis (recent abortion). Natural. Wife of a Clerk. 40 3rd December Hospital. 1. (a) Post Partum. (b) Eclampsia. 18 TABLE 2.-MATERNAL MORTALITY. Year. Total Births (including Stillbirths). Maternal Deaths. Rate (per 1,000 Births). 1913 4,455 6 1.35 1914 4,282 20 4.67 1915 3,962 10 2.52 1916 3,829 12 3.13 1917 3,038 8 2.63 1918 2,757 10 3.63 1919 3,089 16 5.18 1920 4,420 17 3.85 1921 3,615 13 3.60 1922 3,339 12 3.59 1923 3,198 15 4.69 1924 3,044 10 3.29 1925 2,832 11 3.88 1926 2,746 10 3.64 1927 2,503 2 0.80 1928 2,428 8 3.29 1929 2,570 15 5.84 1930 2,438 12 4.92 1931 2,360 9 3.81 1932 2,201 8 3.63 1933 2,003 9 4.49 1934 2,053 6 2.92 1935 2,054 6 2.92 1936 2,166 4 1.85 1937 1,994 6 3.01 19 TABLE 3.—VITAL STATISTICS OF THE BOROUGH HI RING 1937 AND TEN PRECEDING YEARS Year. Population Estimated to Middle of each Year. Births. Total Deaths Registered in the Borough. Transferable Deaths. Nett Deaths Belonging to the Borough. Nett Deaths under one Year. Nett Deaths under Five Years. Zymotic Death Rate (Influenza included). Occurring in the lk>rough. Nett. Of Non Residents registered in the Borough Of Residents not registered in the Borough At all Ages. Under 1 Year of Age. 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 15 1927 161,900 2,356 2,444 15.1 1,588 121 366 1,833 11.3 162 66 8.8 12.3 0.54 1928 155,300 2,319 2,388 15.4 1,548 128 360 1,780 11.5 185 77 10.4 14.4 0.73 1929 153,700 2,328 2,366 15.4 1,882 157 394 2,119 13.7 173 69 8.2 13.5 0.78 1930 153,700 2,226 2,366 15.4 1,473 143 343 1,673 10.8 136 57 8.1 13.4 0.68 1931 151,200 2,103 2,281 15.08 1,532 107 432 1,857 12.3 154 67 8.3 10.7 0.48 1932 149,600 1,842 2,137 14.3 1,569 202 481 1,848 12.4 124 58 6.7 10.7 0.69 1933 148,200 1,579 1,938 13.08 1,531 143 538 1,926 13.0 126 65 6.5 8.9 0.89 1934 145,400 1,592 1,996 13.7 1,531 206 507 1,832 12.6 118 59 6.4 10.9 0.74 1935 143,600 1,653 1,989 13.8 1,353 129 438 1,662 11.6 100 51 6.02 7.6 0.42 1936 141,300 1,576 2,111 14.9 1,486 230 530 1,786 12.6 136 64 7.61 9.69 0.49 1937 138,900 1,343 1,933 13.9 1,518 220 519 - 1,817 13.1 109 56 5.99 7.21 0.84 20 21 TABLE 4. STATISTICS 1901-1937. Year. Population. Structurally separate Dwellings (Census). Number of Private Families (Census). Average size of Family (Census). Birth Rate. Death Rate. Infant Mortality Rate. Pulmonary Tuberculosis Rate. 1901 137,289 (Census) 19,667 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 156,210 - - - 30.5 15.1 145 1.23 1906 149,520 - - - 31.9 14.8 136 1.14 1907 150,670 - - - 30.6 14.6 122 1.23 1908 151,659 - - - 31.1 14 .2 115 1.22 1909 152,501 - - - 28.2 13.9 108 1.30 1910 153,166 - - - 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 13.0 94 1.36 1913 157,117 - - - 26.9 12.7 96 1.34 1914 157,303 - - - 26.4 13.6 113 1.32 1915 153,161 - - - 24.3 15.2 115 1.29 1916 149,428 - - - 23.1 13.3 88 1.41 1917 145,186 - - - 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 158,621 - - - 27.2 11.5 74 0.89 1921 157,944 (Census) 26,630 40,436 3.82 22.1 11.7 83 0.96 1922 159,500 - - - 20.3 12.1 69 1.02 1923 161.600 - - - 19.3 10.5 64 0.92 1924 163,100 - - - 18.2 11.1 72 0.80 1925 163,700 - - - 16.9 10.7 76 0.92 1926 164,300 - - - 16.2 10.8 64 0.98 1927 161,900 - - - 15.1 11.3 66 0.77 1928 155,300 - - - 15.4 11.5 77 0.73 1929 153,700 - - - 15.4 13.7 69 0.96 1930 153,700 - - - 15.4 10.8 57 0.76 1931 150,928 (Census) 26,738 43,153 3.38 15.08 12.3 67 0.97 1932 149,600 - - - 14.3 12.4 58 0.91 1933 148,200 - - - 13.08 13.0 65 0.85 1934 145,400 - - - 13.7 12.6 59 0.77 1935 143,600 - - - 13.8 11.6 51 0.78 1936 141,300 - - - 14.9 12.6 64 0.76 1937 138,900 - - - 13.9 13.1 56 0.78 22 TABLE 5.—VITAL STATISTICS OF LONDON BOROUGHS, 1937. Borough. Estimated Resident Population (mid-1937) 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 138,300 13.65 13.05 12.91 66.0 Kensington 175,600 12.1 13.3 12.4 83.0 Hammersmith 126,500 15.1 12.6 13.0 68.0 Fulham 138,900 13.9 13.08 13.2 56.0 Chelsea 56,510 10.8 14.1 12.0 59.0 City of Westminster 124,300 8.2 11.5 11.8 58.7 NORTH DISTRICTS. St. Marylebone 92,110 9.36 13.10 12.98 73.0 Hampstead 90,690 11.2 11.6 10.9 54.0 St. Pancras 181,900 13.0 12.7 13.0 62.0 Islington 295,400 15.25 12.9 13.02 66.0 Stoke Newington 50,250 14.9 12.5 12.0 37.5 Hackney 206,700 13.8 11.1 11.7 43.38 CENTRAL DISTRICTS. Holborn 34,600 8.09 11.85 12.68 79.0 Finsbury 58,700 13.8 14.6 15.9 71.0 City of London 8,980 6.1 11.2 12.4 36.3 EAST DISTRICTS. Shoreditch 82,240 14.86 12.47 13.72 54.0 Bethnal Green 94,560 13.3 12.5 14.1 54.0 Stepney 203,100 13.5 12.2 14.2 60.5 Poplar 136,800 15.5 12.6 14.0 61.0 SOUTH DISTRICTS. Southwark 147,400 14.7 13.6 14.1 64.0 Bermondsey 98,790 14.4 12.3 14.0 59.0 Lambeth 273,800 14.1 13.2 13.0 68.0 Battersea 143,500 14.94 12.89 12.76 70.43 Wandsworth 341,700 11.53 12.36 11.43 62.0 Camberwell 224,800 14.08 12.83 12.83 58.0 Deptford 96,580 15.1 11.8 12.3 45.0 Greenwich 95,990 13.88 12.03 12.27 50.0 Lewisham 226,000 13.9 10.8 10.9 46.0 Woolwich 149,400 14.2 11.1 11.7 40.0 LONDON, Administrative County 4,094,500 13.4 12.5 - 60.0 ENGLAND AND WALES - 14.9 12.4 - 58.0 23 24 TABLE 6. CAUSES OF AND AGES AT DEATH DURING THE YEAR 1937. Nett deaths at the subjoined ages of "Residents," whether occurring within or without the District. Total Deaths, Whether of "Residents" or "Nonresidents" Institutions in the Destrict. Nett deaths at all ages of " Residents " in the Wards of the Borough, wherever occurring Causes of Death. All ages. Under 1 year. 1 and under 2 years. 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. 55and under 65 years. 65 and under 75 years. 75 years and upwards. Baron's Court Ward. Lillie Ward. Walham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 All Causes Certified 1,817 109 11 11 23 50 76 89 190 330 433 495 900 198 270 183 204 406 98 282 176 Uncertified - - - - - - - - - - - - - - - - - - - - - 1. Typhoid and paratyphoid fevers - - - - - - - - - - - - 2 - - - - - - - - 2. Measles 2 — — I 1 — — — — — - - 1 - - 1 - - 1 - - 3. Scarlet Fever 2 - 1 - - - - - 1 - - - 1 - 2 - - - - 4. Whooping Cough 7 3 1 3 — - - - - - - - 19 - - 2 2 2 - - 1 5. Diphtheria 4 1 1 — 2 — — — — — — - 24 2 1 - - - - 1 - 6. Influenza 69 1 - 1 - 3 1 4 11 11 21 16 41 8 12 7 9 17 2 6 7. Encephalitis Lethargica 7 - - - - 2 3 1 1 - - - 2 - 1 1 1 1 2 - 8. Cerebro-spinal fever 5 2 2 - - 1 - - - - - - 5 - 2 - 1 - - 2 - 9. Tuberculosis of respiratory system 108 - - - - 8 32 20 18 15 11 4 35 16 17 12 13 22 6 12 10 10. Other Tuberculous diseases 10 - 1 - 3 2 3 1 - - - - 8 - 2 1 3 2 - 1 1 11. Syphilis 4 1 - - - - - - - 3 - - 1 - - - - 1 1 2 - 12. General paralysis of the insane 10 - - - 1 - - - 3 2 4 - 6 1 1 - 2 3 - 2 1 13. Cancer, malignant disease 241 - - - - 3 5 17 37 61 76 42 108 31 36 20 20 57 14 44 19 14. Diabetes 25 - - - - 1 2 - 3 5 7 7 16 4 4 1 5 5 1 3 2 15. Cerebral Hemorrhage, etc. 93 - - - - - 1 1 4 21 32 34 57 12 12 3 11 25 4 16 10 16. Heart Disease 509 - - - 1 5 8 12 29 84 138 232 202 47 67 57 58 124 33 78 45 17. Aneurysm 7 - - - - - - - 1 3 3 - 5 - 3 1 1 1 - - 1 18. Other circulatory diseases 81 - - - - - - 3 9 13 21 35 35 9 18 8 13 18 1 8 6 19. Bronchitis 63 3 - 2 - - - 2 7 10 14 25 22 4 13 5 8 14 1 11 7 20. Pneumonia (all forms) 106 13 2 2 2 1 4 3 21 23 16 19 73 13 11 20 13 19 4 17 9 21. Other respiratory diseases 17 - - - - - - - 2 5 9 1 4 - - 2 - 8 - 1 6 22. Peptic ulcer 17 - - - - - - - 3 10 4 - 9 1 2 - 2 3 2 2 5 23. Diarrhoea, etc. 32 27 3 - - - - 1 - - - 1 44 3 8 4 5 7 1 2 2 24. Appendicitis 16 - - - 2 1 1 1 4 3 4 - 11 6 2 - 1 1 3 1 2 25. Cirrhosis of Liver 6 - - - - - - 1 1 3 1 - 3 1 1 2 - 1 - 1 - 26. Other diseases of liver, etc. 10 - - - - 1 - - - 4 - 5 5 - - 1 2 4 1 2 - 27. Other digestive diseases 29 3 - 1 - - 1 - 3 9 4 8 14 2 5 2 4 6 2 6 2 28. Acute and chronic nephritis 45 - - - - 2 3 4 6 9 15 6 23 3 10 3 3 6 5 9 6 29. Puerperal Sepsis - - - - - - - - - - - - - - - - - - - - - 30. Other puerperal causes 6 - - - - 1 3 2 - - - - 5 1 1 1 - - 1 1 1 31. Congenital debility, premature birth, malformations, etc. 46 46 - - - - - - - - - - 12 5 8 6 6 9 1 7 4 32. Senility 29 - - - - - - - - - 2 27 7 3 4 2 1 6 - 8 5 33. Suicide 17 - - - - 2 - 3 1 4 6 1 3 3 3 2 1 3 2 1 2 34. Other violence 60 - - 1 2 11 3 4 9 7 8 15 31 9 9 3 8 11 2 12 6 35. Other defined causes 134 9 - - 9 6 6 9 16 25 37 17 66 14 15 16 11 30 9 22 17 36. Causes ill-defined or unknown - - - - - - - - - - - - - - - - - - - - Total 1,817 109 11 11 23 50 76 89 190 330 433 495 900 198 270 183 204 406 98 282 176 25 26 TABLE 7. INFANT MORTALITY DURING YEAR 1937. Nett. Deaths from staled causes at various ages under One Year of Age. Nell Deaths under One Year in Wards. Causes of Death. Under 1 Week. 1—2 Week. 2—3 Weeks. 3—4 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 8 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under One year. Baron's Court Ward. Lillie Ward. Wallham Ward. Margravine Ward. Munster Ward. Hurlingham Ward. Sands End Ward. Town Ward. All Causes Certified 34 3 3 1 41 17 23 17 11 109 10 20 16 15 20 3 17 8 Uncertified - - - - - - - - - - - - - - - - - - 1. Small-pox - - - - - - - - - - - - - - - - - - 2. Chicken-pox - - - - - - - - - - - - - - - - - - 3. Measles - - - - - - - - - - - - - - - - - - 4. Scarlet Fever - -- - - - - - - - - - - - - - - - - 5. Whooping Cough - - - - - 1 1 1 - 3 - - 1 1 1 - - - 6. Diphtheria and Croup - - - - - - 1 - - 1 1 - - - - - - - 7. Erysipelas - -- - - - - - - - - - - - - - - - - 8. Tuberculous Meningitis - - - - - - - - - - - - - - - - - - 9. Abdominal Tuberculosis - - - - - - - - - - - - - - - - - - 10. Other Tuberculous Diseases - - - - - - - - - - - - - - - - - - 11. Meningitis (not Tuberculous) - - - - - - - - - - - - - - - - - - 12. Convulsions - - - - - - - - - - - - - - - - - - 13. Laryngitis - - - - - - - - - - - - - - - - - - 14. Bronchitis and Pneumonia - - - - - 5 6 4 1 16 - 2 3 3 2 - 6 - 15. Influenza - - - - - - - - 1 1 - - 1 - - - - - 16. Gastro-Enteritis and Diarrhoea - - - 1 1 6 13 5 4 29 2 8 4 3 7 1 2 2 17. Syphilis - - - - - 1 - - - 1 - - - - - 1 - - 18. Rickets - - - - - - 1 - - 1 1 - - - - - - - 19. Suffocation, overlaying - - - - - - - - - - - - - - - - - - 20. Injury by Birth 3 1 - - 4 - - - - 4 - - - - 3 - 1 - 21. Atelectasis 2 - - - 2 - - 1 - 3 - 2 1 - - - - - 22. Congenital Malformations 3 - 3 - 6 2 - - 1 9 1 - 1 - 3 - 3 - 23. Premature Birth. Debility and Marasmus, etc. 26 2 - - 28 1 - 1 1 31 4 5 4 6 4 1 3 4 24. Other Causes - - - - - 1 1 5 3 10 1 2 1 2 - - 2 2 Total 34 3 3 1 41 17 23 17 11 109 10 20 16 15 20 3 17 8 Section II GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA 29 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 3.388 specimens were examined. Arrangements were made with the Clinical Research Association for the examination of specimens during week-ends, holidays and emergencies, 469 specimens being reported on during the year. SPECIMENS EXAMINED Specimens At Council's Laboratory By Clinical Research Association Total examined Material from cases of suspected Diphtheria : Diphtheria isolated 67 23 90 Negative result 1,287 370 l,657 Virulence test—result negative - 1 1 1,354 394 1,748 Blood from cases of Enteric Fever: Agglutination reaction for Typhoid or Para-Typhoid obtained - - - Negative result 3 - 3 Pathological specimens for Enteric Organisms: 3 3 Positive result 4 - 4 Negative result 34 1 35 38 1 39 Sputa from cases of suspected Tuberculosis: Tubercle bacilli found 307 13 320 Tubercle bacilli not found 1,199 34 1,233 1,506 47 1,553 Swabs from suspected Gonorrhoea: Gonococcus found 6 — 6 Gonococcus not found 76 7 83 82 7 89 Eye Smears - 2 2 Examinations of Urine 165 7 172 Throat Swabs, Hæmolytic Streps, etc. 164 7 171 Examinations of Ice Cream 33 — 33 Examinations of Water 2 1 3 Other Examinations 3 2 5 Milk — 1 1 Special Examinations of: Sputa - - - Urine 29 - 29 Faeces 9 — 9 38 - 38 Total Number of Examinations 3,388 469 3,857 30 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. 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 and a table showing the number and type of such cases is given below. During 1937 the Council made a grant to the Association of one shilling per visit but arrangements have now been made for a block grant of £300 per annum to be paid; £200 from the Maternity and Child Welfare Committee and £100 from the Public Health Committee. The District Nursing Association employs twelve full-time nurses and besides nursing cases in their 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 Association. TABLE 8 HOME NURSING BY THE FULHAM NURSING ASSOCIATION ON BEHALF OF THE FULHAM BOROUGH COUNCIL, 1937 Illness January to March April to June July to September October to December Totals. Cases Visits Cases Visits Cases Visits Cases Visits Cases Visits Mammary Abscess - - - - 1 20 - - 1 20 Ante-Natal 5 22 4 15 10 81 9 76 28 194 Post-Natal 1 2 8 54 18 195 12 123 39 374 Vaginitis 1 3 — - - - - - 1 3 Discharging Eyes 4 28 11 91 26 432 17 234 58 785 Mastitis 8 62 2 17 1 6 4 53 15 138 Wet Cord 2 31 6 41 - - 1 3 9 75 Pemphigus - - - - 2 55 - - 2 55 Prematurity - - - - 1 4 - - 1 4 Pyrexia - - 1 4 1 2 - - 2 6 Otorrhœa 1 3 2 19 - - - - 3 22 Diarrhœa 2 23 1 2 - - - - 3 25 Enteritis - - - - - - 6 59 6 59 Constipation 7 18 1 2 3 9 2 4 13 33 Debility 7 88 8 72 10 109 17 134 42 403 Worms - - 2 15 - - - - 2 15 Endometritis — — 1 4 1 8 — - 2 12 Pneumonia 35 425 6 44 5 46 21 240 67 755 Broncho-Pneumonia 17 183 8 147 5 62 10 141 40 533 Bronchitis 2 17 - - 1 3 - - 3 20 Influenza 35 263 - - - - 4 30 39 293 Chicken Pox - - 1 4 2 27 3 43 6 74 Whooping Cough - - 3 44 1 10 1 5 5 59 Tuberculosis 7 380 7 323 1 76 7 160 22 939 Measles - - 3 19 - - 22 221 25 240 Impetigo and Septic Skin - - 3 24 - - 1 5 4 29 Mumps 1 8 3 21 1 7 - - 5 36 Totals 135 1,556 81 962 90 1,152 137 1,531 443 5,201 31 CLINIC AND TREATMENT CENTRES The following is the list of clinics in the borough; all except the Massage Clinic are provided by the Borough Council. There are, in addition, school treatment centres controlled by Voluntary Committees at Bagley's Lane and Bishop Creighton House, Lillie Road. Clinic. Address. Hours. ANTE-NATAL 90/2, Greyhound Road. Mondays— 2p.m. Fridays—10.30a.m. 170, Wandsworth Bridge Road. Fridays—2p.m. 5/7, Parsons Green. Mondays—10a.m. Tuesdays-10a.m. Wednesdays—10a.m. Fridays— 10a.m. and 2p.m. INFANT WELFARE 90 2, Greyhound Road. Mondays 10.30a.m. Tuesdays—10.30a.m. Wednesdays 10.30a.m. and 2p.m. Thursdays—2p.m. Fridays—2p.m. 170 Wandsworth Bridge Road. Mondays—2p.m. Tuesdays—2p.m. Wednesdays-2p.m. 5/7, Parsons Green. Mondays—2p.m. Wednesdays-2p.m. Thursdays—10a.m. and 2p.m. TODDLERS 90/2, Greyhound Road. Thursdays— 10.30a.m. 170, Wandsworth Bridge Road. Fridays—10.30a.m. 5/7, Parsons Green. Mondays—2p.m. POST-NATAL 5/7, Parsons Green. Tuesdays—2p.m. Thursdays—10.30a.m. BREAST FEEDING 90/2, Greyhound Road. Tuesdays—10.30a.m. 5/7, Parsons Green, Mondays—2p.m. Thursdays- 9a.m. and 2p.m. GYNæCOLOGICAL 90/2, Greyhound Road. Tuesdays—2p.m. DENTAL 90/2, Greyhound Road. Fridays—2p.m. 5/7, Parsons Green. Wednesdays—9.30a.m. Thursdays—2p.m. (alternate weeks). 32 CLINIC AND TREATMENT CENTRES—continued. DIPHTHERIA IMMUNISATION 170, Wandsworth Bridge Road. Thursdays—2p.m. MASSAGE Bishop Creighton House. Tuesdays—10a.m. Fridays—10a.m. ARTIFICIAL SUNLIGHT 5/7, Parsons Green. Men: Mondays—6.30p.m. Fridays—1.30p.m. Women: Tuesdays—9.15a.m. Fridays—2p.m. Children: Mondays—9.15a.m. and 2p.m. Wednesdays—9.15a.m. and 2p.m. Thursdays—9.15a.m. and 2p.m. Fridays—9.15a.m. Schoolgirls: Saturdays—9a.m. Schoolboys: Saturdays—10.30a.m. TUBERCULOSIS DISPENSARY 114, New King's Road. Women and Young Children. Mondays—10 to 11.30a.m. School Children: Mondays—1.45 to 3p.m. Men—Old and new cases: Tuesdays-—10 to 11.30a.m. Men and Women Workers: Tuesdays—6 to 7.30p.m. Women—Old and new cases: Wednesdays—10 to 11.30a.m. Children—Old and new cases: Thursdays—1.45 to 3p.m. HOSPITALS (a) GENERAL: There are no voluntary hospitals in the borough, the needs of the district being met by the Fulham Hospital, which is under the control of the London County Council Public Health Committee, and has 555 beds. There are, in addition, several L.C.C. and voluntary hospitals within easy reach of the borough. (b) CHILDREN AND INFANTS: The Fulham Babies Hospital, containing 21 beds, is situated in the borough, and particulars of the cases admitted will be found on page 44. (c) INFECTIOUS DISEASES: There is one hospital for infectious diseases in the borough, the Western Hospital, Seagrave Road, which is one of the L.C.C. Hospitals, and contains 521 beds. 33 SUPPLY OF INSULIN Arrangements were sanctioned by the Ministry of Health in June, 1937, for the temporary supply of insulin to necessitous patients suffering from diabetes. The insulin is only supplied on the application of the medical practitioner undertaking the treatment of the patient, and during 1937 100 units were supplied for one patient. Quarterly reports on the progress of the patients are obtained from the medical practitioners. GYNæCOLOGICAL CLINIC During the year 89 cases attended this clinic for advice on birth control and made 257 attendances ; 129 cases attended for gynaecological advice and made 300 attendances. Birth control advice is given strictly in accordance with the conditions prescribed by the Ministry of Health and is available only to women in whom further pregnancy would be dangerous or injurious to their health. HEALTH PROPAGANDA Besides the usual routine propaganda which is carried on throughout the year by the members of the staff in connection with their ordinary duties, the Department organised, in conjunction with the local branch of the British Social Hygiene Council, a "Keep Fit Week" during the last week of October. An effort was made to cover most of the activities of the Department, and the meetings were held in the Town Hall, the Central Library and the Parsons Green Clinic. Although the attendances at all except the Friday evening meeting were on the meagre side I feel that the effort was worth while. I give below an outline of the programme and the attendances : At the Town Hall: Tuesday afternoon Women "Women and Public Health." Films 60 Friday evening Adults (1) How to avoid Diphtheria." (2) Films on Re-housing and Clean Milk Supply. (3) Display by "Keep Fit" team from Bishop Creighton House Settlement 250 At the Central Library: Monday afternoon Conference for Clergy. Doctors, School Teachers, Industrial and Youth Leaders 60 Monday evening School Children Series of film displays 300 Tuesday evening Adults "Housing in relation to Maternity and Child Welfare.- Films 60 Thursday evening Young People "Keeping Fit and Personal Problems." Films 25 At the Parsons Green Clinic: Wednesday evening Parents "Our Young People of To-day." Films 40 The British Social Hygiene Council have continued their propaganda work in the borough, and, besides assisting in the "Keep Fit Week" have held the following meetings during the year SINGLE LECTURES. Date. Place. Speaker. Film. Attendance. Women: Jan. 10th Munster Road Co-op. Guild. Miss Dugdale Damaged Lives 150 Feb. 4th Church of Christ Miss Bennett — 50 Nov. 16th Bishop Creighton House. Dr. Naomi Dancy - 35 Men: Oct. 25th Rotary Club Captain Buckler - 40 34 COURSE OF LECTURES. Date. Place. Speaker. Film. Attendance. Women: Feb 1st, 8th, 15th Course of 3 lectures at Central Library. Miss Bennett Gift of Life 160 (average) Human Reproduction Irresponsibles April 7th, 14th, 21st Course of 3 lectures to St. John's Women's Fellowship. Mrs. Hume - 40 (average) Miss Bennett Parents: Mar. 11th 18th Course of 2 lectures at Everington Street School. Dr. Naomi Dancy - 25 (average) Young Men: Nov. 22nd, 29th and Dec. 6th Course of 3 lectures at Everington Street School. Mr. Lee Sex in Life 160 (average) Human Reproduction Any Evening after Work ULTRA VIOLET LIGHT CLINIC The Council took advantage of the opportunity provided by the erection of the new Maternity Home and Clinic to provide ultra violet light treatment facilities. The unit consists of two individual treatment cubicles and a large general irradiation room, the general lay-out being decided upon after visiting several other clinics. Following a decision of the Council to make this treatment available for any resident in the borough, in accordance with the powers conveyed by Section 226 of the Public Health (London) Act, 1936, the Public Health Committee assumed responsibility for this part of the new building, vice the Maternity and Child Welfare Committee. Medical supervision is undertaken by the Resident Medical Officer at the Maternity Home, and treatment is given by a whole-time nurse with special training and experience. Two sessions weekly are available for each of the following classes : Men, women, schoolboys, schoolgirls and infants. The attendances between the opening at the end of November and the end of the year were as follows:— First attendances. Re-attendances. Total. Infants (under 5 years of age) 94 299 393 Boys 1 1 2 Girls 1 1 2 Men 5 18 23 Women 45 155 200 Totals 146 474 620 35 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. During the year 1937 the scope of the work of the Maternity and Child Welfare Department was greatly extended. A new Maternity Home and Child Welfare Clinic, to replace the original Maternity Home at 706, Fulham Road, and to add to the clinic facilities of the Department, was opened in October at 5 and 7, Parson's Green; and an additional assistant Medical Officer was appointed, to be resident in the new institution. In addition to the ante-natal and gynaecological clinics it was decided to deal systematically with post-natal work in the borough; and clinic sessions for this purpose were started at Parson's Green. At these sessions any mother in the borough is made welcome. The investigation regarding the nutrition of expectant and nursing mothers, which was begun in August, 1936, by Dr. Meyer-Wedell, continued throughout 1937. Dr. Meyer-Wedell gives nearly three whole days in the week to voluntary work in the borough for purposes of this enquiry and the results promise to be of great interest and value. An extra weekly dental session was inaugurated at Parson's Green and already, by the end of the year, more time has been found to be necessary. HEALTH VISITORS An addition of one Health Visitor was made to the Health Visiting staff in October. Miss Beckett retired after eighteen years of Health Visiting services in the borough, and her successor was appointed in June. The opening of the new clinic at Parson's Green and additional sessions of various kinds which have been inaugurated, have necessitated much more of the Health Visitors' time being devoted to the work of the clinics. Figures show that an intensive drive has been made in connection with the visitation of children between the ages of two and five years—approximately 2,000 more visits having been made than in the previous year. The wide extent of the knowledge and experience of the Health Visitors may again be mentioned. All are fully trained nurses, holding the Certificate of the Central Midwives Board and the Health Visitor's Certificate, representing years of study and practical work. In addition to these essential qualifications, each one has specialised in one or other branch of nursing ; for instance, five are trained Queen's Nurses; two are fever-trained; one has special training in venereal and tropical diseases ; one is a trained actino-therapist, another has had special experience of massage ; and all have had a wide experience of midwifery and the special diseases of women and children ; one has the Diploma in Nursing. There can, therefore, be few conditions occurring in the family where scientific nursing advice cannot be obtained from the Town Hall. 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 wellbeing 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. It should be remembered that a Health Visitor has no right of entry into any house, and much depends upon her tactfulness as to whether or not her mothers keep their children under regular medical supervision. The whole department is controlled by the Maternity and Child Welfare provisions of the Public Health (London) Act, 1936, and a large proportion of the work of the Health Visitor is directly dependent on Section 255, which makes 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. 36 In spite of all that is done by way of explanation and persuasion, the amount of continuous breast-feeding in the Borough is lamentably low, and to encourage perseverance in this direction, special breast-feeding sessions have been started. 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 five years ; and epidemic diarrhoea;—and give advice in such cases as may be desirable. The Health Visitors also visit 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 Health Visitor comes and goes as a friend of the family, and the matters upon which she is consulted are many and varied. The social side of the Health Visitors' work is perhaps not fully appreciated. The Health Visitors and Medical Officers of the department have, on many occasions, been the means of obtaining jobs for mothers requiring part-time work, and in some instances, also for the fathers. They collect, too, from and with the help of their friends, innumerable articles of clothing and toys for the children. During the year well over a thousand articles of clothing and many dozens of toys have been so distributed. This side of the work is, of course, entirely voluntary, but the members of the Staff are satisfied that services of this nature are essential to their work and, although it has not been mentioned before, this work has been carried on unobtrusively as long as the department has existed. For several years the Department has arranged for an annual concert for the mothers attending the clinics and the Mayor has very kindly provided a hall in the Town Hall for this purpose. This year there were about 700 mothers present at the concert. The following table illustrates the scope of the Health Visitors' work:— Visits to cases of stillbirths 53 First visits to infants under one month 1,781 Re-visits to infants under one month 719 First visits to infants aged one to twelve months 119 Re-visits to infants aged one to twelve months 9,623 First visits to infants aged one to two years 62 Re-visits to infants aged one to two years 5,409 First visits to infants aged two to five years 83 Re-visits to infants aged two to five years 11,200 Visits to children over five years of age:— Removal from Infant Welfare Register 215 Measles, etc. 33 Convalescent Homes, Holiday Camps, Parties, etc. 253 Throat swabs, etc. 20 Diphtheria Immunisation Clinic 10 Miscellaneous 28 559 First visits to ante-natal cases 1,574 Re-visits to ante-natal cases 1,794 Visits to puerperal fever cases 19 Visits to puerperal pyrexia cases 14 Enquiries concerning maternal deaths and other visits 326 Total Effective Visits 33,335 "No replies" 4,584 Total Visits 37,919 37 Analysis of Special Visits to Infants under Five Years of Age:— Measles 188 Ophthalmia Neonatorum 21 Pneumonia 21 Epidemic Diarrhœa 80 Mumps 1 Whooping Cough 1 Discharging Eyes 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 At the end of the year there were 85 foster-mothers with 116 children on the register. The Infant Life Protection Visitor paid 1,602 visits to foster-mothers; and made 1,907 inspections of children at such visits. In addition, 208 special visits were made and 175 visits were made to cases of measles. There is still an insufficiency of foster-mothers in the borough and this department would be glad to hear of suitable candidates for approval as foster-mothers. There are more applications for such service than can be met. The duties of the Infant Life 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. MATERNITY HOME For a long time it was apparent that the original Maternity Home in Fulham Road, opened in 1919, did not meet the needs of the Borough and schemes for the erection of an institution on more modern lines have been under consideration. Infant welfare work at Melmoth Hall had always been done under difficulties, and it was decided to replace this by an up-to-date health centre. A site became available at Parsons Green, near a District Railway station and ' bus routes, and of suitable extent—having an area of three-quarters of an acre and a frontage of ninety feet to Parsons Green. This site was acquired by the Council, and plans were made to build a combined Maternity Home and Health Centre which would deal with the work of this Department in all its aspects—ante-natal, maternity, post-natal and infant welfare. Under the inspiration of Councillor Mrs. Marsh, Chairman of the Maternity and Child Welfare Committee, the new Maternity Home and Clinic has come into existence—arranged and equipped in accordance with the most modern standards of efficiency—second to none, except in size, in this country. It was opened on October 16th, 1937, in the presence of the Mayor, Alderman C. Lancaster, J.P., by Sir Ewen Maclean, LL.D., D.Sc., M.D., F.R.C.P., President of the British College of Obstetricians and Gynaecologists. An additional Assistant Medical Officer was added to the staff of the Department to be Resident Medical Officer of the Maternity Home. The Matron of the old home and her staff were transferred to the new institution and suitable additions were made to the nursing and domestic personnel. 38 The building is arranged in three 3-storey blocks, connected on each floor by wide corridors. The child welfare clinic and ante-natal wards are on the ground floor; the maternity wards and babies' nursery on the middle floor; and the staff quarters and main kitchen on the top floor. An isolation unit is also provided on the ground floor. There are separate entrances to the Maternity Home and the Clinic. Suitable staircases, a stretcher bed lift, a service lift and telephones connect the various levels. There is an extensive flat roof for the use of the staff for air and exercise. The clinic part consists of a large waiting hall, communicating through weighing and antenatal examination rooms with two separate doctor's consulting rooms, and, at the other end, with a dispensary for the distribution of dried milks and feeding adjuvants. A covered way leads to a large pram shelter. The middle block on the ground floor contains the dental surgery and recovery rooms, the health visitors' room, and also an extensive Light treatment centre, described elsewhere in the report (page 34). The first floor is entirely occupied by the Maternity Home with an equipment the most up-todate available. There are two six-bed wards, four two-bed wards, two labour wards and sterilising and sluice rooms; a large nursery, etc. The large wards open on wide sun balconies, and adjoining the Nursery is a flat roof where, in fine weather, the babies' cots can stand in the open air. The second floor accommodates the staff quarters and the main kitchen of the Home. Each nurse and maid has a tastefully furnished bed-sitting room. Electricity is used throughout the building for heating, lighting, sterilising, etc. The Department is now equipped with possibilities for the care and treatment of pregnancy throughout all its phases, and the institution of post-natal clinics completes the system for the care of the parturient woman. The first babies born in the Home were twins, and to each of them the Mayor presented a silver spoon. The staff of the Maternity Home receive practical ante-natal training at the clinics as before and have now the opportunity of also attending the post-natal clinics; thus, each midwife sees her case from the beginning to the end. The presence of a Resident Medical Officer, experienced in obstetrics, at the Maternity Home, completes the unit. 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 1937:— Old Home New Home Total Cases admitted 143 55 198 Average duration of stay (days) 14 14 14 Number of cases notified as Puerperal Pyrexia 1 — 1 Cases delivered by— (a) Midwives 140 55 195 (b) Doctors 2 — 2 (c) Born before admission 1 — 1 Number of cases notified as Ophthalmia Neonatorum 2 1 3 Number of infants not entirely breast-fed whilst in the home — — — Number of maternal deaths — — — Number of foetal deaths— (a) Stillborn 4 1 5 (b) Within ten days of birth 1 1 2 Ante-natal cases admitted — 18 18 The highest fees charged during 1937/38 were £5 15s. 0d. (old Home), and £7 5s. 0d. (new Home) for the two weeks, and the average fee charged was £3 5s. 8d. 39 MATERNITY AND CHILD WELFARE CENTRES Melmoth Hall, Eustace Road, was given up as a clinic when the new institution at Parsons Green became available; and the Eustace Road patients were redistributed over the various clinics as suited them best. The new Clinic at Parsons Green was opened on Saturday, 16th October. This Clinic consists of the greater part of the ground floor of the new Maternity Home building. There is a large waiting hall (suitable also for social activities, lectures, etc.), with ample accommodation for the different types of clinic sessions. There is a small kitchen where teas can be made for the mothers. The Free Church Women's Guild have undertaken to prepare and serve the teas, as in our other clinics, and to them we are indebted for this further extension of their voluntary work for the Department. Dried milk is now issued at all the Infant Welfare Centres; and its distribution at the Town Hall has been discontinued. As all mothers buying milk at cost price must 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 it is evident that a large proportion of those children who do not attend the clinics have no medical supervision except in illness. Many mothers still fail to realise the importance of medical supervision for apparently healthy children. 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. The importance of the supervision of the pregnant and nursing mother is laid stress on by the Health Visitors and clinic doctors. It is the foundation of all maternity and child welfare work. In Fulham for many years cards for recording the clinic history of nursing mothers have been specially filed. A gynaecological and birth control clinic is held once a week at Greyhound Road. Sessions for urgent post-natal examinations have been instituted at Parsons Green clinic ; and a notice urging the importance of after care following childbirth is sent out from the Maternity and Child Welfare Department whenever a notification of birth is received. Increasing legislation is continually tending to throw additional work on the clerical and Health Visiting staffs (which are not always concurrently increased) ; and I again place on record my deep appreciation of the wholehearted and loyal services of the Health Visiting and clerical staffs. To our regular voluntary workers also I would here express my appreciation. Upon the mother depends, in large measure, the contentment and well-being of the family and at the Centres we lay great emphasis on this point. The presence in the borough of such open spaces as Eelbrook Common, Parsons Green, the Recreation Ground, South Park and Bishops Park is in itself an important factor towards this end. The total attendances at the clinics increased by 1,555, and the first attendances of children under one year of age represented 58 per cent. of the notified live births. 40 The following table shows the attendances at the Infant Clinics during the year 1937: Clinic. Number of Clinics held. First attendances of Babies. Total Attendances. Age in years 0—1 1—5 0—1 1—5 92, Greyhound Road 255 522 100 6,830 4,147* 170, Wandsworth Bridge Road 196 328 93 4,770 3,107* Melmoth Hall, Eustace Road (Closed 30/9/37) 71 176 44 2,620 1,543 Parsons Green (Opened 10/37) 20 86 17 796 522 Totals 542 1,112 254 15,016 9,319 *Includes 771 attendances made by Toddlers at special clinics (59 sessions). NOTIFICATIONS OF BIRTH The Birth Rate was lower last year (13.9 compared with 14.9 in 1936). Under the Public Health (London) Act, 1936, 1,961 births were notified to the Department during the year, of which 57 were stillborn. The number of births notified by midwives was 1,830, and by doctors and parents 131. The stillbirths equalled 2.9 per cent. of the notified births. ANTE-NATAL CLINICS When the new Maternity Home opened it became possible to meet a pressing demand for additional provision of ante-natal clinics, and the weekly sessions were increased from three to four. Two of these were held at Parsons Green, one at Greyhound Road and one at Wandsworth Bridge Road. The desirability of ante-natal care is gradually being realised by the majority of women, though there is yet much to be done in the direction of securing its general acceptance. The increased hospitalisation of labour is tending towards this end, as no hospital or reputable maternity home now undertakes the care of labour unless ante-natal oversight is also accepted by the patient. In actual emergency, of course, such a rule is set aside. It does not seem to be understood so widely as it should be that any expectant mother in the Borough who is attending an ante-natal department of any hospital may also attend the Borough ante-natal clinics, and avail herself of the various benefits they provide for the pregnant woman. All patients who are booked for confinement at the Council's Maternity Home are required to attend at the ante-natal clinics ; some also are referred by hospitals that they may obtain grants of milk or dinners, and to be under observation between visits to hospital. Women could themselves do much to reduce the number of accidents and risks of childbirth that every year take a toll of the population, if only every prospective mother would accept what is due to herself in ante-natal care. The Medical Officers at the clinics satisfy themselves that abnormalities, if such exist, are known and provided against, and that the expectant mother has made suitable arrangements for the proper conduct of her confinement. Recent legislation has promoted adequate co-operation between clinics, hospitals, midwives and local practitioners. 41 It may be mentioned here that a stock of maternity outfits is maintained at the Town Hall and at the clinics. 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 now of two shillings. The following is a record of the work done at the ante-natal clinics during the year:— Clinic. Number of Sessions. Number of Patients. Number of Attendances. New. Total. 92, Greyhound Road 90 252 591 1,574 170, Wandsworth Bridge Road 51 144 874 Parsons Green 22 110 611 Totals 163 506 591 3,059 OPHTHALMIA NEONATORUM Ophthalmia neonatorum—inflammation in the eyes of the new-born—is a disease which does much harm to the eyes of new-born infants, if infection be contracted at the time of birth, as may occur 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 at the Bagley's Lane Centre, and this has proved a convenient arrangement. Children attending the clinics regularly, who are found to be suffering from any skin condition requiring attention, are referred to the London County Council local School Treatment Centres also. No contagious or infectious disease is allowed in the clinics. MASSAGE CLINIC It was with deep regret that early in the year we learned that Miss Christian Wickham would, for an indefinite period, be unable to carry on her massage clinic, and we are still without her valued services as this Report goes to press; but we hope that she may find it possible to resume this very useful work for the mothers and babies of Fulham. For three months Miss Bevington undertook this responsibility at Bishop Creighton House, so during part of the year massage work was efficiently carried on. DENTAL CLINIC When the new Health Centre was opened at Parsons Green, an extra dental session was inaugurated there in addition to the one already being carried on at Greyhound Road. This has been well attended. During the year the Council gave financial dental assistance in 13 cases, in some instances giving completely free dentures to regular clinic mothers. During the year 313 new cases attended, making 1,002 total attendances; 232 persons had extractions and 51 had fillings carried out, 35 dentures also being supplied. 42 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. To the Superintendent and Nurses of the District Nursing Association I again express my sincere thanks for their co-operation and assistance in the work of this Department. 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; and in addition, every child admitted to the Nursery is provided with medical supervision and examination by members of the Maternity and Child Welfare staff. Children are admitted to the Nursery between the ages of six weeks and five years ; the mothers pay a small fee. The Nursery receives for the clay or half-day the children of mothers who must go out to work daily; and many children thus escape being left to the casual attention of kindly but often ignorant neighbours. The Nursery does not yet cater for the relief of mothers who have to go to hospital for outpatient treatment, or into hospital for operative or other treatment, and often mothers wait too long before submitting themselves to treatment because of the difficulty of arranging for the care of their children during their absence from home. The question of extension of the work of the Nursery in this direction is worthy of consideration. In every case Matron receives a home report of the circumstances of the child; and these reports made by the Health Visitors are of great value. 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 maintained; and an old army hut in the garden makes it possible for the children to be out of doors in both winter and summer, although they arc never allowed out when there is fog. The Day Nursery is affiliated to the National Society of Day Nurseries, 117, Piccadilly, W. 1. Girls 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 1937:— Individual children under 3 years 91 Individual children over 3 years 35 Whole Days— Attendances under 3 years 4,701 Attendances over 3 years 1,825 6,526 Half Days— Attendances under 3 years 1,862 Attendances over 3 years 459 2,321 Total attendances 8,847 The Nursery was closed on fourteen half days. 43 SUPPLY OF MILK AND EXTRA NOURISHMENT Under the provisions of the Public Health (London) Act, 1936, 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 exists ; and a special Milk Sub-Committee of the Maternity and Child Welfare Committee meets very week to consider applications and make grants. The approximate cost of the milk granted free or at less than cost price during 1937 was:— Dried milk £661 13 4 Wet milk £302 6 0 £963 19 4 Dinners for expectant and nursing mothers are also provided by the Council at 170, Wandsworth Bridge Road, the food being prepared on the premises by the resident housekeeper; this supplies the southern area of the Borough. By arrangement with the Invalid Kitchens of London, similar dinners at the cost of the Council continue to be supplied for the northern area of the Borough at Bishop Creighton House. There can be little doubt that an ample well-balanced meal, not cooked by herself, is more useful, mentally and physically, to a pregnant or nursing mother than the mere drinking of a glass of milk. It has been a disappointment that this facility is not more widely made use of by those who are eligible to receive it. There are doubtless many family reasons which may prevent eligible mothers from attending to eat their dinners, but there are also many cases where there appear to be no such valid reasons and yet the mothers will not trouble to attend. It is a consolation however, to realise that did serious privation exist in the Borough the dinners would be more readily accepted. Milk is sold at cost price in cases recommended by the Medical Officers, Health Visitors or any local practitioner or hospital Medical Officer. During 1937 under this part of the scheme 8,669 lbs. of dried milk were supplied at a cost to the families of £670 6s. 10d., as compared with 5,985 lbs. at a cost of £570 18s. 6d. 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 498 lbs. of dried milk were so issued at a cost to the Committee of £44. The Borough Council supplies a full-cream or humanised dried milk prepared by the spray method and similar preparations dried by the roller process. The digestibility of either form of dried milk is greater than that of wet milk; every mother whose infant is receiving dried milk at the clinics is carefully and repeatedly instructed by the doctors and health visitors as to the necessity for adding fresh orange or tomato juice to the diet. Nearly twenty years' experience of regular work at Infant Welfare Centres has not diminished my belief that dried milk and not wet milk should be supplied almost exclusively at such Centres, and this is my invariable practice in the sessions that I personally conduct. A 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. At the infant welfare centres we keep nutrient preparations sufficient to ensure complete balance of diet with the use of any milk. Medical research is constantly bringing to light new adjuvants to diet such as are needed to meet the requirements of children suffering from the conditions of modern life; and at the clinics we, so far as possible, keep up to date in the provision of such dietetic preparations. 44 CHARITABLE ORGANISATIONS The Charity Organisation Society, the Invalid Children's Aid Association and the Invalid Kitchens of London have continued their helpful co-operation. 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. BABIES' HOSPITAL The Fulham Babies' Hospital is under the control of a Voluntary Committee on which the Borough Council is represented. The type of case 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 1937 were as follows:— Cases admitted: 115 Clinic cases 94 General Practitioners 21 Average daily number in Hospital 12.4 Average duration of stay 35 days In Hospital January 1st 14 In Hospital December 31st 10 Reasons for admission: Anæmia 7 Loss of weight 8 Bronchitis 21 Marasmus 14 Broncho-Pneumonia 7 Otitis Media 2 Bronchial Catarrh 7 Rickets. 6 Constipation 1 Stomatitis 1 Diarrhœa 3 Test feeding 4 Debility 1 Vomiting 3 Enteritis 1 After Tonsilectomy 2 For observation 9 After Circumcision 2 For dieting 16 Discharges: Deaths : In good health 69 Broncho-Pneumonia 2 Improved 36 Meningitis 1 Not improved 11 Total 116 Discharged on account of infectious diseases : Diphtheria 2 Scarlet Fever 1 Whooping Cough 1 Dysentery 1 Section III SANITARY CIRCUMSTANCES OF THE AREA 46 RIVERS AND STREAMS No action to check pollution was necessary during the year. CLOSET ACCOMMODATION All closets an; of the water carriage type. There are no closets of the conservancy or wastewider 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 Refuse collection is carried out by means of mechanical transport at an economic cost and with a general freedom 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 five 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 arc being purchased in the immediate future, to replace some of the older ones. 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. Definite arrangements have, however, been made to institute a part bi-weekly collection of refuse from premises where necessary at an early date. The Council has recently inaugurated the "Container" system of storage and collection in connection with its 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, and in one or two instances have adopted it. There are still a few ash pits in the Borough, but these are gradually being abolished as opportunities occur. Special attention is given to 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 is assumed that this is due to the increasing substitution of gas and electric fires in place of solid fuel tires, and so curtailing facilities for burning refuse on the premises. SCAVENGING AND WATERING Practically all the streets in the Borough receive 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. 47 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. Three temporary inspectors were appointed at the end of 1936 to release three of the permanent staff for house-tohouse 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, 1936. These engagements lasted for varying periods, the longest being for ten months. The following table shows the number and nature of inspections carried out by the sanitary inspectors during the year. TABLE 9 DWELLING HOUSES COMPLAINTS. Houses inspected for first time 3,394 Re-inspections 13,656 Intimations served 2,380 do. complied with 2,157 INFECTIOUS DISEASES. Houses inspected for first time 1,361 Re-inspections 626 Intimations served 186 do. complied with 68 HOUSE TO HOUSE INSPECTIONS. Houses inspected for first time 273 Re-inspections 2,197 Intimations served 236 do. complied with 141 STATUTORY NOTICES. Number served under Public Health Act 564 Housing Act 15 Number complied with Public Health Act 520 Housing Act 9 KENT RESTRICTION ACT CERTIFICATES. Number of applications 5 Number of inspections made 8 Number of reports to M.O.H. 3 CLEARANCE AREAS. Number of inspections 957 DRAINAGE. Drains tested 3,348 Inspections of work carried out under Notice 7,265 Number of Notices received of voluntary work 343 Inspections of work carried out voluntarily 2,891 INFIRM AND DIRTY TENANTS. First inspections 53 Re-inspections 145 Notices served 1 MISCELLANEOUS. Inspections in connection with Housing applications 412 Inspections in connection with Underground Rooms 182 Inspections in connection with use of Insecticide Sprays 42 Inspection of re-housed tenants 169 48  OTHER INSPECTIONS FACTORIES, INCLUDING FACTORY LAUNDRIES. Inspections 579 Intimations served 7 do. complied with 6 WORKSHOPS, INCLUDING WORKSHOP FOUNDRIES. Inspections 133 Intimations served 2 do. complied with 1 WORKPLACES. Inspections 192 Intimations served 7 OUTWORKERS' PREMISES. Inspections 192 Intimations served 21 SMOKE ABATEMENT ACT. Complaints received 5 Observations made 37 Intimations served 1 FOOD PREMISES. Total inspections (see page 77 for analysis) 1,786 Number of Intimations served 22 do. do. complied with 18 Number of Statutory Notices served 2 EVENINGS ON MARKET DUTY 61 PHARMACY AND POISONS ACT. Number of inspections 434 SHOPS ACT. Number of inspections 73 MISCELLANEOUS. Inspections of Common Lodging Houses 4 Inspections of Public Conveniences 51 Miscellaneous visits 25 In addition the inspectors made 1,501 ineffectual visits (i.e., cases in which no reply was obtained). SUMMARY Cause of Inspection. First inspections. Reinspections. Total inspections. In consequence of complaint 3,394 13,656 17,050 In consequence of infectious disease 1,361 626 1,987 House to house inspections 273 2,197 2,470 Houses in Clearance Areas 788 169 957 Infirm and Dirty Tenants 53 145 198 Rent Restriction Act applications 8 — 8 Totals 5,877 16,793 22,670 49 The following notices were served in respect of dwelling houses during the year:— INTIMATION NOTICES Served in 1936 but not complied with by 31st December, 1936 570 Served during the year 2,803 3,373 Complied with during the yea 2,366 Number in respect of which Statutory Notices were served during the year 579 2,945 Number outstanding on 31st December, 1937 428 STATUTORY NOTICES Served in 1936 but not complied with by 31st December, 1936 89 Served during the year 579 668 Complied with during the year 529 Number outstanding on 31st December, 1937 139 REPAIRS EFFECTED The following works were carried out and repairs effected as a result of the action of the sanitary inspectors:— TABLE 10 DRAINAGE. Drains cleared 132 Drains repaired 307 Drains relaid 337 Soil and ventilation pipes repaired 47 Soil and ventilation pipes renewed 93 Rain water gutters and pipes repaired and renewed 392 Drains sealed off 12 Fresh Air inlet 95 WATER CLOSETS. Traps cleansed, repaired, etc. 418 Pans renewed 512 Seats repaired or renewed 322 Flushing cisterns repaired 260 Mushing cisterns renewed 9 Additional W.C. accommodation provided 9 Lobbies provided to W.C. apartments 2 Fastenings provided to doors, and doors repaired 70 W.C. apartments ventilated 49 SINKS, BATHS AND LAVATORY BASINS. Sinks provided 34 Sinks renewed 447 Sinks repaired 27 Sink waste pipes trapped 451 New sink waste pipes provided 164 Sink and Bath wastes repaired 86 New baths fitted 87 New lavatory basins fitted 167 New bath and lavatory wastes fitted 46 Sink removed from water closet apartment 11 50 WATER SUPPLY. Drinking water cisterns cleansed, etc. 112 Water supplied from mains 22 Occupied house provided with a sufficient supply 43 Water supply pipes and fittings repaired 68 Water supply provided to separate floors 20 CLEANSING AND INTERNAL WORK. Rooms cleansed 5,046 Verminous rooms cleansed 318 Decorations and internal house repairs 7,006 Fireplaces repaired (nuisances from smoke, etc.) 362 Kitchen ranges repaired or renewed (for cooking purposes) 243 Washing coppers repaired or renewed 104 Ventilation provided under floors 162 Dampness remedied 1,385 Staircases provided with adequate light and ventilation 59 Rooms provided with adequate light and ventilation 17 Ventilated food cupboards provided 74 EXTERNAL REPAIRS AND OTHER NUISANCES. Roofs repaired 734 Other external repairs 438 Accumulation of refuse removed 81 Dustbins provided 260 Yards and forecourts paved and drained 368 Abatement of nuisance from animals 6 Rat runs traced 25 DRAINAGE OF BUILDINGS The following drainage plans were submitted to and approved by the Public Health Committee during 1937. New Buildings Fuel Testing Engine House 1 Earl's Court Car Park 2 Fulham Power Station— New Sub-station 1 Lavatory Accommodation 1 Transforming Station 1 Tobacco Factory 1 Car Park Lavatories (Earl's Court) 1 Shop 1 Garage 2 Public House 2 Borough Council Flats 2 Block of Flats (Private) 2 Casting Sheds (L.P.T.B.) 1 Trinidad Asphalt Co. 2 L.M.& S. Railway Depot 1 Additions to existing buildings 42 Conversion to flats of existing buildings 22 Reconstruction of drainage- of existing buildings 166 51 COMBINED DRAINAGE During the year the Council authorised the carrying out of work in connection with combined drainage in eight cases. TABLE 11 LEGAL PROCEEDINGS Proceedings were instituted in the following cases during the year:— Address. Offence. Result. 20, Stanley Road Nuisance Withdrawn; work done before hearing. 22, Stanley Road do. do. do. 71, Chelmsford Street do. do. do. 3, Darlan Road do. Order for abatement within seven days. 40, Coomer Road do. do. do. 40, Coomer Road Failure to comply with drainage order. Fined £2 0s. 0d. 187, Wandsworth Bridge Road. Obstruction of Sanitary Inspector in performance of his duties. Fined £2 2s. 0d. and £1 1s. 0d. costs. 71, Coomer Road Failure to give notice of drainage work. Dismissed under P.O. Act. 5, Walham Avenue Failure to cause refuse to be placed in covered receptacles. do. do. 39, Hilmer Street Failure to pay drainage costs Order for payment. 22, Stephendale Road Nuisance: failure to comply with drainage notice: failure to provide sufficient ashpits. Withdrawn on payment of £5 5s. 0d. costs. 28, Stephendale Road Nuisance 38, Stephendale Road do. 44, Stephendale Road do. 52 SMOKE ABATEMENT During the year five complaints regarding smoke nuisance were received and 37 observations on chimneys were made by sanitary inspectors; in one case an intimation notice was served on the owner to abate the nuisance. No legal proceedings were necessary during the year. ATMOSPHERIC POLLUTION. Sulphur Activity in the Atmosphere Records. The curves for sulphur activity in the atmosphere for the year 1937, compared with those of last year, show a decrease for all stations during the summer months, but the winter figures are in each case higher. There can be little doubt that the pollution indicated at any one station, consists of two inseparable components. The one due to industrial smoke, spread over a wide area, and the other due to domestic pollution which, owing to the low average height of emission, is of more local significance. It is this latter component which largely accounts for the phenomenal difference between summer and winter pollution at No. 1 Station the May and November readings show more than a fourfold increase. 53 During the year, at the New Power Station, experiments have been successful in trapping the residual dust in the flue gases passed through the gas washer. A method of chemical precipitation is used, and the dust particles, on examination, appear to be amorphous carbon and organic matter, not easily wetted. In size they are of the order of four microns, and in quantity about 0.205 grains per cubic foot. The continuous recording apparatus has shown that on occasions the amount of residual sulphur is only 0.0002 grains per cubic foot of flue gas. When it is realised that the highest recorded sulphur content of the atmosphere in a London fog within the same period was, at the County Hall, 0.00046, and at Chelsea, 0.00024, this achievement can be fully appreciated. The above results indicate that the overall efficiency of elimination of both dust and sulphur is approaching the maximum practically possible. One of the largest commercial users of coal in the Borough has recently carried out extensive plant reconstruction. A range of three modern Sterling Tridrum boilers, with a total evaporative capacity of 99,000 lbs. per hour, has been installed ; these are capable of being worked in a smokeless condition. In the past, some trouble from smoke has been experienced by this firm, and it is hoped that the entire steam demand will be raised smokelessly. RAG FLOCK The sale and use of Rag Flock is regulated by Section 136 of the Public Health (London) Act, 1936, and the Regulations made by the Ministry of Health in 1912. These Regulations 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 1937, six samples of rag flock were taken with the following results:— Sample No. Parts of Chlorine per 100,000 of flock. R.F. 1 20 „ 2 13 „ 3 17 „ 4 10 „ 5 100 „ 6 15 It will be observed that sample No. 5 exceeded the legal maximum for chlorine. The dealer from whom the sample was obtained was warned by letter and sample No. 6 taken subsequently from the same person complied with the Regulations. 54 PUBLIC BATHS AND WASH-HOUSES The rebuilt swimming baths and wash-houses were re-opened to the public in September, 1937. They 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 are provided. The wash-houses contain 12 compartments. In December samples of water were taken from the swimming bath at 8.0 a.m. and 7.40 p.m. and submitted for bacteriological and chemical analysis. The reports are given below, compared with those for similar samples taken in 1936, before the reconstruction. 1937. 1936. Morning. Evening. Morning. Evening. Parts per 100,000. Parts per 100,000. (1) Chemical. Ammonia, Saline .390 .416 .014 .02 Ammonia, "Albuminoid" .056 .058 .018 .014 "Oxygen absorbed" at 27°C.— In 15 minutes .034 .025 .035 .035 In 4 hours .083 .090 .064 .054 Total solid residue 68.3 68.8 55.44 56.00 Chlorine 7.75 7.85 8.95 8.95 Free Chlorine .01 - - - Nitrogen, as Nitrates .16 .17 1.25 1.25 Nitrogen, as Nitrites .02 .02 .004 .002 Total hardness 20.0 20.0 8.4 9.2 Poisonous metals Absent Absent Absent Absent Appearance Clear and bright, faint yellow colour. Fairly clear, colourless and odourless. (2) Bacteriological. Average number of organisms producing visible colonies on agar plates incubated at 22°C. for 3 days. 75,000 in 1 c.c. 180,000 in 1 c.c. 80,000 in 1 c.c. 4,000,000 in 1 c.c. Average number of organisms producing visible colonies on agar plates incubated at 37.5°C. for 2 days. 30,000 in 1 c.c. 150,000 in 1 c.c. 60,000 in 1 c.c. 3,100,000 in 1 c.c. B. Coli Absent Absent Absent Present Streptococci Absent Absent Absent Present 55 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 LILLIE 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 Under the control of the Borough Surveyor's 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. SOUTH PARK: Lodge, Clancarty Rd. 1903 1 1 3 — 3 1 2 Lodge, Hugon Road 1903 2 2 3 — 3 2 — BISHOP'S PARK: Pryor's Bank Paviln. 1898 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 11 p.m. The hours of those in the parks are regulated by the hours of opening and closing of the parks. 56 INCREASE OF RENT AND MORTGAGE INTEREST (RESTRICTIONS) ACTS During 1937 nine applications for certificates under the above-named Acts as to the fitness of the houses for habitation were received and issued. In addition four applications that the work specified in a certificate had been carried out were received from the owners of the premises and "Clearance Certificates" issued. REMOVAL OF AGED, INFIRM AND PHYSICALLY INCAPACITATED PERSONS Under Section 224 of the Public Health (London) Act, 1936, the Council has power 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, application was made for four orders and in three cases the application was granted. In the fourth case the Magistrates were not satisfied that the aged person, an inmate of an Almshouse, was incapable of receiving proper attention from her daughter, living elsewhere. In addition, however, the Council's Woman Sanitary Inspector was able to persuade thirteen persons to enter hospital voluntarily and she also kept thirty-three 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 gained 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 152 formal complaints regarding infestation by rats were received and 1,765 visits were made to dwelling houses and 583 visits to business premises in the Borough. In addition 677 visits to sewers in all parts of the Borough were made. In 59.87 per cent. (91 instances) of the 152 complaints investigated, the rats gained admission to the premises owing to defective drains. The type of drainage defect was:— Defective drains under premises 39 Defective connections under footway 45 Disused drain connections 7 Rats were caught as follows during the year:— In cage traps in sewers 168 In dustbin traps in sewers 329 By ferrets and break-back traps in premises 505 The amount received by the Council from property owners for the services of the Rat Officer during the year ended 31st March, 1938, was £20 and, in addition, £15 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 1st to 6th, the Rat Officer paid special attention to the sewers in the Borough, and laid 18,000 baits in the stunt ends of 12-inch pipe sewers which are known to harbour rats in 80 streets. While, of course, it is difficult 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. 57 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 sent to the two newspapers circulating in the Borough and advertisements also inserted. 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. The Railway Companies and firms having premises in the railway goods yards, co-operated with the Department in an intensive drive against rat infestation. COMMON LODGING HOUSES There was one Common Lodging House in the Borough, accommodating 36 men, and the inspector made 4 inspections of the premises during the year. 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 post-mortem room with modern equipment. During the year 236 bodies were removed to the Mortuary and were admitted as follows:— By order of the Coroner 142 For convenience till funeral 94 236 There were 95 post-mortems made and inquests were held in 68 cases. NUISANCE FROM PIGEONS Under Section 121 of the Public Health (London) Act, 1936, the Council has power to abate or mitigate any nuisance caused by pigeons 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 roofs of three private houses, a Church and the Town Hall. As a result of this action 330 pigeons were caught and killed, the Rat Officer (who carries out this work) paying 353 visits for the purpose. At each visit all eggs and nests found were destroyed. SHOPS ACT, 1934 During the year, the sanitary inspectors made 73 inspections of shops under the abovenamed Act in connection with ventilation, temperature and sanitary conveniences. In 2 cases water closet and washing accommodation was provided as the result of action by the inspectors. 58 INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES TABLE 12 Premises. Number of Inspections. Written Notices. Occupiers Prosecuted. (1) (2) (3) (4) Factories (including factory laundries) 579 66 - Workshops (including workshop laundries) 133 4 - Workplaces (other than outworkers' premises) 192 12 - Total 904 82 - DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES TABLE 13 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 tinder the Public Health Acts:— Want of cleanliness 60 60 — — Want of ventilation 2 1 1 — Overcrowding — — — — Want of drainage of floors 6 6 — — Other nuisances 25 25 — — Sanitary accommodation— Insufficient — — — — Unsuitable or defective 18 18 — — Not separate for sexes 2 2 — — Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouses (Section 101) - - - - Other offences — — — — (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921). Total 113 112 1 — 59 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 of 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 3 12 37 52 Bootmaking 1 — 29 30 Miscellaneous 1 1 19 21 Totals 5 13 85 103 OUTWORK IN UNWHOLESOME PREMISES Nature of work. Instances. Notices served. Prosecutions. Bootmaking 6 4 - Wearing apparel 8 5 - Total 14 9 - TOTAL INSPECTIONS Male Inspectors. Woman Inspector. Total. Factories 504 75 579 Workshops 53 80 133 Workplaces 86 106 192 Outworkers' premises — 192 192 Totals 643 453 1,096 Section IV HOUSING 02 GENERAL A statistical analysis and description of the growth of the Borough, together with the occupations of the residents and their places of work, was given in my report for 1935. The detailed housing programme drawn up at that date involved the immediate displacement of 131 families from seven clearance areas and the subsequent displacement of 925 from a proposed redevelopment area, together with 600 families living in overcrowded houses who would still be overcrowded after making allowance for the maximum reallocation of overcrowded families in houses now overcrowded, but which could be utilised for smaller families. During 1937 accommodation was provided on new Estates as follows:— For the abatement of overcrowding 22 flats. For slum clearance 70 flats. The following table indicates the position at the end of 1937, after making allowance for the two estates mentioned above. TABLE 14 EXISTING COMMITMENTS AND EXISTING REPLACEMENT ACCOMMODATION For Demolition:- Flats Required. 1930 Clearance Orders 30 Avenues Clearance Section 392 Avenues Redevelopment Section 533 955 For relief of overcrowding 600 1,555 Replacement Sites:- Flats to be Erected. St. James' Home Ill Bagley's Lane 90 Field Road 80 Carnwath Road 8 North End Road 95 Fulham Road 83 467 Replacements on Avenues Site 485 952 Deficiency for which sites are not yet available 603 flats. THE AVENUES PROPOSED REDEVELOPMENT AREA This area, which is a typical legacy from Fulham's expansion period of 1881—1891, contains 438 houses and 925 families, with a population in 1936 of 3,213 persons and has an area of 12.55 acres. I reported on this area, giving its history and details of existing conditions in June, 1936, and the Council gave formal notice to the London County Council on the 24th June under Section 2 (5) of the Housing Act, 1935, of their intention to pass a resolution under Section 13 of the Housing Act, 1935. The County Council intimated that they did not themselves intend to deal with the area and a formal resolution declaring the area to be a proposed redevelopment area was passed |FULHAM ROAD DISTRICT RAILWAY EELBROOK COMMON DAWES ROAD LEWIS TRUST BUILDINGS AVENUES REDEVELOPMENT AREA FULHAM ROAD. | WALHAM GREEN STATION SCALE MODEL OF THE AVENUES REDEVELOPMENT AREA. Back Yards of 1—23 (odd) Warham Avenue, and 2—24 (even) Lodge Avenue. TYPICAL VIEW IN THE AREA. 63 on the 2nd December, 1936. In the meantime official representations were made on the 18th November, 1936, in pursuance of Section 51 (2) of the Housing Act, 1930, in respect of 169 houses in the area, and three Clearance Orders were made by the Council on 27th January, 1937. A Public Inquiry into these Orders was held on the 20th, 21st and 22nd April, 1937, as a result of which the Minister of Health confirmed The Avenues Nos. 1 and 2 Orders but did not confirm the No. 3 Order relating to two houses. Appeals against the Minister's decision were lodged in the High Court in respect of No. 1 Order, but were dismissed on the 10th March, 1938. The Orders as confirmed involved 402 families, with a population of 1,482 persons. The Proposed Redevelopment Plan was approved by the Council on the 25th August, 1937, and submitted to the Minister of Health for confirmation. A Public Inquiry was subsequently held and the Minister's decision is now awaited. An aerial photograph and photographs of a scale model and typical part of the area are given on the preceeding pages. 64 INSPECTION OF DWELLING-HOUSES A detailed analysis of all the inspections carried out during 1937 is given on pages 47-48. The following table gives the housing statistics in the form required by the Minister of Health. TABLE 15 1. Inspection of Dwelling-houses during the Year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 5,877 (b) Number of inspections made for the purpose 22,670 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 273 (b) Number of inspections made for the purpose 2,470 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation - (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 2,803 2. Remedy of Defects during the Year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 2,366* 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 15 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 9 (b) By Local Authority in default of owners 3* (b).—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 564 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 520* (b) By Local Authority in default of owners — (c).—Proceedings under sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made - (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 2 (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 71 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit - 65 4. Housing Act, 1935.—Overcrowding:— (a).— (i) Number of dwellings overcrowded at ,the end of the year 1,312 (ii) Number of families dwelling therein 1,312 (iii) Number of persons dwelling therein 7,651 (b).—Number of new cases of overcrowding reported during the year 413 (c).— (i) Number of cases of overcrowding relieved during the year 882 (ii) Number of persons concerned in such cases 5,518 (d).—Particulars of any cases in which dwelling-houses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding — (e).—Any other particulars with respect to overcrowding conditions upon which the Medical Officer of Health may consider it desirable to report See below. * Including Notices served during 1936, but not complied with up to 31st December, 1936. Comments on Table 15 3 (c) (2).—Demolition. Two houses were demolished in consequence of Orders made by the Council during 1936, one being in respect of a house excluded by the Minister from the Mulgrave Road Clearance Order, 1936. 3 (d) (1).—Underground Rooms. During the year Closing Orders were made in respect of 71 underground rooms. Six Orders were in respect of rooms already closed for sleeping purposes under Section 20 of the Housing Act, 1930, as it was found that these rooms were still being used for living purposes. 4.—Overcrowding. Work on the detailed measurement, preparation of records and supply of information to landlords and tenants, together with the "permitted number," was commenced on the 8th February, 1937, and completed on the 4th June, 1938. Every landlord and responsible tenant has now been supplied with a statement of the "permitted number" and a copy of a memorandum setting out their duties under the Act. It is encouraging to note that only three dwelling-houses have again been let so as to become overcrowded after the appointed day. In each case the owner was able to plead either wrong information from the tenant or some other equally good reason. No prosecutions were necessary. The following is a summary of the work carried out and the position at the end of 1937. TABLE 16 Total dwellings measured ... 24,926 Statements of "permitted numbers" sent ... 30,328 Number of cases of overcrowding found on 1935 Survey ... 1,795 Number of cases of overcrowding abated 1936 14 1937 882 896 New cases of overcrowding found on 1937 Survey ... 413 Overcrowded cases on books at end of 1937 ... 1,312 Analysis of the 896 cases abated:— (a) Re-housed on Borough Council Estates ... 30 (b) Re-housed on L.C.C. Estates ... 24 (c) Re-housed by Public Trusts ... — (d) Family obtained more accommodation in same house ... 174 (e) Family reduced in number ... 241 (f) Family found other accommodation ... 427 66 LONDON COUNTY COUNCIL BYELAWS WITH RESPECT TO HOUSES DIVIDED INTO SEPARATE TENEMENTS No action was necessary under these Byelaws during the year. DISINFESTATION During the year the household effects of 98 families were disinfested by the HCN process prior to transfer to new dwellings, bedding and bed linen being treated by steam before delivery to the new flat. No cases of reinfestation have been reported. As usual, woodwork from condemned houses in clearance areas was burnt on the site and all building debris carted away to a tip. It is probable that the rubble believed carted away to a tip is, in fact, used for hardcore on other building works, and to this I can see no objection, as the period which must inevitably elapse between vacation and demolition, is sufficient to allow the effects of weathering to destroy all traces of vermin. In addition the walls and ceilings of new working-class flats are usually finished off with a hard gypsum plaster and the floors with a float of cement, so as to render reinfestation impossible. There does not appear to be any reason from this point of view why the rubble should not be left on the site and used as hardcore in the erection of the new flats, thus reducing demolition costs. The fumigation of infested premises by sulphur or formalin is an inconvenient, objectionable and unsatisfactory method and experiments with various proprietary insecticides were continued with encouraging results and a total of 385 rooms were treated in this manner. Tenants were again 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 68 issues of such sprays were made during the course of the year. ADVICE AND ASSISTANCE TO TENANTS IN COUNCIL FLATS During the year the Council decided to give advice and assistance to tenants re-housed in their flats such as is referred to in paragraph 22 of Memorandum A. General, which was issued with Circular 1500 A. on 22nd October, 1935—particular attention being given to tenants re-housed under Clearance Orders. The Public Health and Housing Committees accordingly authorised Miss Sexton, the Woman Sanitary Inspector, who is also a qualified Health Visitor and Certified Midwife, to make systematic inspections of the Council's dwellings. This procedure produced an improvement in the flats of the less responsive tenants, and by the advice given, enabled them to settle down in their new surroundings and benefit more fully than they would otherwise have done from the change in their environment. As a result of this work the need for the appointment of a full-time Housing Welfare Adviser was realised, and the Council decided, pending the publication of the Report of the Central Housing Advisory Committee on the management of Municipally-owned houses, to appoint a temporary visitor to work under the direction of the Medical Officer of Health. This arrangement released Miss Sexton for her normal duties and enabled the system to be extended to all the Council flats. LONDON COUNTY COUNCIL ESTATES During the year 1937 42 families were alloted 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 up to the end of 1937:— 67 TABLE 17 Estate. Accommodated on recommendation by the Fulham Borough Council. Accommodated on applying direct to the London County Council. Total Fulham families accommodated. EAST HILL, Wandsworth 16 40 56 WATLING, Middlesex 140 86 226 DOWNHAM, Kent 54 20 74 BECONTREE, Essex 110 460 570 ST. HELIER, Morden 142 308 450 HANWELL, Middlesex 23 146 169 BROXHOLME HOUSE, Fulham 1 50 51 ROEHAMPTON, CASTELNAU, CENTRAL LONDON, etc. 165 577 742 Totals 651 1,687 2,338 During the year applications made to the Public Health Department of the Borough for accommodation on the London County Council Estates were dealt with in the following manner:— 47 families were recommended to the County Council for preferential consideration; 24 families proved upon enquiry to be unsuitable for recommendation, but 11 of these applications were forwarded to the London County Council for inclusion in the "ordinary list " of applicants; 31 applicants made inquiries, but did not return their application forms; 27 certificates of overcrowding were issued on request to the London County Council, and 6 cases were certified as "not overcrowded"; 25 cases of families occupying basement rooms were referred to the Department by the London County Council, but in no instance were the rooms found to be "underground rooms," which could be closed under the provisions of the Housing Act ; 11 cases were referred to the Department by the County Medical Officer of Health for certificates of the need for other accommodation on health grounds; certificates were issued in nine instances; 21 applicants refused accommodation offered by the London County Council, mainly on account of the distance of the Estate from their place of employment. 68 VITAL STATISTICS OF WORKING-CLASS FLATS Table 18 shows, for the third successive year, the vital statistics of certain groups of flats in the Borough. Any one year's figures arc, because of the comparative smallness of the population concerned, insufficient on which to base sound conclusions. Their yearly compilation, however, will, in due course, enable a five-year and then a ten-year average to be computed. This should provide reliable evidence. It will be denoted that the infant mortality in Lewis Trust, S.W. 6, Block is particularly high. It was based on three deaths, the first from failure of the lungs to expand at birth, the second from prematurity and the final one from whooping cough and bronchial pneumonia. The one death in Peabody Buildings which gave rise to the high infant mortality rate of 250 was due to prematurity. The infant death at Fulham Court was due to influenzal meningitis which was bacteriologically confirmed. TABLE 18 Fulham Borough. Fulham Court. Lewis Trust, S.W.6. Lewis Trust, W.14. Peabody Buildings. Population:- (a) Total 138,900 2,010 1,356 762 598 (b) Under 10 16,291 577 388 202 67 (c) Percent. under 10 11.8 28.7 28.6 26.5 11.2 Births 1,933 28 14 1 4 Birth rate 13.9 13.9 10.3 1.3 6.7 Deaths (a) Total 1,817 15 10 6 9 (b) Under 10 161 5 5 - - (c) Under 1 109 1 3 - 1 Total Death Rate (crude) 131 7.5 7.4 7.9 15.1 Death Rate under 10 on population under 10 9.9 8.7 12.9 — — Infant Mortality Rate 56 36 214 — 250 Diphtheria, No. of Cases:- (a) Total 206 5 10 3 1 (b) Under 10 157 3 9 1 — Attack rate per 1,000 (a) Total 1.5 2.5 7.4 3.9 1-7 (b) Under 10 9.3 5.2 23.2 5.0 — Scarlet Fever, No. of Cases (a) Total 319 7 11 1 2 (b) Under 10 228 3 9 — 1 Attack rate per 1,000:— (a) Total 2.3 3.5 81 1.3 3.3 (b) Under 10 14.0 5.2 23.2 - 14.9 Section V INSPECTION AND SUPERVISION OF FOOD 70 MILK During the year under review, 571 samples of milk (including one of machine.skimmed milk) were purchased by Inspector Gammack in his capacity as Sampling Officer, and submitted to the Council's Public Analyst for chemical analysis. Of these, 293 were purchased from milk vendors in the streets during the early hours of the morning, 61 were taken at the early morning delivery to hospitals, etc., in the Borough which are under the control of the London County Council and 105 were purchased on Sundays and public holidays. Two, or 0.35 per cent. of the 571 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 19 Sample No. Result of Analysis. Action taken. Result. 247 6% deficient in fat Prosecution Summons dismissed, the Justices holding that the firm prosecuted (who bottled, sealed and supplied the milk to a subsidiary company) were not responsible as the milk had left their control and custody at time of sampling. 547 3% added water (as shown by freezing point) Vendor warned by letter. Particulars of the number and percentage of adulterated samples of milk for the years 1928 to 1937 inclusive are given in the following table:— TABLE 20 SAMPLES OF MILK ADULTERATED Year. 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 No. examined 591 565 548 540 543 641 554 580 566 571 No. adulterated 15 28 4 3 4 18 6 2 6 2 Percentage of adulteration 2.5 4.7 0.7 0.55 0.74 2.8 1.1 0.3 1.06 0.35 As in previous years, the arrangement for samples of milk to be taken in course of delivery to the hospitals, institution and schools in the Borough which are under the control of the London County Council was continued and the following were taken for chemical analysis during 1937. No adulterations were reported. 71 TABLE 21 Institution. No. of samples taken. Fulham Hospital 33 Fulham Institution 2 Western Hospital 23 Elizabethan Open Air School 3 L.C.C. Schools 24 Total 85 AUTOMATIC MILK MACHINES There are in the Borough four automatic milk machines fixed to the doors of registered milk. shops from which milk is obtainable after ordinary trading hours. During 1937 twelve samples were obtained from these machines for chemical analysis and in all cases the milk was reported to be genuine. COMPOSITION OF MILK SAMPLES The monthly average composition of all samples of milk (excluding machine.skimmed milk) is given in the following table and it is satisfactory to record that the quality of the milk retailed in Fulham is well maintained and compares very favourably with the standards of the Ministry of Agriculture and Fisheries:— TABLE 22 Month. No. of Samples. Fat. Solids not Fat. Remarks. % % January 48 3.62 8.85 . v/ J February 48 3.45 8.83 . March 49 3.43 8.64 Including one adulterated sample. April 44 3.68 8.65 — May 52 3.21 8.85 . June 47 3.34 8.78 . July 42 3.44 8.68 Including one adulterated sample. August 35 3.71 8.78 . September 56 3.61 8.84 . October 48 3.82 8.90 . November 51 3.83 8.87 . December 50 3.76 8.90 . 570 3.54 8.78 Legal Standards 3.00 8.50 Average composition of normal cow's milk 3.76 8.84 72 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 if they are satisfied that the public health is, or is likely to be, endangered by any act or default of the person in relation to the quality, storage or distribution of the milk. It was not necessary to exercise the provisions of the latter Section during 1937. No contraventions of Article 31 (2) of the Milk and Dairies Order, 1926, which requires that the bottling of milk shall be carried out only on registered premises were reported during the year. At the end of 1937, there were on the register 106 dairymen occupying 106 registered dairy premises within the Borough. In addition, there were 26 dairymen retailing milk in Fulham from premises situated and registered in adjoining districts. The following are details of the changes which took place during 1937:— Number of Dairymen on the Register:— Number on register at 31st December, 1936 107 Number who transferred their business or discontinued selling milk during 1937 9 98 Number of registrations granted during 1937 8 Number on register at 31st December, 1937 106 During 1937, registration as purveyors of milk in properly closed and unopened receptacles was granted to 27 persons and there are now 189 names on the Register. INSPECTION AND SUPERVISION OF DAIRIES AND MILKSHOPS During 1937, the Sampling Officer made 485 visits to dairies and milkshops and served 20 written notices and in addition gave many verbal intimations of defects noted during his inspections. 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. It was not necessary to take action under this Section during 1937. 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 1937 were as follows:— Number of Licences to sell Tuberculin Tested Milk 28 Number of Supplementary Licences to sell Tuberculin Tested Milk 4 Number of Licences to sell Pasteurised Milk 40 Number of Supplementary Licences to sell Pasteurised Milk 7 Number of samples taken in accordance with the instructions of the Ministry of Health — 73 BACTERIOLOGICAL EXAMINATION OF MILK Under the Milk (Special Designations) Order, 1936, there are six designations applicable to graded milks, as follows:— 1. Tuberculin Tested Milk Certified; 2. Tuberculin Tested Milk ; 3. Tuberculin Tested Milk (Pasteurised) ; 4. Accredited Milk ; 5. Accredited Milk, Farm bottled ; 6. Pasteurised Milk. Complete details of the standards, etc., laid down for these milks will be found in my Annual Report for 1936. During the year under review 110 samples of graded milk, 22 of ungraded milk and 4 of raw milk were purchased by the Sampling Officer for bacteriological examination. Forty-three of the samples were purchased from milk vendors in the streets in the early hours of the morning and 41 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 136 samples examined, 24 were especially tested by animal inoculation for the presence of tubercle bacilli under Section 5 of the Milk and Dairies (Amendment) Act, 1922. One sample of raw milk so examined was reported to contain tubercle bacilli and the matter was communicated to the Medical Officer of Health for the County in which the farm from which the milk was obtained is situated. The herd was examined by a Veterinary Officer for the County and samples of milk taken. One sample taken from a cow which had a mild attack of Mastitis, was found to contain tubercle bacilli and the animal was slaughtered under the provisions of the Tuberculosis Order. The Chief Veterinary Officer for the County in which the farm is situated reported that " the post-mortem examination revealed that she was affected with ' Advanced ' Tuberculosis including lesions in the udder. This animal would be the cause of the tubercle infection of the milk sample taken by the Fulham Borough Council." The following table gives details of the various examinations carried out:— TABLE 23 Grade. Methylene blue and Coliform Tests. Count only. Count and Coliform Test. Count, Coliform and Phosphatase Tests. Count and Phosphatase Test. Complete Examination. Total. Tuberculin Tested 7 — — — — 5 12 Tuberculin Tested (Pasteurised) — 2 1 — — *— 3 Pasteurised — 60 10 6 5 14 95 Homogenised — — 1 — — — 1 Ordinary — 1 17 — — 3 21 Raw — — 2 — — 2 4 Totals 7 63 31 6 5 24 136 74 Tuberculin Tested Milk. Seven samples were examined all of which satisfied the methylene blue and coliform tests. Tuberculin Tested Milk (Pasteurised). The three samples taken were reported to contain respectively 1,980, 3,430 and 20 bacteria per millilitre—legal maximum 30,000 per millilitre. Pasteurised Milk. A maximum of 100,000 bacteria per millilitre is prescribed for milk sold under this designation and 85 of the 95 samples examined during 1937 were reported as satisfactory, the average count for these being 26,288 bacteria per millilitre. Two samples gave counts slightly in excess of the legal standard, viz. : 115,000 and 141,000 bacteria per millilitre. Two others taken from the same vendor were reported to contain respectively " probably more than 2,000,000 " and 1,036,000 bacteria per millilitre. In connection with these latter samples, I arranged for further tests to be carried out by three different bacteriologists and for this purpose the contents of one half-pint bottle of milk were divided into three parts under sterile conditions and sent to the three laboratories together with three unopened half-pint bottles of milk from the same delivery. The following results were obtained:— Laboratory. Bacteria per Millilitre. Legal maximum. Unopened ½ pint. One-third of \ pint. A 43,800 52,000 100,000 B 145,500 132,500 C 300,000 300,000 I communicated with the wholesalers who supplied the milk to the Fulham retailer and had an interview with the Chief Chemist to the Company, who gave an explanation of the temporary difficulties which accounted for the bad results. Several samples have since been purchased from this Company and satisfactory reports received. All the milk supplied to the London County Council hospitals, etc., in the Borough must have been Pasteurised in accordance with the requirements of the Milk (Special Designations) Order, 1936, and comply with the bacteriological standard laid down by that Order. During 1937, seventy-one samples were taken for bacteriological examination as under:— Institution, etc. Number of samples taken. Fulham Hospital 16 Fulham Institution 2 Western Hospital 23 Elizabethan Open Air School 3 L.C.C. Schools 27 Total 71 75 Fulham Hospital. The average count of 16 samples examined was 14,788 bacteria per millilitre. Fulham Institution. Two samples taken containing respectively 7,330 and 10,900 bacteria per millilitre. Western Hospital. Twenty.three samples were examined all of which were reported to be satisfactory, the average count being 15,539 bacteria per millilitre. Elizabethan Open Air School. The three samples taken were reported to contain respectively 19,600, 8,330 and 51,000 bacteria per millilitre. L.C.C. Schools. Two of the 27 samples examined were reported to have counts slightly in excess of the legal standard. The average of all the samples, however, was only 33,925 bacteria per millilitre. Ordinary Milk. This is milk which has been treated by heat although not sold under the designation " Pasteurised " and there is, therefore, no bacteriological standard for such milk. It is satisfactory to record that the lowest count was reported to be 9,230 bacteria per millilitre, and the highest 150,330 per millilitre, while the average for the 21 samples examined was 47,608 bacteria per millilitre. FOOD AND DRUGS—ADULTERATION, ETC. During the year under review, 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, 30 or 3.0 per cent. were adversely reported upon and full details of the adulterated samples will be found in Table 19 (milk) and Table 25 (other articles). The practice of reporting all adulterated samples to the Public Health Committee was continued during 1937 and the appropriate action taken. In the following table will be found details of the number and percentage of adulterated samples of all articles of food during the years 1928 to 1937 inclusive:— TABLE 24 SAMPLES OF ALL FOOD (INCLUDING MILK) REPORTED AS ADULTERATED ON CHEMICAL ANALYSIS Year. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 1935. 1936. 1937. No. examined 1,000 1,000 1,000 1,000 1,001 1,000 1,000 1,002 1,000 1,000 No. Adulterated 31 44 40 22 29 35 43 40 26 30 Percentage of adulteration 31 4.4 40 2.2 2.89 3.5 4.3 3.99 2.6 3.0 During 1937, one sample of jam roly.poly pudding, one of tinned condensed milk and one of peaches were examined by the Clinical Research Association for the presence of organisms of the food poisoning (Salmonella) group, but in none of the samples was food poisoning or other microorganisms of importance found. 76 PUBLIC HEALTH (CONDENSED MILK) REGULATIONS, 1923 & 1927 AND PUBLIC HEALTH (DRIED MILK) REGULATIONS, 1923 & 1927 Ten samples of condensed milk were purchased during 1937 and in all cases the milk, labelling of tins, etc., were in accordance with the Regulations. PUBLIC HEALTH (PRESERVATIVES, ETC., IN FOOD) REGULATIONS, 1925—1927 During the year under review samples were examined for the presence of preservative and one contravention reported. In this case the offence consisted of selling sausages containing preservative without disclosing its presence at the time of sale. The preservative used was sulphur dioxide and the amount present below the limit which would have been allowed had there been a declaration. TABLE 25 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. 52 Split Peas 10% of the peas attacked by maggots Remainder of stock returned to wholesalers. 135 Yeast Extract Contained 25 parts of copper per million Result of analysis communicated to manufacturers who have installed stainless steel pans to replace copper pans. 191 Split Peas 10% of the peas attacked by maggots Vendor using remainder of stock for pigeon food. 194 Butter Beans 17% of beans attacked by maggots Remainder of stock sorted. 216 Malt Vinegar 100% non.brewed vinegar Vendor warned by letter. 219 Malt Vinegar 100% non.brewed vinegar Vendor warned by letter. 314 Wood Vinegar 3.25% deficient in Acetic Acid Vendor warned by letter. 321 Bread and Butter This bread was spread with Margarine, not butter Informal sample. See report on Sample No. 353. 353 Bread and Butter This bread was spread with Margarine, not butter Summons. Vendor convicted and fined 20s. 393 Dripping Contained 3.94% of free acids as Oleic acid Vendor warned by letter. Subsequent sample genuine. 394 Dripping Contained 1.4% of free acids as Oleic acid and 1.7% of water Vendor warned by letter. Subsequent sample genuine. 425 Lemonade powder Contained tartaric acid Communication addressed to manufacturers, who agreed to amend their formulae and use citric acid instead of tartaric acid. 426 Lemonade powder Contained tartaric acid 427 Lemonade powder Contained tartaric acid 428 Lemonade powder Contained tartaric acid 518 Glauber's salts 20% deficient in water of crystallisation Vendor warned by letter. 551 Lemonade powder Contained tartaric acid Communication addressed to manufacturers who agreed to amend their formulae and use citric acid instead of tartaric acid. 552 Lemonade powder Contained tartaric acid 553 Lemonade powder Contained tartaric acid 554 Lemonade powder Contained tartaric acid 688 Vinegar Consisted of artificial vinegar Attention of vendors drawn to new legal requirements relating to sale of non.brewed vinegar. 689 Vinegar Consisted of artificial vinegar 690 Vinegar Consisted of artificial vinegar 692 Vinegar Consisted of artificial vinegar 823 Beef sausages Contained 240 parts of Sulphur Dioxide per million parts of sausage— Undeclared Vendor warned by letter. 861 Whisky 36.59° under proof Vendor warned by letter. 862 Whisky 36.77° under proof Vendor warned by letter. 880 Rum 43.64° under proof Summons. Dismissed under P.O. Act on payment of £5 5s. costs. 77 In addition to the above, three vendors of margarine were warned by letter for failing to comply with Section 6 (3) (c) of the Food and Drugs (Adulteration) Act, 1928, which provides as follows:— " Margarine, when sold by retail . . . shall in every case be delivered to the purchaser in a paper wrapper and the word ' Margarine ' shall be printed on the outside of such wrapper in capital block letters not less than half an inch long and distinctly legible. . . INSPECTION OF BAKEHOUSES AND BAKERS' SHOPS At the end of 1937 there were 57 registered bakehouses in the Borough, 29 of which were underground. Of the 57 bakehouses 54 are factories and 3 are workshops ; in addition there are 15 retail bakers' shops in the Borough without bakehouses attached. During the year 452 visits were made and 66 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. 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 485 Ice Cream premises 94 Butchers' shops 151 Fish shops 45 Fried fish shops 31 Fish curing premises 8 Greengrocers' and Fruiterers' Premises 89 Cooked meat shops 6 Dining rooms and eating rooms 104 Restaurants 6 Licensed Premises 49 Street Traders' Storage Premises 28 Slaughter-Houses 54 Factory Bakehouses 365 Workshop Bakehouses 22 Workplace Bakehouses 65 Baker's shops 25 Food factories other than those included above 6 Other food premises 153 1,786 78 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 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 220 sheep. Visits to slaughter-house 54 Meat condemned 11 pairs of lungs (abscess). 1 liver (2 lbs.) (abscess). 1 liver (l½ lbs.) (fluke). PREMISES USED FOR THE PREPARATION OF FOOD Under the provisions of Section 187 of the Public Health (London) Act, 1936, premises used for the preparation of certain specified articles of food have to be registered with the Local Authority. At the end of 1937 there were 120 premises on the Register relating to the preparation of preserved foods and 238 premises on the Register relating to the manufacture or sale of ice cream, the latter being analysed as follows:— Premises registered for manufacture, storage and sale of ice cream 94 Premises registered for storage and sale of ice cream 129 Premises registered for the manufacture and storage of ice cream 11 Premises registered only for the manufacture of ice cream 4 238 Ice Cream. During 1937, the Sampling Officer purchased 33 samples of Ice Cream for bacteriological examination at the Council's Laboratory, 114, New King's Road. There is, unfortunately, no bacteriological standard for ice cream but the examination of samples affords a useful indication of the cleanliness or otherwise of the methods employed by manufacturers. Samples of " wrapped " and " loose " Ice Cream are examined and where the bacteriological count is regarded as excessive the premises of the manufacturer are visited and the methods employed are investigated to ascertain, if possible, the source of contamination and advice given. In the case of Ice Cream manufactured outside the Borough, a copy of the report is forwarded to the local authority in which the premises are situated and also to the manufacturer. Further samples are taken to see what improvement, if any, has taken place. Bulk or loose Ice Cream sold from metal containers or " sleeves " on barrows in the streets is, of course, liable to gross contamination, particularly in windy weather, and it is this type of vendor who receives close attention. 79 UNSOUND FOOD The undermentioned articles of food examined at the request of the owners were condemned and destroyed during the year:— Pears 42 lbs. Haddock 2 boxes. Oranges 13 tons 8 cwt. 2 qrs. Corned Beef 43 tins. Bananas 6 tons 4 cwt. 3 qrs. Tinned Sild 672 tins. Beef 48 lbs. Tinned Food 77 cases and 3 sacks. Tinned Ham 59 lbs. Veal Kidneys 10 ounces. Winkles 5 gallons The following food was seized as unfit for consumption:— Tinned Food 472 tins. THE PHARMACY AND POISONS ACT, 1933 THE POISONS RULES, 1935 A resume of the provisions of this Act and the Rules will be found in my Annual Report for 1936. . During the year under review Inspector Gammack made 434 visits to the premises of Listed Sellers of Poisons in the Borough and purchased 8 samples of Part II poisons for analysis, two of which (Ammonia) were reported to be deficient in Ammonia. The results of the analyses of these samples were communicated to the manufacturers. At the end of 1937 there were 97 names on the Council's Register of Listed Sellers of Part II Poisons. 80 REPORT OF THE PUBLIC ANALYST (Thomas McLachlan, Esq., A.C.G.F.C., F.I.C.) It is satisfactory to note that the percentage of adulteration during the year has remained low (3.0 per cent.). Of a total of 571 samples of milk and skimmed milk, two only were reported as adulterated. One of these samples was 6 per cent. deficient in fat and the other, whilst it showed a solid.not.fat content of 8.5 per cent., gave a freezing point determination, which showed that it contained at least 3 per cent. of added water. There appear to be one or two dairymen in London at the present time, who are watering their milk deliberately and scientifically, knowing that any action taken against them will have to be taken under the Milk and Dairies Act, 1922, on the evidence of the freezing point test. It is possible that their original supply comes from one wholesale dealer. Of a total of 356 samples of foods, other than milk, beers or spirits, 23 (or 6.5 per cent.) were reported as adulterated. Whereas good butter and margarine seldom contain more than 14 per cent., and it is illegal to sell those containing more than 16 per cent., of water, it has been noticed that there has been a tendency for the water content to vary from 15.0 to 15.6 per cent. in the case of butter and from 14.0 to 15.0 per cent. in the case of margarine. This may be one of the methods of creating an impression that the price of foodstuffs is not rising unduly. Two samples of bread and butter were found to be spread with margarine. There is so little difference in the price of butter and margarine at present that it is difficult to understand why such a practice should be adopted. Exception was taken to two samples of dripping, one of which contained 3.94 per cent. of free fatty acids, while the other contained 1 .4 per cent. of free fatty acids and 1 .7 per cent. of water. If good wholesome fat is employed for the manufacture of dripping it should certainly not contain more than 1 per cent. of free fatty acids. Fortunately this high acidity imparts a definite flavour to the dripping, and it behoves vendors to see that their product is sweet or they will lost their custom. Eight out of nine samples of lemonade powder were reported as adulterated because they were prepared with tartaric acid instead of citric acid, the acid natural to citrus fruits. In the opinion of your analyst a powder sold as lemonade or orangeade powder should contain citric acid in exactly the same way that one expects to find this acid in a liquid cordial. Tartaric acid is an acid derived from grapes, but it is present in the grapes in the partially neutralised state and not as the free acid. Again, it is further stated in medical literature that there is a distinct difference between the physiological action of citric acid and of tartaric acid ; your analyst therefore felt that on either of these grounds the use of tartaric acid should be condemned. In one case the manufacturer objected to your analyst's report and brought the Director of the British Association of Research for the Cocoa, Chocolate, Sugar Confectionery and Jam Trades to support his claim that the use of tartaric acid was recognised in the trade and that it had been generally employed for a number of years. Recently citric acid has become cheaper than tartaric acid, but the advantage claimed for tartaric acid is that it does not absorb water so readily as citric acid, and that the powder keeps better in consequence. At the same time it was admitted that it is the custom to use citric acid for these powder preparations when sold as blocks. This case is particularly interesting for in a similar case in another borough the vendor gave the name of the wrong manufacturer, who was indignant that any suggestion should be made that he would employ anything but citric acid in his lemonade powder. Further, when representations were made to the real manufacturers, who are one of the largest confectionery firms in the country, an apology was immediately given with the explanation that the formula had been changed by the foreman without the permission of either the scientific staff or the management. 81 One sample of sausages contained preservatives, but was sold without any declaration to that effect. All other samples of sausages contained either no preservatives or only the permitted quantity. Two samples of split peas and one of butter beans were condemned because, in each case, about 10 per cent.of the peas or beans had been attacked by maggots. In the case of some of these dried vegetables, maggots are actually present in the bags when they are opened. It may be mentioned that although a number of samples of this type have been reported as adulterated by your analyst, he has seldom had occasion to do so when they are sold in packets, showing that there is a tendency for packed goods to be better than loose ones in this respect. On January 27th, an important case relating to the sale of artificial vinegar was heard at Bow Street Police Court and was later reheard at London Sessions. At each hearing it was decided that the use of the description vinegar without any qualification denotes that the product is a brewed one. Six samples, sold as vinegar, were accordingly reported as adulterated, because they consisted of, or were thought to consist of, 100 per cent.artificial vinegar. In one instance the manufacturer pointed out that the vinegar was in fact spirit vinegar, but admitted that he was unable to inform your analyst of any tests by which artificial vinegar and spirit vinegar could be differentiated. At the same time he pointed out that all the barrels sold by his firm and all labels stated distinctly that the vinegar should be sold as " spirit vinegar " and not simply as vinegar. Whilst the odour might normally give some clue to the analyst as to the difference between spirit and artificial vinegar, the latter product is often put into old malt vinegar barrels or even wine barrels to impart the necessary aroma to the product and also to add a trace of extractive, which would not otherwise be present. The brewers of spirit vinegar are endeavouring to assist analysts in this problem of differentiation. One sample of wood vinegar was found to be 3.25 per cent.deficient in acetic acid. Three out of thirteen samples of spirits (23 per cent.) were reported as adulterated. One sample of rum was 43.6° Under Proof whereas the Food and Drugs (Adulteration) Act stipulates that spirits shall not be more than 35° Under Proof. Two samples of whisky were only slightly adulterated, being 36.6° and 36.8° Under Proof respectively. The quality of drugs examined during the year has been maintained. Out of 45 samples examined only one was returned as adulterated and the offence in this case was technical, as distinct from dangerous. The British Pharmacopoeia requires various salts such as Epsom salts and Glauber's salt to be crystalline and to contain the full amount of water necessary to give this appearance. If such salts are kept badly they effloresce and powder with the result that the user cannot be so sure of the dose which is being taken. In the particular case reported as adulterated a sample of Glauber's salt was 20 per cent.deficient in the water of crystallisation. It is interesting to note that since the action taken by the Council some years ago in connection with carbolic ointment, the quality of this product has improved considerably and all samples now conform to the standard suggested by your analyst when the cases were brought. During the year 19 samples of milk were examined bacteriologically under the Milk (Special Designations) Order, 1936. Thirteen samples complied with the requirements of the Order, but six contained an excessive number of bacteria, this number amounting in one case to at least 2,000,000 bacteria per c.c., whereas the order requires not more than 100,000 bacteria per c.c. Eight samples were examined in connection with the Pharmacy and Poisons Act, 1933, and in the course of the analyses it was found that two samples of ammonia were considerably below the strength mentioned on the labels. 82 TABLE 26—SAMPLES ANALYSED, 1937. Article. Number of Samples. Total Samples Analysed. Total Samples Adulterated. Percentage of Adulteration. Taken Formally. Adulterated. Taken Informally. Adulterated. Milk 563 2 7 — 570 2 .35 Milk (Skimmed) 1 — — — 1 — — Milk (Condensed) — — 10 — 10 — — Cream . 3 — 5 — 8 — — Butter . 53 — 8 — 61 — — Bread and Butter 1 1 7 1 8 2 250 Barley — — 4 — 4 — — Beers 15 — — — 15 — — Cheese . 10 — 1 — 11 — — Cocoa . — — 2 — 2 — — Coffee — — 4 — 4 — — Confectionery . 13 — — — 13 — — Cornflour — — 9 — 9 — — Dripping 7 2 — — 7 2 28-5 Fish Paste — — 2 — 2 — — Fish (Potted) . 1 — — — 1 — — Flour — — 4 — 4 — — Flour (Self-raising) — — 4 — 4 — — Fruit Cordials . 7 — 1 — 8 — — Fruit (Dried) . 19 — 2 — 21 — — Gelatine — — 2 — 2 — — Ground Almonds 7 — — — 7 — — Ground Ginger. 2 — — — 2 — — Jelly — — 3 — 3 — — Lard 7 — 1 — 8 — '— Lemonade Powder 9 8 — — 9 8 88.8 Margarine 19 — — — 19 — — Meat Pies 4 — 1 — 5 — — Meat Paste — — 1 — 1 — — Mincemeat 5 — — — 5 — — Pepper . 3 — — — 3 — — Pepper (Cayenne) 4 — — — 4 — — Rice 12 — 5 — 17 — — Sago — — 6 — 6 — — Sausages 16 1 3 — 19 1 5-25 Sausages (Preserved) . 1 — 1 — 2 — — Suet 5 — — — 5 — — Sugar 8 —— — — 8 — — Sugar (Demerara) 1 — — — 1 — — Tea 1 — — — 1 — — Tea (Green) — — 2 — 2 — — Tapioca. — — 4 — 4 — — Vegetables (Dried) 10 3 5 — 15 3 20.0 Vinegar 14 6 — — 14 6 42.8 Vinegar (Artificial) 4 1 — — 4 1 25.0 Wine 4 — 2 — 6 — — Wine (Non-alcoholic) . 7 — — — 7 — — Brandy . 2 — — — 2 — — Gin 2 — _ — 2 — — Rum 4 1 r — 4 1 25.0 Whisky. 5 2 — — 5 2 40.0 Basilicon Ointment — 2 — 2 — — Bile Ovals — 1 — 1 — — Camphorated Oil — — 7 — 7 — — Carbolic Ointment 1 4 — 5 — — Cascara Tablets — __ 1 1 — — Epsom Salts — — 4 — 4 — — Glauber's Salt . — — 4 1 4 1 25.0 Liquorice Powder — — 5 — 5 — — Parrish's Food. 2 _ 2 — 4 — — Sulphur Ointment 2 - - 2 — — Yeast Extract . — 1 1 1 1 100.0 Zinc Ointment. 3 — 6 — 9 — — Totals . 857 27 143 3 1,000 30 3.0 Section VI PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DISEASES 84 TABLE 27 TABLE SHOWING THE AGE AND WARD DISTRIBUTION OF THE CASES OF INFECTIOUS DISEASES NOTIFIED DURING 1937 Notifiable Diseases. Number of cases notified. Total cases notified in each Ward of Borough Total cases removed to Hospital. Deaths. D.N.C. At all Ages. At Ages—Years. Baron's Court Lillie Walham Margravine Munster Hurlingham Sands End Town 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 206 3 9 17 23 21 83 16 4 23 6 1 - 11 46 39 20 34 23 21 12 205 4 17 Erysipelas 63 — 1 1 — — 2 1 1 6 10 25 16 — 13 13 10 11 1 8 7 46 — — Scarlet Fever 319 3 20 22 18 40 125 41 14 26 4 6 — 10 58 49 45 61 32 36 28 310 2 15 Typhus Fever Enteric Fever 3 — — — — 2 1 — 3 — 2 Relapsing Fever, Continued Fever - - - - - - - - - - - - - - - - - - - - - - - - Puerperal Fever 2 — — — — — — — 2 — — 1 1 — 2 Puerperal Pyrexia 25 — — — — 1 20 4 4 2 7 3 4 1 4 25 Cerebro-SpinalMeningitis 12 3 2 — — — 1 2 — 3 1 — 4 3 1 2 2 12 5 1 Polio-myelitis . 3 1 — — — — — 1 — — 1 — — - 2 1 — - 2 - Ophthalmia Neonatorum 19 19 - - - - - - - - - - - 1 2 — 1 5 2 4 4 8 — — Tuberculosis of Respiratory System. 204 - 1 - - 1 3 5 20 93 28 42 11 23 27 31 20 42 16 ?6 19 - 108 Non-Pulmonary Tuberculosis 29 - 2 - - - 7 1 6 11 2 - - 2 5 4 5 8 4 1 - 10 Measles . 807 40 78 76 105 145 338 5 5 13 2 - 126 122 155 65 118 61 67 93 121 2 Encephalitis Lethargica 1 - - - - 1 - - - - 1 - - - - - - 7 Pneumonia 171 13 5 2 5 5 20 5 6 23 20 39 28 9 42 20 28 34 10 20 8 - 106 Diarrhoea 104 34 34 17 8 11 - - - 5 20 20 11 10 2 25 11 63 31 2 Malaria . - - - - - Dysentery 29 1 4 4 i i 9 1 1 - 4 3 1 3 5 13 2 1 2 9 29 - - Trench Fever — — — — — — — - - — - - - - - - - - — — - — — Totals 1,997 117 156 139 160 224 588 77 58 223 78 119 58 196 346 348 222 332 148 216 189 825 275 35 85 86 87 TABLE 28. NUMBER OF CASES OF INFECTIOUS DISEASE NOTIFIED FROM 1900.1937 INCLUSIVE 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 191 1 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 Small.Pox 9 16 94 11 . . . . . . . _ . . .7 . . . . . . . . . . . . 1 . 7 . 2 . . . . . Scarlet Fever 552 600 552 404 294 779 674 668 596 511 354 384 484 766 1,042 621 286 234 228 371 930 961 626 466 360 398 311 360 416 489 595 331 543 720 691 317 323 319 Diphtheria 641 644 429 293 302 286 403 604 400 322 257 311 231 270 272 271 312 237 206 336 623 579 438 277 259 276 345 390 359 370 402 225 177 185 473 375 179 206 Entric Fever 92 133 74 80 39 56 45 58 39 41 18 38 26 34 40 14 5 11 15 6 7 16 3 7 10 8 11 41 2 13 3 Erysipelas... 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 86 106 104 117 56 63 63 Cholera — 1 . . . . .—. . .! . . . . — — . . . . . — . . — . . . . . . . . . — . . . . Cerebro.Spinal Meningitis . . . . . . . 3 4 3 7 . . . 1 . . . . . 3 . . .2. 4 7 4 3 2 9 8 5 6 1 4 12 Polio.myelitis 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 Measles Notifiable from 1st January, 1916 — — 1 — — — — — — 1,592 615 942 396 2,438 1,951 1,692 589 3,700 463 2,099 948 2,526 110 2,682 163 2,967 41 2,S75 Encephalitis Lethargica — Notifiable from 1st Januar y, 1919 2 10 12 5 2 5 2 1 3 — 1 2 — 1 Pneumonia Notifiable from 1st March, 1919 — — — — — — — — 297 345 207 275 241 203 ISO 139 226 Epidemic Diarrhœa Notifiable from 2nd July. 1919 140 17 79 40 70 50 IS 60 36 31 33 22 13 14 4 104 Puerperal Fever g 7 7 19 8 24 17 15 17l 34 20 23 30 19 27 31 32 26 21 15 16 16 23 17 11 11 4 6 2 Puerperal Pyrexia — Notifiable from 1st October, 1926 28 51 51 33 47 37 27 37 28 25 25 Trench Fever — Notifiable from 1st March, 1919 —• — Dysentery Notifiable from 1st March, 1919 6 1 — - -2- - 1 4 29 Malaria — Notifiable from 1st March, 1919 - - - - - - - - - - - - - - - - 1 1 3 — — 1 1 — 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 1,709 3,473 2,391 3,933 3,876 1,454 4,512 997 3,747 1,764 TABLE 29. NUMBER OF DEATHS FROM THE SEVEN PRINCIPAL ZYMOTIC DISEASES DURING 1900.1937 INCLUSIVE 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 3 13 3 1 168 62 64 85 53 69 71 74 65 64 65 49 75 46 14 24 2 41 23 29 2 47 15 10 27 1 26 2 31 — 14 2 23 20 19 8 4 23 18 14 17 10 7 6 6 4 21 17 5 4 4 3 9 15 12 5 5 3 4 1 2 3 2 2 2 6 1 — 1 2 24 24 24 33 38 32 39 14 27 15 23 27 20 16 12 32 44 43 33 20 11 11 14 11 13 10 19 9 10 8 30 12 10 4 54 76 65 48 58 82 31 75 34 48 60 28 45 27 43 51 32 22 58 4 17 30 26 14 14 35 6 8 12 25 5 7 12 14 7 5 6 7 Enteric Fever 19 22 9 16 6 10 13 8 10 4 . 4 — 1 — — 2 — 2 — 1 — — 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 19 53 35 34 15 22 20 18 19 22 31 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 ss .36 73 50 88 36 56 46 Zymotic Death Rate 3. 17 2.93 3.25 2. 19 2.57 2.73 2.66 200 1 94 1 .83 1 .45 2.25 112 1 28 1 .62 200 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 0.33 88 TABLE 30 MONTHLY DISTRIBUTION OF INFECTIOUS DISEASE, 1937 Notifiable Disease. Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Total . Pneumonia 58 17 16 11 11 4 7 2 4 13 16 12 171 Scarlet Fever 23 22 35 34 30 28 38 12 16 36 27 18 319 Diphtheria 10 21 13 26 17 15 15 12 24 17 18 18 206 Puerperal Fever 1 1 2 Puerperal Pyrexia 2 4 4 3 3 1 2 1 1 2 1 1 25 Erysipelas 6 8 2 2 7 4 5 9 7 5 6 2 63 Ophthalmia Neonatorum 2 1 - 2 3 3 1 1 1 2 2 1 19 Cerebro-Spinal Meningitis 3 2 1 1 2 1 - 1 - - - 1 12 Enteric Fever -— — — — — — — — - 1 1 1 3 Polio-myelitis — 1 — — — — — — 1 1 — — 3 Encephalitis Lethargica 1 - - - - - - - - - - - 1 Measles 5 11 31 25 19 57 16 12 10 84 141 396 807 Dysenterv 7 2 - - - - - - 1 4 9 6 29 Epidemic Diarrhoea — 1 — — 4 10 2 9 5 6 50 17 104 Totals 118 90 102 104 96 123 86 60 70 171 271 473 1,764 SCARLET FEVER There were 319 cases during the year compared with 323 in 1936. The attack rate was 2-3 per cent., the same as in the previous year. The age distribution and seasonal incidence are shown in Tables 27 and 30 at the beginning of this section. 310 cases were hospitalised and 2 deaths occurred. MEASLES EPIDEMIC The expected epidemic commenced in October, 1937, no less than 621 of the 807 cases during the year occurring in the last three months. The epidemic will be more fully dealt with in my next annual Report. ENTERIC FEVER Three cases were notified compared with 16 during the previous year. One of these cases was a female who contracted the disease in Croydon and came to a relative's house in this borough on a holiday ; the case proved fatal. CEREBRO-SPINAL MENINGITIS Twelve cases occurred during the year—three being of infants under 1 year of age, two of children aged 1 year, one of a child aged 5 years ; and the other six in persons over 10 years of age. 89 DIPHTHERIA During the year 206 cases were notified compared with 179 the previous year, the attack rate being 1.5 per 1,000 of the population compared with 1.3. All cases were removed to hospital for treatment ; 4 deaths occurred, the fatality rate being 1 .9 per cent., as compared with 5.6 per cent., last year. The age distribution of the cases is shown in Table 27 (page 84). DIPHTHERIA ANTITOXIN This is available to practitioners upon request at the Public Health Department. During the year, 36 issues each of 8,000 units were made, 12 of them being in a special packing with the serum already in a " syringe." DIPHTHERIA IMMUNISATION No. of Clinic Sessions held 47 New cases treated 411 Total attendances of old and new cases 2,467 Average attendance 50.2 Primary Schick Test— Positive 345 Negative 60 Not read 6 Refused treatment 2 Posterior Schick Test— Positive 4 Negative 373 Inoculations— With T.A.F 23 With A.P.T. (1) 339 With A.P.T. (2) 334 With A.P.T. (3) 2 With A.P.T. (4) 1 676 Discontinued treatment 31 Transferred to other areas 2 Certificates of immunity issued 453 90 TABLE 31 SUMMARY OF TREATMENTS Age Groups in Years. Primary Schick. Inoculations A.P.T. Inoculations T. A.F. Posterior Schick. Transferred to other areas. Discontinued treatment. Positive Negative Not read 1st 2nd 3rd 4th 1st 2nd 3rd Positive Negative ½ — 1 5 1 1 5 5 - - - - - 1 5 - - 1 — 2 48 - — 48 48 — — — — — - 44 1 3 2—3 45 1 — 45 45 — — — — — - 43 - 3 3 — 4 32 2 1 31 31 — — — — — - 31 l 3 4—5 45 2 - 45 45 — — — — — - 46 - 1 5—6 38 6 2 38 37 1 — — — - 1 41 - 4 6—7 40 4 — 40 38 1 1 2 2 - 2 37 - 5 7—8 26 8 1 26 25 - — 1 1 - - 31 - 4 8—9 19 7 1 19 18 - — 1 1 - - 24 - 3 9 — 10 15 7 — 15 15 - — — — - - 21 - 1 10 — 11 9 3 — 9 9 - — — — - - 11 - 1 11 — 12 10 7 — 10 10 - — — — - - 17 - - 12 — 13 4 4 — 4 4 - — — — - - 8 - - 13 — 14 4 3 — 4 4 - — — — - - 4 - 3 14 — 15 - - — — - . - — — — - - — - - 15 and upwards 5 5 - - - - 5 5 5 - 10 - - Totals 345 60 6 339 334 2 1 9 9 5 4 373 2 31 91 PUERPERAL FEVER Two cases were notified, but there were no deaths from puerperal sepsis. The incidence was equal to 1.003 per 1,000 of the registered births (live and still). Both cases occurred in Fulham Hospital. PUERPERAL PYREXIA Twenty-five cases were notified during 1937, the same number as in the previous year. incidence per 1,000 registered births (live and still) was 12.54 compared with 11.5. 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 and also for difficult obstetric cases. During the year no request was made for his services. OPHTHALMIA NEONATORUM During the year nineteen cases of ophthalmia neonatorum were notified compared with 13 during the previous year giving an attack rate of 9.8 per 1,000 of the registered live births. Through 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. The following table shows the place of treatment and the result of the 19 cases:— Cases notified 19 Treated at Home 11 Treated in Hospital 8 Vision Impaired - Vision Unimpaired 12 Total Blindness - Still under Treatment at the end of the year 2 Deaths 1 Left the Borough (condition not known) 4 EPIDEMIC DIARRHœA This condition became very prevalent in London in the autumn, the causal organism, where it could be recovered, being the Sonne type of dysentery bacillus. 104 cases in children under 5 years of age were notified and, in addition, 57 cases at ages varying from 6 years to 71 years were reported to me by medical practitioners at my special request. Specimens of faeces from 26 of the cases were examined, the Sonne dysentery bacillus being discovered in 4 instances. The attack was sharp in character, and the mortality appreciable ; 32 deaths occurred, giving a case mortality of 19.88. It is a little tempting to speculate on the identity of this condition with the summer diarrhoea which in the pre-war days was a regular and serious cause of infant mortality. Infective diseases do exhibit a marked cyclical incidence and further experience will soon show whether the diarrhœal group is again growing troublesome. EPIDEMIC CATARRHAL JAUNDICE Epidemics of catarrhal jaundice have appeared in various parts of the country in recent years. The causative organism is not yet established but the condition appears to be distinct from that found in miners and amongst workers in damp underground places, which is due to a spirochaete. A very interesting outbreak which mainly affected the Fulham Day Nursery occurred in May, 1937. A probationer nurse was removed to the Western Fever Hospital on January 11th, suffering from scarlet fever. During her convalescence she had an attack of jaundice, but there was no evidence to suggest that this was infective. She was discharged from hospital on April 3rd and returned to duty on April 13th. 92 On May 6th another probationer felt unwell, vomiting the following day and looking jaundiced on May 10th and 11th. On May 9th, two other probationers felt unwell, one of them vomiting, and both subsequently becoming jaundiced. A fourth nurse who felt unwell on May 9th became jaundiced on May 14th. Rises of temperature were either absent or of slight degree and no hæmorrhagic lesions in the skin occurred. These nurses all shared the same bedroom, the room being partially sub-divided into cubicles by curtains. No dietetic or other common aetiological factor could be discovered except (1) contact with the first case and (2) a common bedroom and common work-place. A further case occurred in a cleaner who worked half-days at the Nursery. She felt ill and had abdominal pain on May 15th, this continuing on May 16th and 17th. Her urine was very dark, but nothing abnormal was discovered on examination. She still showed definite icterus on May 20th. Her daughter, aged 14 months, vomited twice on May 20th but on examination on May 25th showed nothing significant. A medical officer from the Ministry of Health kindly assisted in the investigation of the outbreak and various examinations of throat swabs and specimens of urine and faeces were made, nothing significant being discovered. The Nursery was closed to children for a week and on being re-opened, careful clinical observation was kept on all the children, their urine also being examined for bile salts and bile pigment. One child, aged 9 months was discovered towards the end of May to have a transient glycosuria. His mother, who attended the Nursery night and morning to bring and fetch him, felt unwell on May 24th, vomited on May 26th and subsequently for some days suffered from nausea and flatulence. She noticed that her motion was clay coloured and her urine dark on May 26th, continuing so for a few days. Recovery, as in the case of the nurses, was uneventful. No further cases occurred in the children and the marked susceptibility of adults in this outbreak is curious. One further, apparently independent, outbreak was discovered. Mrs. L., aged 31 years, was in Fulham Hospital with phlebitis from July, 1936, to January 16th, 1937. She vomited about a week after returning home and one week later was jaundiced, the condition persisting about three weeks. Her son, John, aged 13 years, felt sick towards the end of February (no vomiting) and then became jaundiced. He was away from school three weeks with this condition. Ann, aged three years, was feverish and restless, feeling sick also on May 27th, having appeared listless for two or three days. She showed no definite icterus but bile salts were present in the urine. No contact of any kind could be discovered between this family and the Day Nursery and its staff or children. It will be noted that this outbreak was unaccompanied either by deaths or complications. NON-NOTIFIABLE INFECTIOUS DISEASES During 1937 the Woman Sanitary Inspector paid visits to cases of non-notifiable infectious diseases as follows:— Chicken pox 50 Whooping Cough 30 Mumps 60 Suspicious cases (sore throats, spots, etc.) 80 220 93 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 in the Borough on Form 84. The Table on page 30 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 241 deaths classified as Cancer occurred as follows:— TABLE 32 Organ Affected. Total. Males. Females. Digestive Organs and Peritoneum 116 63 53 Respiratory Organs 34 26 8 Buccal cavity and Pharynx 23 19 4 Breast 20 - 20 Uterus 25 - 25 Genito-Urinary Organs (males) 8 8 — Other Organs 15 6 9 Totals 241 122 119 Classification. Total. Males. Females. Carcinoma 227 116 111 Sarcoma 9 3 6 Epithelioma 5 3 2 Not defined — — — Total 241 122 119 The ages at death of persons dying from Cancer were TABLE 33 Age Periods. Total. Males. Females. 0-25 years 3 2 1 25-35 years 5 1 4 35-45 years 17 8 9 45-55 years 37 14 23 55-65 years 62 34 28 65-75 years 75 41 34 75 years and upwards 42 22 20 Totals 241 122 119 From the table showing the principal causes of death it will be seen that one out of every seven deaths in the Borough during 1937 was due to Cancer. The death rate from the disease was 1.73 per 1,000 compared with 1.63 for England and Wales. 94 The yearly death-rates from Cancer since 1920 have been as follows :— 1920 1.19 1929 1.53 1921 132 1930 1.57 1922 1.27 1931 1.51 1923 1.31 1932 1.57 1924 1.35 1933 1.62 1925 1.20 1934 1.86 1926 1.59 1935 1.52 1927 1.36 1936 1.77 1928 1.38 1937 1.73 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). 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: S. Males. Females. Males. Females. Number of cases on Register at commencement of 1937 591 585 299 309 1,784 Number of cases removed during the year 231 202 111 71 614 360 383 188 238 1,170 Number of cases notified for the first time during the year 108 96 12 17 233 Number of cases coming to knowledge of Medical Officer of Health otherwise than by formal notification 11 10 1 - 21 Number of cases remaining on Register at end of year 479 489 201 255 1,424 The cases notified for the first time during the year are analysed in Table 36, page 98 and those coming to the knowledge of Medical Officer of Health otherwise than by formal notification in Table 37. 95 In Table 27, page 84, 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: 108 Deaths 63 males, 45 females. Death rate 0.78 per 1,000, being 0.02 higher than in the previous year. 95 notified (87.96 per cent.). 13 not notified (12.04 per cent.). Of these 13 cases 7 died in institutions ; in 1 case an inquest was held and in 3 cases the Coroner certified the death without an inquest. Other Tuberculous Diseases: 10 Deaths 4 males, 6 females. Death rate 0 07 per 1,000, being 0.02 lower than in the previous year. All notified. PERIOD BETWEEN PRIMARY NOTIFICATION AND DEATH Respiratory system : Under 1 month 7 (7.37 per cent.) 1—3 months 14 (14.74 per cent.) 3—6 months 12 (12.63 per cent.) 6—12 months 12 (12.63 per cent.) 1—2 years 18 (18.95 per cent.) Over two years 32 (33.68 per cent.) Other Tuberculous Diseases: Under 1 month 7 (70 per cent. 1—3 months 1 (10 per cent.) 3—6 months - 6—12 months 1—2 years - Over two years 2 (20 per cent.) 96 TABLE 34 DISPENSARY STATISTICS, 1913—1937 Year. New Patients. Attendances at Dispensary. Doctors' Home Visits. Nurses' Home Visits. Suffering from Pulmonary Tuberculosis. Suffering from other forms of Tuberculosis. Doubtful Cases. NonTuberculous Cases. Insured. Uninsured. 1913 324 86 323 429 2,361 11,967 2,175 1,517 1914 203 45 261 361 2,276 8,084 2,385 2,547 1915 174 28 260 323 1,171 5,568 1,910 2,918 1916 225 13 311 200 852 5,954 1,079 2,828 1917 286 13 349 329 1,052 6,528 1,141 2,789 1918 235 14 201 478 1,223 8,465 1,435 2,317 1919 221 50 251 281 1,444 8,116 1,724 4,043 1920 142 37 239 342 1,850 6,713 2,004 4,989 1921 116 23 163 344 2,074 5,387 2,217 5,640 1922 155 35 13 388 2,507 3,703 1,264 5,447 1923 132 70 24 401 2,288 3,261 552 4,603 1924 142 65 32 443 2,133 3,619 549 4,775 1925 162 44 46 414 1,956 3,405 605 5,421 1926 183 53 37 318 1,741 2,876 481 5,355 1927 143 56 14 431 1,612 2,666 592 5,422 1928 160 42 26 490 1,548 2,448 571 4,989 1929 158 48 23 436 1,411 1,834 521 5,272 1930 154 25 7 407 1,558 1,545 427 4,532 1931 159 20 7 422 1,444 1,625 292 4,156 1932 143 35 7 380 1,329 1,521 291 4,125 1933 161 14 - 331 1,312 1,916 409 3,936 1934 172 25 6 338 1,265 2,262 435 3,895 1935 144 21 12 328 1,232 1,871 448 3,857 1936 158 11 18 386 1,164 2,321 426 3,655 1937 152 18 4 378 1,223 2,254 466 3,959 97 TABLE 35 PRIMARY NOTIFICATIONS AND DEATHS, 1913-37 Year. Notifications. Deaths. Death-Rate. Pulmonary. Other forms of Tuberculosis. Pulmonary. Other forms of Tuberculosis. Pulmonary. forms of Tuberculosis. 1913 765 289 215 49 1.34 0.31 1914 531 164 207 45 1.32 0.29 1915 461 97 198 51 1.29 0.34 1916 496 92 210 56 1.41 0.38 1917 582 118 191 49 1.32 0.34 1918 561 80 207 47 1.45 0.33 1919 433 145 168 42 1.01 0.27 1920 282 93 142 30 0.89 0.19 1921 287 76 153 31 0.96 0.19 1922 272 113 163 33 1.02 0.20 1923 319 155 149 32 0.92 0.19 1924 270 126 129 33 0.80 0.20 1925 279 114 151 22 0.92 0.13 1926 312 122 161 17 0.98 0.10 1927 251 95 126 21 0.77 0.13 1928 258 75 114 33 0.73 0.21 1929 279 85 149 24 0.96 0.15 1930 244 52 118 16 0.76 0.10 1931 275 78 146 23 0.97 0.15 1932 236 90 137 23 0.91 0.15 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 1937 225 30 108 10 0.78 0.07 98 TABLE 36.—PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1930 Summary of notifications during the period from 1st January, 1937 to 31st December, 1937. Age Periods. Formal Notifications. Number of Primary Notifications of 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 — 1 2 1 8 9 34 18 15 11 9 108 184 Females — 1 1 4 12 21 29 10 12 4 2 96 171 Non-Pulmonary: Males — — 4 1 1 1 4 1 — — — 12 19 Females — 2 3 — 5 2 4 1 — — — 17 19 Totals — 4 10 6 26 33 71 30 27 15 11 233 393 66 TABLE 37 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 — — — - 1 - 1 1 1 2 5 11 Females — - — 1 — 2 3 — 1 1 2 10 Non-Pulmonary:— Males - - 1 - - - - - - - - 1 Females - - - - - - - - - - - - Totals — — 1 1 1 2 4 1 2 3 7 22 100 TUBERCULOSIS DISPENSARY REPORT FOR THE YEAR 1937 By Dr. P. L. T. BENNETT Clinical Tuberculosis Officer and Medical Officer, Bacteriological Laboratory Staff Changes. The part-time clerk at the Dispensary, Miss Grimston, resigned in September after her marriage, and the vacant post was temporarily filled by Miss Goodchild for a few weeks, followed by Miss E. Maiden who was still acting at the end of the year. Holiday duties were efficiently carried out by Dr. J. T. Crowe and Dr. M. Orpwood (the latter having been appointed as unpaid Clinical Assistant at the Dispensary for a period of six months previously). Routine. Beyond some increase in the number of special appointments for examination at " nonclinic " times, there has been no change in the Dispensary routine. Renovations and repairs. A fairly comprehensive scheme of repairs and redecoration was carried out during the summer months without any great disturbance of the normal work; some items being left for completion in 1938. The building (originally a private house) adapted as the Borough Dispensary many years ago without any special structural change, whilst sufficiently adequate for its purpose, is by no means situated in an ideal position. The increase of heavy traffic in the New King's Road in front, and the noise from continual shunting on the Parsons Green sidings of the District Railway, and from the children in the adjacent school playgrounds every morning and afternoon—combine to make accurate physical examination very difficult. The excessive vibration caused by the heavy traffic in front, shakes the structure, causing cracks in the plaster work and ceilings, and it is extraordinary how quickly even a newly renovated building begins to look untidy from this cause. The presence of corners, mouldings, cornices and recessed panelling also makes real cleansing very difficult, especially when the nature of the Dispensary work is considered. Statistics. There is nothing particularly calling for comment in the year's returns, which do not show any marked variation from those of 1936. Nine deaths less and twenty-one fewer new cases were recorded; but these figures do not signify very much in a year, except that (as I explained in last year's report) there is at present a very gradual decline in tuberculosis figures in certain vital returns such as mortality rates and incidence. There is some increase in items such as attendances, etc., but these are fluctuating returns and vary from year to year and have only an indirect bearing as regards statistics and depend more on routine, seasonal variations and such like causes. 101 Contact re-examinations and Mantoux testing is responsible for an increase in the number of attendances, but this special work may not necessarily be repeated on the same scale in the following year. It is again satisfactory to note that the co-operation of medical practitioners, and medical officers in all other departments of State services has been very well maintained—no less than 426 out of a total of 552 new cases being directly referred by them to the Dispensary. X-Ray Examinations. As in previous years, these are carried out at Brompton Hospital under the usual arrangements, 421 being recommended during the year. In addition it should be pointed out that a large number of patients are X-rayed whilst in Fulham Hospital. These are carried out under the L.C.C., the films remaining in the Hospital. Home Visiting, Supervision and Contact Examinations. The Dispensary Staff has made 4,425 visits during the year, of which number 466 were made by the Tuberculosis Officer, including visits to patients in Institutions for consultations or examination, and to homes for the purpose of supervision. Appointments for examination of Contacts are frequently arranged by the Tuberculosis Health Visitors at these home visits, the contacts being advised to attend the Dispensary at the appropriate Clinic hours. It is to the credit of the nursing staff that so many do come up, though many young people prefer to trust to luck, if they are not actually scared to come. If, however, they have once attended, it is usually not difficult to secure re-attendance for future examination either through the panel doctor or at the Dispensary and this is invariably advised. Special Diagnostic Tests. As explained before, Mantoux "Tuberculin" tests are carried out to establish the fact of tuberculous infection. Except in certain rather rare circumstances a negative reaction to all tests definitely rules out the possibility of tuberculous infection having been acquired previously, and it is therefore a very useful aid in excluding tuberculosis in some otherwise doubtful cases in children. MANTOUX, 1937 (1) Total number of Injections:— 1—10,000 dilution 228 Total 538. 1—1,000 dilution 161 1—100 dilution 149 (2) Total number of Positive Reactions:— 1—10,000 dilution 44 or 19.3% 1—1,000 dilution 6 or 3.7% 1—100 dilution 15 or 10% Total 65 or 12% approx (3) Number of those who received the test — For the first time 154 (55+ : 99-) For the second time 25 ( 6+ : 19-) For the third time 22 ( 0+ : 22-) For the fourth time 20 ( 5+ : 15-) For the fifth time 7 (0+ : 7-) Total 228 102 I would like to place on record my great appreciation of the help given by Miss Robinson in the preparation of Tuberculin dilutions and carrying out tests and their classification. It should be pointed out that the consent of parents or guardians is invariably obtained before commencing the Mantoux Tests—and where consent is refused the tests are not carried out. No deleterious effects of any description have ever been noticed at the Dispensary as a result of carrying out these tests. Bacteriological Tests. Miss Robinson has carried out 1,533 examinations of sputum, etc., for Tubercle Bacilli, in addition to bacteriological work for the Public Health and other Departments. The work in the Borough Laboratory has increased very considerably during the past few years, and includes important and highly technical investigations which are summarised in Section II. Examinations for Tubercle Bacilli in Laboratory:— Number of Sputa Examinations 1,506 (307+ : 1,199—) Number of Urine Examinations 18 (4+ : 14—) Number of Faeces Cultural Examinations 9 (0+ : 9—) Treatment of Tuberculosis. Sanatorium still remains the best general form of treatment for tuberculosis patients and forms the basis of all treatment, surgical or otherwise. The chief aims of Sanatorium treatment lie in the rebuilding of lost resistance, control of intercurrent disease, consolidation of "repair" to the system, and education for future life. All these are closely connected and equally important; but a great deal indeed depends on the temperament and co-operation of the patient. A well-known physician once said "You cannot cure a fool of Tuberculosis," and no doubt this has been proved over and over again. The total number of patients recommended for treatment in Sanatoria or other institutions through the L.C.C. was 118; in addition seven children were boarded out by them under the Contact Scheme. Altogether 164 patients or contacts have been sent away either to Sanatoria, hospitals or convalescent homes during the year. Various specialised treatments have been arranged by the Dispensary during the year, as the following list shows:— Special Treatments:— 687 Artificial pneumo-thorax refills at a cost of £360 13 6 60 Finsen Light treatments „ „ „ „ 15 0 0 45 Sanacrysin treatments „ „ „ „ 5 15 0 23 Ultra Violet Light treatments „ „ „ „2 17 6 815 treatments at a total cost of £385 6 0 Tuberculous Children. It is generally accepted that primary infection with the Tubercle Bacillus occurs in the majority of children during the first few years of life—a fact which is well demonstrated by the results of Mantoux testing. 103 A severe infection in the infant, before powers of resistance had been raised, might cause fatal disease of pneumonic or meningeal type; but a mild tuberculisation gives rise to but few symptoms of any importance, and this is no doubt the reason why comparatively few children show signs of definitely recognisable disease. The number of small infections received in civilised communities must be considerable, and tend to raise an individual resistance which is probably of the highest benefit in later years. Mantoux Tests show that a large number of the children on the Dispensary Register, or attending for periodical examination, have been infected; but continued supervision fails to reveal the presence of disease requiring special treatment. One often feels that more attention and supervision is necessary in the case of "non-reactors" —as they are an "uncertain quantity," and to this end all such children are seen and re-tested again and again, for years if possible. Children who are badly debilitated after illness, contacts, and those who have definitely been notified and require more active treatment, are recommended for institutional treatment in Convalescent Homes, Sanatoria or Surgical Homes, through the L.C.C., P.A.C., or the Invalid Children's Aid Association. This will in most cases tend to arrest disease; and many of the children are afterwards sent on to special schools according to their specific disability. Thus many mild gland, pulmonary and other type cases, also contacts, are referred to the Elizabethan Open Air School in Broomhouse Lane, which has accommodation for sixty boys and girls. These children, who attend as day scholars, are under constant supervision by one of the Dispensary Tuberculosis Nurses; and the Tuberculosis Officer is in medical charge, making a weekly visit to the School at which a number of children are re-examined in rotation, all the children thus being seen once every five or six weeks. Classes are held under open air conditions in two specially designed class rooms built in the garden behind the main building. In severe weather the children are taught in the school hall, whilst special woodwork and needlework classes are held in an upper school room which is also exceptionally lofty and spacious. The daily routine is under the control of the Head Mistress who arranges a very excellent dietary for the week, and superintends the serving of meals. The following daily time-table is carried out:— 9.0 - 9.20 a.m. Breakfast. (1/3 pint milk extra given). 9.30 — 9.45 a.m. Temperatures taken. 9.45 — 11.0 a.m. School lessons. 11.0 — 11.15 a.m. Break for recreation. 11.15 — 12 noon School lessons. 12.0 — 2 p.m. Dinner, with hour's rest following. 2.0 — 3.15 p.m. School lessons. 3.15 — 3.30 p.m. Break for recreation (a 1 /3 pint milk given) 3.30 — 4.0 p.m. School lessons. 4.0 — 4.15 p.m. Temperatures taken, and school closes. Under this regime the children do remarkably well, and there is very little evidence of break down in their health either during school years or after they have left and are in work. Convalescence through the I.C.A.A. and other care work. This Association continues to give most valuable help in dealing with many children who, although originally referred to the Dispensary for examination, are not found to be suffering from clinically recognisable disease, but are debilitated and in special need of a holiday away in the country or at the seaside. 104 Some of these children are convalescent after whooping cough, acute bronchitis, pneumonia or measles; and home conditions may from a variety of causes be very inadequate to promote satisfactory building up of impaired vitality. The benefit to such cases by convalescence through the I.C.A.A. is thus extremely important; and I might add that the intimate knowledge of the districts, families and homes possessed by this Association is specially valuable in dealing with other social and economic aspects of Tuberculosis. I would like to thank the Secretary and other members of the I.C.A.A., C.O.S., and other associations together with the secretary and other members of the Care committee, who have given valuable help to the Tuberculosis Dispensary in various ways during the past year. Dental Treatment. Seven persons were recommended for treatment under the Borough Scheme, dentures being supplied in four cases. Extra Nourishment. Seventy-one persons were given grants of extra nourishment under the Public Health scheme for varying periods. Gloving Class. The class has met thirty-five times during the year, a total of 331 attendances being made. A very successful Sale was held at the Dispensary in October when the Mayor was present and bought several pairs of gloves. The total sales through the Care Committee amounted to £53 13s. 9d. during the year. An afternoon's outing was arranged for the Class in July when they went by steamer to Greenwich and back, spending a couple of hours in the new Naval Museum there. Conclusion. As I pointed out in my previous report tuberculosis work is not spectacular, and probably few people who have not been in actual contact with such work realise the steady concentration which has to be brought to bear on the subject, and the far-reaching and vital decisions which have to be made daily in connection with this most enigmatical and persistent disease. To all the Dispensary Staff I extend my thanks for their excellent work and interest during the year. SUMMARY OF STATISTICS Number of New Patients:— Insured 253 Uninsured 299 Total 552 Number of Attendances:— Insured 1,223 Uninsured 2,254 Attendances of Contacts 538 Other Attendances 1,186 Total 5,201 105 Number of Patients who have attended, old and new 1,216 Number of Notifications:— Pulmonary 154 Non-pulmonary 19 Total 173 Number of Sputa examined 1,507 Number of physical examinations 2,574 Number of Contacts examined 228 Number of Home Visits paid by Doctor 466 Bedside consultations included in above 309 Consultations otherwise 861 Number of Home Visits paid by Nurses 3,959 Number of Reports sent to Public Bodies 447 Number of Reports sent to Doctors 890 Number of Letters written 5,476 Number of Patients referred to Brompton Hospital 6 For X-ray 421 Number of Notified cases on Dispensary Books on 31st December, 1937 655 Number of Patients sent away to institutions or to the country in 1937 164 TABLE 38 164 Patients were sent away to residential institutions on the recommendation of the Dispensary Medical Officers. (a) 118 by the London County Council Public Health Department:— 42 to Sanatoria. 3 to Colonies. 8 to Convalescent Homes. 65 to Hospitals. Men 26 3 - 25 Women 16 - 3 30 Children - - 5 10 (b) 3 by the Public Assistance Committee:— 1 Man to Hospital. 1 Woman to Hospital. 1 Child to Convalescent Home. 12 Children were sent to Convalescent Homes by the Invalid Children's Aid Association. 7 Children were boarded out under the Contact Scheme. 1 Child went away through Children's Country Holiday Fund. 20 Children went to St. Mary's Camp. 1 Woman was convalesced by the Charity Organisation Society. 2 Men were sent to Douglas House through the Red Cross. 164 106 TABLE 39 Showing sources of New Cases 219 were recommended by private doctors. 45 „ „ „ the Medical Officer of Health. 2 „ „ „ the School Medical Authorities. 4 „ „ „ the School Authorities. 129 „ „ „ Hospitals and Sanatoria. 27 „ „ „ other Dispensaries. 93 „ „ „ the Dispensary Staff. 3 „ „ „ the London County Council. 12 „ „ „ Friends 16 „ „ „ the Doorplate. 1 was „ „ the Relieving Officer. 1 „ „ „ Bishop Creighton House. 552 TABLE 40 New Cases. Pulmonary Tuberculosis. Other Forms. Suspects. NonTubercular. Percentage Tubercular. 267 Males 82 7 3 175 33.33 285 Females 70 11 1 203 28.42 552 Both Sexes 152 18 4 378 30.61 TABLE 41 Sex and Age of the New Patients for 1937 ] Under 5 years. 5 to 10 years. 10 to 15 years. 15 to 25 years. 25 to 35 years. 35 to 45 years. 45 years and over. All ages. Males 30 36 14 37 51 29 70 267 Females 15 38 16 72 76 30 38 285 Both Sexes 45 74 30 109 127 59 108 552 107 TABLE 42 Diagnosis at various Age Periods. New Patients. ] Pulmonary Tuberculosis. Other Forms. Suspects. NonTuberculous. Percentage Tuberculous. Under 5 years 2 - 1 42 4.44 Under 10 years 3 2 1 68 6.75 Under 15 years 3 1 1 25 13.33 Under 25 years 39 8 1 61 43.12 Under 35 years 44 3 — 80 37.00 Under 45 years 17 4 — 38 35.59 45 years and over 44 — — 64 41.66 All ages 152 18 4 378 30.61 TABLE 43 Of 161 of the 170 tuberculous patients found in 1937:- 2 lived in the basement. 41 lived on the ground floor. 49 lived on the first floor. 14 lived on the second floor. 6 lived on the third floor. 1 lived on the fourth floor. 10 lived on the top floor. 13 lived on more than one floor. 25 lived in the whole house. TABLE 44 Housing A ccommodation ] Number of Families occupying One room. Two rooms. Three rooms. Four rooms. Five rooms. Six rooms or more. Patient living alone 7 - 1 - - - Patient living with- 1 other 4 13 17 3 - - 2 others — 7 21 7 2 1 3 „ — 1 14 9 3 2 4 „ — 2 7 4 2 2 5 „ — — 3 9 — 5 6 „ — — 2 2 — 3 7 „ — — 1 1 — - 8 „ — — — 2 — 2 9 „ - - - - - 1 12 „ - - - - 1 — 11 23 66 37 8 16 108 TABLE 45 Sleeping Accommodation of 164 Tuberculous Patients The patient slept:— In a separate room in 55 cases. Alone in bed with one other in room in 13 cases. Alone in bed with two others in room in 6 cases. Alone in bed with three others in room in 2 cases In bed with one person and no others in room in 64 cases. In bed with one person and one other in room in 18 cases. In bed with one person and two others in room in 1 case. In bed with one person and three others in room in 1 case. In bed with two persons and no others in room in 3 cases. In bed with two persons and one other in room in 1 case. TABLE 46 Occupations of 83 Men (New Cases) in 1937 1 Baker 1 Hotel Storekeeper 2 Barmen 1 House Porter 1 Billiard Marker 9 Labourers 1 Blacksmith 1 Lath Fixer 1 Bricklayer 1 Machinery Dealer 1 Bus Driver 1 Manager, Public House 1 Bus Conductor 1 Marble Mason 1 Canvasser 6 Motor Drivers 2 Carpenters 1 Painter 1 Caterer 1 Paymaster 5 Clerks 1 Plasterer 1 Coach Trimmer 1 Plate Cleaner 2 Commercial Travellers 3 Plumbers 1 Converter 4 Porters 1 Cycle Dealer 1 Printer's Reader 1 Draughtsman 1 Railway Clerk 1 Dry Cleaner 1 Scaffolder 2 Electricians 3 Shop Assistants 2 Factory Hands 2 Shopkeepers 3 Fitters 1 Sorter (P.O.) 1 Gas Fitter 1 Student 1 Greengrocer 1 Switch Inspector 1 Hairdresser 1 Theatrical Dresser 1 Handyman 1 Timber Salesman 1 Hawker 1 Storeman 1 Nil. Occupations of 76 Women (New Cases) in 1937 1 Advertiser 1 Hospital Maid 1 Bakery Packer 1 Housekeeper 2 Cinema Attendants 26 Housewives 1 Cinema Manageress 2 Laundry Hands 1 Cleaner 1 Librarian 6 Clerks 1 Nurse 1 Counter Hand (Milk Bar) 1 Pumper 9 Domestics 4 Shop Assistants 3 Dressmakers 2 Typists 8 Factory Hands 4 Nil. Under 15 years of age 6 Boys 5 Girls 109 VACCINATION The Vaccination Officer has supplied me with the following figures relating to his work Number of births registered during 1936 1,576 Success/fully vaccinated 867 Insusceptible of vaccination Unvaccinated on account of conscientious objections made by the parents 404 Died unvaccinated 73 Postponed by medical certificate and unvaccinated on 31st January, 1938 28 Removed to other districts and unvaccinated on 31st January, 1938 32 Removed to places unknown 140 Outstanding on 31st January, 1938 32 Number of successful primary vaccination certificates received during 1937 1,055 Number of Conscientious Objection Certificates received during 1937 307 The figures show that 55 per cent. of the infants born in 1936 had been successfully vaccinated by the end of January, 1938. Figures for recent years (in percentages) are as follows:— 1929 55 1933 54 1930 60 1934 58 1931 57 1935 55 1932 57 1936 55 DISINFECTION The following rooms were disinfected and cleansed after Infectious Diseases, etc.:— TABLE 47 Scarlet Fever 294 Diphtheria 163 Measles 15 Erysipelas 47 Tuberculosis 186 Puerperal Fever 1 Vermin 385 Cancer 12 Cerebro-Spinal Meningitis 13 Poliomyelitis 1 Influenza 2 School Class rooms after Diphtheria 2 Chicken Pox 2 Scabies 4 Whooping Cough 1 Impetigo 1 Enteric Fever 2 Dysentery 3 Epidemic Diarrhœa 1 By request 21 Maternity Home 25 Day Nursery 30 Babies' Hospital 1 Infant Welfare Clinics 40 1,252 110 The following articles were disinfected at the Council's Disinfecting Station:— TABLE 48 Articles. From Private Houses. From Institutions. Total. Beds 489 - 489 Mattresses 1,042 89 1,131 Palliasses 2 - 2 Pillows 2,151 80 2,231 Cushions 321 — 321 Bolsters 593 — 593 Blankets 2,111 253 2,364 Sheets 1,360 167 1,527 Covers 488 10 498 Counterpanes 295 6 301 Curtains 7 — 7 Carpets 13 — 13 Hearth rugs 153 2 155 Clothing 5,151 474 5,625 Eiderdowns 268 — 268 Sundries 1,209 135 1,344 15,653 1,216 16,869 During November it was necessary to fumigate a room in a modern block of flats. The room, which had nine-inch brick walls on three sides, a breeze block partition on the fourth, solid floors above and below, no permanent ventilation or flue and a steel-framed double hung sash-window, was subjected to sulphur fumigation at 10.30 a.m. The occupant reported a strong concentration of sulphur dioxide in the room adjoining at 6 p.m., although the room under fumigation was theoretically gas tight. After investigation, it was found that the gas had escaped into the other room by two means:— (a) Via the small space surrounding the service pipes and the wastes, and (b) by diffusing through the nine-inch brick wall below the skirting board where the plastering had finished short of the floor. The capacity of the room was 1,768 cubic feet and the resultant concentration of gas after burning 3 lbs. of sulphur was 1.91 per cent. 1ll INDEX Pages Aged and Infirm Persons 56 Ambulance Facilities 30 Atmospheric Pollution and New Power Station 52 Babies' Hospital 44 Bacteriological Examinations 29 Bakehouses and Bakers' Shops, Inspections of 77 Cancer 93 Catarrhal Jaundice 91 Clinic and Treatment Centres 31 Closet Accommodation 46 Combined Drainage 51 Committees, Public Health and Maternity. and Child Welfare 7 Common Lodging House 57 Deaths, Causes of 15,23,24 Certification of Causes 14 of Fulham Residents outside the Borough 14 in Public Institutions 14 Diarrhoea, Epidemic 91 Diphtheria 89 Antitoxin 89 Immunisation 89 Disinfection 109 Disinfestation 66 Drainage of Buildings 50 Extracts from Vital Statistics 12 Factories, Workshops and Workplaces 58 Food and Drugs, Adulteration 75,76 Food and Food Premises, Inspection of 48, 77 Food, Unsound 79 General Statistics 12 Graph, Birth, Death and Infant Mortality Rates 20 Gyntecological Clinic 33 Health Propaganda 33 Home Nursing 30 Hospitals 32 House-to-House Inspection 47, 64 Housing 62-68 General 62 Redevelopment Area 62 Photographs 63 Overcrowding 65 Disinfestation 66 Advice to Tenants 66 London County Council Estates 66 Vital Statistics of Working-class Flats 68 112 Pages Ice Cream 78 Infantile Mortality 16, 20, 25, 26 Infectious Diseases 84-91 Infectious Diseases, Non-notifiable 92 Insulin, Supply of 33 Introduction 3 Laboratory Facilities 29 Legal Proceedings (Adulteration of Food) 70, 76 (Sanitary and Housing) 51 Maternity and Child Welfare (Report by Dr. Ruby Thomson) 35 Ante-natal Clinics 40 Charitable Organisations 44 Day Nursery 42 Dental Clinic 41 Eye and Skin Defects 41 Health Visitors 35 Home Nursing 30, 42 Infant Life Protection 37 Maternity and Child Welfare Centres 39 Massage Clinic 41 Maternity Home 37 Maternal Mortality 17, 18 Notification of Births 40 Provision of Milk 43 Measles Epidemic 88 Milk, Automatic Milk Machines 71 Bacteriological Examinations of 73 Examination of 70 Inspection and Supervision of Dairies and Milkshops 72 Purveyors 72 Samples, Composition of 71 Milk and Dairies (Amendment) Act, 1922, and Milk and Dairies Order, 1926 72 Milk (Special Designation) Order, 1936 72 Mortuary 57 National Rat Week 56 Outworkers 59 Overcrowding 65 Pharmacy and Poisons Act, 1933 79 Pigeons, Nuisance from 57 Prevention of Blindness 94 Preserved Food, Registration of Premises 78 Public Analyst, Report of 80-82 Baths and Washhouses 54 Cleansing 46 Conveniences 55 Public Health (Condensed Milk) Regulations, 1923 and 1927 76 Public Health (Dried Milk) Regulations, 1923 and 1927 76 113 Pages Public Health (Preservatives, etc. in food) Regulations, 1925 and 1927 76 Rag Flock 53 Rat Repression and Destruction 56 Rent Restrictions Acts 56 Refuse Collection and Disposal 46 Repairs effected 49 Rivers and Streams 46 Samples purchased for Analysis 82 Sanitary Inspection of Area 47 Scavenging and Street Watering 46 Scarlet Fever 88 Seasonal Mortality 15 Shops Act, 1934 57 Slaughter-House 78 Smoke Abatement 52 Social Conditions 13 Staff—Public Health and Maternity and Child Welfare Departments 8-10 Statistics, 1901-1937 21 Summary of Sanitary Inspections 47-49 Tuberculosis 94 Tuberculosis Dispensary (Report by Dr. P. L. T. Bennett) 100 Bacteriological Department 102 Dental Treatment 104 Extra Nourishment 104 Handicraft Class 104 Home Visits 101 Mantoux Test 101 Open-air School 103 Sanatorium Treatment 102 Special Treatment 102 Summary of Statistics—Tables 104-108 X-Ray Examinations 101 Notifications, 1913-1937 97 Ultra-Violet Light Clinic 34 Vaccination 109 Vital Statistics for the Borough 19 of London Boroughs, 1937 22 of Working-Class Flats 68 comments on 13 1901-1937 21 Zymotic Deaths 15, 85