H AC 32 Metropolitan Borough of Hackney. REPORT on the SANITARY CONDITION of the metropolitan borough of hackney FOR THE YEAR 1918, BY W. W. E. FLETCHER, M.B., CAMB., D.P.H., Acting Medical Officer of Health for the Borough and Chief Executive Tuberculosis Officer. London: Chas. Straker & Sons, Ltd., 5-9, Bishopsgate Avenue, E.C.3. 1919. INDEX. page Alcoholism 23 Ante.natal Welfare 32 Anthrax 19 Birth Rate 9 By.laws—Houses let in Lodgings—Inspection under 27 Canal Boats Acts 52 Cancer 23 Cerebro.Spinal Meningitis 18 Chicken Pox 19 Cleansing of Persons Act, 1897 45 Combined Drainage and Sewers 44 Cowhouses, Dairies, and Milkshop? 27 Customs and Inland Revenue Act 27 Day Nursery 40 Day Sanatoria 31, 60 Death Rate 10 Deaths in Public Institutions 11 Diarrhoea 22 Diphtheria 17 Disinfection 44 Enteric Fever 18 Erysipelas 18 Estimated Population 8 Factories 40 Food—Unsound 24 Factory and Workshops Act, 1901 40 Glanders and Farcy Order 2i Home Work and Home Workers 43 Housing and Town Planning Act, 1909 28 Ice Cream Vendors 27 Illegitimacy 9 Infant Mortality 10 Infant Welfare Work 31 Influenza 20 A 2 4 index page Marriage Rate 8 Maternity and Child Welfare Act 36 Measles and German Measles 19 Midwives—Medical assistance to 40 Mortuary 46 Notification of Births Act 9 Notifiable Diseases 16 Non.Notifiable Diseases 20 Offensive Trades 25 Ophthalmia Neonatorum 19 Plague IS Polio.myelitis 18 Population 8 Public Health (London) Act, 1891—Inspections under 23 Public Health (London) Act, 1891—Prosecutions under 51 Public Health (Tuberculosis) Regulations, 1912 ... ... ... 28 Puerperal Fever ... ... ... ... ... ... ... ... 18 Removal of House Refuse 45 River Lee—Floodings 28 Sale of Food and Drugs Act—Samples purchased 47 Sale of Food and Drugs Act—Prosecutions under 49 Senile Mortality 11 Scarlet Fever 17 Shelter 45 Slaughter.houses 25 Small.pox 16 Smoke Nuisances 27 Tuberculous Diseases 23 Tuberculosis Dispensaries 30 Verminous Children 45 Whooping Cough 20 Workshops 41 Zymotic Diseases 16 SPECIAL REPORTS. Ante.natal Welfare—Report as to establishment of clinic 70 Day Sanatoria—Report as to establishment of 60 Food—Report of Food Inspector 24 Infant Welfare Centres—Reports of Welfare Medical Officers 36, 37, 38, 39, 40 River Lee—Report as to overflow and flooding of cottages 67 Sale of Food and Drugs Acts—Report re warranties 48, 54 PUBLIC HEALTH DEPARTMENT. Committee. Ex.officio. L. Stanley Johnson, Esq., j.p. (Mayor). Chairman—Councillor John Genese. Vice.Chairman—Alderman T. Rushbrooke, j.p., m.a. Councillor Arnold, G. E. Councillor Genese, J. Ashdown, Mrs. F. M Grant, H. Barley, J. R. Minde, A. F. Alderman Beven, S. Mustard, J. T. Bourne.Newton, F. Alderman Payne, A. W., f.c.a. Councillor Chapman, T., j.p., l.c.c. Councillor Payton, L. Cornish, W. Phillimore, W. E. Feesey, R. Alderman Rushbrooke, T., j.p., m.a. Alderman Frye, F. E. Councillor Sinclair, H. A. Staff. Medical Officer of Health—J. King Warry, m.d., d.p.h. Tuberculosis Officers. Metropolitan Hospital—*H. O. West, m.d. F. K. Moos, m.b. (Acting). Victoria Park Hospital—*H. T. Howell, m.r.c.s. G. T. Hebert, m.b. (Acting). Public Analyst—Leo Taylor, f.i.c., &c. Clerical Staff. Chief Clerk J.D.Wilde. First Assistant Clerk A. Higgins. Second Assistant Clerk P. A. Hitch. Third Assistant Clerk L. W. Harvey. Fourth Assistant Clerk. *E. Whittaker. Temporary Clerk H. C. Bowman Messenger *V. Welham. Sanitary Inspectors. R. H. Ellis. *E. S. Crook (temporary). W. Harvey. *W. C. Vobe. *R. H. Bew. J. W. Hall. *H. Body. *W. Goldsworthy (temporary). G. F. High. A. J. Bobbitt R. J. Sheppard. (For Cowhouses, Milkshops, Slaughter. S. Punter. houses, &c.). W. Peverett. Alice Teebay *A. Sadler. (For Workshops, Laundries, &c.). *G. White Mabel Portlock (Also Canal Boats Inspector). (For Outworker's Premises). Health Visitors. Mrs. A. Rhodes. Mrs. E. A. Cowley. Miss M. Clarke. Mrs. L. Harrison. Miss K. Teebay. Miss M. Chitson Miss G. M. Servante for Tuberculosis Cases. Miss M. Morrison Dust Inspectors. *E. J. Tietjen. T. Saunders. Disinfecting Station and Shelter. Caretaker Mrs. J. Winn. Mortuary Keeper—J. Brown. *With H.M. Forces. Metropolitan Borough of Hackney. REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1918. THE PUBLIC HEALTH DEPARTMENT, Town Hall, Hackney, E.8. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Hackney. Madam and Gentlemen, I have pleasure in submitting to you my Annual Report upon the Health of the Borough of Hackney for the year 1918. During the whole of the year in question the late Dr. John King Warry held office; and he continued to do so until his sudden and much regretted death on March 9th, 1919. In accordance with the wish of the Local Government Board, expressed year by year during the latter part of the Great War, Dr. King Warry's Annual Reports had been very considerably abridged during that period, mainly on account of the great cost of paper and printing. The desire for brevity has been expressed again by the Local Government Board with respect to the Annual Report for 1918. For this reason I have endeavoured to be as brief as possible consistently with the importance of the facts dealt with ; and, as a tribute to the memory of Dr. King Warry, and because the year was really one of his years, I have adopted the form of report produced by him during his last years of office, thus completing in his own way the long series of reports written by him during his twenty.six years of service as Medical Officer of Health. 8 Population Estimated to the middle of 1918. The census of the population is made at the end of the first quarter of the first year of each decade, i.e., in 1901, 1911, etc. The population of the Borough was— At the Census of 1901 219,110, and At the Census of 1911 222,533. In normal times the population at the middle of each of the years intervening between 1911 and the next Census in 1921 would have been estimated upon the basis of the increase between the Census of 1901 and that of 1911, which the figures given above show to have been 3,423, roughly, some 340 a year; but, owing to the Great War, there was an enormous exodus of the male population of the young adult and middle-aged periods of life, and this completely altered the age and sex constitution of every district in the country, in addition to reducing actual numbers. Thus, the preponderance of females was largely increased; and, as the average length of life of females is greater than that of males, the tendency of this condition would be to lower the death-rate. On the other hand, the removal of large numbers of healthy young and middleaged men, leaving the very young and old people at home, would tend to raise the death-rate, because this rate is greater at the two extremes of life than at the young adult and middle-aged period. It is obvious, therefore, that any statistics based on an estimated population computed on normal lines would be altogether misleading. For this reason the Registrar-General has calculated for each district two distinct populations, from one of which the birth-rate is to be estimated, and from the other the death-rate. The figures he gives are— Population for estimating the birth-rate, 219,391. Population for estimating the death-rate, 195,804. Marriages and Marriage Rate.—During 1918 there were 2,011 marriages solemnised in the Borough of Hackney, being an increase 9 of 49 on the previous year. The annual rate for persons married during this period is therefore 18.3 per 1,000 of the population. Births and Birth-rate.—The births registered in Hackney during the year 1918 numbered 3,828, of which 1,993 were male and 1,835 females. This total is the actual number of births registered in Hackney and requires correction for transferable births. After making these necessary corrections the total of registered births amongst Hackney residents is 3,266. From this figure the birth-rate during 1918 is calculated to be 14.8 per 1,000 of the population. For this calculation the Registrar-General's estimated population of 219,391 is used. Notification of Births Act, 1907.—Under the provisions of this Act, 3,784 notifications of births occurring in the Borough were received during 1918. This total includes notifications from medical practitioners, midwives, and other persons. It also includes still births. Still Births.—Amongst the births notified were 108 still-born This is equal to 2.8 per cent, of those notified. A table is here given showing the number of notifications received, with other details in connection with the same. NOTIFICATION OF BIRTHS ACT, 1907. Notifications of Births (Live or Still-born) received during the year 1918. Year 1918. Medical Practitioners. Midwives. Parents and Others. Total. Live. Still. Live. Still. Live. Still. Live. Still. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Totals. 352 343 19 7 1,315 1,218 46 32 226 217 2 2 1,893 1,783 67 41 Illegitimate Births and Birth-rate.—The total number of illegitimate births registered in the Borough during the year 1918 was 626; but of these, the Registrar-General reports that 482 10 should be transferred to districts outside Hackney, as the mothers were not Hackney residents, and 32 births, taking place in other districts should be transferred to Hackney. Making these corrections, there remain 176 illegitimate births amongst Hackney residents. This is an increase of 12 on the number during 1917. The illegitimate birth-rate for Hackney during 1918 is 53.8 per 1,000 births, that for 1917 was 43.7 per 1,000 births. Deaths.—After making the necessary corrections for residents dying outside the Borough and for non-residents dying within the Borough, the corrected number of deaths amongst Hackney residents during 1918 is 3,708. This is an increase of 855 upon the number occurring during 1917. The general deathrate from all causes for the year 1918 is therefore 18.9 per 1,000 of the population. For the calculation of this rate the RegistrarGeneral's estimated population of 195,804 is used. It must be recognised, however, that this is merely the "crude" death-rate, uncorrected for sex and age distribution, each of which differs widely in different districts. In normal times the RegistrarGeneral supplies for each of the various large towns figures which are known as the "factor-for-correction." but these factors have not been calculated for the latter years of the war. The "crude" death-rate of a district multiplied by the factor for that district gives a result corrected for age and sex for that district; and it is only when this process has been applied all round that the deathrates of different districts are brought to a common basis, and therefore become fairly comparable. Comparisons between "crude" death rates may give misleading impressions, and should not be relied upon for more than a rough indication of the relatively high or low position of the death-rate of a given district. Infant Mortality.—The deaths under one year of age in the Borough during 1918, numbered 365. This is an increase of 20 upon the number of infant deaths recorded during 1917. The infant mortality for the year is 111 per 1,000 births. 11 INFANT MORTALITY. 1918. Nett deaths from stated causes atvarious ages under 1 Year of age. CAUSE OF DEATH. Under 1 week. 1.2 weeks. 2.3 weeks. 3.4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 0 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths under 1 year. Small.pox ... ... ... ... ... ... ... ... ... ... Chicken.pox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... 1 3 4 Scarlet Fever ... ... ... ... ... ... ... ... 1 1 Whooping Cough ... ... 1 ... ... 3 6 4 8 22 Diphtheria and Croup ... ... ... ... ... 1 ... ... 1 1 Erysipelas ... ... ... ... ... ... ... 1 3 Tuberculous Meningitis ... ... ... ... ... l ... ... ... 2 Abdominal Tuberculosis ... ... ... ... ... ... ... ... ... ... Other Tuberculous Diseases ... ... ... ... ... ... 1 1 ... 2 Meningitis (not Tuberculous) ... ... ... ... ... 1 2 3 ... 0 Convulsions ... ... ... ... ... 3 5 ... 1 11 Laryngitis ... ... ... ... ... ... ... ... ... 28 Bronchitis ... ... ... ... ... 4 6 11 7 Pneumonia (all forms) ... ... 2 1 ... 6 6 18 16 49 Diarrhoea ... ... ... ... ... 4 10 6 4 24 Enteritis ... ... ... ... ... 5 10 5 5 25 Gastritis ... l 1 1 3 Syphilis ... ... ... ... ... 1 ... ... 1 Rickets ... ... ... ... ... ... 1 ... ... 1 Suffocation, overlying 1 ... ... "2 6 2 ... ... ... 8 Injury at Birth 1 ... ... ... 1 ... ... ... ... 1 Atelectasis 2 ... 1 2 6 l 2 ... ... 9 Congenital Malformations 4 ... 1 2 7 2 ... ... ... 9 Premature Birth 43 6 1 3 53 5 ... ... ... 59 Atrophy, Debility and Marasmus 7 6 3 5 21 18 25 7 ... 71 Other Causes 5 ... ... 1 6 1 8 3 7 25 Total 66 16 9 17 108 57 85 61 54 365 Senile Mortality.—The deaths which occurred in Hackney at 65 years and upwards during 1918 numbered 988, of which 501 were between the ages of 65 and 75 years, 381 between 75 and 85 years, and 106 at 85 years and upwards. The annual mortality rate of persons at 65 years and upwards is 5.0 per 1,000 of the whole population. Deaths in Public Institutions.—There were 1,853 deaths in public institutions in the Borough during 1918; of these 820 were residents of other districts, and the remaining 1,033 were residents of Hackney. TABLE I.—HACKNEY DISTRICT. Vital Statistics of Whole District during 1918 and Previous Years. Year. Population estimated to middle of each year. Births. Total Deaths Registered in the District. Transferable Deaths Nett Deaths belonging to the District. Uncorrected Number. Nett. of Nonresidents registered in the District. of residents not registered in the District. Under 1 Year of Age. At all Ages. Number. Rate. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1910 222,384 5,493 5,240 23.5 2,878 12.9 506 450 543 104 2,822 12.6 1911 222,674 5,410 5,243 23.5 3,546 15.9 779 443 633 120 3,210 14.4 1912 223,022 5,425 5,267 23.6 2,952 13.2 663 431 426 79 2,720 12.2 1913 223,369 5,733 5,523 24.7 3,156 14.1 665 563 549 99 3,054 13.6 1914 223,718 5,708 5,460 25.5 3,233 14.4 662 557 492 85 3,128 13.9 1915 217,883 5,091 4,827 22.1 3,402 15.6 723 552 520 107 3,231 14.8 1916 209,636 5,331 5,026 22.0 2,917 13.9 617 581 423 84 2,881 13.7 1917 196,598 4,207 3,750 17.1 2,929 14.9 661 585 345 92 2,853 14.6 1918 195,804 3,828 3,266 14.8 3,836 19.5 820 692 365 111 3,708 18.9 TABLE II.—HACKNEY DISTRICT. Cases of Infectious Disease Notified during the Year 1918. Notifiable Disease. Cases Notified in whole Districts. Total Cases Notified in each Locality. Total cases removed to Hospital. At all Ages. At Ages—Years. North. Central. South.East. South.West. Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to 65. 65 and upwards. Small Pox 3 ... ... 1 ... 2 ... ... ... ... ... 3 3 Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... ... ... ... Anthrax 1 ... ... ... ... ......... 1 ... ... ... ... 1 1 Diphtheria (including Membranous Croup) 450 9 126 266 39 11 4 1 69 137 174 76 415 Erysipelas 97 4 4 7 9 29 34 10 13 24 26 34 24 Scarlet Fever 266 9 55 167 32 9 1 ... 59 88 56 63 234 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever 27 ... 2 2 9 ii 3 ... 7 5 10 5 20 Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Continued Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever 8 ... ... ... 5 3 ... ... ... 5 2 1 5 Cerebro.Spinal Meningitis 5 ... 1 2 1 ... 1 ... 1 2 2 ... 5 Polio Myelitis 2 ... 9 ... ... ... ... ... 1 ... 1 ... 0 Ophthalmia Neonatorum 20 20 ... ... ... ... ... ... 4 6 8 2 3 Pulmonary Tuberculosis 793 ... 3 64 187 408 126 5 194 160 190 249 240 Other forms of Tuberculosis 109 6 11 50 24 13 5 ... 14 23 34 38 27 Measles 1,564 69 750 709 25 10 1 ... 384 434 349 397 66 German Measles 226 5 44 124 39 13 1 ... 91 34 19 82 1 Chicken Pox 285 12 103 163 5 2 ... ... 83 51 65 86 7 Totals 3,862 127 1,101 1,555 375 511 177 16 920 969 936 1,037 1,053 13 TABLE III.—HACKNEY DISTRICT. Causes of, and Ages at, Death during the Year 1918. CAUSES OF DEATH. Deaths in whole Districts at Subjoined Ages. Deaths in Public Institutions. All Ages. Under 1. 1 and under 2. j 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Enteric Fever 8 ... ... ... 1 3 4 ... ... 7 Small Pox ... ... ... ... ... ... ... ... ... Measles 38 4 12 15 7 ... ... ... ... 30 Scarlet Fever 6 1 1 2 2 ... ... ... ... 19 Whooping.cough 55 25 15 13 2 ... ... ... ... 16 Diphtheria and Croup 51 1 6 18 26 ... ... ... ... 118 Influenza 698 10 25 48 64 114 290 101 46 149 Erysipelas 8 3 1 ... ... ... 1 2 1 6 Phthisis (Pulmonary Tuberculosis) 307 ... 2 2 15 59 140 83 6 145 Tuberculous Meningitis 32 3 7 11 8 2 1 ... ... 15 Other Tuberculous Diseases 32 2 2 4 5 6 9 4 ... 21 Cancer, Malignant Disease 236 ... ... 1 ... 3 18 132 82 143 Rheumatic Fever 8 ... ... ... 3 1 2 1 1 ... Meningitis 11 5 2 1 2 1 ... ... 135 7 Organic Heart Disease 322 ... 1 2 10 16 44 114 186 Bronchitis 319 27 14 6 1 1 21 91 158 189 Pneumonia (all forms) 364 48 52 55 20 22 63 50 54 175 Carried forward 2,495 129 140 178 166 228 593 578 483 1,226 11 TABLE III.—HACKNEY DISTRICT—continued. Causes of, and Ages at, Death during the Year 1918. CAUSES OF DEATH. Deaths in whole Districts at Subjoined Ages. Deaths in Public Institutions. All Ages. Under 1. 1 and under 2. 2 and under 5. | 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Brought forward 2,495 129 140 178 166 228 593 578 483 1,226 Other Diseases of Respiratory Organs 25 ... 1 2 ... ... 4 15 3 9 Diarrhoea and Enteritis 55 42 6 1 ... ... 2 1 3 32 Appendicitis and Typhlitis 18 ... ... 2 4 5 1 4 0 ... Cirrhosis of Liver 12 ... ... ... ... ... 1 6 5 2 Alcoholism 1 ... ... ... ... ... 1 ... ... ... Nephritis and Bright's Disease 76 ... ... ... 4 2 11 43 16 36 Puerperal Fever 2 ... ... ... ... 2 ... ... ... 2 Other Accidents and Diseases of Pregnancy and Parturition 5 ... ... ... ... 1 4 ... ... 2 Congenital Debility and Malformation, including Premature Birth 123 116 5 2 ... ... ... ... ... 104 Violent Deaths, excluding Suicide 85 11 ... 3 15 4 14 10 22 51 Suicides 17 ... ... ... ... ... 6 8 3 6 Other Defined Diseases 677 61 3 7 10 12 40 137 407 251 Diseases ill.defined or unknown 117 6 10 4 1 3 18 31 44 132 Totals 3,708 365 165 199 200 257 695 839 988 1,853 Sub.Entries (included in above figures)— 14 Cerebro.Spinal Meningitis 2 ... ... ... 2 ... ... ... ... Poliomyelitis 1 ... ... ... 1 ... ... ... ... ... Encephalitis.lethargica ... ... ... ... ... ... ... ... ... ... 15 16 SPECIFIC INFECTIOUS DISEASE. During 1918 there were 2,994 cases of acute infectious disease notified in the Borough; of these 34 were subsequently found not to be suffering from infectious disease, thus reducing the number of genuine cases to 2,960. The attack rate in respect of the acute notifiable infectious diseases for the year is 15.1 per 1,000 living. The deaths from the chief zymotic diseases numbered 213. This is equivalent to a zymotic death rate of 108 per 1,000 living in the Borough. A.—NOTIFIABLE INFECTIOUS DISEASE (ACUTE). Small.pox.—Three cases of this disease were notified in the Borough during 1918. The first case, Hy. W., aged 33 years, residing in Dalston, was removed to hospital on 5th March. This patient was an undertaker and had arranged the burial some three weeks previously of a child who died from "measles," at an address in Bethnal Green. On the 13th March, Ethel W., aged 25 years, the wife of the first case, developed a rash, which was diagnosed as small.pox and she was removed to hospital the same day. The next day, 14th March, Ethel W., aged six years, daughter of the previous cases, was found to have a suspicious rash and was accordingly removed to hospital. Disinfection of rooms, clothing and all infected articles was carried out in each case, and observation kept upon the contacts; all the patients had been vaccinated primarily, and re.vaccination was performed in the two latter cases immediately upon the removal of the first one. All the cases subsequently recovered. 17 Scarlet Fever or Scarlatina.—The number of cases of scarlet fever notified during 1918 was 274 but of these 8 were found afterwards not to be suffering from this disease, thus reducing the genuine cases to 266. This is a decrease of 26 upon the number o f genuine cases notified during 1917. The attack rate for scarlet fever is 1.3 per 1,000 persons living. The number of cases removed to hospital was 234 which is 85 per cent, of the total notified. The deaths from this disease numbered 6, which is equal to a mortality rate of 2.2 per cent, attacked, and .03 per 1,000 living. Diphtheria and Membranous Croup.—There were 480 cases of diphtheria and membranous croup notified during the year, but of these 24 cases were found subsequently not to be suffering from diphtheritic disease, thus reducing the genuine cases to 456. This is an increase of 170 upon the number of cases occurring during 1917. The attack rate is 2.3 per 1,000 living. There were 415 cases of diphtheria and membranous croup removed to hospital during 1918. This is equal to 86 per cent, of the cases notified. The deaths from diphtheritic disease numbered 51. This is equal to a mortality rate of 11.2 per cent, attacked, and .25 per 1,000 living. During the year 311 swabbings from throats of persons suspected to be suffering from diphtheria were bacteriologically examined, 74 of which gave positive results, 215 negative results, and 22 were doubtful. Diphtheria Anti.toxin Order.—In accordance with the above Order 20 bottles of anti.toxin of 2,000 units each were supplied to medical practitioners during the year 1918. Most of the anti.toxin was administered for prophylactic purposes. B 13 Typhoid Fever or Enteric Fever.—During the period under consideration, 29 cases of typhoid were notified, but of these 2 cases were afterwards found not to be suffering from this disease. This is an increase of 8 on the number of genuine cases notified during 1917. The attack rate is .13 per 1,000 living. Only 8 deaths were registered in the Borough from this disease during 1918. Thus, the case.mortality was 26 9 per cent. Of the 27 cases notified 20 were removed to hospital. During the year 15 specimens of blood from persons suspected to be suffering from enteric fever were submitted to Widal's test 5 of which gave a positive and 10 a negative reaction. Continued Fever.—No case of continued fever was notified during the year. Typhus Fever.—No case of this disease was notified during 1918. Puerperal Fever.—There were 8 cases of puerperal fever notified during 1918, of which 2 died, a case.mortality of 25 per cent. Plague.—No case of this disease occurred in the Borough last year. Erysipelas.—There were 97 cases of erysipelas notified during 1918. This is equal to an attack rate of .49 per 1,000 living. The deaths numbered 8 which gives a mortality rate of .04 per 1,000 living. Cerebro.Spinal Meningitis.—During 1918 there were 5 cases of this disease notified in the Borough all of which were removed to hospital. The deaths numbered 2 which is equivalent to a mortality of .01 per 1,000 living. Polio.myelitis or Polio.encephalitis.—There were two cases of this disease notified during 1918, of which one died. 19 Ophthalmia Neonatorum.—The number of cases of this disease notified during the year was 20, all of which were visited by the Health Visitors and the mothers advised to seek medical treatment. Special nurses were sent in 2 cases. All the cases recovered without damage to the eye. Glanders, Anthrax and Hydrophobia in man.—No case of these diseases was notified during the year. Anthrax.—One case of anthrax was notifed during the year. The case was afterwards diagnosed as anomalous septic inflammation and was discharged from hospital apparently quite well. Chicken-pox.—No death was registered in the Borough during 1918. During the three months of the year this disease was made notifiable 285 cases were notified by medical practitioners. Seven were removed to hospital. THE PUBLIC HEALTH (MEASLES AND GERMAN MEASLES) REGULATIONS, 1915. Measles.—During the year 1,564 cases of measles were notified by medical practitioners under the Regulations, and 627 other cases were brought to the notice of the Department by parents and others. Of the total, 66 were removed to hospital. The deaths from measles numbered 38 of which 31 were under 5 years of age. The annual mortality is equivalent to .18 per 1,000 living. The whole of these cases were visited by the Health Visitors to obtain particulars as to whether the home conditions were satisfactory for home nursing and treatment of the child. Arrangements were continued with the King's Home for Nurses and the Shoreditch and Bethnal Green Nursing Association for nurses to be sent to very serious cases, to attend daily until their services became unnecessary. The total number of patients visited by these cases Associations was 40. b2 20 German Measles.—During the same period 226 cases of this disease were notified. There were no deaths registered from this disease. Whooping-cough.—There were 55 deaths from this cause during 1918, of which 53 occurred in amongst children under 5 years of age. The annual mortality is 27 per 1,000 living. Information of 494 cases of whooping-cough was received from the head masters and mistresses of Elementary schools in the Borough, occurring amongst their scholars during the year. Influenza.—During 1918 there were 698 deaths in the Borough due to influenza. The annual mortality rate is 3.5 per 1,000. The year was characterised by the occurrence of a world-wide epidemic of this disease, and Hackney was involved with the remainder of London. The following table sets out the deaths from influenza during the epidemic period, and certain other causes of death which may have had some relation to influenza:— Week ended Influenza. Diseases of Heart. Bronchitis. Pneumonia. Pulmonary Tuberculosis. 5th Oct. - 10 2 3 4 12th 6 14 3 9 6 19th „ 33 5 8 8 6 26th „ 90 4 10 13 7 2nd Nov. 167 6 16 23 10 9th 140 6 16 22 7 16th „ 69 9 10 14 3 23rd „ 48 5 13 14 5 30th „ 58 6 11 7 10 7th Dec. 21 8 12 8 5 14th „ 10 7 6 7 6 21st „ 5 6 9 9 6 28th „ 4 12 5 4 2 651 98 121 141 77 21 During the outbreak the following poster was placarded throughout the Boroug:— METROPOLITAN BOROUGH OF HACKNEY. INFLUENZA. As this disease is prevalent in the Borough, and responsible for many deaths, it has been thought desirable by the Public Health Committee to issue the following few rules of precaution, and at the same time to point out that everyone suffering from catarrh or influenza is a likely source of infection to others, that some of the persons so infected may die as the result of this infection, and that it is the duty of everyone at the present time to observe any rule which has for its object the prevention of the spread of this disease. Precautions— 1. Isolation.—Every person feeling ill or suffering from fever during the prevalence of influenza should remain at home and consult a doctor. 2. Personal precaution.—Infection is spread by the scattering of droplets of mucus from the nose and throat during coughing and sneezing. This should be prevented by the use of a handkerchief which should after use be boiled, or, if of paper, burnt. 3. Relapses.—Influenza patients are very subject to relapses, and pneumonia may occur as a complication. Relapse is less likely to occur if the patient takes to bed at the first onset of symptoms, and remains there until all fever has gone. During recovery, for the same reason, chills should be avoided. 4. Complications.—These are often set up, especially pneumonia, by a septic condition of the mouth or throat. Any such condition of the teeth or throat should have special attention. 5. Nursing.—Good nursing is important in preventing complication and in helping recovery from a severe attack. 22 6. Medicinal preventives.—The throat should be gargled every morning and evening with the following disinfecting solution:— Two grains of permanganate of potash and four grains of common salt in one pint of water, a little of this may be poured into the hollowed palm of the hand and snuffed up the nostrils, two or three times a day. 7. General.—(a) Occupied bed and living rooms and workplaces should be well ventilated, and flushed at intervals with air by opening doors and windows. This implies the need for sufficient warm clothing, especially for the young and old and those engaged in sedentary occupations. (b) Overcrowding in dwellings, workplaces, or in public places of assembly, or in public vehicles should as far as possible be avoided. (c) Mental strain, over fatigue or excessive drinking favours the spread of infection (d) Dirtiness, whether personal or of living or working rooms also favours the spread of infection. (Sgd.) J. KING WARRY, M.D., &c., Medical Officer of Health. Diarrhoea.—The total number of deaths due to this cause was 55, of which 21 were registered as diarrhoea and 34 as enteritis or gastro-enteritis ; and of these 42 were under one year of age. The annual mortality rate for diarrhoeal disease is .28 per 1,000 living. CONSTITUTIONAL DISEASES. PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Under these regulations, 1,063 notifications of cases of pulmonary tuberculosis were received during the year 1918, of which 270 were duplicates; also 131 non-pulmonary notifications, of which 22 were duplicates. The following tables A and B give the age and sex distribution of the notified cases. Summary of Notifications during the period from the 30th December, 1917, to the 28th December, 1918. Age-periods Notifications on Form A. Number of Primary Notifications. Total Notifications on Form A. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 and upwards. Total Primary Notifications. Pulmonary Males — — 15 12 61 56 159 148 65 36 2 554 620 „ Females — 2 5 21 35 35 58 43 18 7 3 227 261 Non-pulmonary Males 2 6 8 8 5 2 3 3 1 2 — 40 45 „ „ Females 4 5 7 12 14 3 5 2 2 — — 54 63 Age-periods Notifications on Form B. Number of Notifications on Form C. Number of Primary Notifications. Total Notifications on Form B. Poor Law Institutions. Sanatoria. Under 5 5 to 10 10 to 15 Total Primary Notifications. Pulmonary Males 1 1 2 4 4 36 120 „ Females — 6 2 8 8 26 50 Non-pulmonary Males — 6 4 10 12 1 6 „ „ Females — 4 1 5 5 — 1 23 24 Bacteriological examination of sputa from 287 cases was made during the same period. In 44 of these examinations the specific organism of the disease was found ; in 243 the results were negative. The number of deaths from tuberculous disease in Hackney during 1918 was 371. These deaths are classified as follows:— Tuberculous phthisis 292 Phthisis 15 General tuberculosis 8 Tuberculous meningitis 32 „ peritonitis 7 Tabes mesenterica 2 Tubercle of other organs 15 371 This number of deaths gives an annual mortality of 1.8 per 1,000 living. ACTION TAKEN DURING THE YEAR 1918. The action taken includes disinfection of rooms and the articles infected by tuberculous patients, inspection of dwellings occupied by tuberculous persons, and the removal of any condition prejudicial to health, instruction of patients in measures to prevent the spread of the disease, and the gratuitous supply of sputum flasks, the number of these supplied during the year being 82. During the year 2,617 visits were made by the Tuberculosis Health Visitors to patients, including 149 visits to discharged soldiers and sailors. TREATMENT—TUBERCULOSIS DISPENSARIES. A.—Dispensary at Victoria Park Hospital.—During the year 1918 there were 1,241 new patients examined at the Dispensary, 584 males and 657 females. Of the total 401 were insured and 840 25 uninsured persons. Examination showed that 202 had pulmonary tuberculosis, and 44 non-pulmonary tuberculosis ; while 63 were doubtful and 932 were not suffering from tuberculosis. Contact Cases.—There were 701 contact cases examined, of which 12 were found to be tuberculous, 22 doubtful and 667 non-tuberculous. Attendances.—The total number of attendances during the year was 4,779. B.—Dispensary at Metropolitan Hospital.—During the same period 864 new patients were examined at this Dispensary, 450 male and 414 female. Of the total, 298 were insured, and 566 were uninsured persons. Examination showed that 274 had pulmonary tuberculosis, and 18 non-pulmonary tuberculosis ; while 68 were doubtful, and 504 were not suffering from tuberculosis. Contact Cases.—There were 411 contact cases examined, of which 24 were found to be tuberculous, 20 were doubtful, and 367 non-tuberculous. Attendances.—The total number of attendances during the year was 3,546. DAY SANATORIA. On the recommendation of the late Medical Officer, the Council resolved that the Tuberculosis Dispensary Scheme of the Borough be extended to include the provision of one or more Day Sanatoria, and that a scheme be prepared showing in detail particulars as to proposed site, total cost, and proportion of the cost to be contributed by the Local Government Board and the London County Council. (For report on this subject see Appendix, page 60.) Cancer.—There were 236 deaths during 1918 due to the different varieties of malignant disease. The annual mortalityrate from malignant disease for last year is 1.2 per 1,000 living. 26 Alcoholism.—One death was registered during last year as due to acute alcoholic poisoning, and 12 deaths registered as due to cirrhosis of the liver, a condition regarded as being caused by excessive indulgence in alcohol extending over lengthy periods. PUBLIC HEALTH (LONDON) ACT, 1891. (a) Complaints of Nuisance.—During the year 1918 there were 1,890 complaints of nuisance made to the Public Health Department and investigated by Sanitary Inspectors of the Borough. Defects or nuisance were discovered in 1,425 of the complaints. Notices for the remedy or abatement of these were served upon the owner or person responsible under the above Act. (b) Infectious Disease.—The occupied dwellings inspected during the year after infectious disease numbered 1,347. This is an increase of 18 upon the number inspected during 1917. Any nuisances or defects found were dealt with under the provisions of the above Act, (c) House-to-House Inspections.—The number of house-to-house inspections made by the Inspectors during the year was 312. These inspections are in addition to those made under (a) and (b). The nuisances or sanitary defects found were dealt with in the same manner as those under (a) and (b). Nuisances or defects found on inspection were remedied in most cases on service of an intimation notice only. The total number of such notices served during 1918 was 2,629. The number of Statutory Notices served was 228. Legal proceedings were initiated in 23 cases. ARTICLES OF FOOD SEIZED OR SURRENDERED AS UNFIT FOR FOOD. During the year the following articles of food were seized by the Inspectors, with the exception of Mr. Bobbitt (Food Inspector), or surrended to them as being unfit for food, viz: fish 7¾ cwt.; 27 meat 3i cwt. ; tinned foods 1¼ cwt. ; eggs 680; margarine and butter 71 lbs.; tea 250 lbs.; coffee 50 lbs.; biscuits 58 lbs.; carbonate of soda 1¼ cwt.; cream of tartar \ cwt.; sugar 1½ cwt.; flour 140 lbs. ; rabbits 134. (For further particulars of food surrendered, see report of Food Inspector, below). REPORT OF FOOD INSPECTOR FOR THE YEAR 1918. In January, 1917, owing to the absence of several inspectors on war service, I was instructed to discontinue the greater part of my usual work and take charge of sections of Nos. 4 and 9 Sanitary Districts. These duties I continued to carry out until the return of Mr. White in November, 1918, from military service, when I again took up the work of inspecting dairies, cow-sheds, slaughter-houses and food inspection generally. Considerable time during the year has also been devoted to the work under the Food Control Orders. Dairies' and Milkshops.—One hundred and thirty-eight visits were made to these and 3 dirty unwashed measures found. Four new milksellers have been registered. One summons has been heard under the Dairies, Cow-sheds and Milkshops Order resulting in a fine of £2 and £2 2s. costs. Cow-houses.—Seventeen visits were made to cow-houses. Several were found in a very dirty and neglected condition. These were all cleaned without the service of a notice. Offensive Trades.—One visit was made to the only offensive business in the Borough and this establishment was found in a satisfactory condition. Slaughter-houses and Meat Inspection.—Fifty visits were made to slaughter-houses in the Borough all of which were found in a satisfactory condition. I examined the carcases and organs of 28 41 oxen, 5 cows, 280 sheep, 25 pigs, 30 calves and 5 goats. The following I found diseased and had removed and destroyed:— Carcase and all the organs of an ox affected with tuberculosis. Carcase and all the organs of a cow affected with tuberculosis. Sheeps' plucks, 3 affected with parasitic cysts. Ox livers, 2 affected with distoma hepaticum. Ox liver, 1 affected with abscess. Miscellaneous Inspections and Unsound Food.—During the year I have examined quantities of imported bacon and hams, approximately 250 tons, at the premises of a wholesale provision dealer and bacon dryer who at the request of the Ministry of Food dealt with parcels of faulty bacon and hams which had to be cleansed, smoked and after inspection disposed of to tradesmen with a quick sale who were given permits to sell the same free of coupon. This entailed a large amount of work in examination for taint, etc., and 4 tons 8 cwt. 2 qrs. 27 lbs. were condemned and sent to the soap boilers. Four hundred and fifty-six visits and enquiries have been made on complaint and in connection with the sale of food. The following have been destroyed:— 1 carcase of imported lamb. 11 pigs' plucks. 83 lbs. of bacon. 35 lbs. of cheese. 25½ lbs. of margarine 24 lbs. of chitterlings. 460 rabbits. 1 box of imported rabbits. 910 imported eggs. 12 bags of potatoes. 29 13 boxes of chocolate truffles. 1 box of coal fish. 17 boxes of kippers. 4 boxes of bloaters. 2 boxes of mackerel. 2 boxes of crayfish. 1 case of dabs. 1 case of mackerel. 2 bushels of winkles. 18 cwt. 2 qrs. 8 lbs. of imported beef. Arthur J. Bobbitt, Inspector of Meat and other Foods. The following statement refers to the milk-places, cow-sheds, slaughter-houses and offensive trades in the Borough:— Premises. Number of Places. Number of Inspections, 1918. Number of Notices, 1918. Number of Prosecutions. On Register at end of 1917. Added in 1918. Removed in 1918. On Register at end of 1918. Milk premises 287 6 21 272 138 — 1 Cow-sheds 15 — — 15 17 — None. Slaughter-houses 20 — 1 19 15 — ,, Other offensive trade premises 1 — — 1 — — ,, Preserved Provision Manufacturers.—These have been periodically inspected by Inspector Bobbitt during the year. Smoke Nuisances.—There were 7 notices served for the abatement of smoke nuisances during the year. 30 Water Supply.—No certificates for proper and sufficient water supply under Section 48 (2) of the Public Health (London) Act, 1891, were applied for during the year. Bye-laws for Houses let in Lodgings.—The number of these houses on the Register at the end of 1918 was 470. Of these 117 were inspected during the year and any defects found were remedied by the service of a notice. CUSTOMS AND INLAND REVENUE ACT, 1890. No certificate for exemption from Inhabited House Duty was granted during 1918. ICE-CREAM VENDORS. At the end of 1918 there were 112 ice-cream premises in the Borough, all of which were inspected during the year. GLANDERS AND FARCY ORDER, 1907. No notification of this disease was received during 1918. DISEASE OF ANIMALS ACT.—ANTHRAX ORDER OF 1910. No notification of anthrax in animals in the Borough was received during 1918. HOUSING, TOWN PLANNING, etc., ACT, 1909. Flooding of cottages by overflow of River Lee. On the recommendation of the late Medical Officer the Council decided to issue closing orders for each of the following cottages:— Retreat Place, Nos. 1 to 8, consecutive numbers. Spring Lane, Nos. 4 to 16, even numbers. Spring Lane, Nos. 38 to 64, even numbers. Middlesex Wharf, Nos. 20 to 42, even numbers. Middlesex Wharf, Nos. 57 to 91, odd numbers. 31 The Council also decided to draw the attention of the Local Government Board to the serious floodings of the Lee Valley with a view to immediate action being taken to prevent these occurrences ; also that the Lee Conservancy Board be asked to apply pressure to forward the carrying out of the Lee Valley Drainage Scheme which has been under consideration for some years. (For report of late Medical Officer on this subject, see Appendix, page 67.) MATERNITY AND INFANT WELFARE. During the year important developments in the scope of this work have taken place in certain directions which promise to have important and beneficial results in the future upon the health both of mothers and children. One development was the institution of two ante-natal centres in the Borough, one in connection with the "All Souls'" Infant Welfare Centre, and the other in connection with the " Brooksbys' Walk " Infant Welfare Centre. Another development was the issue on the 18th February by the Food Controller of" The Milk (Mothers' and Children) Order, 1918," which gives to local authorities the power to arrange for the supply of food and milk to expectant and nursing mothers and of milk for children under five years of age, subject to the following conditions:— 1. The quantities of food and milk to be supplied shall not in any case exceed the amount certified to be necessary by the Medical Officer of Health, or the Medical Officer of a Maternity or Child Welfare Centre working in co-operation with the local authority, or by a person authorised in his behalf by either of such Medical Officers, or by some other person appointed by the local authority for this purpose. 32 2. In necessitous cases in which the Medical Officer of Health or the Medical Officer of a Maternity or Child Welfare Centre working in co-operation with the local authority, or any person authorised in that behalf by either of such Medical Officers, or by some other person appointed by the local authority for this purpose, certifies that the provision of food or milk may be supplied free or may be sold at less than cost price. With respect to the establishment of the ante-natal centres, the "All Souls' " Centre was opened on the 1st August, and that at Brooksby Walk on the 7th August, so that these centres were open during, practically, the last five months of the year. The results achieved have been quite satisfactory, but the former shows a much better attendance than the latter-named centre. The following table gives this and other information relating to the Centres:— Ante-natal Welfare Centres, 1918. All Souls. Brooksbys Walk. Number of time Centre opened 17 12 Number of expectant mothers attending 76 23 Number of repeated attendances at Centre 63 16 Total attendances 139 39 Number of visits to expectant mothers at their homes by the Health Visitors:— Number of cases 68 23 Number of visits 68 21 The value of the year's work in connection with these centres however, must not be estimated solely by the number of patients attending. The medical reports will indicate more correctly the worth of the Centres. It must be remembered also, that the growth in the attendance at a Maternity Centre is always slow. It 33 is a new idea both to old-fashioned midwives as well as to expectant mothers to prepare the way for a safe delivery by the early removal of any adverse causes ; consequently some midwives and expectant mothers do not look very favourably upon Maternity Centres. However, the nett result of the year's work is distinctly encouraging. Certain measures are in preparation which, it is confidently believed, will increase the attendances. In regard to the Milk (Mothers' and Children) Order, 1918, some little time elapsed before this was applied to many cases in the Borough. However, by the end of the year, a considerable number of necessitous cases were receiving milk under its provisions. The procedure observed in all cases is as follows:—Where a case is mentioned by the Medical Officers of the Centres, an enquiry is made by a Health Visitor as to its necessitous character. The nature of the enquiry may be seen from the following form of enquiry used by the Health Visitor in these cases. Enquiry form re grant of milk to expectant or nursing mothers, or children under five years of age. Financial Circumstances. Name Address Maternal or Infant Centre attended No. of persons in family No. of rooms occupied Rental of home Estimated weekly income of family from all sources Remarks Enquiries made by Date of enquiries Health Visitor. If the circumstances show the case to be necessitous, an order is given for milk, to be supplied to the patient by the usual milk vendor, to the amount and for the time recommended by the doctor attending the Welfare Centre. Milk supplied free of cost to necessitous cases during the year involved the Council in an expenditure of £114 3s. c 34 (Report upon Ante-natal Welfare by the late Medical Officer, see Appendix, page 70.) Infant Centres. The year's work at these Centres has been particularly good, even in normal peaceful times the results would be considered good, but the past year has been one of unexampled anxiety and distress in the Borough, and attendance fell off on many occasions during the year owing to anticipated air raids, or as a result of those which actually occurred. Many mothers at times could not attend because they had to wait long hours in queues at provision shops, often to find, long before their turn came to be served, that the stock had been sold out. In spite of these and many other drawbacks, the average attendance on the whole was distinctly good. The following is a table setting forth these attendances, etc., at the three municipal Infant Welfare Centres and the two Voluntary Centres:— Summary of Infant Welfare Centre Work during the Year 1918. Centre. No. of times Centre open. No. of primary cases brought to Centre. Repeated visits to Centre. Total attendances Total attendances of Infants under 1 year. Total attendances of children over 1 year. 1. All Souls, Overbury Street 51 375 2,666 3,041 2,254 787 2. Brooksby Walk 51 395 2,221 2,616 2,168 448 3. Mayfield Road 52 310 1,625 1,935 1,554 381 4.*Hackney Mothers' and Babies', Hackney Grove. 50 299 1,400 1,699 1,220 479 5.*Eton Mission, Gainsborough Road. 49 147 730 885 681 204 Total 253 1,526 8,650 10,176 7,877 2,299 * These are Voluntary Centres and are co-ordinated with the Infant Welfare work in the Borough. The Hackney Mothers' and Babies' Welfare Centre receives an annual grant of £100 from the Council. 35 These figures shew how well appreciated the Centres are by the mothers, and there is little doubt that they will become very popular. The total attendances exceeded those of 1917 by 4,507, those under one year by 2,886 ; while the children over one year were approximately more than doubled in number. Home Visitation.—In spite of one or two changes in the staff of Health Visitors during the year, the work of home visitation did not suffer. The following table gives detailed results of these visits:— Particulars respecting the feeding, care and environment of the infants visited at their homes by the Health Visitors during the year 1918. No. of Infants visited. Method of Feeding. Separate cot provided for Infant. Use of Comforter. Home conditions. Secondary visits. Breast. Artificial. Mixed. Yes. No. Yes. No. Satisfac tory. Unsatis factory. 1,824 1,426 206 192 605 1,219 1,134 690 1,651 173 5,153 Food and drugs, &c., set out below to the value of £1,551 14s. 1d. were supplied at cost price, at the Municipal Welfare Centres during the year: £ s. d. Glaxo 963 10 0 Lactogen 59 10 0 Cow and Gate 174 6 8 Mellin's Food 15 9 7 Virol 97 15 3 Condensed Milk 132 12 0 Sugar 5 0 6 Lactagol 6 19 3 Marylebone Cream 12 11 9 Petroleum Emulsion 19 19 0 Svrup. Ferri 19 18 3 Malt 5 0 6 Cod Liver Oil and Malt 13 17 6 Sundries 25 13 10 £1,551 14 1 In addition dried milk and drugs, &c., of the same character to the value of £23 8s. 2d. were supplied to mothers free of cost. c2 36 MATERNITY AND CHILD WELFARE ACT, 1918. The powers under this Act were delegated to the Public Health Committee by the Council in December, 1918, and a Maternity and Child Welfare Committee was appointed consisting of the members of the Public Health Committee together with three co-opted members, who were engaged on social and infant welfare work in the Borough. This Committee met for the first time on 2nd January, 1919. The following are reports of the Medical Officers of the Borough Council's Infant Welfare Centres on the cases attended at the Centres during the year 1918:— Brooksbys' Walk, Homerton, Infant Welfare Centre. During 1918, 465 mothers with their babies attended the Centre; of these 365 were new cases. 2,616 visits were paid by the mothers. During the year, so far as can be ascertained, nine of the children died—1 of meningitis, 4 of diarrhoea and vomiting, and 4 of pneumonia. No child died of any complaint that was being attended to at the Centre ; all deaths were due to intercurrent disease. A very large amount of advice has been given to mothers in regard to the feeding of their children and to general questions of hygiene. One case of congenital syphilis presented itself and was much benefitted by the treatment. Another doubtful case was sent with a note to the London Hospital, but I have not yet heard if a Wasserman reaction has been tried. Two cases of Mongolian imbecility, and 1 of mental deficiency were diagnosed, and the mothers were advised of the condition, and asked to attend regularly for observation to be kept. 37 Two cases of congenital heart disease were found and the mothers similarly advised. One marked case of tetany was sent with a card to the Queen's Hospital for Children and admitted. This case made a good recovery from a very serious condition, and is, I believe, now doing well. One case of marasmus was carefully treated at the Centre with marked improvement, and was sent with a letter to Dr. Robert Hutchinson, the Hospital for Sick Children, Great Ormond Street. He kindly saw the child and wrote me in regard to its diet; when last seen it was slowly improving. I should like to take this opportunity of thanking Dr. Hutchinson for his invariable kindness in seeing any cases I may send, and personally writing to me about their condition and advising me in regard to their treatment. Nine cases of rickets, 4 cases of impetigo, and 1 case of acute eczema were treated with good results, while 2 cases of tonsillitis were referred to their own doctor. One case of hydrocephalus was advised. I should like to bring before your notice the splendid work done by my staff. They have been very patient and tactful, and of the greatest help to the work of the Centre. The Centre has, I finally believe, proved of great value to the many mothers who have attended it. It has enabled them to obtain advice in regard to the rearing of their babies, to obtain dried milk when the milk supply was in a very difficult position, and in suitable cases, to obtain grants of free milk. This last benefit has been of tremendous practical help to some poor mothers who have been very grateful for it. Ante-natal Centre. Since the opening of the Centre, 23 women have presented themselves for examination or advice. Of these 19 were pregnant, while 4 came up for advice in regard to various gynaecological conditions. 38 The following abnormal cases were observed:—One case in which the patient had had four premature labours, with a dead child in each. This patient was examined carefully and sent to the London Hospital for a Wasserman reaction of her blood to be made. This proved negative, and the patient has since been delivered of a healthy child and is now attending the Infant Welfare Centre. One case of glycosuria was discovered, but this cleared up entirely after partutition. In one case a woman with a small round pelvis was advised in regard to her third pregnacy. One case of procidentia uteri was treated by a support being introduced, with very great relief to the patient, who now attends regularly for this purpose. I feel that this Centre offers opportunities of the highest importance in the conserving of child life to expectant mothers; but the number of mothers presenting themselves so far has been small. It is, therefore, in my opinion, essential to the greater success of the Centre to obtain the cordial co-operation of the midwives practicing in this district. (Sgd.) Reginald Brown, M.R.C.S., etc. All Souls, Clapton, Infant Welfare Centre. Ante-natal Centre. Of the 76 cases which have so far attended the clinic, 28 have been strictly ante-natal, and have for the most part been sent up by the local midwives for examination. These have mostly been primiperae, or women whose previous confinements have been abnormal in some way. The majority of these expectant mothers have been assured that they may look forward to a normal confinement, and some of them have come up occasionally for advice. In several cases of slight pelvic contraction and abnormal position, the midwife has been informed, and the patient has been kept under observation for the remainder of the pregnancy. Forty women have attended as post-natal, frequently complaining of anaemia and debility associated with threatened failure of lactation ; to these the milk supplied to poor women by 39 the Borough Council has been of great value. Six women have attended for sterility, or to ascertain the cause of frequent miscarriages, etc. In quite a considerable minority of cases an unexpected disease has been discovered, and this has necessitated the sending of the patient to a hospital for operation or for further treatment. The diseases thus discovered have been syphilis, 2 cases; gonorrhoeal phthisis, 3; fistula, 1 ; haemorrhoids, 1 ; tape-worm, 1; heart disease, 1 ; albuminuria, 1. In most of these cases no doctor would have been consulted at an early stage had the patient not attended the clinic. The most urgent need for these women is a Dental Clinic, for the teeth frequently are in a very bad condition. Infant Welfare. The infants brought are generally normal, although a surprisingly large number suffer from small ailments, which are treated at the clinic or elsewhere. There has been the usual proportion of premature or abnormally small babies, weighing from 4½ to 6 lbs. at the first attendance; a few of these are now among our finest babies, but during the year a considerable number of them have died. The mothers need and desire an immense amount of teaching, I see the children and mothers in groups, and discourse a little about each child in order to make the clinic an educational centre ; my little can only be done owing to want of time, yet there is no doubt that knowledge about the bringing up of children is spreading in the district, partly through the clinic, partly through the instructions given in the homes by the enthusiastic Health Visitors. The Borough Council milk has been invaluable to some of the babies, who had previously had none or an insufficient supply; the weight increases very rapidly, and after a few weeks the child has changed from a pale, flabby, spiritless being into a robust and healthy little person. (Sgd.) Elizabeth Wilks, M.D., B.Sc. 40 Mayfield Road Infant Welfare Centre. Owing to the serious illness of Dr. J. W. Hunt, the Medical Officer of this Centre, a special report other than the statistics given on page 34 is unobtainable. " John " Day Creche. This creche is now co-ordinated with the Infant Welfare work in the Borough, and the Council, towards the end of the year, decided to make an annual grant of £100 towards its expenditure, provided that a proper account of income and expenditure of the creche be audited by a chartered accountant and presented annually to the Council. The Board of Education also contributed towards the cost of £112 for the financial year, April, 1918, to March, 1919. MEDICAL ASSISTANCE TO MIDWIVES. Arrangements were made under Section 77 of the Public Health (London) Act, 1891, for the provision of the services of a doctor when medical assistance is required by a midwife for aid in confinement of necessitous women, and the following scale of fees were approved:— 1. Attendance at cases requiring operative assistance and subsequent visits during the first ten days, £2 2s. 2. Attendance at cases without operative assistance and subsequent necessary visits during the first ten days, £1 1s. 3. Any visit not covered by 1 or 2, including any necessary prescription:—Day (8 a.m. to 8 p.m.), 3s. 6d. ; Night (8 p.m. to 8 a.m.), 7s. 6d. During the year, fees amounting to £23 16s. were paid. THE FACTORY AND WORKSHOP ACT. 1901. Factories.—During the year 249 factories were inspected by the officers of the Public Health Department, 16 being factory 41 laundries, and 233 factories in which articles of clothing, &c., were made and altered. In 24 of these factories, the sanitary accommodation was defective, unsuitable, or insufficient:— Nuisance. Found. Abated by Workshop Inspector. Abated by District Inspector. Outstanding Total. Unsuitable or Defective w.c.'s 19 18 — 1 19 Insufficient W.C. Accommodation 4 4 — — 4 Not separate for the sexes. 1 1 — — 1 Workshops.—The number of workshops registered in Hackney at the end of 1918 was 987, a decrease of 52 on the number registered at the end of 1917. Of this total, 681 were workshops in which females were employed. Of these latter, 440 were workshops in which articles of wearing apparel were manufactured, altered or prepared for sale, etc., 209 in which other articles were manufactured, etc., and 32 were domestic workshops. Amongst the workshops manufacturing wearing apparel, there were 304 employing females alone, and 136 employing both males and females. In workshops of other occupations, there were 130 employing females alone, and 79 employing both males and females. Of the domestic workshops, females alone were employed in 19, and both males and females in 13. During the year notices and complaints were received from H.M. Inspectors of Factories, as follows:— Complaints Factories 9 ,, Workshops 2 Notices „ 38 42 Analysis of Occupations Carried on in the Registered Workshops of Hackney. (a) Wearing Apparel. Occupations. No. of Workshops. Occupations. No. of Workshops Artifical Flower Makers 7 Sats 7 Baby Linen 2 Infants' Millinery 7 Beading 1 Mantles 50 Belts 1 Millinery 35 Blouses 40 Needlework 0 Boot and Shoe Manufacturers 53 Pinafores 0 Shirts 2 Boot Machinists 109 Stays 7 Children's Costumes 9 Tailoring 61 Clerical Robes 1 Ties 31 Clothing 5 Trimmings 10 Collars 1 Underclothing 13 Dressmakers 62 Vests 7 Dressing and Tea Gowns 3 Waterproofs 4 Fancy Bows on Shoes 5 596 Fall Net Chenilling 0 Furriers 63 (b) Other Occupations. Bakers and Confectioners 35 Rubber Goods 5 Baskets 4 Toy Makers 6 Box Makers 20 Trunk and Bag Makers 8 Brush Makers 10 Umbrella Makers 2 Cabinet Makers 63 Upholsterers 11 Doll Manufacturers and Dressers 9 Upholsterers' Trimmings 3 Miscellaneous 120 Fancy Leather Goods 30 391 Laundries 45 Pianoforte Makers 20 During 1918 Miss Teebay, the Workshops Inspector, made 2,447 inspections and re-inspections of factories and workshops where females are employed. In connection with these inspections 237 intimation and 32 statutory notices were served for the abatement of the nuisances found. 43 Outworkers.—The number of outworkers on the register at the end of 1918 was 1,988, against 1,884 at the end of 1917. The following analysis shows the trades followed by these outworkers:— Trade. No. of Outworkers. rs. Trade. No. of Outworkers. Artificial Florist 46 Hats 7 Baby Linen 4 Lace Trimmed Goods 1 Belts 16 Millinery 92 Blouses 241 Shirts 56 Boots and Shoes 422 Shoe Bows 4 Boxes 141 Skirts and Mantles 148 Braces 1 Tailoring 72 Brushes 172 Ties 47 Canvas Goods 4 Trimming 64 Children's Costumes 12 Umbrellas 4 Clothiers and Outfitters 70 Underclothing 42 Collars and Bibs 8 Upholsterers' Trimmings Confectionery Packing 11 Miscellaneous 136 Dolls 117 1,988 Fancy Goods 8 Fur Trade 32 In addition 2,462 names and addresses of outworkers residing in Hackney and receiving work from other districts were forwarded by the Local Authorities concerned. On examination of the list of outworkers sent in by employers in this Borough the addresses of 2,301 were found to be in other districts, and these names and addresses were forwarded to the local authorities of the respective districts. During the year 1918 Miss Portlock (the Inspector appointed for the inspection of outworkers' premises) made 1,376 inspections and 984 re-inspections. She also made 487 visits which were fruitless on account of wrong addresses, or because the home-worker had given up work. 44 Miss Portlock also discovered 5 new workshops and handed in their addresses for registration. During her visits of inspection Miss Portlock found 365 outworkers' premises with sanitary defects. For the abatement of these she served 308 intimation notices. Of the 1,376 outworkers' premises inspected, in only 55 was a room set apart entirely for work. COMBINED DRAINAGE WORKS REFERRED TO THE BOROUGH ENGINEER AND SURVEYOR DURING 1918. During this year 1 notice of defective system of combined drainage works was referred for consideration to the Surveyor. DISINFECTION. (a) Rooms.—During 1918 2,002 rooms were fumigated, and 106 rooms were cleansed by the staff of the Public Health Department. These totals include disinfections after measles, whooping cough and tuberculosis, in addition to those in connection with notifiable infectious diseases. (b) Articles of Clothing, Furniture, etc.—The number of articl under this head disinfected during last year was as follows:— House linen and furniture 9,455 Men's clothing 98 Women's clothing 113 Children's clothing 46 Other articles 1,779 Total 11,491 (c) Public Library Books.—During the past year 167 books from homes in which infectious diseases had occurred were disinfected. 45 THE SHELTER. During 1918 no persons were admitted to the shelter. CLEANSING OF PERSONS ACT, 1897. The baths provided by the Borough Council under the above Act for the cleansing of verminous persons were in constant use during last year, 4,218 baths being given during that period. This total shows an increase of 2,054 upon the number given during 1917. Of the 4,218 baths given, 3,779 were sulphur baths for scabies and 439 for pediculi. The great majority of those persons presenting themselves for baths were children from the elementary schools in the Borough. These children received 3,965 baths, an increase of 1,870 upon the number given during 1917. Of those persons receiving hot baths, 18 were men, 4 women and 417 children; of those receiving sulphur baths, 19 were men, 112 women and 3,648 children. LONDON COUNTY COUNCIL (GENERAL POWERS) ACT, 1904. During the year attention was drawn by the Medical Officer (Education) of the London County Council to 190 houses in the Borough from which children were attending school in a verminous condition, and they asked the Council to deal with them under the above Act. These houses were inspected, with the result that of the 190 homes, 8 only were found to have verminous rooms. REMOVAL AND DISPOSAL OF HOUSE REFUSE. The total quantity of refuse removed from occupied houses in the Borough by the Council's contractors during the year 1918 amounted to 29,326 tons, 19 cwts, at a total cost of £11,992 17s. 9d. In addition the contractors removed 846 loads of clinker from institutions at a cost of £282 5s. 6d. 46 THE MORTUARY. The following tables give the number of bodies deposited in the Mortuary during the year, also the number of inquests held there, with the causes of death, etc.:— Number of bodies deposited in the Mortuary 445 1. To await inquests—(a) Infectious 5 (b) Non-infectious 400 2. To await burial 40 Number of post-mortems made 132 INQUESTS. Verdicts. Sex. Male. Female. Natural causes 140 141 Accidental death 46 47 Suicide 12 9 Open Verdict 1 2 Murder 1 1 Misadventure 2 3 Total 202 203 47 SALE OF FOOD AND DRUGS ACTS. Samples purchased during 1918. Article. Number Purchased. Number Adulterated. Number where proceedings taken. Milk 590 44 24 „ (Condensed) 6 — — Butter 51 1 1 Margarine 16 — — Dripping 3 — — Cocoa 42 — — Coffee 42 1 — Arrowroot 25 — — Custard Powder 6 — — Cornflour 12 — — Tapioca 1 — — Flour 24 — — Maize flour 2 — — Pepper 13 — — Mustard 11 — — Ground Rice 18 — — Confectionery 12 — — Baking Powder 9 — — Vinegar 6 — — Semolina 5 — — 894 46 25 48 WARRANTIES.—SALE OF FOOD AND DRUGS ACTS. Towards the end of 1918, the late Medical Officer again reported to the Public Health Committee the result of prosecutions for adulterations under the Sale of Food and Drugs Acts, and that these results had been frequently unfavourable to the Council, many summonses having been dismissed owing to the production of a warranty by the defendants at the hearing of the summons; also that this form of defence was becoming so popular and successful, especially with milk vendors, that the Council could not be certain of obtaining a conviction in any particular prosecution for adulteration of milk or butter. Upon the recommendation of the Public Health Committee the Council resolved— "1. That the Borough Council press upon the Local Government Board, the Board of Agriculture and the Food Controller, the necessity for the repeal of the warranty clauses in the Food and Drugs Acts. 2. That the Borough Council ask the Metropolitan Borough Councils to support the action of the Hackney Borough Council. 3. That a copy of the report of the Medical Officer of Health be forwarded to the Local Government Board, the Board of Agriculture, the Food Controller and to each of the Metropolitan Borough Councils." (For report on this subject, see Appendix, page 54.) 49 Prosecutions under the Sale of Food and Drugs Acts during the year 1918. No. of Sample Article. Adulteration or Offence. Result of Legal Proceedings. Fine. Costs. £ s. d. £ s. d. 61J Milk 16.7% fat abstractec Withdrawn on payment of — 5 5 0 Obstructing Inspector Dismissed — — 75j „ 2.94% added water Fined 1 0 0 4 4 0 137J „ 8.58% Dismissed. (Warranty proved). — — 76k „ 6% Fined 5 0 0 1 11 6 138k „ 2.12% Dismissed. (Warranty proved.) — — 33l „ 2.83% Withdrawn on payment of — 2 2 0 29l „ 3.3% fat abstracted. Dismissed. (Warranty proved.) — — 61l „ 10% „ „ — — 67l „ 2.35% added water Dismissed. £1 1s. costs against Council. — 101l 139l „ 4.71% Dismissed. (Warranty proved.) — — „ 36.7% fat abstracted „ „ — — 125l „ 837% Ordered to pay — 0 12 6 16.12% added water 2m Butter 4.2% excess of water Withdrawn by order of Public Health Committee. — — 38m Mil„Vk 15.88% added water Fined 10 0 0 2 2 0 41m „ 4.36% Dismissed. (Warranty proved.) — — 130m „ 318% Dismissed — 29l „ Giving false warranty to milk vendor. „ — — 61l „ „ „ — — 101l „ „ „ „ — — 138k „ „ „ „ — — 139l „ „ „ Dismissed on payment of — 3 3 0 41m „ „ „ „ „ — 2 2 0 139n Margarine Served in plain wrapper. Dismissed — — 140n „ — — 139n „ Exposed for sale unlabeled. Fined 0 10 0 — 141n „ „ „ „ 1 0 0 1 1 0 143N „ Served in plain wrapper. „ 0 10 0 D 50 Prosecutions under the Sale of Food and Drugs Acts during the year 1918—continued. No. of Sample. Article. Adulteration or Offence. Result of Legal Proceedings. Fine. Costs. £ s. d. £ s. d. — Failing to adopt precautions for preserving the purity of milk. Fined 0 0 0 2 2 0 79p Milk 36.83% added water „ 20 0 0 - 80p „ 22.36% „ 20 0 0 15 15 0 54p Margarine Served in plain wrapper. Dismissed — - 54p „ Exposed for sale unlabelled. „ — 1 1 0 97p Milk 24.71% added water Fined 10 0 0 0 2 0 119p „ 16.7% fat abstracted Dismissed. £5 5s. costs against Council. - - 127p „ 4.59% added water Fined 2 0 0 1 10 0 128p „ „ „ Dismissed. (Warranty proved.) — — 156p „ 14.47% „ „ „ — — 137p „ 9.77% „ Fined 5 0 0 2 2 0 163p „ 5.88% „ Defendant moved away. Summons not served. - - 145p Margarine Served in plain wrapper. Fined 1 0 0 „ „ Exposed for sale unlabelled. „ 2 0 0 1 1 0 145p Milk Refusal to sell „ 2 0 0 1 1 0 £82 0 0 48 17 1 51 Prosecutions under the Public Health (London) Act, 1891, during the year 1918. Address. Complaint. Magistrate's Decision. Penalty. Costs. £ s. d. £ s. d. 171, Lower Clapton Road. Walls damp, roof leaky. Withdrawn. (Work done.) — 2 2 0 4, Wardle Street Roof and gutters defective. „ „ — 2 2 0 156, Morning Lane General insanitary condition. „ „ — 2 2 0 57, Berger Road Roof defective „ „ — 0 2 6 65, Wallis Road Defective rain water pipe and roof. House damp. Order to abate in 21 days. - 1 15 6 33, Felstead Street Roof defective and rooms dirty. Order to abate in 14 days. — 1 15 6 11, Sylvester Road General insanitary condition. Order to abate in 21 days. — 1 1 0 38, De Beauvoir Sq. Roof defective; rooms dilapidated. Withdrawn. (Work done.) — 2 2 0 18, Banister Street Dust bin defective. „ „ — 1 13 6 29, Essex Street Rooms dirty and dilapidated. „ „ — 2 2 0 134, Lansdowne Rd. Roof defective „ „ — 1 11 6 2, Walsingham Road W.C. and roof defective. „ „ — 3 3 0 425, Wick Road Rooms dirty and dilapidated. Order to abate in 14 days. — 2 2 0 44, Areola Street Defective drain Order to abate in one month. 2 2 0 19, Berger Road W.C. defective; no dust bin. Withdrawn. (Work done.) — 0 10 0 21, „ „ No dust bin Withdrawn. (Dust bin provided. 1 3 0 23, „ „ W.C. defective; no dust bin. Order to abate in 7 days. — 1 5 0 37, Felstead Street General dilapidation. Order to abate in 14 days. — 1 16 6 39, „ „ Roof and dust bin defective. „ „ — 1 16 6 24, London Road Leaky roofs Order to abate in 7 days. — 2 2 0 31, Navarino Road Area drain choked; roof and eaves gutters defective. Withdrawn. (Work done.) 2 2 0 104, Shrubl and Rd. House without water supply. Withdrawn. Water supply reinstated — — 35, Felstead Street Scullery sink without waste pipe; Passage walls and ceiling dilapidated. Withdrawn. (Work done.) 1 15 6 24, London Road Non-compliance with Magistrate's Order. Fined 2 0 0 2 4 0 Total 2 0 0 40 11 0 d 2 52 INSPECTION OF CANAL BOATS. During the year, 1918, there were not any inspections of Canal Boats. This was due to the facts that, on account of the great war, the staff of the sanitary inspectors was greatly depleted, and unable to cope with all the work; that the two inspectors specially detailed for Canal Boat Inspection were both absent on military service; and that the Government had commandeered very nearly all the canal boats for use us lighters. WORK OF THE STAFF OF THE PUBLIC HEALTH DEPARTMENT. It was the custom of the late Dr. King Warry to make in his Annual Reports some reference as to the performance of their duties by members of the staff of the Public Health Department; and, believing that any expression of appreciation on the part of the Head of a Department is valued by, and is an encouragement to, the staff, I feel that before closing this Report for the year, 1918, I ought to make some statement with respect to the manner in which the staff of this Department performed during the year mentioned the many and various duties which have to be dealt with, usually promptly and efficiently if full benefit is to be secured. My difficulty lies in the fact that I did not come into office here until the end of March, 1919, and, therefore, I cannot write of my own direct knowledge of events which occurred during 1918; but, if I may base a judgment upon the following facts— (a) That all the information, figures, statistics and records, with respect to the multiplicity of subjects dealt with in this report were promptly produced by the clerical staff when required; (b) That the clerical staff could not have collated the information required unless the Sanitary Inspectors, Health 53 Visitors, Tuberculosis Visitors, and other workers, had performed their duties and handed in their reports systematically and (c) That I have now had twelve months' personal experience of working with the staff, I feel that I am justified in assuming that the late Dr. King Warry, if he had lived, would have followed his usual custom, and would have expressed his appreciation of the sendees rendered by the whole staff of the Public Health Department during the year in question. Personally, although I do not know, I believe that during the year, 1918, the several groups of the staff did the work of the department promptly, efficiently and conscientiously, and in writing this I make no distinction between the groups,—Clerks, Sanitary Inspectors, Health Visitors, Tuberculosis Visitors, and others. I shall have something further to say on this subject when I am writing my Annual Report for the year, 1919. In conclusion, I desire to express my very sincere thanks to the whole of the Public Health Department for the very friendly manner in which all the members of the staff received me when I came among them as a stranger a year ago; for their hearty cooperation and ever-ready assistance at all times; and for their willingness to comply with all my wishes, sometimes, indeed, to anticipate them. My thanks are, perhaps, most expecially due to the clerical staff for cheerfully performing the drudgery of the work entailed in the preparation of this report, I am, Madam and Gentlemen, Your obedient servant, WILFRED W. E. FLETCHER. 54 (APPENDIX.) SUPPLEMENTAL REPORT ON THE USE OF WARRANTIES IN PROSECUTIONS UNDER THE SALE OF FOOD AND DRUGS ACTS. Public Health Department, Town Hall Hackney, E.8. 12th October, 1918. To the Chairman and Members of the Public Health Committee. Gentlemen, I beg herewith to present to the Committee as Supplement to my Report of the 25th May, 1915, further particulars as to the effect of the use of waranties as a defence on the administration of the Sale of Food and Drugs Acts. In the report referred to, I submitted the following propositions, viz.:— (1) The warranty defence is seriously and adversely affecting the administration of the Sale of Food and Drugs Acts. (2) It is encouraging the operations of an unscrupulous class of trader. (3) It is causing increased cost and great waste of time and energy on the part of public officers without any adequate return, with a corresponding loss of protection to the public against fraud. The facts referred to in my former report were drawn from the years 1910-14 inclusive. Since that period, further experience as to the baneful effects of the warranty defence has accumulated, from which it appears that it is slowly but surely paralysing the efforts of Local Authorities to administer the Sale of Food and Drugs Acts. This later 55 experience I propose to set before you, thus bringing our knowledge of the operations of the warranty defence in London up to the end of the year 1917, which, together with the facts given in my previous report, will constitute a record of eight years' London experience. I have only been able to obtain this information for the whole of London by receiving the cordial help of all the Medical Officers of the Health of the London Boroughs, for which co-operation, I gratefully tender my earnest thanks. In addition to the facts recorded in my last report, I have obtained information as to the extent and result of the pleading of warranties in London prosecutions during the years 1915, 1916 and 1917. This information I have arranged as in my last report, under the following heads :— (1) Number of summonses taken out under the Sale of Food and Drugs Acts during the respective years 1915, 1916 and 1917. (2) Number of convictions obtained during the same years. (3) Number of instances in which the production of a warranty by the defendant was successfully used as a defence. (4) Number of cases where the warrantor had been prosecuted, with results. During the three years in question, 3,244 summonses were issued in London against vendors under the Sale of Food and Drugs Acts, of which no less than 592 were dismissed owing to warranties being produced and proved, by the defendants. This amounts to over 18 per cent. of the total summonses. During the five previous years ending 1915, 12 per cent. of the total summonses were dismissed owing to the same cause. 56 In order to show more clearly the progressive increase in the successful use of the warranty defence, I give below a table showing in more detail the above figures grouped in biennial periods for the eight years 1910-1917 inclusive:— Biennial Periods. Total number of Summonses taken out in London under the Sale of Food and Drugs Acts. Number of Warranties used successfully as a defence. Percentage of Summonses dismissed. 1910-11 2,423 280 11.5 1912-13 2.184 266 12.1 1914-15 2,187 333 15.2 1916-17 2,113 393 18.6 1910-17 8,907 1,272 14.2 In the first period 1910-11, the percentage of dismissed summonses due to the pleading of warranties amounted to 11.5; in the last period 1916-17, the percentage had risen to 18.6, an increase of 7.1 per cent. These figures are startling enough, but they do not fully represent the mischievous effects of the warranty defence. It is only in certain classes of offences that the warranty defence is used. Although this defence is allowed in summonses under the Sale of Food and Drugs Acts, in practice it is only used in summonses for adulteration of dairy products such as milk, cream and butter. In the above table the prosecutions include many in which it would not be possible to plead a warranty in defence. As an illustration of this point, I refer to the prosecutions initiated in Hackney during the year 1916-17 for offences against the provisions of the Sale of Food and Drugs Acts. The total number of such prosecutions during this period was 56, but amongst these were the following:— Two summonses for refusing to sell. 57 One summons for absence of name and address on the milk barrow. Four summonses for exposing margarine for sale unlabelled. Six summonses for serving margarine in a plain wrapper. Thus 13 summonses were taken out for offences in which the warranty defence was not possible. The rate of dismissed summonses owing to warranty pleading calculated on the total summonses for the two years was 12.5 per cent., but if calculated only on those summonses where it is possible and usual to plead a warranty, the rate would be 16.3 per cent., an increase of 3.8 per cent. If we add this to the percentage of dismissals relating to all the London Boroughs, for I believe their experience is much the same as Hackney's, we get for the years 1916-17, a total percentage dismissal of 22.4. This figure more accurately represents the pernicious effect of the warranty defence on the efforts of Local Authorities to enforce the provision of the Sale of Food and Drugs Acts. If we consider the question of prosecutions for false warranty we will obtain further evidence of the adverse effect of the warranty clauses. Prosecutions for False Warranty. Under Section 20 (6) Sale of Food and Drugs Acts, 1899, which deals with such prosecutions, Local Authorities are provided with a remedy where summonses have been dismissed on production of a warranty, viz., the person giving the warranty may be prosecuted for false warranty. The data I have collected relating to this point, during the last eight years, enables one to say definitely whether this is an effectual remedy. 58 The following table shows in biennial periods the number of prosecutions by London Boroughs during the last eight years with the results of such prosecutions :— Biennial periods. Total number of prosecutions for false Warranty. Number and percentage of summonses dismissed or or withdrawn. Number and percentage of successful prosecutions. No. per cent. No. per cent. 1910-11 21 12 57.1 9 42.9 1912-13 31 20 64.5 11 35.5 1914-15 12 8 66.7 4 33.3 1916-17 23 19 82.6 4 17.4 1910-17 87 59 67.8 23 32.2 This table shows that while the dismissals in prosecutions for false warranty have progressively increased in the four periods, viz.:—57.1 per cent. in 1910-11 to 82.6 per cent. in 1916-17, the successful prosecutions have progressively decreased from 42.9 per cent. to 17.4 per cent. in the same periods. In the face of these figures, which are eloquent enough, how is it possible for any Local Authority to hope to protect the public from fraudulent adulteration of food ? No wonder Local Authorities are adverse to prosecuting for false warranty when the chances of successful prosecution have almost vanished. The position has now reached such a point that most of the London Authorities decline to initiate proceedings for this offence. Only one remedy exists for the present conditions, and that is the unconditional repeal of the warranty clauses in the Sale of Food and Drugs Acts. In 1915 I urged this view in my report, and the Borough Council on the Committee's recommendation pressed the Local Government Board and Board of Agriculture to repeal the harmful 59 clauses. If the matter was urgent in 1915, how much more is it now under the prevailing conditions! It is no exaggeration to say that it is a grave scandal that at a time when the prices of all articles of food, especially milk and butter, are so high, very little security exists in the present state of the law against the wholesale adulteration of the chief articles of food for young and old. I repeat here with more emphasis the remarks I made in my earlier report:—"The public must be protected from fraud, and the purveyor made wholly responsible that the article sold by him shall be of the nature, substance and quality demanded by the purchaser. The Local Authority should not be required in their duty of protecting the public, to go beyond the actual local purveyor. It is ths duty of the local dealers to see that they are supplied from wholesale dealers with genuine articles, and if they are not so supplied, they have their own remedy at law." I repeat that I am of opinion the warranty defence should be abolished, and I recommend the Borough Council to obtain the support of the other Metropolitan Boroughs to this view, and to press it without delay upon the Local Government Board, the Board of Agriculture, and the Food Controller. I remain, Yours obediently, (Sgd.) J. King Warry, M.D., M.R.C.P., D.P.H. 60 REPORT ON THE DESIRABILITY OF ESTABLISHING DAY SANATORIA IN THE BOROUGH OF HACKNEY. Public Health Department, Town Hall, Hackney, E.8. 8th May, 1918. To the Chairman and Members of the Public Health Committee. Gentlemen, I have carefully considered the letter dated 4th February, 1918, from the Clerk of the London County Council, on the above subject, and beg herewith to submit my report thereon. It appears from enquiries made, that many children are found to be suffering from various forms of tuberculosis to such an extent as to preclude their attendance at the ordinary elementary schools, and it has been suggested that these children would gain great benefit, and, in some cases, complete cure from attendance at such institutions where treatment would be the chief feature, and where education would be given suitable to the condition of the child. In a few of the London boroughs, arrangements of the kind indicated have been made by Voluntary Committees working in connection with the Tuberculosis Dispensaries, and the London County Council as the Education Authority has supplied teachers. The Council has had the working of these arrangements under close observation for some time, and now regards them as a basis of a development likely to prove of great value in combating the disease. The Council is further of opinion that as the arrangements for Day Sanatoria are necessarily closely related to the work of the Dispensaries, the establishment of Day Sanatoria might be regarded as part of the work of the Dispensaries. 61 It is understood that the Local Government Board would be prepared to regard Day Sanatoria established in connection with Tuberculosis Dispensaries of the Metropolitan Borough Councils, as part of the Dispensary organisation, and to pay a grant of 50 per cent. of any expenditure incurred by the Borough Councils concerned. The London County Council in its letter asks whether the Hackney Borough Council would be prepared to extend the scope of its Dispensary scheme in the direction indicated, on the understanding that the provision of education so far as it may be considered necessary, shall be provided by the London County Council as the Education Authority. Before considering the desirability or otherwise of extending the scope of the Tuberculosis Dispensary scheme in the direction indicated, I think it is desirable, in the first place, to give the Committee some particulars regarding the Day Sanatoria, their work, utility and cost, as follows:— Definition.—A Day Sanatorium is an institution at which certain classes of children suffering from tuberculosis attend daily, i.e., children who are unfit, for various reasons, to attend an ordinary elementary or open-air school. During their attendance these children are under constant medical supervision, and their education, though subsidiary to medical treatment, is not neglected. It appears that only children in weak health, arising from other causes other than tuberculosis, attend open-air schools, except perhaps cases in the pre-tuberculosis stage. Class of Cases suitable for Day Sanatoria. The following are suitable for Day Sanatoria:— (a) Medical Cases—Children suffering from tuberculosis of glands of neck, thorax and of other parts of body; tuberculosis of 62 lungs in its very early stage; also cases somewhat more advanced but showing symptoms of only slightly active disease of the lungs. (b) Surgical Cases.—Children suffering from various forms of tuberculous disease of bones or joints, tuberculous children discharged from residential institutions, and special gland cases after operation. The type of child most suitable for a Day Sanatorium is one suffering from active pulmonary tuberculosis but, for one reason or another, not deemed suitable for, or unable to be admitted to, a sanatorium or open-air school. Such a child should, for choice, be in attendance at a dispensary. The Fulham Day Sanatorium. There are several Day Sanatoria in London, varying somewhat in their arrangements and working; but the one which seems to fulfil most efficiently the functions of a Day Sanatorium, is that instituted by the Fulham Borough Council and opened in May, 1917, in connection with their Tuberculosis Dispensary* in the New Kings Road, Fulham. By the kindness of Dr. Jackson, the Medical Officer of Health, I was allowed to visit this institution and obtain from the Secretary and the Teacher-in-Charge full information as to its working. The site is the garden at the rear of the Tuberculosis Dispensary, which has an area of about 50 feet by 80 feet. It is walled in, but there are no high buildings in its neighbourhood except on one side, neither are there any factories in the immediate neighbourhood, and, being close to Fulham Common, the children get the benefit of fresh and clean air. * I am informed by Dr. Jackson that their Tuberculosis Dispensary, to which the Day Sanatorium is connected, is not directly under the Fulham Borough Council, though they subscribe £700 a year towards its support, but it is managed by a voluntary Committee. 63 Attached to the Dispensary is an old garage, which has been converted into a kitchen and resting place for the children during inclement weather. Lavatories for both sexes are also provided in suitable positions. Number Attending.—The number of children now on the roll is 25, but the Board of Education, I understand, fixes the maximum at 20. Selection of Children.—These are selected by the Tuberculosis Officer in conjuction with the Medical Officer of Health of the London County Council. Staff.—This consists of (1) a female attendant at a salary of £1 per week to look after the children at dinner-time, clean up the premises, wash linen, etc.; and (2) a Teacher-in-Charge who supervises and directs the teaching of the children. Her salary is paid by the London County Council, which latter also provides all educational and other equipment. Curriculum.—The children attending come from the homes in the neighbourhood or from parts of the Borough not too distant for walking. They remain at the institution all day, the hours being 9.30 a.m. to 4 p.m. in summer, and 9.30 a.m. to 3 p.m. in winter. The subjects taught are reading, writing and arithmetic, scripture and other elementary subjects (from 9.30 to 11.30); handwork, singing, etc. (from 2.30 to 4 p.m.). During the day four intervals of ten minutes are given to physical exercises, games and breathing exercises. The teaching, resting and exercises take place entirely in the open air, except during bad. weather, when they are conducted under shelter. 64 Meals.—The children are provided with a suitable dinner at 10' clock which is brought from the School for Physically Defective Children at a cost of 3½d. each. A glass of milk is also served out to each child during the morning. The total cost to each child for food is 4½d. per diem. Medical Treatment.—Each child is weighed once a week and its weight recorded; its temperature is also taken, morning and afternoon, and recorded. Rest.—Before dinner each child has a rest, lying down on stretchers and blankets (in winter time the couches are warmed by means of hot water bottles) for one hour before dinner and half an hour or longer, if required, after dinner. Examination of Children by the Tuberculosis Officer.—This takes place once a week on Thursday afternoon. Medicine.—Cod liver oil and malt is provided, on the order of the Tuberculosis Officer, by the Dispensary. Results of Day Sanatorium Treatment. On my visit to the Fulham Day Sanatorium, I made particular enquiries as to the results of the treatment of children attending the institution. In a way the results have been more favourable than might have been expected. While the whole of the children have gained in weight, some considerably, their general condition and progress have, in other respects, been good. In only one case was the general condition stationary, and in two other cases, while not regarded as good, it was yet satisfactory. From the time of the opening of the Day Sanatorium on 21st May, 1917, to the date of my visits, seven children had been discharged from the Sanatorium and allowed to attend the ordinary 65 schools. The condition of these children on leaving was as follows:— Six of them were cases of pulmonary tuberculosis; their weights had increased considerably—the highest increase was 9¼ lbs. and the lowest 5 lbs.—their temperatures had become normal, sweating had ceased, and their general condition was much improved. In five of these cases the disease in the lungs had become quiescent, and in one it appears to have cleared up entirely. The seventh case was one of enlarged tubercular cervical glands, with sweating and dyspnoea on exertion. On leaving, the glands had diminished almost to their normal size, and the other signs of disease had disappeared. In brief, the results achieved may well be regarded as excellent. Home Environment of the Children. It must be kept in mind that the results of Day Sanatorium treatment may be quite neutralised if the hygiene of the home is unsatisfactory; therefore, simultaneously with the treatment, attention must be kept upon the home, and a standard of hygiene maintained there which will supplement the day treatment. Particular attention must be given to the ventilation and cleansing of the home. All overcrowding must be removed, and a clean and well ventilated bedroom must be provided for the child. A high standard of home hygiene must be maintained if the child is to benefit by the Day Sanatorium treatment. The Day Sanatorium in the Tuberculosis Scheme. From what has already been said it is evident that the Day Sanatorium fills an important place in the treatment of tuberculosis. This institution brings practically all the advantages of a sanatorium to the immediate homes of the children, without breaking with the home life and without interrupting their education. This institution must also have an educational effect upon the E 66 parents of the children attending by giving them an object lesson in the value of fresh air in the prevention and cure of tuberculosis. Moreover, the visits of an inspector to their homes will tend to ensure a higher standard of home hygiene. The cost of Day Sanatorium treatment is, moreover, much less than that of the residental sanatorium, although the results are equally satisfactory. Cost. I have obtained from the Medical Officer of Health of Fulham, the receipts and expenditure for their Day Sanatorium for the eight months—May to December, 1917. The cost has been borne by voluntary subscriptions. The total expenditure for the eight months was only £97 2s. and of this total, £15 13s. 3d. was repaid by the London County Council and £9 6s. 2d. by parents, leaving a balance of £72 16s. l0d. to be paid from the funds of the institution. It must be remembered that the institution forms part of the Tuberculosis Dispensary premises and the rent of this is not included in this account. If a Day Sanatorium were instituted in the Borough of Hackney, the total expenditure should not exceed the following approximate estimate, viz.:— Capital expenses £50 Maintenance £150 per annum. Of this, the Local Government Board will, I understand, be prepared to pay 50 per cent. and the London County Council will furnish the Teacher-in-charge. From a consideration of the foregoing facts, I am of opinion, with the London County Council, that Day Sanatorium treatment may justly be regarded as part of the work of the Tuberculosis 67 Dispensaries. This being so, I strongly advise the Public Health Committee to extend' the work of the Tuberculosis Dispensaries in the borough so as to include one or more Day Sanatoria. These cannot, like the Fulham institution, be situated so near the Dispensaries, but this, though convenient, is not essential. The essential point is to have the site in or adjacent to some open space, where the air is fresh and pure and frequently renewed. Situations such as the borders of Victoria Park, Hackney Downs or Springfield Park, would fulfil this essential. I recommend— 1. That the Tuberculosis Dispensary scheme of the Borough be extended to include the provision of one or more Day Sanatoria. 2. That a scheme be prepared for the establishment of one or more Day Sanatoria in the Borough, showing in detail, particulars as to proposed sites, total cost, and the proportion of the cost to be contributed by the Local Government Board and the London County Council. I remain, Yours obediently, (Sgd.) J. King Warry, M.D., D.P.H., etc., Medical Officer of Health, and Chief Executive Tuberculosis Officer. REPORT WITH REGARD TO THE FLOODING OF COTTAGES BY OVERFLOW OF RIVER LEE. 18th July, 1918. To the Chairman and Members of the Public Health Committee. I have considered the Rev. Oliver R. Dawson's letter, dated 26th April, 1918, on the above subject, and beg herewith to report thereon. E2 68 As to the dates of the floods referred to, and their cause, I have received the following statement from the Engineer to the Lee Conservancy Board:—"The valley (Lee) commenced to be flooded on 16th January last, and the flood reached the maximum on the 19th and 20th. The flood was due primarily to a heavy fall of snow which followed a sharp frost over the Lee Valley and this was succeeded on 16th January by a considerable rise in the temperature and a fall of 0.26 inch of warm rain, whilst the snow when melted registered 1.04 inch of rain. The combined effect of rain and rise in the temperature was to cause a rapid thaw and a heavy flood. The valley was again subject to flood for several days in April, the flood being at its highest on the 18th. This flood was caused by snow melting on the hills, coupled with warm rain, 1.54 inch falling in three consecutive days." The premises affected in January were as follows, viz.:— Retreat Place, Nos. 1 to 8, consecutive numbers; Spring Lane, Nos. 4 to 16, even numbers; Spring Lane, Nos. 38 to 64, even numbers; Middlesex Wharf, Nos. 20 to 42, even numbers; Middlesex Wharf, Nos. 57 to 91, odd numbers. In January, the ground floors of the above cottages were flooded to a depth varying from an inch or less, to 2½ feet; in April to a maximum depth of not more than 2 feet. The result of these floods is not only to leave a deposit of filth in the houses but to render the living rooms so damp that it takes months for the walls to dry out; and the repetition of a flood within four months means that practically for a period of at least six to eight months, or longer, these houses are so damp as to be, in my opinion, so prejudicial to health as to be unfit for habitation. Hitherto the floods have recurred infrequently, at most, once a year; but two floods within a little more than four months arouses the suspicion that they may recur more frequently in the future. In order to ascertain if this were probable, I asked the Engineer to the Lee Conservancy Board, whether any engineering work had been carried 69 out during recent years in the upper reaches of the river, which would bring about such a result. On this point, I received the following reply.-"By reason of improved works in the middle reaches between Wormley and Tottenham, the water comes down faster than 25 years ago, and as the low lying land becomes covered by reservoirs, buildings and rubbish tips, the natural reservoirs for floods are more restricted and the discharging capacity of Lee Bridge Weir is diminished by reason of the tail water being held back by obstruction in the old river below Lee Bridge, and by the embankment around the Hackney Marshes which was formerly a large natural reservoir and the rubbish tip across the valley near Temple Mills. "No doubt the two floods referred to were quite exceptional, but I should not like to say they will not recur. "In my opinion, a comprehensive scheme is necessary for improving, widening, straightening and deepening the old waterways between Lee Bridge and the three mills, Bow Creek, but as there are so many interests involved, I am afraid this scheme could only be carried out under Acts of Parliament." From the above statement of the Engineer to the Lee Conservancy Board, it is not unreasonable to expect in the future, a more frequent overflow of the river. But premises which are liable at intervals to become so damp as to require months to become dry, are dangerous to health, and should be closed, in order to give the owners an opportunity of adopting remedial measures, if such are practicable. I therefore beg to report that in my opinion, the above dwellings are in a state so dangerous or injurious to health as to be unfit for human habitation, and to recommend the Council to issue a Closing Order, under Section 17 (2) of the Housing, Town Planning, 70 etc., Act, 1909, prohibiting the use of these for human habitation until, in the judgment of the Council, they are rendered fit for that purpose. I remain, Yours obediently, (Sgd.) J. King Warry, M.D., D.P.H., etc., Medical Officer of Health. REPORT AS TO ANTE-NATAL WELFARE. Public Health Department, Town Hall, Hackney, E.8. 3rd January, 1918. To the Chairman and Members of the Public Health Committee. Gentlemen, Maternity and Infant Welfare. The Committee will remember that in April, 1916, they presented to the Borough Council a report on Maternity and Infant Welfare in the Borough, recommending that two Infant Welfare Centres be established, and four additional Health Visitors be appointed for home visitation and attendance at the Centres. It was also recommended at that time that the complete measures for dealing with ante-natal and natal mortality should be suspended until after the War. In January, 1917, the Council was recommended to establish another Infant Centre. The three Centres have been satisfactorily working up to the present time. In the circular letter of the Local Government Board, dated July, 1914, the Board called attention to the necessity for extending the measures for preventing infant mortality, as follows:— "Extension of the existing work is needed in two directions: on the one hand it is necessary that measures should be 71 taken for securing improved ante-natal and natal conditions; and on the other, provision should be made for continuing the work in relation to children beyond the first year of life." The original scheme presented to the Committee contemplated measures dealing with ante-natal, natal and post-natal conditions, but it was thought more advisable to deal at first only with postnatal conditions, the scheme presented to the Council comprising measures for preventing infant mortality and the extension of these measures to children beyond the first year of life, viz., the institution of several Infant Welfare Centres in the Borough, and the appointment of a sufficient number of Health Visitors for assisting at the Centres and home visitations. This part of a complete scheme has been in operation now during a year and has more than realised the hopes and anticipations of the Committee. The experience gained during the year has revealed the fact that the time is now ripe for the institution of the ante-natal and natal part of the Welfare Scheme, and I strongly recommend the Committee to consider the desirability of immediately extending the Welfare work in the direction indicated. At this point I think it is desirable to call the attention of the Committee to some facts stated in my original report relating to maternal mortality during child-birth and infant mortality before and during birth which will, I am sure, help to convince them of the immediate necessity for dealing with the welfare of expectant mothers. The Mother during Child-bearing and Child-birth. Both mother and child are exposed to special perils during this period which may lead to the death of either or both, or to subsequent ill-health and suffering of the mother and feeble vitality of the infant. The dangers threatening the mother are chiefly puerperal fever and other complications. 72 The annual death-rates per 1,000 births for the County of London and the Borough of Hackney from these causes during the four years 1911-1914 were as follows:— Puerperal fever. Other complications of child-birth Total mortality from child-birth. London 1.48 1.86 3.06 Hackney 1.54 1.54 3.08 Expressed in words these figures mean that during the four years in question (1911-1914) there died in London 1,356 mothers, and in Hackney 66 mothers from puerperal fever and other complications of child-birth. On this subject the Chief Medical Officer of the Local Government Board, Dr. A. Newsholme, C.B., makes the following remarks in his report on maternal mortality in connection with childbearing:— "The majority of the deaths of mothers from childbearing are caused by puerperal fever, haemorrhage and convulsions. Most cases of these conditions are well within the range of preventive medicine, including in this the early treatment of illness. The prevention of early infant mortality is inseparable from that of mortality of mothers in child-bearing. Excessive mortality of mothers in child-bearing means also an excessive proportion of still-born infants, and an excessive proportion of deaths of infants in the early weeks after birth." The figures quoted above refer only to the mortality amongst mothers; they take no account of deaths associated with, but not classed as due to, pregnancy and child-bearing, the commonest of which are heart disease, pneumonia and tuberculosis; nor do they take account of cases of partial recovery, with subsequent suffering and ill-health. 73 The Infant Before, During and After Birth up to Five Years of Age. The factors influencing infant mortality may be divided into the three following classes:—(1) Ante-natal, acting through the mother and dependent on her health; (2) Natal, also to a great extent due to the condition of the mother, e.g., causes of difficult and delayed parturition, as well as to want of skill on the part of the doctor or midwife; (3) Post-natal, due to environmental conditions. 1. Ante-natal Period.—The maintenance of the health of the mother during the ante-natal or child-bearing period is of vast importance to the future of both mother and child. During the period in question the life of the future child may be lost, shortened, or permanently affected by neglect of the laws of hygiene ; on the other hand, care on the part of the mother and an observance of hygienic rules will establish the health of the mother and preserve the life of the child to the nation. The chief dangers affecting the life of the infant during this period are (a) miscarriage, (b) still-birth. (a) There is no statistical evidence to show the proportion of miscarriages to live births in the Borough, but there is no reason to believe they are more or less numerous than in other parts of the country. Estimates have, however, been made of the proportion of miscarriages to still-births, and the average estimate arrived at is 4 miscarriages to 1 still-birth. If we apply this rate to Hackney, we shall get a local rate which will be rather startling as to the loss in infant life due to this cause alone. During the year 1914 there were 174 still-births notified to me; therefore, on the basis of the above estimate, there were 696 miscarriages. 74 (b) The causes leading to still-births are very complex, but in great measure they are connected with the health of the mother during the child-bearing period, and may be expressed in general terms as due to the diseases and complications of pregnancy which may be largely controlled by early treatment of the mother before serious symptoms arise. Summing up the loss to infant life during the pre-natal period, we find it amounts approximately, in Hackney, to an annual loss of 870 infant lives. 2. Natal Period.—It is not possible to separate entirely this period in its effects from the earlier period. This is borne out by by the statement by Dr. Newsholme already quoted. Experience moreover, shows that many deaths occur from conditions arising during the birth of the infant. It is not necessary to go into details. It is sufficient to recognise that this period is one requiring skilled attention and watchfulness in order to prevent any of the incidents of this period from being harmful either to mother or child. The above will, I am sure, dissipate any doubt still lingering in the minds of the Committee as to the urgency of extending their Welfare work to expectant mothers. Such an extension would include the provision of medical advice and, where necessary, treatment for expectant mothers, including arrangements for skilled assistance during confinement at home, and also arrangements for dealing with complications arising during or after confinement. The Committee have already under consideration the provision of skilled advice during confinement, and the present time would be most opportune to fit whatever arrangements are finally made with those relating to the welfare of expectant mothers. 75 In my original report, the Committee will remember that under the head of Ante-natal Welfare, I reported as follows:— 1. An Ante-natal Clinic for Expectant Mothers. (a) This should be provided, if possible, at some hospital in the Borough at which a physician for diseases of women would attend one afternoon a week, to see expectant mothers. Cases of complication arising after parturition, in the mother, might be examined by the same physician and dealt with by him; or referred to the appropriate physician or surgeon at the hospital. The Metropolitan Hospital fulfils the condition of being in the Borough, and it has a department for diseases of women. If the hospital authorities are willing, I have no doubt the Clinic might be arranged with this Department. Negotiations would be necessary to ascertain if such an arrangement could be made, and at what cost. (b) In connection with this Clinic, one or more Health Visitors should be appointed. This officer should have the qualification of a midwife, with some knowledge of sanitation of the home. Her duties would be to visit the homes of expectant mothers, advise them to attend the Clinic for consultation with the physician, to hear the physician's instructions to the expectant mothers, and to see, if possible, that his advice is followed. She would also see if the sanitary condition of the home is satisfactory. While it will be necessary for the above Central Clinic to be established, I am of opinion that the Infant Welfare Centres may be utilised in dealing with expectant mothers. It would only be necessary to arrange for the Centres to be open for these mothers one afternoon a fortnight, and to make arrangements with the present doctors attending the Infant Welfare Centres to see and advise such cases as attend. 76 Some slight alterations will require to be made in the accommodation at the Centres, and some addition to the equipment. The ante-natal and natal part of the scheme should consist of the following:— 1. A Central Maternal Clinic, as recommended in ray original report and quoted above. 2. The Infant Welfare Centres to be used one afternoon every two weeks as Maternal Welfare Centres, where expectant mothers may consult the doctor and receive advice and simple treatment. 3. Arrangements to be made with a conveniently situated lying-in hospital to receive difficult cases of parturition. It will be the duty of the doctor attending the Maternal and Infant Welfare Centres to send such cases as cannot be dealt with by advice and simple treatment at the Centres, to the Central Clinic or Lying-in hospital. The cost of establishing and maintaining the above extensions will not be very great. The following is an approximate estimate Maternal Welfare Centre. (a) Cost of Establishment. 1. Alterations and equipment at each £ Centre 20 (b) Maintenance. 1. Salary of Medical Attendant 26 per annum. 2. Rent, firing and attendance 15 „ „ 3. Sundry expenses 10 „ Total at each Centre £51 „ „ 77 Central Ante-Natal Clinic. Total annual cost £180 Lying-in Hospital. Total annual cost £50 Additional Health Visitor £120 Summary of Cost. 1. Alterations and equipment at each £ Centre (3) 60 2. Maintenance of Centres 153 3. Maintenance of Ante-natal Clinic 180 4. Grant to Lying-in Hospital 50 5. Additional Health Visitor 120 £563 Of this total, the Local Government Board will make grants approximately to the amount of 50 per cent. of the total. This will leave a charge upon the Borough Council of approximately £285 the first year and £255 per annum afterwards. Recommendations. I recommend:—1. That the Infant Welfare Centres be adapted and equipped for consultations for expectant mothers, and that they be opened one afternoon a fortnight for this purpose. 2. That arrangements be made with the medical attendants at the Centres to attend one afternoon a fortnight to see and treat any expectant mothers attending. 3. To open negotiations with the Metropolitan Hospital authorities, with the view to opening a Central Ante-natal Clinic at the hospital and to ascertain the cost of the same. 78 4. To open negotiations with a conveniently situated Lying-in Hospital for the reception of difficult cases of parturition, and to ascertain the cost of the same. 5. To appoint an additional Health Visitor. I remain, Yours obediently, (Sgd.) J. King Warry, M.D., D.P.H., etc., Medical Officer of Health.