BER 41 Metropolitan Borough of Bermondsey. REPORT ON THE SANITARY CONDITION OF THE BOROUGH OF BERMONDSEY For the Year 1922. BY R. KING BROWN, B.A., M.D., D.P.H., Medical Officer of Health. TABLE OF CONTENTS. PAGE. VITAL STATISTICS— Population 7 Births 7 Marriages 8 Deaths 8 Infantile Mortality 9 Zymotic Diseases 10 Measles 10 Whooping Cough 10 Enteric Fever 10 Tubercular Diseases 10 Phthisis 10 NOTIFICATION OF INFECTIOUS DISEASE— Diphtheria 11 SmallPox 11 Scarlet Fever 11 Enteric Fever 12 Puerperal Fever 12 Ophthalmia Neonatorum 12 Cerebrospinal Meningitis 12 Polio-Myelitis 12 Bacteriological Laboratory 12 SANITARY ADMINISTRATION— Food Inspectors' Work 13 Unsound Food 14 Milk Premises 14 Slaughterhouses 14 Ice Cream Premises 14 Milk and Dairies Amendment Act, 1922 15 Food and Drugs 16 General Sanitary Work 16 PAGE. Smoke Nuisances 16 House Refuse 17 Offensive Trades 17 Disinfection 17 Cleansing of Persons Act, 1897 17 Proceedings during year 18 Mortuary 19 Insanitary Areas 19 Work of District Inspectors 20 MATERNITY AND CHILD WELFARE— Health Visitors 21 Municipal Lying-in Hostel 23 Municipal Dental Officer's Report 24 TUBERCULOSIS— Assistant Tuberculosis Officer's Report 28 APPENDIX TABLES— Ministry of Health Tables 53 Outworkers 59 Deaths from Zymotic Diseases 60 Prosecutions (Foods and Drugs) 61 Factories and Workshops 64 Bakehouses 65 Unsound Food and Foreign Meat Regulations 66 (11408)Q A 2 PUBLIC HEALTH DEPARTMENT. Public Health Committee, 1922. Chairman—Councillor STOKES. Alderman Trott, Councillor Monk, Councillor Baker, „ Salter, „ Broughton, „ Stephen, " Gamble, „ Sullivan, " Gledhill, „ Vezey, " Jeffery, " Wallsgrove, „ Lawrence, G. C., „ Weightman. Ex-officio: W. C. BUSTIN, Esq., J.P. Mayor of Bermondsey. Maternity and Child Welfare Committee, 1922. Chairman—Councillor G. C. LAWRENCE. Councillor Stephen, Alderman Squires, Trott, „ Stokes, Councillor Baker, Co-opted Members: „ Broughton, „ Gledhill, Mrs. A. Bustin (Mayoress), „ Jeffery, Mrs. Langton, „ Jones, Mrs. M. Nix, „ Salter, Miss Payne. Ex-officio: W. C. BUSTIN, Esq., J.P. Mayor of Bermondsey. Staff: Medical Officer of Health —R. KING BROWN, B.A., M.D., D.P.H. Clinical Tuberculosis Officer and Acting Medical Officer of Health— Dr. D. M. Connan, M.B., D.P.H. Assistant Medical Officer of Health (Maternity and Child Welfare) — Dr. Stella Churchill, M.R.C.S., L.R.C.P., D.P.H. Municipal Dental Officer —Mr. Grantley Smith, H.D.D. Edin., L.D.S. Eng. Sanitary Inspectors: District. District. No. 1.—Mr. J. G. Francksen. No. 5.—Mr. E. C. Freeman. No. 2.—Mr. J. W. Wood. No. 6.—Mr. E. J. Pitts. No. 3. —Mr. A. H. Merryman. No. 7.—Mr. W. Davis. No. 4. —Mr. H. J. Toogood. No. 8.—Mr. W. J. Luke. Food Inspectors: Mr. T. Ashdown, Mr. G. A. Hoskins and Mr. G. L. Scott. Health Visitors: District. District. No. 1.—Miss Helden. No. 5.—Miss Bache. No. 2.—Miss Sumner. No. 6.—Mrs. Cottier. No. 3.—Miss Islip. No. 7.—Miss Carlton. No. 4.—Miss Child. No. 8.—Miss Wadds. Dental Nurse—Miss Lambert. Clerical Staff: Mr. H. W. Bush, Chief Clerk. Mr. A. I. Fair, Second Clerk Mr. C. F. Yaxley, General Clerk Mr. F. W. Smith, Third „ Mr. C. W. Whye, General „ Mr. E. F. Walsh, Fourth „ Mr. H. E. Butcher, Junior „ Mr. A. Manning, M. & C. W. Clerk. W. C. Tapsfield, Office Lad. Municipal Lying-in Hostel —Matron: Miss A. E. Sewell. Nurses—Miss Taylor, Miss Hughes, Miss Wells. Tuberculosis Dispensary—Miss Pike and Miss Stevens, Nurses; Miss Deighton, Dispenser; Miss Dutch, Assistant Clerk. PUBLIC HEALTH DEPARTMENT, TOWN HALL, SPA ROAD, S.E. 16. Metropolitan Borough of Bermondsey. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Bermondsey. Ladies and Gentlemen, — I have the honour to submit my Twenty-second Annual Report on the sanitary condition of the Borough of Bermondsey during the year 1922. The death-rate was 16.7 compared with 13.7 in 1921, and 12.7 in 1920. The death-rate is discussed in an early section. The sections of the report are, as usual, divided into:— I. —Vital Statistics. II.—Notification of Infectious Diseases. III.—Sanitary Administration. IV.—Factories and Workshops. At the end of the Report will be found two Special Reports from Dr. Connan on Tuberculosis and Mr. Grantley Smith on the Dental Work of the Borough. In the Appendix will be found the Ministry of Health Tables, including a special Table on Infantile Mortality. I wish once more to record that between the Chairman and Members of the Public Health Committee and myself, there has been the usual cordial co-operation during the year under report. The members of the staff of the Department have also shown themselves most willing to fall in with the various new and additional duties cast upon them, and have done their part loyally in the promotion of the Public Health of Bermondsey. I am, Ladies and Gentlemen, Your obedient servant, R. KING BROWN. Owing to the regrettable illness of Dr. King Brown, the Medical Officer of Health, his comments, which have been a feature of previous reports will not be found in the present issue. The present report has, however, been read and approved by him. D. M. CONNAN, Acting M.O.H. 1.—VITAL STATISTICS. Population. The populations of the Borough of Bermondsey, as enumerated in the Census of 1911 and 1921, and the estimate of the year under report are as follows: — Estimated 1911. 1921. to June 30th, 1922. 125,903 119,452 121,100 The population of Bermondsey for 1922 has been estimated by the Registrar-General as 121,100, and this figure has been utilised in estimating the birth and death rates. Births. The total number of births registered in the Borough for the 52 weeks ended December 30th, 1922, was 3,167, consisting of 1,631 males and 1,536 females. This is 141 below the average for the last 10 years, and 64 below the figure for 1921. The birth-rate for 1922 was 26.2 per thousand persons living, which is 0.6 below that for 1921 and 0.5 below the average for the last 10 years. Marriages. The total number of marriages in the Borough in 1922 was 1,008, being 76 below the number for 1921, and 230 below the average for the last 10 years. The figures have been supplied by the Superintendent Registrar. This makes a marriage rate of 16.64 per 1,000 of the population, compared with a marriage rate last year of 19.93 per 1,000 of the population, 121,100. Year. No. Rate. 1912 1,182 18-81 1913 1,203 19.21 1914 1,236 19.90 1915 1,714 28.12 1916 1,215 19.65 1917 1,015 16.92 1918 1,106 18.21 1919 1,242 19.19 1920 1,383 21.40 1921 1,084 17.99 Average for years 1912-1921 1,238 19.94 1922 1,008 16.64 Deaths. In Tables III and IV of Appendix will be found tables dealing with deaths in the Borough. The total number of deaths registered in the Borough for the year ended December 31st, 1922, was 1,572, which is 259 more than in 1921 and 119 below the average for the last 10 years. When this figure is corrected by exclusion of deaths of nonparishioners occurring in the district, and the inclusion of deaths of parishioners occurring outside the district, the number is raised to 2,025. This is 369 more than in 1921, and 23 less than the average for the last 10 years. The death rate for the Borough in 1922 was 16.7 per thousand living inhabitants, being 3.0 above that recorded in 1921, and 0.5 below the average for the last 10 years. In column 1, foot of Table 1 of the Appendix will be found a list of places where deaths of non-parishioners occurred in the district. There were 43 such deaths in all, against 51 in 1921 and 105 in 1920. 16 such deaths occurred in the infirmary; 22 in the River Thames and the Surrey Commercial Docks, 1 in a Canal, 1 in a school, and 3 in private houses. 496 persons belonging to this Borough died in outlying institutions, against 394 in 1921, and 281 in 1920. The names of the various places where the deaths occurred will be found in columns 2 and 3 at foot of Table I of Appendix. Infantile Mortality. The figure for this is 102 deaths under one year to every 1,000 births. Table A.—lnfantile Mortality. Year. Whole Borough. London. Rate per 1,000 Births. No. of Deaths. Rate per 1,000 Births. No. of Deaths. 1912 433 114 91 10,056 131 105 1913 505 11,869 487 129 104 1914 11,395 1915 537 154 11,369 104 88 1916 364 108 8,819 335 1917 125 8273 103 322 107 1918 139 7,965 1919 262 85 99 7,039 1920 83 337 75 - 1921 306 95 - 80 388 Average for years 1912-1921 94 - 117 1922 324 102 - - DEATHS FROM ZYMOTIC DISEASES. There has been an increase in the deaths from these diseases, the figures being 292 against 197 in the previous year, and 227 the average for the last 10 years. This gives a zymotic death-rate of 2.41. Measles. There were 101 deaths due to this disease, which is above the average for the last 10 years, and 98 above the number for 1921. Whooping Cough. 65 deaths were due to this cause, against 14 in 1921. Enteric Fever. 1 death was due to this cause. There were 3 deaths in 1921. Tubercular Diseases. The number of deaths from all forms of tubercular disease in 1922 was 206, against 185 in 1921. Phthisis. In Table B will be found particulars of deaths from phthisis since the year 1912. There were 169 deaths due to this cause, which is 6 more than the number recorded in the previous year. Table B. —Phthisis. Rotherhithe. St. Olave. Whole Borough. London. Sub. District. Bermondsey. Rate. No. Rate. No. Rate. No. Rate. No. No. Year. Rate. 1.64 1.69 1.68 57 17 1.98 1912 138 6069 1.35 212 1.61 1913 125 1.53 64 1.86 1.42 201 5981 1.30 12 1.35 1914 136 1.66 21 2.53 203 1.63 6281 1.39 46 57 20 1915 156 1.76 1.77 2.42 233 1.97 6782 1.54 1.61 6288 1.45 1916 126 1.70 44 1.38 14 1.78 184 123 14 1.83 1.57 1917 1.75 61 2.02 1.88 198 6658 169 1.66 9 1.56 7048 1.78 1918 117 43 1.42 1.20 1.28 58 1.66 12 1.39 174 1.40 5332 - 1919 104 46 1920 81 0.96 1.27 10 1.12 137 1.06 - - 163 1.35 1921 106 43 14 - - - — - Averages for years 1912- 1921 121 51 14 187 - - - - - — 1.39 43 - 7 - 169 - 1922 119 - - 10 II.—NOTIFICATION OF INFECTIOUS DISEASE. In Table V. of Appendix will be found particulars of infectious diseases notified during the year under report. The number of cases notified, exclusive of notifications of tuberculosis, which numbered 413, was 2,077 compared with 2,045 in 1921 and 1,486 in 1920. The disease showing the principal increase was diphtheria. The attack rate per thousand inhabitants was 17.15 against 16.29 in 1921. 41 cases were returned from hospital as not suffering from the disease for which they were notified, but, if allowance is made for mild unreported cases, the recorded notifications would, if anything, understate the actual number of cases. Diphtheria. There were 1,110 cases of diphtheria notified in 1922 as against 741 cases in 1921. The attack rate per thousand inhabitants was 9.16, against 5.90 in 1921. The case mortality was 8.1 per cent., against 9.3 per cent, in 1921, and 9.3 per cent. in 1920. 25 cases were returned as not suffering from this disease. Small Pox. 2 cases notified; I returned as not suffering. Scarlet Fever. The notifications of scarlet fever in 1922 were 652, against 1,164 in 1921. This is a decrease of 512. The distribution of the disease in the various Wards, as shown in Table V. of Appendix, was fairly uniform. 15 cases were returned from hospital as not suffering from scarlet fever. There were 11 deaths, which gives the very low case mortality of l.7 per cent., against 1.5 per cent. in 1921. The disease, as in recent years, was of a very mild type. The attack rate per thousand inhabitants was 5.37 against 9.66 in 1921. Enteric Fever. 4 cases of enteric fever were notified, being 3 for Bermondsey, and 1 for Rotherhithe. The total number of cases notified in the previous year was 8. Puerperal Fever. 7 cases of puerperal fever were notified. Death resulted in 2 cases. Ophthalmia Neonatorum. There were 12 cases of this disease notified during the year. Under this heading is included every kind of "sore eyes" occurring in the newly-born. They were all visited by the Health Visitors, who instructed the mother in each case to immediately seek medical advice. Cerebrospinal Meningitis. 5 cases were notified in 1922. Polio-Myelitis. No cases were notified in 1922. Bacteriological Laboratory. The total number of specimens examined in 1922 was 3,977 as compared with 3,284 in 1921, and 1,422 in 1920. Table C. Total Examinatìons. Results of Examination. Nature of Specimen. Negative. Positive. 1921 1921 1922 1922 1921 1922 Diphtheria (specimens taken by Medical Officer of Health) 1,035 58 1,698 78 977 1,620 Ditto (taken by general practitioners) 982 148 1,092 159 834 933 Diphtheria (total specimens taken) 2,017 206 2,790 237 1,811 2,553 Phthisis 1,258 1,174 138 179 1,120 995 Enteric 6 1 5 - - - 3 Various 13 - 7 3 6 Total specimens taken 3,284 3,977 345 423 2,939 3,554 FOOD INSPECTORS. Particulars of Work, 1922. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Bakehouses. Butchers. Fishmongers, Friers and Curers. Food Stores. Food Wharves and Depots. Fruiterers and Greengrocers. Ice Cream. Markets. Milk Sellers. Destruction of Food. Nuisances Reported. Number of Samples taken. Visits. Food Factories. Slaughterhouses. Restaurants and Eating Houses. Various. SANITARY ADMINISTRATION. Jam. Butter and Margarine. Other. Re-visits - - - - - - 3994 - - - - - 542 4 65 16 595 10 Re-visits 3 70 500 182 496 16 40 344 304 138 30 77 132 565 218 307 121 New occupiers - - - 3 1 3 18 - 1 - - 10 6 - - - - - New premises - - - - - 2 4 - 1 6 4 4 3 - - - - - Closed - - - - - - - 1 - - - - 1 - - - - - Re-visits 201 - 138 311 127 1018 295 173 129 427 593 202 - 117 34 196 603 46 New occupiers - - 1 4 3 4 40 1 21 11 - 20 12 - - - - - New premises - - 1 1 5 3 13 1 12 18 - 8 4 - - - - - Unsound Food. The following were brought to the notice of the Department, found to be unfit for human food, and destroyed as trade refuse:— Tons. Cwts. Qrs. Lbs. Meat— Fresh 5 17 3 14 Canned 4 3 3 11 Fish— Fresh 1 8 1 4 Canned - 9 1 22 Fruit— - Fresh 29 12 22 Canned 40 8 12 Dairy Produce — Various 5 7 3 5 Various Various Canned Goods 2 12 4 - 90 - 2 6 Milk Premises. There were 308 milk premises on the Register at the end of 1921. 12 were added and 8 removed during 1922, making a total of 312 at end of the year under report. Slaughterhouses. There is one slaughterhouse in the Borough, 30 inspections were made. No notices were served. Ice Cream Premises. There were 116 premises where ice cream is manufactured on the Register at the end of 1921. 24 were added and 9 removed during the year under report, making a total of 131; 169 inspections were made. Milk and Dairies Amendment Act, 1922. As powers are now given to Local Authorities not only to refuse registration of milk-sellers, but also to remove the names of sellers from the register, it would be convenient for the Inspectors and others administering the Act, if some of the conditions which we consider sufficient to warrant us refusing to register, or erasing a name from the register, were set out on back of the Registration Form. In consultation with the Food Inspectors I have drawn up the following conditions for signature by the person applying for registration:- "I, the undersigned, hereby give an undertaking that I will comply with the following conditions, while holding a certificate of registration as a milk trader. 1. The milk container, metal or earthenware, will be nonabsorbent with a tight-fitting cover, which will always be in position when not serving. 2. No milk will be stored in any living or sleeping room. 3. The container, cover, and measures will be kept clean, and scalded out at least once a day, and always before using each morning. 4. Paraffin or similar oil, vegetables, fish, uncooked meat or offal will not be sold from or stored in the shop. 5. If jams, syrups and pickles are sold from open jars, a tight-fitting cover will be provided and kept in position except when serving. 6. If bacon and cooked meats are sold, they will be kept in a fly-proof receptacle. 7. The floor and fittings of the shop will always be kept clean and free from dust. 8. No "milk and water" will be sold from the premises. 9. No milk will be declared as 'milk and water,' and no declaration will be exhibited that the milk is otherwise than genuine. Witness Signed Failure to comply with the above conditions will render the milk seller liable to have his name removed from the register." Under the Act the milk vendor has a right to appear before the Committee, or appeal against their decision at the Police Court, so I think it would be advisable if we were in agreement on certain broad conditions. Of course, special cases may arise where injury to health comes in question, which can be dealt with on their merits. I might add that all these conditions are in the interests of Public Health, and many of them are designed to prevent the contamination of milk by flies and dust. FOOD AND DRUGS. In Table IX of Appendix will be found a list of the samples taken in 1922, and the action taken; 1,202 samples were taken, compared with 1,201 in 1921, and 1,200 in 1920. Of these 2. per cent. were found adulterated, compared with 5.6 per cent, in the previous year, and 5.3 per cent. in 1920. GENERAL SANITARY WORK. Inspections. In Tables F and G (pages 18 and 20) will be found particulars of the general sanitary work by the District Inspectors during 1922. The house-to-house inspections numbered 3,954. This is 1,526 below the total for the previous year. 5,412 intimation notices were served, compared with 6,366 in the previous year. Smoke Nuisances. 11 observations were kept on chimneys and 7 notices served. House and Trade Refuse. The following table shows the amount of house and trade refuse disposed of during the year ended December, 1922: — Loads. Tons. Cwt. Qrs. Dust to Barge 12,787 21,281 3 2 „ various Shoots 433 725 5 2 Trade Refuse to various Shoots 92 154 2 0 „ „ Barge 1,743 1,510 2 1 15,055 23,670 13 1 Offensive Trades. The offensive trades on the Register are as follows:— Tripe boiler 1 Glue and size makers 4 Fellmongers 3 Fatmelters 4 Manure Manufacturer 1 DISINFECTION. The following table shows the number of articles passed through the steam disinfector during the year under report:— Beds 1,784 Blankets 3,433 Bolsters 1,208 „ (cases) 360 Carpets 6 Cushions 474 Mattresses 601 Overlays 855 Pillows 3,383 Pillows (cases) 2,534 Quilts 2,053 Sheets 2,388 Books 958 Miscellaneous 3,669 Verminous Clothing 261 „ Bedding 277 Hair (bundles) Nil „ (cases) Nil 15,378 new tabs were used to replace those taken off mattresses, palliasses, and cushions before disinfection. Number of rooms disinfected 3,407 Cleansing of Persons Act, 1897. During the year under report 27 male and 8 female adults used the Verminous Baths and had their clothing disinfected. The total number of articles disinfected for this purpose was 261. (11408)q B 17 Table F.—Proceedings during 1922. Premises. Number of Places. Number of Inspections, 1922. Number of Notices, 1922. Number of Prosecutions, 1922. On Register at end of 1921. Added in 1922. Removed in 1922. On Register at end of 1922. Milk Premises 8 312 897 308 12 .. .. Cowsheds .. .. .. .. .. .. Slaughter-houses .. 1 1 30 .. .. .. .. Other offensive trade premises 13 .. 13 .. .. .. .. Ice-cream premises 116 24 9 131 169 .. .. Registered houses let in lodgings 223 .. 446 .. 223 .. .. Overcrowding, 1922 — Number of dwelling rooms overcrowded Number remedied Number of prosecutions Underground rooms — Illegal occupation dealt with during year Number of rooms closed Insanitary houses— Number closed under the Public Health (London) Act, 1891 - Number closed under the Housing of the Working Classes Act - Number of premises cleansed under Section 20 of the L.C.C. (General Powers) Act, 1904 — Number closed under the Housing, Town Planning, etc., Act, 1909 — Shelters provided under Sec. 60 (4) of the Public Health Act, 1891— Number of persons accommodated 55 Revenue Acts— Number of houses for which applications were received during the year — Number of tenements for which certificates were granted — Number of tenements for which certificates were deferred — Housing, Town Planning, etc., Act, 1909, Sec. 35 — Number of houses for which applications were received during the year — Number of houses for which certificates were granted — Number of prosecutions under Bye-laws under Public Health Act, 1891— (a) For prevention of nuisance arising from snow, ice, salt, filth, etc. — (b) For prevention of nuisance arising from offensive matter running out of any manufactory, etc. — (c) For the prevention of keeping of animals in such a manner as to be injurious to health — (d) As to paving of yards, etc., of dwelling houses — (e) In connection with the removal of offensive matter, etc — (f) As to cesspools and privies, removal and disposal of refuse, etc. — (g) For securing the cleanliness of tanks, cisterns, etc. — (h) With respect to water closets, earth closets, etc. — (i) With respect to sufficiency of water supply to water closets — (j) With respect to drainage, etc. (Metropolis Management Act, Sec. 202) — (k) With respect to deposit of plans as to drainage, etc. (Metropolis Management Acts Amendment (Byelaws) Act, 1899) — Mortuary— Total number of infectious bodies removed 8 Total number of bodies removed 101 (11408)q B 2 19 Table G.—Work of District Inspectors, 1922. 1 2 3 4 5 6 7 8 9 10 11 12 13 House-to-House. Special Inspections. Complaints. Infectious Diseases. Factories and Workshops Specially Inspected. Offensive Trades. Outworkers' Bi-Annual Inspection. Underground Conveniences. Drains Tested. Re-Inspections. Other Calls and Visits. Chimneys Watched. Totals. No. Ints. No. Ints. No. Ints. No. Ints. No. Ints. No. Ints. No. Ints. No. No. No. No. No. Ints. Visits Ints. 482 323 165 70 183 125 39 91 21 - 84 9 194 92 376 5 4 3955 148 2158 614 - 582 344 255 102 246 140 146 39 56 23 4 - 38 7 2 25 2415 476 3 1 4248 656 490 230 164 93 251 183 263 39 16 3 1 - 88 1 54 48 2545 300 - - 4220 549 502 296 179 61 372 285 398 76 7 2 19 - 35 3 - 67 2380 361 - - 4320 723 558 380 187 49 357 231 272 75 31 13 9 - 78 8 - 73 2344 314 1 1 4224 757 393 231 160 84 366 272 304 87 9 3 3 - 120 10 126 68 2452 187 - - 4188 687 479 382 110 54 243 192 210 61 29 12 - 18 2 135 59 2871 138 2 1 4294 704 - 468 261 194 135 349 280 232 37 17 7 - - 47 2 66 145 2618 109 - - 4245 722 3954 2447 1414 648 2367 1731 1950 453 256 84 36 1 508 42 577 577 19783 2261 11 7 33694 5412 Health Visitors. The following Tables show the work done by the Health Visitors during the year 1922. Health Visitors. Births Notified. First Visits. Subsequent Visits. Antenatal. Puerperal Fever. Ophthalmia Neonatorum. Various calls and visits. Reports to M.O.H. Under 1 year. 1 to 5 years. Miss Helden 253 241 928 14 1 14 246 24 720 32 Miss Sumner 379 358 367 364 - 16 564 25 505 570 705 597 38 - - 286 35 Miss Islip Miss Child 453 405 694 261 18 1 3 649 38 Miss Bache 438 448 494 339 62 1 1 287 8 Mrs. Cottier 362 360 701 412 38 - 19 313 42 Miss Carlton 402 403 907 307 16 - 5 406 21 Miss Wadds 395 388 820 738 16 - 2 374 11 Salomon's Centre 189 1,906 2,407 3,079 - - 97 52 127 Princess Club 336 - - 92 - - 1,129 2 - Fulford Street 88 469 169 206 - - 643 - - St. George's Hall 173 2,164 2,691 216 - - 353 27 - Central Hall 464 44 - - 171 1 - 123 534 Attendances at Mother's and Children's Welfare Centres for the 52 weeks ended December 30th, 1922. Summary. Class for Mothers. Sewing Class. Ante-Natal Clinic. No. of Sessions. Nos. attending Children. No. attending. Name of Centre. No. of Sessions. No. of Sessions. No. attending. Under 1 year. 1 to 5 years. 103 2,523 Town Hall 47 436 1,335 - 98, Rotherhithe New Road 2,908 - 111 1,173 48 224 322 23 MUNICIPAL LYING-IN HOSTEL. Report from January Ist to December 31 st, 1922. (1) Total Number of Cases Admitted 138 (2) Average Duration of Stay 14 days (3) Number of Cases Delivered by Midwives 124 (4) Number of Cases Delivered by Doctors 14 (5) Number of Cases in which Medical Assistance was sought by Midwives 29 (a) Ante-Natal Nil (b) during Labour 17 (c) after Labour 10 (d) for Infant 2 (6) Number of Cases Puerperal Sepsis with Result of Treatment Nil (7) Number of Cases in which Temperature rose above 100.4 for 24 hours with Rise of Pulse Rate 3 (8) Number of Cases notified as Ophthalmia Neonatorum, with Result of Treatment Nil (9) Number of Cases Inflammation of the Eyes, however slight 4 (10) Number of Infants not entirely Breast-fed while in the Institution, with the reasons why they were not Breast-fed 6 Badly-formed nipples or milk delayed in primiparæ. Supplementary feeds given. (11) Number of Maternal Deaths with Causes Nil (12) Number of Fœtal Deaths, Stillborn or within 10 days of Birth, and their Causes, and the results of PostMortem Examination, if obtainable 7 Stillborn—3 Macerated foetus; 1 Complicated breech; 1 Delayed labour. Deaths —1 Premature; 1 Persistent vomiting. DENTAL TREATMENT. The following report has been submitted by the Municipal Dental Officer which shows a steady advance in so short a period in this branch of the Council's work:— I have the honour to submit the second annual report of the work carried out at the Dental Treatment Centre during the year 1922. During the year Miss Helden, the dental nurse, accepted an appointment as a Health Visitor, and Miss Lambert was appointed in her stead, commencing duty on May 8th, 1922. As the work has considerably increased, it was found necessary to appoint a second dental mechanic. A temporary appointment was made, and Mr. W. B. Monger commenced duty on May 8th, 1922. Unfortunately, one has to record that very little headway has been made in dealing with the problem of dental disease in the child of pre-school age. It is necessary to bear in mind the following facts. Generally, it is from the third year onward, when the temporary dentition is fully erupted, that the child's teeth begin to decay. Although children are examined in the Maternity and Child Welfare Centres and Toddlers' Clinics, usually they are too young to need much attention, and they are but few in comparison with the number in the Borough needing treatment. To deal with the problem in any satisfactory manner it is necessary that the children be congregated, in order that they may be inspected. Such a condition does not exist, and the child from 3—5 years may only be found in the home. With the present staff, a house-to-house inspection is impracticable. On the other hand, as it has been found that parents pay more attention to chair-side demonstrations than to lectures, mothers and adult patients generally are instructed in oral hygiene, and so it is hoped that, by thus educatively overcoming parental lethargy, and popular prejudice as to the importance of the temporary dentition, the child in turn may be benefited. Parents whose children have undergone dental inspection and treatment are desired to bring their children every six months for any necessary following-up, and many do so. The difficulty of the problem is keenly felt, since there is little doubt that if a satisfactory solution is possible, much of the work, now necessary in the school clinics, would be prevented. During the year an endeavour has been made to obtain the attendance of unmarried girls, since for these work may be carried out that will prevent the usually wide extractions found necessary when treating maternity cases. It was found, however, that the higher scale of fees applicable to these patients, acted as a deterrent to their attendance, and it was recommended that the lower scale of fees which applies to maternity cases, apply to these. As a result of the Council's acquiescence, the attendance has been greater, and it has enabled more to be done for the individual. In many cases of pyorrhœa dealt with, cultures have been made from the apices of teeth, and these usually show infection by the streptococcus longus group. While many patients do not actually complain of ill-health, many show signs of general debility, and many present arthritic symptoms. Cases are healed by scaling, appropriate gum treatment, and excision of pockets, others by extraction. As a result some patients report considerable benefit, others a persistence of general symptoms. Many cases where conservative methods were applied report recurrence of the oral condition, due in part, no doubt, to lack of personal care. But where once the alveolus becomes infected it is difficult to cure the oral condition, clear up the general symptoms, and save the teeth. It is hoped that vaccine treatment may be available for these cases shortly. During the year 14 maternity and 4 tuberculosis cases, being unable to pay the full fee were assessed, the total reduction in the fees being £37 11s. 6d. Although local economic conditions react adversely, it is gratifying to be able to report that the Centre has made steady progress during its 20 months' existence, no doubt due in great part to the advertisement of past patients. The evening session, held weekly for those unable to attend during the day, has proved a success, 257 attendances being recorded during the year. At the time of writing the staff is fully occupied. In conclusion, Sir, I desire to express my thanks to you for your unfailing kindness. I am greatly indebted to Dr. D. M. Connan, Assistant Medical Officer of Health, and to the Medical Officers in charge of voluntary centres for their kindly co-operation. I am greatly obliged to Messrs. H. W. Bush and A. Fair, of your office staff; to Messrs. Knott, Love and Rogers of the Accountancy Department; to Miss Lambert, the dental nurse and to Messrs. G. W. Clark and W. B. Monger, the dental mechanics. GRANTLEY SMITH, Municipal Dental Officer. Table I. —Dental Inspection of the Pre-School Child. Number Inspected. Number of Children with Diseased Teeth. Average number of Carious Teeth per child of those Diseased. Age. per cent. 34 2 years and under 13 = 32.3 4.7 44 3 years 32 = 72.7 4.4 29 29 = 100 4 years 4.9 5 years 30 30 = 100 6.3 Total 137 104 = 74 5.07 Table II.—Dental Treatment of Children. Number referred for treatment. Number refusing treatment. Number of Extractions. Number of Administrations of Anæsthetics. Number of Fillings. Number treated for Regulations. Number of Appliances Fitted. Number of Visits for Treatment. Age. 5 and under 4 General. Local. 104 Over 5 101 0 Totals 2 4 205 4 762 135 132 255 22 Table III.—Dental Treatment carried out during 1922. Number of Patients Examined. Number of Patients Treated. Number of Extractions. Number of Administrations of Anæsthetics. Number of Dressings. Number of Fillings. Number of Scalings and Gum Treatments. Number of Dentures Fitted. Number of Repairs to Dentures. Number of Crowns. Number of Visits. General. Local. 323 1,551 94 96 24 .. 314 180 24 Maternity Cases 313 8 1,334 Unmarried Girls (16 to 20 years) 64 64 97 14 1 24 42 8 3 6 2 165 Men 197 193 24 208 25 47 51 762 17 5 20 630 1,391 Women 275 273 249 34 27 87 32 152 1,101 34 .. 55 41 Tuberculosis Cases 5 .. 239 18 49 3 24 11 184 .. Totals (including Children— Table II) 81 1,086 1,117 72 4,802 372 357 6 883 82 *400 3,872 Including 1 obturator and 8 remakes. TUBERCULOSIS DISPENSARY. Number of Primary Notifications 413 Number of Deaths (all forms) 206 Death Rate per annum 1.70 Number of cases admitted to Sanatorium 251 Total number of attendances 5,985 Total number of examinations (including new cases, re-examinations and contacts) 3,281 Total number of new patients 784 Number of nurses' home visits 4,399 Number of doctors' home visits 103 Number of contacts examined 723 Number of reports to public authorities ... 1,137 Number of letters to doctors 567 Number of sputum examinations 1,174 Number of X-ray examinations 96 No. of beds on loan 13 A special report, a copy of which is subjoined, was submitted to the Council in October, 1922. Prevalence of Tuberculosis. The following report was drawn up jointly by the Assistant Tuberculosis Officer, Dr. D. M. Connan and myself in January, 1922:— "Prevalence of the Disease in Bermondsey.—lt is extremely difficult to form an estimate of the prevalence of Tuberculosis in the Borough, but taking the basis adopted by the County Council, which is made on the assumption that the average life of a tuberculous patient is five years, this means that at any given time there are five cases for each notification, viz., 2,275 for the whole Borough. As the inhabitants of the Borough almost entirely belong to the working classes, this must be considered as a rather conservative figure, as it is based on the experience of all London. On the books of the Dispensary there are 7,433 cases, and as we have had some 2,000 deaths since the Dispensary started, this would leave about 5,400 cases still alive, the large majority of whom are, probably, still living in the Borough. The removals from the district would be equalised by the un-notified cases. Work of the Dispensary. —The following are the figures of the work of the Dispensary for the year ending 31st December, 1921: — Total Number of Attendances 10,636 Per Session. „ „ New Cases 763 3.09 „ „ Re-Examinations 3,080 12-47 „ „ Contacts Examined 485 5 „ „ Letters to Doctors, etc. 784 „ „ Reports to Public Authorities 1,124 „ „ Home Visits by Medical Officers 483 The working week of the Dispensary averages for each Medical Officer 37½ hours, and each examining session lasts three hours or more. Between seven and eight cases are examined or re-examined by each Medical Officer at each session, and we do not consider that a larger number than this could be efficiently examined in one session. In addition to the examinations, between 12 and 13 cases are prescribed for by each Medical Officer at each session. Re-examinations are made as far as possible every three months. So far as the more chronic cases are concerned, examination at three-monthly intervals is sufficient, but in cases in which the diagnosis has not been definitely made, re-examinations ought to be at least once a month. At present this is not being done owing to lack of time. The morning sessions on Tuesdays and Saturdays are reserved for the examination of contacts. During the year 485 contacts were examined, i.e., 5 per session, out of a probable 2,729. Considerable difficulty is often experienced in securing the attendance of contacts. In many instances repeated visits by the nurses are required before this is accomplished. This in part accounts for the small number of contacts examined. The afternoon of Friday and the mornings of Monday, Wednesday and Thursday are devoted to the administrative work of the Dispensary, pensary, the writing of letters and of reports; attendance at the I.T.C.C., the examination of sputum and home visiting. Very little time is available for consulting with the practitioners of the neighbourhood about their own cases, and so far no time has been found for having consultation with the Tuberculosis Physician of Guy's Hospital. If the centre at Guy's Hospital is to be of use, a certain amount of time ought to be available for this purpose each week. A number of children recommended for Sanatorium treatment have been sent by the London County Council to Great Ormond Street Hospital, and returned therefrom as not suffering from active Tuberculosis. Experience, however, has shown that it is most desirable to keep these cases under observation, as a considerable number of them, though not suffering from active Tuberculosis at the time of their examination at the hospital, subsequently develop active symptoms, and it then becomes necessary to make some provision for their treatment, as they are not sent to Sanatoria, and cannot be sent to ordinary convalescent homes. In these cases it is very desirable, therefore, that the Tuberculosis Officer should be able to consult the physicians in charge of the cases at the special hospitals. If a part-time Medical Officer were employed, his time would be fully taken up in attending the ordinary examining sessions, and the contact session on Saturday morning. As time is insufficient during an examining session to allow of reports to Public Authorities being written at the time of examination, his work would be confined to the treatment and re-examination of old cases, and the examination of contacts on Saturday mornings. All reports to Public Authorities on these cases, as well as his own, would have to be written by the whole-time Medical Officer, and this would further reduce the time available for home visitations, the examination of sputum, and consultation with the part-time man over difficult cases. The next point to consider is the cost of the part-time Assistant and the nature of his engagement. If this were a guinea and a half per session of two hours, the cost would work out at about £500 per annum. On the other hand, he might be engaged at half the cost of a whole-time assistant, but we do not think it possible to get a competent man on these terms, and here, again, there would be great difficulties in fixing his hours. For instance, we do not know if it would be possible to get a half-time man for Monday morning afternoon and evening. No doubt, it would also be difficult to get a man for Saturday morning, or, indeed, any morning, if he were doing other work." R. KING BROWN. D. M. CONNAN. From a consideration of the above report, it will be evident that it is difficult to decide the question as to whether the second Assistant Tuberculosis Officer should be a whole or part-time man. From a mere consideration of figures it would seem that it is possible to get through the work with a whole-time Tuberculosis Officer and a part-time Assistant, but this can only be done by cutting down certain work, such as Home Visitations, consultations with practitioners, and with the Medical Officers of the Consulting Centres, and by not increasing the examination of contacts, but this seems a very unsatisfactory method of working. The actual working week of a Tuberculosis Officer is considered by the London County Council to be 36 hours, and, taking the nature of the work into consideration, it is most undesirable that this should be substantially increased. Your part-time officer would be available for about 18 to 20 hours, and this would be taken up by six sessions of three hours each, and his services would not be available for home visiting, writing report and letters, or sputum examination, all of which things take up a considerable amount of the time of a Tuberculosis Officer. The character and the population of the Borough, the prevalence of Tuberculosis, and the importance and the desirability of continuing the work at the very least to the standard which has been maintained so far, in my opinion justify the appointment of a wholetime Second Assistant. The following report was submitted to me by Dr. Connan, in October, 1922, and my comments will be found at the conclusion:— "I beg to submit the following report of the work of the Dispensary since March Ist, 1922. It will perhaps make matters clearer if an indication is given of the lines upon which the Dispensary was conducted previously to its transference to the control of the Borough Council. The clientele of the Dispensary includes notified cases, patients attending voluntarily, and persons referred to the Dispensary by local medical practitioners; the Ministry of Pensions; the London County Council and other public bodies. Under the Central Fund all such cases were examined, and given medicinal treatment if necessary, with the exception of insured persons and patients sent by Doctors for opinion only. For every patient a case sheet was made out, which remained as a permanent record, whether that particular case was one of Tuberculosis or not, and even after discharge, death, or the removal of the person to another district, no provision was made for using the space rendered available by such discharge, removal, etc. As a result of this sytem it was found that out of 7,600 cases of which records were kept, only about 1,400 were definitely Tuberculous or suspect. The hours of attendance under the old regime were 2-5 in the afternoons; 6-8 Monday evening, and 10-1 Friday morning. Examinations by appointment at a definite hour were rarely made, and thus it was impossible to say how many patients were to be seen for treatment, and how many were to be examined at any given session. This resulted very often in a patient waiting two hours or more to be seen, and, of course, many patients made a practice of arriving just before the closing hour in order to avoid a long wait. The system has been altered so as to meet, as far as possible, the uggestions of the Ministry of Health, which are given below:— Circular 149. (1) Complete co-ordination with the work of the Public Health Department. (2) One whole-time Tuberculosis Officer to about 160 deaths and a thirty-six hour week. (3) Consultation Centres. (4) Diagnosis at the earliest possible date. (5) Treatment limited to patients unable to obtain other adequate medical attendance and to patients whose treatment requires special knowledge. (6) Education of patients out of the belief in the efficacy of drugs. (7) Co-operation with school medical service. (8) One evening session a week and session on Saturday morning for school children. (9) Examination by appointment. (10) Examination of contacts and 'following up' of patients. (11) Personal acquaintance of Tuberculosis Officer with practitioners of the neighbourhood. (12) Tuberculosis Officer should visit the home of each patient at least once. (13) Adequate clerical staff. The two most important alterations have been in:— (1) The method of recording cases. (2) The hours of attendance. (1) All definite Tuberculosis cases are recorded upon the standard case sheet, which is modelled upon Form 'A' of the L.C.C. The examination of all other cases is entered on a Temporary card on which provision is made for three examinations in two months. If one of these latter cases is diagnosed, at any time during the two months, as Tuberculosis, the entries on the Temporary card are transferred to a case sheet. Where the diagnosis is negative, a permanent record of the examination is made, and the case discharged. In cases which are still doubtful at the end of two months, an appointment is made for another examination at a later date. (11408)q c 33 In the case of children of school age, where the diagnosis is still indefinite after a period of observation, advantage is taken of Form M.o.33 L.C.C., to refer the child to the School Medical Officer, who may send the child back to the Dispensary at any time, if he thinks it advisable to do so. This system appears to work satisfactorily, and has the merit of insuring a definite diagnosis within a reasonable time, and thus avoids the attendance at the Dispensary, for indefinite periods, of undiagnosed cases. All cases which have ceased attendance at the Dispensary because of discharge, death, or removal to another district, are recorded in outline on a card. It is intended that this record should go back for five years only, and that it should be brought up to date at the end of each year. (2) The hours of attendance have been altered so that patients who have previously attended the Dispensary, i.e., 'Old cases,' have to attend on afternoons between 1 and 2 p.m.; on Monday evening from 6.30-7.30 p.m., and on Friday morning from 9.30- 10.30 a.m. Local practitioners and public institutions interested have been informed of the change. Every allowance is made to suit the convenience of patients, particularly with regard to Monday evening. All examinations are made by appointment, with the exception only of urgent cases. The appointment is made by post-card, as this method has been found more effective than any other. The effect of this change has been very noticeable. Old patients who do not require special examination are rarely detained more than half an hour at the Dispensary. By this means the Dispensary is rapidly cleared of patients, and the quiet thus caused is very advantageous for the physical examination of patients who come by appointment. Very little difficulty has been experienced in getting patients to understand the change, and there is no doubt they greatly appreciate the promptness with which they are seen. Between eight and ten cases are examined at a session. 1921. April. May. | June. July. August. No. of Attendances 941 905 I 1011 I 923 I 769 No. of Examinations 374 359 440 410 259 1922. April. May. June. July. August. No. of Attendances 398 472 453 377 349 No. of Examinations 218 273 207 225 220 During July and August, 1922, 55 cases were discharged as non- Tuberculous; no record of discharges was kept previously. Number of Deaths of Tuberculous persons in Borough:— In 1920 170 In 1921 171 The Dispensary is intended to be a centre for:— (1) Examination of suspects. (2) Examination and supervision of definite cases of Tuberculosis; including the arrangement of residential treatment when necessary, and supervision thereafter. (3) Treatment of cases of Tuberculosis for whom no other provision is made, i.e., uninsured adults and children who have no private practitioner. As Tuberculosis is a chronic disease it is unnecessary for patients receiving treatment to attend at frequent intervals, except in a few cases. (11408)q C 2 35 When urgent symptoms arise patients are at liberty to attend during any session, but, as a routine, attendance once a month is quite sufficient to ensure a careful watch being kept on each case. It will be seen from the above figures that the number of attendances and the number of examinations have both decreased, but that the decline in the number of attendances is greater than that in the number of examinations. One Medical Officer cannot do the same amount of work which was formerly done by two. An approximate standard of the work which should be done at the Dispensary is obtained from the number of primary notifications of Tuberculosis, which was 455 in 1921, i.e., approximately 38 a month. Taking contacts into account there should therefore be about 190 examinations per month. A reasonable margin above this has been maintained. It has only been possible to maintain this level by spacing out the attendances of chronic cases, and by discharging cases which show no evidence of Tubercle. Under the present system, I believe that it will be possible for one Medical Officer to conduct the Dispensary to the satisfaction of the Ministry of Health, London County Council and Borough Council, and without detriment to any Tuberculous person in the Borough, though it is necessary to point out that the work is always heavier during the winter, and that this report is based on the experience during the summer months of the year. With regard to the requirement of the Ministry of Health, in their circular of December, 1920, that the Tuberculosis Officer should visit the home of every patient at least once, this will be somewhat difficult to carry out. Sixty minutes is estimated as the time necessary for each home visit by the London County Council, and as there are about ten new cases a week, this means 10 hours out of the Dispensary time of 36 hours per week. This requirement has been cut down by the London County Council in their letter of July 15th, 1922, presumably with the cognizance of the Ministry of Health, and personally I do not think it is necessary to visit every home. The present practice is only to do this where the nurse thinks a personal visit of the Medical Officer is advisable." I have been very carefully through the above report, and agree with Dr. Connan's conclusions, namely, that if conditions do not materially alter during the next six months, from what they were during the six months under report, one Medical Officer is sufficient for the Dispensary. There is a good deal of misapprehension as to the functions of the Dispensary. It is really not intended to be a kind of Out-Patients' Department of an ordinary hospital for treating all cases of Tuberculosis, or cases about which there is some suspicion of this disease, but is intended rather to co-ordinate the treatment which is available by Institutions and Practitioners in or near the Borough, and to see that cases of Tuberculosis are not neglected.* If it was to develop on the lines of the Out-Patients' Department of an ordinary hospital, it would become in a short time a very costly Institution, and the work would be merely overlapping that of other agencies. The Medical Officer of the Dispensary should act in the capacity of a Consultant, and not waste his time attending ordinary routine treatment. The Dispensary was visited in December by representatives of the Ministry of Health and of the L.C.C. Scheme for the Treatment of Tuberculosis for the Financial Year commencing 1st April, 1923. As the County Council have requested this Council to submit a scheme before the end of the present month for the financial year commencing Ist April, 1923, I beg to submit the following report, which embodies all the points alluded to in the letter from the County Council. The following is the staff concerned with the work of Tuberculosis in the borough:— Olive Pike Ditto £208 Ditto Ditto Rose Dutch Apothecaries Hall £225 Clerk and Dispenser Ditto Dispensing Qualification Frederick W. Smith* - - C lerk January, 1920 Caretaker — £156; fire, lodging Various; weigh and light patients, etc. *Mr. F. W. Smith is a clerk in the Public Health Department, who devotes about six hours weekly to the Tuberculosis Dispensary. The above staff is a part of the Public Health Department, and the duties comprise the following:— (1) Receiving notifications of Tuberculosis on Forms A, B, C, and D, and keeping a register of these. (2) Keeping administrative and clinical records of all cases and suspected cases of Tuberculosis in the Borough. (3) Supervision and periodical examinations of all cases of Tuberculosis, including regular visitation of the homes by a Dispensary Nurse, the giving of advice on hygiene and reporting insanitary conditions to the Medical Officer of Health. (4) Assisting general practitioners in the diagnosis of Tuberdulosis, and advising them as to treatment both in insured and non-insured cases. (5) Examination of "contacts." (6) Special examinations of ex-sailors and ex-soldiers for the Local Pensions Committee and the Medical Boards of the Ministry of Pensions. (7) Giving special treatment, such as "Tuberculin," and giving medicinal treatment in cases where, for special reasons, they are not being treated by general practitioners, Poor Law doctors, or other medical men. Cases requiring the administration of ordinary medicine (including cod liver oil, etc.), comprise those under treatment by "Tuberculin." Not infrequently cases of this sort improve so much under the strict supervision and treatment of the Dispensary that residence in a sanatorium becomes unnecessary. These cases requiring ordinary drugs do not constitute a large number, as the amount of money spent on drugs will show. (8) Making recommendations to the London County Council regarding treatment in residential institutions, and making progress reports to the London County Council of cases that have been treated in a sanatorium. Special Facilities at Hospitals, etc. The Tuberculosis Dispensary has been linked up with Guy's Hospital for the purpose of providing observation beds and special facilities for treatment and diagnosis. The authorities and medical staff at Guy's have agreed to undertake this work free of charge. Arrangements have also been made for the taking of X-Ray photographs at a charge of 7s. 6d. each. Finsen light treatment has so far been carried out at the London Hospital at a cost of 5s. per sitting for each patient, but a special arrangement with the Hospital is not necessary. Tuberculous subjects will attend at our Municipal Dental Clinic at 98, Rotherhithe New Road. A special fortnightly session is set aside for these patients, and the following are the charges:— Adults— Fillings, 2s. 6d. each. Scalings, 2s. 6d. Extractions : With gas, irrespective of number of extractions, 2s. 6d. With local anæsthesia: Single extractions, 1s.; Multiple do., 2s. 6d. Dentures: Complete, upper or lower, £2. Partial upper or lower, at 3s. per tooth. Children— Free. Special cases where patients are unable to pay the above fees will be brought before the Committee for assessment. The following will be the scheme for the distribution of extra nourishment, subject to the sanction of the Ministry of Health: — Supply of extra nourishment to Tuberculous persons. (1) Extra nourishment should comprise milk, eggs, butter, oatmeal. (2) That it should be supplied only to necessitous tuberculous persons of the borough. (3) That extra nourishment should only be supplied on the recommendation of the Tuberculosis Officer, after investigation of the conditions by the Dispensary nurse, to necessitous cases well known to him. (4) The period for which milk is given to be limited by the Tuberculosis Officer, and be decided on medical grounds. It is estimated that the expenditure for next year will be as follows : £ Salaries and Wages 1,534 Rents, Rates, Insurance, etc 100 Drugs, "Tuberculin," Medical Appliances, etc. 75 Repairs and Maintenance 100 Fuel, Lighting and Water 55 Extra nourishment for patients 240 Printing, Stationery and General Establishment Charges 45 Bottles for Carbolic Acid and Sputum, etc. 30 Dental treatment 78 X-Ray reports 60 Finsen Light treatment 70 National Insurance Act 13 Total £2,400 The total estimate for last year was £2,885, which did not include X-Ray reports or Finsen Light treatment. Report of Tuberculosis Officer. "Tuberculous" Houses. In dealing with any disease from a public health point of view, a knowledge of the extent and distribution of the disease is essential. With the object of acquiring this knowledge concerning Tuberculosis, notification of the disease was made compulsory in 1912. A register of notifications is kept by the Medical Officer of Health, and a weekly list is supplied to the Dispensary. This list gives the names and addresses of the persons notified during the week, and it has been pointed out that the same address often appears on the list several times in the course of a year. Such re-appearance of the same address is not surprising, in view of the fact that if more than one member of a family is suffering from Tuberculosis, there must be a separate notification for each member. But, arising out of this observation the question has been asked, " Is it possible to contract Tuberculosis merely through living in a house in which a person suffering from the disease has previously lived ?" We are told that there are "Cancer Houses"; is it possible that there are also "Tuberculous Houses"? We know that the Tubercle Bacillus has considerable powers of resistance to adverse influences. It can exist in a dry state in dust for as long as two months. It has been shown that the Bacillus can be recovered from the wall paper of a room inhabited by a phthisical person. On the face of it there is no obvious reason why the answer to the question should not be in the affirmative; but a little consideration, however, shows that the matter is by no means as simple as it looks. Assuming for a moment that Tuberculosis can be contracted in this way, what facts must be adduced to prove the assumption? It is necessary to consider the following three points, and if, as a result of investigation, one or more houses can be found to comply with the conditions, a strong case will have been put forward to show that Tuberculosis may be contracted by a person through merely living in an infected house. (1) Three or more cases must have occurred in succession in the same house. Two cases occurring in succession would not be sufficient evidence, because Tuberculosis is so widespread that this might merely be a coincidence. The cases must occur in succession, i.e., two cases must not have lived in the house together, because otherwise the second person notified might have contracted the disease from the first person. (2) Each person must:— (a) Have been free from Tuberculosis, as far as is known, on taking up residence in the house. (b) Have no family history of the disease. (c) Have no other known source of infection. (3) The question arises whether there are any local conditions, specially favourable to the development of Tuberculosis, e.g., dampness, back-to-back houses, etc. This point has to be considered because a series of cases might occur in the same house simply as a result of the existence of some such local conditions. Bearing these three points in mind, the register of Tuberculosis notifications in Bermondsey was examined for the ten-year period January Ist, 1912, to December 31st, 1921, both dates inclusive. The total number of notifications of Tuberculosis —all forms—during that period was 5,443. — i ii iii iv v vi vii viii ix Cases 3 4 5 6 7 8 11 22 55 Houses 143 27 7 1 2 2 1 1 1 In the upper Section of the table is given the number of cases which have occurred in the house under consideration. In the lower Section is shown the number of houses in which three, four, five, etc., cases of Tuberculosis have been notified: thus, three cases of Tuberculosis have occurred in each of 143 houses, four cases in each of 27 houses, and so on. Setting aside the last three columns and Column v, which will be dealt with later, there remain five columns referring to houses in which 3, 4, 5, 6, and 8 cases respectively have occurred. Eight cases.—Two houses each have sheltered eight cases of Tuberculosis in 10 years. In one of these houses, all the cases notified were members of the same family, with the exception of one person, a lodger, who was suffering from Tuberculosis before she entered the house. In the second of these two houses, six cases were members of the same family, and the remaining two cases were living in the house at the same time. No specially unfavourable conditions were noted in connection with either of these houses. Six cases.—ln the house in which six cases of Tuberculosis have occurred, all were members of the same family, and three have died at home. Five cases.—In four of the seven houses having five cases, all the cases were of the same family, and in one of these houses four members died in two months. Another house in this class has to be excluded, because the cases did not occur in succession. The sixth house in this series fails to comply with the conditions, because one tenant had Tuberculosis on entering the house, and three of the remaining cases were living together in the house at the same time. The seventh house is a hostel for girls, where the conditions are good. One of the girls had Tuberculosis for some years before living in the Hostel, another girl had a family history of Tubercle, and two others lived in the hostel at the same time. Four cases.—Four cases of Tuberculosis have been notified as occurring in each of 27 houses. For one reason or another —mainly because the cases did not occur in succession—or because members of the same family were involved, all of these houses had to be excluded. Three cases.—As the number of cases notified in each house decreases, the number of houses increases, and it was found from the register that 143 houses had each been inhabited by three cases of Tuberculosis in the 10 years. With one exception, in which no information could be obtained, either from the Dispensary records, the register, or by means of visiting the house, not one of these houses complied with all three conditions set out above. Returning now to the above table, Columns v, vii, viii and ix remain to be discussed. The address referred to in Column vii as having had 11 cases is a Salvation Army Hostel for men; Columns v, viii and ix show that in two houses there have occurred seven cases, another house has had 22 cases, and the last house has had 55 cases. These three houses are all common lodging houses, and it is nearly always impossible to obtain any information about the persons notified once they have left the house, so these figures shed no light on the question of house infection. So far as Bermondsey is concerned, therefore, there seems to be no evidence to show that "Tuberculous houses" exist. In pursuing this investigation the notification register has been the starting point. The information contained in the register is, however, at best, scanty, and has been supplemented from the Dispensary records, and by visitation of the houses concerned. Certain observations remain to be made, arising out of the enquiry. (1) Lodging houses. (2) Local distribution. (3) Notification. (1) It is apparent that common lodging houses shelter a large number of cases of Tuberculosis. The probable explanation is that the Tuberculous person is deprived of the power of earning to a very large extent, and can find no better home. The congregation of such persons in common lodging houses must expose the other lodgers to considerable risk, and the Sanitary Authority ought to have power to remove cases notified from common lodging houses, and other similar places, e.g., Hostels, compulsorily to an institution or hospital. As a matter of fact, these cases never remain for long in a common lodging house after notification, but the point is that they should be under control, and should not be free to wander from one house to another shedding infection. (2) The local distribution of the disease is interesting; 8,114 dwellings in Bermondsey are occupied by two or more families; 10,152 dwellings house one family only. This latter figure seems a large one for a Borough like Bermondsey, but the figure includes lodgers —except where boarding separately—as members of the family, and also each flat, in a block of flats, is regarded as a separate dwelling. If it were possible to exclude those houses having lodgers, this figure would undoubtedly be smaller, Comparing the number of cases which have occurred in 10 years in any particular street with the number of houses in that street, the highest proportion is found in Princes Street, where 44 cases have occurred in a street of 41 houses, and in Dix's Place, where 33 cases have occurred in 25 houses. The lowest proportion is found in Reverdy Road, where six cases have occurred in a street of 65 houses. With regard to Princes Street, the houses are old and large, and are nearly all occupied by members of more than one family, and most of the occupants are casual labourers at the waterside. These two streets are streets in which one would expect a high proportion of cases of Tuberculosis. On the other hand, the Reverdy Road houses are of more recent construction, in better repair, and are inhabited by persons of the artisan type of more substantial means and in more regular work than the casual labourer. Following this method of comparison, it can be said generally that the street in which a large number of cases have occurred is a street in which the houses are old and in an unsatisfactory sanitary condition, and that in those streets where few cases have occurred the houses are of more recent construction, and in good repair. Although it is not susceptible of proof, it is probable also that the economic status of the inhabitant of the "good" street is higher and more permanent than that of the inhabitant of the "bad" street. It is estimated that there are 19,142 houses in the Borough. As the total number of notifications during the 10 years is 5,443, this gives a proportion of one notified case to every 3½ houses. Considering blocks of buildings, the figures for some of the larger blocks are given:— - Cases. Flats. Proportion to Flats. Devon Buildings 59 554 1 in 9.4 Guinness Buildings, Page's Walk 119 454 1 in 3.8 Guinness Buildings, Snow's Fields 87 352 1 in 4.0 Park Buildings 36 224 1 in 6.2 Wolseley Buildings 62 189 1 in 3.0 Sutton Dwellings 19 194 1 in 10.0 Vine Street Buildings 60 214 1 in 3.5 Barnham Street Buildings 21 147 1 in 7.0 Barnaby Buildings 19 80 1 in 4.0 Hythe Buildings 20 70 1 in 3.5 Eastbourne Buildings 2 36 1 in 18.0 Hastings Buildings 1 36 1 in 36.0 Peabody Buildings 8 72 1 in 9.0 Abbey Buildings 10 128 1 in 12.8 The remarks made above about streets apply to buildings also Devon Buildings and Abbey Buildings are in a good sanitary condition, while Wolseley Buildings are very far from satisfactory. One point to be noted about children living in buildings is that they frequently get too little sleep. When they inhabit the higher storeys their parents seldom think to go down to the playground to fetch them at bedtime, while when they live in a lower storey, the noise of older children at play effectually prevents sleep. Children as young as two years may be seen playing in the yards till 10 p.m. summer and winter. (3) It cannot but be apparent to anyone who is sufficiently interested to look up the notification register, that the present method of notification serves only one useful purpose, and that ineffectively. Notification as at present in force supplies a certain amount of information concerning some of the persons suffering from Tuberculosis in the area concerned. By no means all of the Tuberculous persons in that area are notified, while at the same time a number of non-tuberculous persons find their way into the register, and no adequate system of denotification is practised. The number of non-tuberculous persons notified can never be accurately determined because the diagnosis is always a matter of opinion, but in one year, taking into account the history of the patient, and the result of examination by the Tuberculosis Officer, 71 cases have been marked for denotification as probably not Tuberculous. Again, the notification register is inaccurate because of duplicated entries. In the report of the Medical Officer to the Ministry of Health, 1921, it is stated that the Ministry receives from County and County Borough Medical Officers of Health annual summaries showing duplicate notifications, and hence it is possible to show the actual number of "new cases"of the disease during the year. But on investigating the local register, duplicated entries have been found which were unknown to the Medical Officer of Health. As the register was not being searched with the object of discovering these unknown duplicates the actual error has not been determined, but in the course of looking up 788 entries, 38 duplicates not known to the Medical Officer of Health were discovered, an error of about 5 per cent. This error is in part to be ascribed to the disturbance of routine work in the office due to the war. Two cases are known in which deliberate concealment of information was practised by the patient. Change of name on marriage is also responsible for a portion of the error. Six of these cases were notified first as Non-Pulmonary, and later as Pulmonary Tuberculosis. Inaccurate filling up of the notification form, together with change of address not reported, accounts for the remaining part of the error. It appears to be impossible to obtain under the present system an accurate estimate of the total number of persons actually suffering from Tuberculosis at any given time in a particular locality. The dispensary service has been revised and remodelled very largely, and a similar revision of notification, to bring it into harmony with the dispensary service, is now due. A suggested re-modelling is outlined below. The purpose of notification is to supply the Medical Officer of Health with accurate knowledge as to the extent (i.e., number of cases) and distribution of Tuberculosis in his area. The present system is too rigid. The doctor must notify a case of Tuberculosis as soon as his diagnosis is made. He hesitates to do so because he feels that in notifying a case he is branding his patient for life, while at the same time he is conferring no compensating benefit upon the patient. For this reason he may retain or magnify a doubt, make no definite diagnosis, and refrain from notifying. If the doctor could feel that in notifying he was really helping his patient personally, as well as taking his part in preserving the public health, many more notifications would probably be received. A standard notification form as described below is suggested for the use of all medical practitioners. (11408)Q D 49 Sex Symptoms:— Physical Signs Married Cough or Expectoration Hæmoptysis Single Dyspnœa Night Sweats Appetite Indigestion Lassitude Temperature Pulse Weight (2) Non-Pulmonary Doctor's Signature Symptoms Signs Date Signature Date Referred for opinion to Dispensary at— 108, Grange Road, S.E.I. This form merely refers the patient to the Dispensary for an opinion. Part II of the form should be completed accurately and sent to the Medical Officer of Health, the patient being given instructions to attend the Dispensary, and Part I be retained by the doctor. The following advantages are claimed for this system : — (1) The doctor would examine his patient. Many doctors send cases to the dispensary without having personally examined them as a preliminary. (2) The doctor merely expresses an opinion, and it is for the Medical Officer of Health or the Tuberculosis Officer to accept or modify the diagnosis after careful investigation (including X-ray examination, observation in Hospital, etc.) over a longer or shorter period of time, as the case may be. Some cases would be rejected and some retained as Tuberculous. These latter cases would be entered in the Notification Register, and, of course, the doctor would be informed of the diagnosis and registration. (3) De-notification would be simple since the notifying practitioner would be the Medical Officer of Health or the Tuberculosis Officer. The question of notification fee would certainly be raised, and the fee should be adequate, and an accurate completion of the form required. Undoubtedly, wilful cases of non-notification would occur in the more well-to-do districts, and these could only be met by removing the excusing phrases in the present regulations, and prosecuting on every possible occasion. What will the patient gain from this modified system of notification? He will have an accurate diagnosis, in all probability made much earlier than at present. At the same time he will be protected from unnecessary notification if he is not suffering from Tuberculosis. Recently a case was sent to the Bermondsey Dispensary as Tuberculosis of the Cervical Glands, peeling freely all over, and having a history of a rash and a sore throat three weeks previously. (11408)q D 2 51 Finally as a further help to the really Tuberculous person, it is suggested that all adult cases entered on the notification register should automatically be entitled to come under the Insurance Act, and should be entitled to all the benefits of that Act. This latter suggestion raises many knotty points, and is bound to provoke the scorn of the economist. It is, however, quite feasible were the money forthcoming, and considering that the Tuberculous person, in the large majority of cases, is at some time or other supported by public money, the idea is not so ridiculous as it appears to be. D.M.CONNAN. Table I. —Vital Statistics of whole District during 1922 and previous Years. Year. 1 Population estimated to Middle of each Year. Total Deaths registered in the District. Net Deaths at all Ages belonging to the District. Births. Deaths of Non- Residents registered in Public Institutions in the District. 10 Deaths of Residents registered in Public Institutions beyond the District. 11 No. 3 Rate. 4 Under 1 Year of Age. At all Ages. Total Deaths in Public Institutions in the District. 9 No. 12 Rate.* 13 No. 5 Rate per 1,000 Births registered. 6 No. 7 Rate.* 8 1912 125,388 3,799 30.3 433 114 1,601 12.8 483 20 538 2,119 16.9 APPENDIX. 21 1913 124,739 3,842 30.8 505 131 1,730 13.9 529 534 2,243 17.9 1914 124,213 3,757 30.2 487 129 1,694 13.6 615 26 2,184 17.6 516 1915 123,665 3,482 29.6 537 154 2,053 17.5 654 38 542 2,514 21.4 1916 123,665 3,361 27.1 364 108 1,507 13.2 608 155 453 1,960 17.2 1917 119,983 2,613 21.7 329 125 1,807 18.8 840 186 411 2,032 18.8 1918 121,465 2,323 19.1 322 139 2,142 19.8 1,007 191 2,390 22.0 439 124,239 1919 2,637 20.4 212 80 1,600 12.8 709 165 313 1,748 14,1 1920 129,189 4,038 31.2 280 69 1,466 11.3 689 105 281 1,642 12.7 1921 120,500 3,231 26.8 261 80 1,313 10.8 657 51 394 1,656 13.7 123,702 3,308 26.7 112 1,691 14.4 679 442 2,048 17.2 Averages for years 1912- 1921 95 373 1922 121,100 3,167 26.1 259 81 1,572 12.9 778 43 496 2,025 16.7 * Rates in columns 4, 8 and 13 calculated per 1,000 of estimated population. Area of District in acres (exclusive of area covered by water), 1336-1, At Census of 1921—Total population of all ages, 119,455. Do. Number of inhabited houses, 14,967 Do. Average number of persons per house, 8.41. Other Institutions, Etc., Etc. I. Institutions within the District receiving sick and infirm persons from outside the District. II. Institutions outside the District receiving sick and infirm persons from the District. III. Other Institutions, the Deaths in which have been distributed among the several localities in the District. No. of Deaths Bermondsey Infirmary 16 Deaths in River Thames, Surrey Commercial Docks, Wharves, etc. 23 Private Houses 3 School 1 Total 43 No. of Deaths Ambulance on way to Hospital 3 Banstead Mental Hospital 4 Bexley Mental Hospital 1 Brentwood Mental Hospital 1 Brook Hospital 10 Camberwell Hospital 1 Camberwell Institution 1 Cane Hill Mental Hospital 10 Caterham Mental Hospital 8 Central London Throat and Ear Hospital 1 Charing Cross Hospital 2 City of London Institution, Bow 1 Claybury Mental Hospital 4 Colindale Hospital 12 Darenth Training Colony 1 Dartford Heath Mental Hospital 11 Dollis Hill House Hospital 1 East London Hospital 4 East Sussex Hospital 1 Evelina Hospital 6 Great Ormonde Street Hospital 2 Grove Hospital 4 Guy's Hospital 125 Hackney Institution, Brentwood 1 Hanwell Mental Hospital 1 High Wood Hospital 1 Homoœpathic Hospital 1 Horton Mental Hospital 1 Hull Infirmary 1 Joyce Green Hospital 3 Ladywell Institution 47 Leavesden Mental Hospital 6 Lewisham Hospital 3 London Hospital 2 Long Grove Mental Hospital 4 Ministry of Pensions Hospital, Brixton 2 „ „ Orpington 3 „ „ Ruskin Park 1 Manor House Hospital 1 Metropolitan Asylum Board Hospital, Cleveland Street 2 Middlesex Hospital 2 Miller Hospital 2 National Heart Hospital 1 Newington Institution 1 North Middlesex Hospital 1 North Western Hospital 2 Park Hospital 41 Peckham Rye Pond 1 Poplar Hospital 2 Poplar Institution 1 Private Houses 13 Queen's Hospital, Frognal 2 Queen Mary's Hospital 1 Railway 1 River Thames 4 Royal Albert Docks 1 Royal Chest Hospital 1 Royal Ear Hospital 1 Royal Waterloo Hospital 1 St. Bartholomew's Hospital 1 St. Columbus Hospital 1 St. George's Home, Chelsea 1 St. James' Infirmary, Battersea 1 St. Joseph's Hospital, Hackney 1 St. Margaret's Hospital 1 St. Thomas's Hospital 3 Seamen's Hospital 2 South Eastern Hospital 57 Southend Esplanade 1 Southern Hospital 1 Southwark Hospital 2 Street 7 Thames Ditton Cottage Hospital 1 Tooting Bee Mental Hospital 19 University College Hospital 2 Western Hospital 1 475 54 TABLE III.—Abbreviated Tables of Causes of Death. CAUSES OF DEATH. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 1 month. 1-3 months. 3-6 months. 6-9 months. 9-12 months. Total Deaths under 1 year. 1922. Total Deaths under 1 year. 1921. All causes Certified 66 19 17 14 116 51 39 54 64 324 306 Uncertified - - - - - - - - - - - Small-pox - - - - - - - - - - - Chicken-pox - - - - - - - - - - - 1 Measles - - - - - 7 10 18 - - Scarlet Fever - - - - - - - - - 2 - Whooping Cough - - - - - 4 5 4 6 19 4 Diphtheria and Croup - - - 1 1 - 1 5 7 4 - - Erysipelas - - 1 1 - - 1 - 2 1 Tuberculous Meningitis - - - - - - - 1 2 3 2 Abdominal Tuberculosis - - - - - 1 - 1 - - - - Other Tuberculous Diseases - - - - 1 3 - 1 5 - Meningitis (not Tuberculous) - - - - - - - - 6 2 - Convulsions 2 - 1 - 3 1 - - - 4 5 Laryngitis - - 1 - 1 - - - - 1 - Bronchitis - - 4 4 2 - 4 2 12 14 - Pneumonia (all forms) 2 1 4 3 10 18 12 24 26 90 68 Diarrhœa - - - - - 2 1 - - 3 9 Enteritis - - 1 - 1 1 4 1 5 12 3 - Gastritis - - - - - - - - - - Syphilis 1 - - - 1 2 1 - - 4 6 Rickets - 2 - - 2 - - - - 2 - - Injury at Birth 1 - - 1 - - - - 1 7 Atelectesis 6 - - 1 7 2 1 - - 10 4 Congenital Malformations - - - 1 1 - - 1 2 8 - Premature Birth 36 7 6 - 49 3 - 2 - 54 52 Atrophy, Debility and Marasmus 2 3 14 10 3 33 8 1 4 2 52 41 Other Causes 10 7 3 - 20 5 7 5 4 59 116 66 Totals 19 17 14 51 39 54 64 306 324 Nett births in the year—Legitimate, 3,167; Illegitimate, 55. TABLE IV. —Causes of, and Ages at Deaths, during the Year 1922. Causes of Death. Deaths at the subjoined ages of "Residents" whether occurring in or beyond the District. 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. 2,025 324 175 161 118 98 398 510 241 Certified All Causes Uncertified - - - - - - - - - Enteric Fever 1 - - - - 1 - - - 56 Small-pox - - - - - - - - - Measles 18 44 35 4 101 - - - - scarlet Fever 11 - 1 8 - 1 - Whooping Cough 56 - - 19 24 22 - - - Diphtheria and Croup 90 7 33 - - 16 3 1 - - - - Influenza 72 3 2 2 5 5 14 23 18 Erysipelas 3 2 - 1 - - 161 - — - Phthisis (Pulmonary Tuberculosis) 1 2 1 8 37 39 64 9 Tuberculous Meningitis 23 3 9 2 8 1 - Other Tuberculous Diseases 22 — - 6 1 1 6 2 2 3 Cancer, Malignant Disease 1 135 - 2 - - 22 - 60 51 Rheumatic Fever 7 - - - 5 1 1 - 1 Meningitis - - - - - 1 - - Organic Heart Disease 190 - - - - 11 12 23 58 86 Bronchitis 160 12 5 1 1 - 14 46 81 Pneumonia 298 90 58 34 10 4 19 39 44 - 1 3 Other Diseases of Respiratory Organs 20 1 7 8 - - Diarrhœa and Enteritis under 2 years 22 17 5 - - - - - - 3 2 - Appendicitis and Typhlitis 8 - 3 - - - - Cirrhosis of Liver 2 - 1 1 - - - - Alcoholism - - - - - - - - - Nephritis and Bright's Disease 2 9 41 - - 7 23 - - 2 1 Puerperal Fever - - 1 - - - - Other Accidents and Diseases of Pregnancy and Parturition - - I - - - 2 2 - - Congenital Debility and Malformation, including Premature Birth - 2 - - - 104 102 - - 13 6 9 Violent Deaths, excluding Suicide 54 3 3 3 9 8 13 Suicide - 1 - 7 2 3 - - 197 9 8 23 84 Other Defined Diseases 426 41 10 47 Diseases ill-defined or unknown - - - - - - - - - All Causes 98 398 510 2,025 175 161 118 241 324 57 TAMLE V.—Cases of Infectious Diseases Notified during the Year 1922. NOTIFIABLE DISEASE. NUMBER OF CASES NOTIFIED. BERMONDSEY. ROTHERHITHE. At Ages—Years. 1 2 3 4 5 6 Total. 1 2 3 Total. St. John. St. Olave. At all Ages. 1 and under 5 years. 5 and under 15 years. 15 and under 25 years. 45 and under 65 years. 65 and up wards. 25 and under 45 years. Under 1 year. Small-pox 2 - - - - 1 1 - 1 1 - - - - 2 - - - - - - Diphtheria (including Membranous Croup) 1111 30 382 551 86 53 9 - 90 154 119 157 117 144 781 125 92 45 262 42 21 Erysipelas 50 3 4 6 6 13 13 5 6 6 6 2 1 3 24 8 10 5 23 2 1 Scarlet Fever 652 9 194 384 48 17 - - 75 85 56 91 60 52 419 70 87 49 206 7 14 Relapsing Fever - - - - - - - - - - - - - - - - - - - - - Cerebro-Spinal Meningitis 5 2 1 1 1 - - - - - - 1 1 3 - 1 - 1 - 1 1 Polio-Myelitis and Polio-encephalitis 2 1 1 - - - - - - - - 1 - - 1 - - - - - - Polio-encephalitis Ophthalmia Neonatorum 12 - - - - - - 1 1 6 2 1 5 1 12 2 1 1 - 2 - Anthrax 1 - - 1 - - - 1 - - - - - 1 - - - - - - - 4 - - - 3 1 - - - 2 - - - 1 3 - - 1 Enteric Fever 1 - - 7 - - - 1 6 - - 2 - - - 1 3 6 1 - - 1 - - Puerperal Fever Encephalitis Lethargica 2 - - 1 - - 1 - 2 - - - - - 2 - - - - - - Dysentery - - - - - - - - - - - - - - - - - - - - - Malaria 1 - - - 1 - - 1 - - - 1 - - - - - - - - - Continued Fever - - - - - - - - - - - - - - - - - - - - - 89 Pneumonia (Acute Primary and Acute Influenzal) 234 18 36 18 24 12 11 51 15 27 133 37 37 20 9 28 14 79 17 5 4 Pulmonary Tuberculosis 317 1 3 55 78 129 47 30 33 51 30 26 23 193 37 35 28 100 13 9 Other Forms of Tuberculosis 96 2 14 57 13 5 5 - 6 12 20 10 12 6 66 8 12 7 27 2 1 Totals 2496 78 688 1091 255 263 100 21 227 345 1641 288 267 150 705 92 44 301 233 261 274 OUTWORKERS' LISTS, SECTION 107. OUTWORK IN INFECTED PREMISES, SECTIONS 109, 110. OUTWORK IN UNWHOLESOMEPREMISES, SECTION 108. Nature of Work. (1) Lists received from Employers. Prosecutions. Instances. (11) Notices served. (12) Prosecutions. (13) Instances. (14) Order made (S. 110) (15) Prosecutions (Sections 109, 110). (16) Notices served on Occupier as to keeping or sending lists. (8) Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of lists. (9) Failing to send lists. (10) Lists. (2) Outworkers. Outworkers. Lists. (5) Contractors. (6) Workmen. (7) Contractors. (3) Workmen. (4) Wearing Apparel:— I „„ I I I . I I I ! I I I (1) Making, &c. 38 18 1 - 1 13 - - 5 5 - - - - 219 (2) Cleansing and Washing - - - - - - - - - - - - - - - Household linen - - 3 - - - - - - - - - - - - Lace, lace curtains and nets - - 3 - - - - - - - - - - - - Curtains and furniture hangings - - - - - - - - - - - - - - - Furniture and upholstery - - - - - - - - - - - - - - - Electro-plate - - - - - - - - - - - - - - - File making - - - - - - - - - - - - - - - Brass and brass articles - - - - - - - - - - - - - - - Fur pulling - - - - - - - - - - - - - - - Cables and chains - - - - - - - - - - - - - - - Anchors and grapnels - - - - - - - - - - - - - - - Cart gear - - - - - - - - - - - - - - - Locks, latches and keys - - - - - - - - - - - - - - - Umbrellas, &c. 2 5 - - - 1 - - - - - - - - - Artificial flowers 8 - - - - - - - - - - - - - - - - - - - - - - - - - - - - Nets, other than wire nets - Tents 4 - 3 - - - 1 - - - - - - - - Sacks 8 - 39 1 - - 2 - - - - - - - - Racquets and Tennis Balls - 5 - - - - - - - - - - - - - Paper, &c., Boxes, Paper Bags - - - 3 - - - - - - 6 - 25 - - Brush Making - - - - - - - - - - - - - - 5 Pea Picking - - - - - - - - - - - - - - - Feather Sorting - - - - - - - - - - - - - - - Carding,&c.,of Buttons,&c. - - - - - - - - - - - - - - - Surgical Instruments - 7 - - - - - - - - - - 2 - - - Basket Making - - - - - - - - - - - - - - Chocolates and Sweetmeats - - - - - - - - - - - - - - - Cosaques, Christmas Crackers, Christmas Stockings, &c. - - - - - - - - - - - - - - - Textile Weaving - - - - - - - - - - - - - - - Leather Goods - 8 - - - - - - - - - - - - - 60 327 2 20 - - 5 5 - - - - TABLE VII.—Deaths from Zymotic Diseases, 1922. Year. All Causes Principal Zymotic Diseases. Smallpox. Measles. Scarlet Fever. Diphtheria. Whooping Cough. Typhus Fever. Enteric Fever. Pyrexia (origin uncertain). Diarrhœa. No. No. No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate Rate Rate 2119 16.9 252 1.21 - - 101 .81 .06 17 .14 36 1 5 .04 - 84 .67 .29 .00 1912 8 - .02 1913 2243 17.9 320 2.56 - 88 .70 5 .04 16 .13 47 .38 - - 2 - - 162 1.30 - 2184 17.6 262 2.11 - - 79 .64 9 .07 17 .14 14 .11 - - 2 .02 - - 141 1.14 1914 1915 2514 21.4 367 3.13 - - 110 .93 9 .07 20 .17 79 .67 - - 3 .03 - - 146 1.24 1916 1960 17.2 155 1.36 - - 42 .36 5 .04 29 .25 16 .14 - - 2 .01 - - 61 .53 2032 18.8 218 - 72 .66 1 .01 18 .16 32 .29 - - 6 .05 - - 89 .82 1917 2.02 - 1918 2390 22.0 229 2.11 - - 71 .66 3 .03 23 .21 84 .78 - - - - - 48 .44 - 1919 1748 14.1 113 - 18 .14 5 .04 21 .17 4 .03 - - 3 .02 - - 62 .49 .91 - 1920 1642 12.7 163 11.26 - - 56 .44 7 .06 25 .19 41 .32 - - 1 .01 - - 33 .26 1921 1656 13.7 197 1.63 3 - 18 .15 69 .57 14 .11 - - 3 .03 - - 87 .72 - - Average for years 1912-1921 2048 17.2 227 18.3 .53 7 .05 25 .21 36 .31 - - 3 - - 91 .03 .76 - - 64 1922 2025 16.7 292 2.41 - - 101 .83 11 .09 90 .74 65 .53 - 1 - - 24 .19 - TABLE VIII.-PROSECUTIONS IN CONNECTION WITH SAMPLES TAKEN DURING 1922. No. Sample. Adulteration or Infringement. Remarks. 547s Milk Added water 6 per cent. Ordered to pay costs, 17/6. 33H Margarine Wrapper Ordered to pay costs, 17/6. 67s 2.1 per cent. water in excess Ordered to pay costs, 17/6. Margarine 153s Milk Deficient in fat 5.3 per cent. Ordered to pay costs, 17/6. 197H Milk Added water 8.4 per cent. Dismissed. Warranty proved. 256H Margarine Wrapper Fine 10/-. Costs 17/6. 258s Milk Deficient in fat 10 per cent. Ordered to pay costs, 17/6. 262S Vinegar Deficient in acetic acid 15 per cent. Ordered to pay costs, 17/6. 318H Milk Deficient in fat 6.3 per cent. Fine 20/-. Costs, 17/6. 312H Milk Deficient in fat 10 per cent. Dismissed. Warranty proved. 302S Vinegar Deficient in acetic acid 22.5 per cent. Bound over under Probation Act and ordered to pay costs, 40/-. 334S Vinegar Deficient in acetic acid 41.5 per cent. Ordered to pay costs, 17/6. 341H Margarine 1.4 per cent. water in excess Fine 20/-. Costs, 17/6. 386S 100 per cent. margarine Fine 10/-. Costs, 17/6. Butter 380H Raspberry Jam Not less than 20 per cent. apple pulp Added water 17.3 per cent. Ordered to pay costs, 17/6. 395H Milk Fine 10/-. Costs, 17/6. 493S Milk Deficient in fat 21.3 per cent. Dismissed. Warranty proved. SUMMARY. £ s. d. Fines 3 10 0 Costs 13 7 6 £16 17 6 FOOD AND DRUGS. Articles submitted for Analysis. Total Samples Taken. Number Genuine. Number Adulterated. Percentage of Articles Adulterated. 1 1 - Acetic Acid - Baking Powder 1 1 - - Breakfast Relish 1 1 - - Butter 182 181 1 .5 Cakeoma 3 3 - - Camphorated Oil 1 1 - - Castor Oil 1 1 - - Chicken and Ham 2 1 1 50.0 Citrate of Magnesia 1 1 - - Cocoa 23 23 - - Coffee 3 3 - - Coffee, French 1 1 - - Coffee and Chicory 2 2 - - Cordial, Vanilla 1 1 - - Cordial, Lime Juice 3 3 - — Corn Flour 1 1 - - Cream 1 1 - - Curry, Indian 1 1 - - Curry Powder 1 1 - - Custard Powder 4 4 - - Dripping 39 39 - - Egg Substitute 3 3 - - Fish Paste 1 1 - - Flour 2 2 - - Flour, Self-Raising 22 22 - - Ginger 1 1 - - Ginger Beer Powder 1 1 - - Ginger Wine 1 1 - - Golden Syrup 1 1 - - Grape Nuts 1 1 - - Ice Cream Soda Powder 1 1 - - Jam, Black Currant 1 1 - - Jam, Plum 1 1 - - Jam, Raspberry 9 7 2 22.2 Jam, Red Currant and Apple 1 1 - - Jam, Strawberry 6 5 1 16.6 Jelly, Raspberry 1 1 - - Jelly, Strawberry 1 1 - - Jelly Crystals, Lemon 1 1 - - Ketchup (Mushroom) 1 1 - - Lard 60 60 - - Lemon Cheese (Laitova) 2 2 - - Lemonade Powder 3 3 - - Linseed, Crushed 1 1 - - Liquid Paraffin 1 1 - - Margarine 133 131 2 1.5 Marmalade, Orange 1 1 - - FOOD AND D RUGS—continued. Articles submitted for Analysis. Total Samples Taken. Number Genuine. Number Adulterated. 2 2 - Milk, Sterilized Milk, Dried 4 4 - Milk Powder 1 1 - Mincemeat 5 5 - Mustard 8 8 - Olive Oil 2 2 - Orange Quinine Wine 1 - 1 Ox Tail Soup 1 1 - Pepper 23 23 - Quaker Oats 3 3 - Raspberry Crystals 2 2 - Rice 1 1 - Rolled Oats 2 2 - Saccharine Tablets 1 1 - Sardines, Potted 1 1 - Sauce 1 1 - Sausages 1 1 - Sherbet 1 1 - Shredded Beef Suet 2 2 - Shredded Whole Wheat 1 1 - Stout 1 - 1 Syrup of Figs 1 1 - Tapioca 1 1 - Tapioca, Flaked 1 1 - Vinegar 125 119 6 Vinegar, Malt 41 41 - TABLE X. — Factories, Workshops, Laundries, Workplaces and Homework. Inspection. Number of Premises. Written Notices. Prosecutions. Inspections. 117 Factories (including Factory Laundries) 51 - Workshops (including Workshop Laundries) 114 30 1 Workplaces (other than Outworkers' Premises) 181 46 - Total 412 127 1 Defects found. Number of Defects. Number of Prosecutions. Particulars. Referred to H.M. Inspector. Remedied. Found. Nuisances under the Public Health Acts— Want of Cleanliness 23 23 - - Want of Ventilation 3 3 - - Overcrowding - - Want of Drainage of Floors 1 1 - - 59 Other Nuisances 59 1 - Sanitary Accommodation— 3 3 Insufficient - - 54 54 Unsuitable or Defective - - 1 1 Not separate for Sexes - - Offences under the Factory and Workshop Act — Illegal Occupation of Underground Bakehouse (s.101) - - - - Breach of Special Sanitary Requirements for Bakehouses (ss. 97 to 100) - - - - Other Offences - - - - Total 144 144 - 1 - - TABLE XI.—No. of Bakehouses in the Borough. Inspector. Not in Use. In Use. Underground. Above Ground. Underground Above Ground. Mr. Scott 1 2 9 20 Mr.Hoskins 10 23 4 3 23 of these are Factory Bakehouses. OTHER MATTERS. Class. Number. Matters notified to H.M. Inspectors of Factories— Failure to affix Abstract of the Factory and Workshop Act(s.133) .. Action taken in matters referred)} by H.M. Inspectors as remediable} under the Public Health} Acts, but not under the Factorics} Act (s.7)} Notified by H.M. Inspectors 30 Reports (of action taken, sent to H.M. Inspectors) 30 Other .. Underground Bakehouses (s. 101)- Certificates granted during 1922 .. In use at end of 1922 .. Workshops on the Register(s. 131) at the end of 1922 336 Workshop Bakhouses 64 460 Total Number of Workshops on Register E (11408)Q 65 UNSOUND FOOD AND FOREIGN MEAT REGULATIONS. THE FOLLOWING ARTICLES OF FOOD WERE DEALT WITH UNDER THE ABOVE REGULATIONS DURING THE PERIOD UNDER REPORT. QUANTITY UNSOUND. ARTICLES. Destroyed. Exported. Disposed of for other purposes than Human Food. Removed for sorting under S.A. Quantity. Weight. Quantity. Weight. Quantity. Quantity. Weight. Weight. tons cwts. 1bs. tons cwts. lbs. tons cwts. lbs. tons cwts. qrs. lbs. qrs. qrs. qrs. Apples 237 barrels 1925 boxes 76 1 14 1 Appels and Pears 6 19 1 14 223 boxes Apricot Pulp 8 2 3 1 162 cases and 35 tins Bacon 3 3 15 2 19 10 Cases 2 11 3 0 123 Bales & 15 9 0 0 Baked Beans 234 cases 2 10 0 16 3 Barrels Baked Pork and Beans 244 cases 2 3 3 0 1 10 0 0 Bananas 40 crates Beans 270 bags 35 1 0 0 36 0 0 0 Butter 317 Boxes 7 18 2 0 . Canned Goods, Various 7 cases & 48450 tins 51 1 4 16 3 Carrots 73 bags 13 0 0 Cauliflower 4 92 crates & 13 casks 1 2 16 9 Cheese 13 Casks 98 boxes & 15 crates 3 16 1 0 Cherries 0 0 1 package 24 161 bags 3 0 1 14 79 bags 2 2 0 14 Chestnuts 3 Condensed Milk 5351 Cases 114 3 2 2 791 Cases & 100 Tins 15 15 12 70 Cases 1 10 0 0 Copra 456 0 0 0 _ Dates 30 0 0 0 Eggs 32 Cases, 33 half Cases, 117 Boxes & 2793 202 1 3 1 10 Cases 0 7 2 0 Tins Egg Yolk 10 Casks 2 0 0 0 Evaporated Milk 9 Tins 0 0 0 9 Fish, fresh 8 Boxes 0 10 3 14 1 Box 0 2 1 0 Fish, canned 36 Tins 0 0 1 8 Flour 4952 Bags 325 17 2 20 6153 Bags 78 11 1 0 Fruit 0 4 0 3 10 2 6 0 194 Cases, 31 P'kages & 32 Tins 16 2 0 2 Geese 38 Cases m Greengage Pulp 1 18 0 15 Jam 48 Cases 7 Cases 1 9 3 12 Lemons 0 7 0 0 464 Cases & 2 half cases 17 9 2 0 Liquid Egg 270 Cases & 19 Casks 16 5 1 22 Maize 340 14 3 0 19 casks Meat, fresh 18 19 1 2 10 6 0 12 20 Tierces 1 15 0 0 Meat, canned 445 Cases & 10 Tins 14 0 1 12 6 Cases & 2633 Tins 5 7 2 6 Melons 2 9 1 0 51 Boxes Mushrooms 5 Packages 0 5 0 0 Oatmeal 16 Bags 0 16 0 0 Oats 0 13 0 14 Onions 3923 Bags 177 0 1 0 Oranges 1512 Cases 35 19 3 0 Orange Skins 29 half pipes 11 12 0 0 Ox Tails 0 0 1 Case 1 20 Ox Tongues 24 0 1 2 7 Ox Tongue Butts 13 4 2 0 529 Bags Parsnips 13 Bags 0 13 0 0 Pears 523 Boxes, 25 Cases & 6 Packages 17 10 0 0 Peas 8 12 0 0 3 18 0 0 Pigs Heads 6 Barrels 1 2 2 0 76 Casks 20 0 0 0 Plums 505 P'kages 10 2 0 0 Pork 6 Carcases 0 12 0 0 1 Barrel 0 4 0 0 Potatoes 26 5 0 0 1 Sack 0 1 1 0 0 520 Bags 300 0 0 Rabbits 0 5 3 12 173 Crates 3 17 0 26 Rice 5 13 3 24 I Sausage Casings 9 Kegs 2 13 2 0 27 Casks 2 8 0 0 7 Cases 0 2 0 12 Soup Mixture Strawberry Pulp m 6 5 0 I I 0 0 8 18 2 0 Tomatoes 238 Crates - 23 8 2 8 London: Harrison & Sons, Ltd., Printers, St. Martin's Lane, W.C.2.