CAM 21 London ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE BOROUGH OF CAMBERWELL For the Year, 1921 BY F. J. STEVENS, D.M. Hon. Consulting Medical Officer of Health, Borough of Camberwell; Examiner in Public Health in the University of Oxford, and to the Conjoint Board of the Royal Colleges of Physicians and Surgeons, etc. Printed by Henderson & Spalding Ltd., Sylvan Grove, S.E.22. CAM 21 Report of the medical Officer of health. In this, the last report that I shall have the honour to present to the Borough of Camberwell, I propose to follow the instructions of the Ministry of Health in 1919 in its arrangements and contents, but only in so far as the physical features and the general character of the district have undergone any change from that year will they receive any special notice. The estimated population used by the Registrar-General in the preparation of the vital statistics for 1920 in Camberwell was 284,995. In the last two reports the possibility was mentioned of this being an over-estimate, and the census figures of 1921 show these doubts to have had some foundation. In fact, in 1919 an estimate was given of the population for housing purposes and needs, which is interesting from the fact that it was apparently considered so inaccurate by the Council that they, acting, I presume, on information supplied from other sources, revised my figures. Whether their information came from inside or outside the confines of the Council I know not; suffice it to say that the alteration was made. The Registrar-General's adjusted figure for 1921 is 269,600, while my estimate for 1919 was 263,000, that substituted by the Council being increased to 278,000. The decision as to which was the more correct with confidence I can leave to the judgment of my readers. The latest figures furnished by the Registrar General still more closely approach the estimate I made for the Council in 1919. The total number of births registered in the Borough was 6,301, some 1,200 less than in 1920. In 1919, when the effects of the war were still evident, it was 5,183, but in 1921 the disturbing factor of so many men being away on active service did not exist, and the considerable decrease would certainly point to the existence of some other cause directly limiting the number of births. Births in Camberwell and its Sub-Districts, 1921. * South Peckham, North Peckham and St. George's. 1,753 2,080 1,360 825* 1,718 2,010 1,398 632 814 1,654 2,064 1,467 1,166 996 1,114 772 584 180 237 186 163 North Camberwell. Peckham. North-West Camberwell. E. Dulwich Dulwich. 6,301 7,505 5,183 4,186 Borough. 1921 1920 1919 1918 Year. TABLE I.—CAUSES OF, AND AGES AT, DEATH DURING YEAR 1921. Total Deaths whether of "Residents" or "non-Residents" in Institutions in the District. Net Deaths at subjoined ages of "Residents" whether occurring within or without the District. 25 and under 45. Under 1 year. 1 and under 2. 2 and under 5. Causes of Death. 5 and under 15. 15 and under 25. 45 and under 64. All Ages. 65 and upwards. 1 2 3 4 5 6 7 8 9 10 11 I — 2 All causes Certified 3,241 462 98 91 127 1,150 142 398 773 Uncertified ... ... 4 ... ... ... 1 3 ... 1. Enteric Fever 5 2 2 1 1 ... ... 2. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... 3. Measles 3 2 1 1 ... ... ... 4. Scarlet Fever 19 5 7 ... ... ... 5 2 ... 5. Whooping Cough 1 ... ... ... ... 29 15 8 4 1 13 30 ... ... ... 6. Diphtheria and Croup 64 6 7 19 1 1 3 7. Influenza 51 2 1 3 ... ... 14 16 15 10 ... 8. Erysipelas ... 15 10 1 1 1 1 16 6 ... ... 9. Phthisis (Pulmonary Tuberculosis) 273 2 3 52 2 6 113 84 11 94 10. Tuberculous Meningitis 5 34 9 6 10 2 1 1 12 11. Other Tuberculous Diseases ... 45 4 3 2 10 9 4 5 8 12 12. Cancer, Malignant Disease 343 1 1 162 30 149 125 ... ... ... 12 1 2 1 3 2 3 1 13. Rheumatic Fever ... ... 2 3 14. Meningitis 25 9 4 2 2 3 6 ... 348 4 1 3 19 12 39 97 173 78 15. Organic Heart Disease 4 207 342 3 2 4 22 79 107 16. Bronchitis 4 68 57 79 17. Pneumonia (all forms) 269 45 25 25 9 10 30 30 18. Other Diseases of Respiratory Organs 2 6 1 1 1 1 ... ... 1 ... 1 6 35 19. Diarrhœa and Enteritis 112 85 14 1 1 3 1 20. Appendicitis and Syphilis 1 6 4 1 6 14 ... ... ... 1 2 21. Cirrhosis of Liver 16 1 8 4 9 ... ... ... ... 21A. Alcoholism 1 1 ... ... ... ... ... ... ... 11 22. Nephritis and Bright's Disease 68 1 1 27 28 34 ... ... ... 7 5 23. Puerperal Fever 9 ... 2 ... ... ... ... ... 24. Other Accidents and Diseases of Pregnancy and Parturition 3 7 3 1 4 ... ... ... ... ... 25. Congenital Debility and Malformation, including Premature Birth I — 3 ... 104 104 19 ... ... ... ... ... ... 7 7 17 19 26. Violent Deaths, excluding Suicide 58 1 4 5 5 12 8 12 3 27. Suicide 25 5 10 3 ... ... ... 170 234 28. Other Defined Diseases 645 145 10 6 18 54 182 8 29. Diseases ill-defined or unknown ... ... ... ... ... ... ... ... ... ... 1 2 1 Sub- Entries not included in the above figures Cerebro-spinal Meningitis 3 ... ... ... ... ... ... Poliomyelitis ... ... ... ... ... ... ... ... ... ... 28 3 1 3 7 9 16 12 11 Other Septic Diseases 62 8 1 2 5 3 Pleurisy ... ... ... ... ... Mental Diseases 8 2 5 9 1 ... ... ... ... ... Old Age 218 4 214 85 ... ... ... ... ... ... 142 398 776 1,151 982 3,245 462 98 91 127 Total We are now faced with the curious position of one section of the community maintaining that a serious loss to the country is coming into being in that the births are not keeping pace with those in some other countries, perhaps our most dangerous rivals in the future. This was used as an argument during the war in favour of the establishment and multiplication of maternity centres, as a special attempt to reduce the infantile mortality. On the other hand, we have a small but energetic party which is clamouring for birth control and limitation, and which even seeks to use the centres you have already established for that purpose. From the figures given above it would certainly seem that the efforts of the latter faction are meeting with active approval; but if there had not been this interference with the course of nature I still maintain that the gloomy views of 1915 as to the early disappearance of the English have no solid foundation. 3,630 deaths were actually registered in the Borough; but only those of the actual inhabitants of the Borough, whether they died inside or outside its confines, have been taken into account for statistical purposes, the remaining persons being assigned to the localities in which they had their dwelling, while the deaths of our own people occurring in institutions outside are included in the first. When this has been done there results a total of 3,245, which has to be used in the calculation of the death rate, compared with 3,318 in the previous year. The death rate therefore works out at 12.0, compared with 12.6 in 1919 and 11.6 in 1920; but as that of the first year was calculated on a population of 273,803 and that of the second on one of 284,995 it is obvious that these are both lower than they should be. It is therefore difficult to see that there has been any great improvement, but, on the other hand, it is evident that after a certain rate has been reached it is impossible to go any further. Our sanitary progress, or otherwise, however, must be considered in its relation to that of London as a whole, and also in its position on the list of Metropolitan Boroughs. We were seventh in 1919 compared with eighth in 1920, when the Boroughs with a lower rate were Paddington, Fulham, Hampstead, Wandsworth, Lewisham and Woolwich; whereas in 1921 we are bracketed with Stoke Newington and Paddington as ninth on the list, the death rate for the County of London being 12.5, and the Boroughs having a lower death rate than ourselves being Fulham, Westminster, Hampstead, Hackney, Wandsworth, Lewisham, Woolwich, and the City of London. Although our position is not quite so high in the comparative list, it will be observed that Camberwell occupies no dishonourable place among Boroughs of the same character in population and housing. In past reports it was the custom to give the death rates for the various registration districts, but it is no longer any use making a comparison, for the registration districts were altered in the later intercensal period, and the former boundaries and populations no longer apply, but for future use the figures for 1921 are set out. Deaths Registered in Sub-Districts of Camberwell. Dulwich. North West Camberwell. Peckham. North Camberwell. Unattached. East Dulwich. Borough. 493 160 801 32 3,245 819 940 Re-Distributed in Sub-Districts. Borough. Dulwich. East Dulwich. North West Camberwell. North Camberwell. Peckham. 162 498 827 809 3,245 949 Just as happened last year, there have been no deaths from small-pox or anterior poliomyelitis. The fall in measles has been very large, namely, from 57 to 3, the deaths all being under the age of 15. It is, however, very unlikely that this means that a greater success has been attained in dealing with this disease, and very likely the succeeding year or 1923 will again show an increase. The evil effects of measles, however, are working not only in the way of direct and immediate mortality, but also in fatality later on from other diseases. But it is difficult to convince wrongly-thinking mothers of the danger of the complaint, for if its seriousness be dwelt upon in too forcible and lurid terms they are always able to quote many instances of complete and permanent recovery, oblivious to the possibility that their child may form one of the percentage of the unfortunates. They do not realise that in a disease so prevalent there must be many of those attacked who emerge without harm. A conference was held in February, 1921, between the London County Council and the representatives of all the Boroughs for the purpose of considering measures for the better control of measles in London. While there exists the present system of dual responsibility for children, in that while they are at school they come within the purview of the London County Council, and at all other times they are under the care of the Borough Council, it seems hardly necessary to pass a resolution to endorse the obvious advantage of the fullest co-ordination among the agencies concerned in the care of children, and it is only when the proposals towards this end are examined that it is necessary to make some observations. It was evident that other Boroughs had experienced the same difficulties as we had in the delay that arose through the return of absences from school only being sent in once a week. The result of this is that on Saturday morning a long list is received of names, which refer to absences, in many cases ascribed to the presence of measles occurring earlier in the week, and in regard to which much valuable time had been lost. The suggestion, therefore, by the County Medical Officer that the local authorities should at once be informed seems to have a prima facie value. Serious difficulties arise in the way of getting patients and guardians promptly to notify the reason for absences from school, and the County Council dwell on the difficulties due to their active or passive neglect. Legal proceedings, even if successful, will hardly reach beyond the few actually proceeded against, and it would seem the only course is to wait for an enlightenment of public opinion, whenever that may arise. The other proposal concerns the nursing, to which attention is drawn further on. Although the conference passed a resolution in favour of the compulsory notification of measles, it is gratifying to see that the County Council do not, for the present, consider it desirable to put it on the list of notifiable disease. As this view has so often been dealt with in my previous reports, with a similar conclusion, I do not again propose to discuss it further. At present, however, it is difficult to see that any direct measures can be taken against its spread beyond trying to keep untoward results from all those of tender years. The cost of removing all serious cases would be colossal, but it might be possible to take away those who are certain to get little attention at home but where too often the prejudice against removal is especially great. Nursing at home has not been very successful, and, indeed, unless it can consist of attention extending over a much greater part of the twenty-four hours than is usually given, it is not likely to be of very great help. One is always faced with the fact that measles ordinarily occurs in epidemic form, and to keep the large staff of nurses always ready would be expensive and, unless they could be used for other purposes, wasteful to a degree. The day when this disease will no longer be with us is very far off, and under existing circumstances the best way of dealing with it seems to be an attempt to minimise its dangerous complications. These and the evil after-effects are not so prevalent among the children of those who can afford to provide the proper attention; and to prevent the infection is not always an advantage, on account of the serious form it often takes among those who have never suffered from it in childhood and who contract it later on in life. Hospital accommodation for the serious cases among the poor seems to be the most likely way of lessening the mischief of the disease, but the experiment would be a costly one and by no means certain of success. Scarlet fever caused 19 deaths as compared with 13 last year, an exceedingly small total compared with the number of notifications. As usual, the great majority of deaths was of persons under 15 years, with an especial incidence on the age period 5 —15. Two deaths were reported in the case of those over 25. This is so exceptional that suspicion might arise as to the correctness of the diagnosis, but as one occurred in a fever hospital error is not likely. Diphtheria, in spite of the especial efforts that are now made, keeps up its evil pre-eminence, there being two more deaths than last year, the age incidence being pretty much the same as last year, the greatest fatality being in the ages 2-15. Influenza was a little less than last year, but it is depressing to say that it has of late years shown a tendency to become endemic, with an occasional flare up, instead of, as formerly, appearing occasionally in epidemic form, with only an occasional case in the intervening years. The maximum fatality was, as previously, over the age of 25. From erysipelas there were three more deaths than last year, and coincident with this there was an increase among the deaths from other septic diseases. Meningitis, apart from the tuberculous form, also has a larger record. From all the forms of tuberculous disease there were 352 deaths, contrasted with almost the same (353) in last year. Curiously enough, this resemblance is seen in all forms—phthisis, 273 against 274; tuberculous meningitis, 34 against 35; and all other forms of this disease, 45 against 44. Cancer unfortunately registers an increase from 318 to 343, but the somewhat disquieting number of young persons that was recorded in 1919 no longer exists. The mortality from bronchitis is 10 higher than last year, but this is to some extent compensated for by the marked drop from 45 to 21 that took place in infants under one year, and coincident with this slight increase there is a marked fall in pneumonia (including broncho-pneumonia) from 348 to 269. As well might be expected from the hot summer, there was a marked increase in the diarrhœa class, there being 41 more deaths but it speaks well that the increase is no greater. The age period 1-2 years had a heavier incidence, which also appeared later on in life. From cirrhosis of the liver there were 16 deaths, compared with the five of the previous record; these five, however, were all in persons over 24, and in the year under review there were 12 over the same age, an increase of seven, a fact which, perhaps, has some bearing on the next condition on the list, i.e. alcoholism, in which there is no numerical change. The number of deaths and age incidence of fatal cases of heart disease, mental disease, and old age shows little difference from last year. TABLE II.—INFANTILE MORTALITY DURING THE YEAR 1921. Nett Deaths from stated Causes at Various Ages under One Year of Age. Total under 1 month. Under 1 week. 1 to 3 months. 3 to 6 months. 1 to 2 weeks. 2 to 3 weeks. 3 to 4 weeks. 6 to 9 months. Cause of Death. Certified ... ... ... 105 33 26 17 181 73 93 66 All Causes Uncertified ... ... ... ... ... ... ... ... 1. Small-pox ... ... ... ... ... ... ... ... 2. Chicken-pox ... ... ... ... ... ... ... ... 3. Measles ... ... ... ... ... ... ... ... 4. Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... 5. Whooping Cough ... 7 1 1 3 3 ... ... ... 1 1 6. Diphtheria 3 ... ... ... ... ... 1 7. Erysipelas ... ... ... ... ... ... ... 8. Tuberculous Meningitis 3 2 ... ... ... ... ... 9. Abdominal Tuberculosis b ... 3 ... ... ... ... 10. Other Tuberculous Diseases ... ... ... 2 11. Meningitis (not Tuberculous) ... ... ... ... ... ... ... 1 2 1 4 ... ... ... ... 12. Convulsions 3 2 5 1 ... 2 1 ... 13. Laryngitis ... ... ... .. ... .. ... ... 14. Bronchitis 2 2 5 6 6 ... ... ... 2 11 9 15. Pneumonia (all forms) 2 7 ... ... ... 16. Diarrhœa 8 17 10 1 1 ... ... ... 17. Enteritis. 7 17 10 1 2 1 4 ... 18. Gastritis 1 1 1 ... ... ... ... ... 19. Syphilis 1 2 1 4 1 3 ... ... 20. Rickets 1 ... ... ... ... ... ... ... 21. Suffocation, Overlying ... 6 ... ... ... ... ... ... 22. Injury at Birth 6 6 1 ... 10 ... ... 12 ... ... 23. Atelectasis 2 ... ... ... ... ... 24. Congenital Malformation 1 16 9 4 2 4 2 ... 25. Premature Birth 66 13 7 4 90 11 3 ... 26. Atrophy, Debility and Marasmus 11 3 27 10 3 17 15 8 27. Other Causes 1 4 4 2 11 4 3 2 105 33 26 17 181 73 93 66 INFANTILE MORTALITY. The total number of deaths under one year was 462, compared with 526, but, as the number of births declined from 7,505 to 6,301, the rate per 1,000 births is 74 compared with 71 in 1920 and 82 in 1919. The rate for the County, which was 76 in 1920, was 81 in 1921. Compared with other London boroughs, Camberwell is seventh in the list; while in 1920 it was tenth and in 1919 sixth. It is bracketed in this position with Battersea, a borough which in previous year 3 has often shown some similarity with us, and which was one of the first to start a milk depot. As the rate has such a direct bearing on the new crusade that is leading to so much ante-natal and post-natal work all over England, it is interesting to note how we have progressed or otherwise in the lessening of those diseases which take a large toll of young life. The mortality of the first four weeks is worthy of special consideration, in that here is felt the special effects of deaths from premature birth and the other causes which have been held up as a justification for ante-natal clinics. There were 181 deaths in the first four weeks, compared with 219 in ]920. In 1919 for the same period there were 181 deaths, with 5,183 births. From premature birth in this division there were 90 deaths, the same number in 1920 and 93 in 1919. Closely bound up in this regard are the deaths during the first month from marasmus and defective vitality ; these were 27 in 1921, 57 in 1920, and 34 in 1919. Examining the totals for 1921, one is struck by the absence of deaths from measles and the fall in the numbers from bronchitis and pneumonia, especially for the latter. It is also particularly gratifying to report that there were no deaths from overlying. Those from diarrhoea and enteritis were 21 more than last year, but, considering the hot summer, one can fairly claim that we came off very well. There was a slight increase in tuberculous diseases. The year under review was a hot one, and one would have expected the diarrhoea death rate to have been much higher if one were to gauge it by the figures of 1911, but one has to realise the enormous change that has taken place in the chances of contamination from manure in the streets on account of the substitution of motor traction for that of the horse. Apart, however, from such exceptional years as this, the infantile mortality has tended to fall steadily since 1901, and this is a point made by the supporters of the Maternity scheme, for they say that although the general mortality went down before that date, only was there a reduction at the beginning of the present century, when the special efforts in the way of health visitors had their inception. The reduction so far as London is concerned first showed itself in 1900, and with the exception of some bad years, such as 1911,1913,1914, 1917, and 1918, has shown a steady fall. It is quite possible that the fall which started about 1885, and which may be held to indicate an improvement in the general health of the then living children, did not begin to show appreciable effect on the infantile mortality till 1901, when those who were children in 1885, in 1901 had reached the age of child production. Taking London as an example, although the fall commenced in 1901, with a set-back in 1904, the first mention in Sir Shirley Murphy's Report comes in the latter year, and not until later on (1911) did the efforts obtain to any widespread extent. In fact, it was not until 1914 that, following on pressure from the Local Government Board, Maternity Committees began to be established in wide measure, and their existence had become fairly general in 1917. In spite of this delayed general adoption of the proposition the fall continued without check until 1911, and since then has shown a zigzag of falls and rises, but the mean of 142.7 was never once exceeded. No doubt it will be said that the appointment of health visitors was largely responsible for this, but Camberwell, which had made no appointment of health visitors who preceded the Centres, shared in the decline in practically identical amount with its fellows. Some would go so far as to measure the amount of good done by the health visitors appointed. If this is to be the criterion, Camberwell should indeed cut a sorry figure. A neighbouring Borough where there is official health visiting, in 1911 (a bad year) had a rate figure of 123 to Camberwell's 109, while in 1912 it was reduced to 86 in the former and 83 in the latter, and in 1921 went down to 76 in the first and 74 in the second. Many factors are probably at work, the improvement in housing, the diminution of smoke, improved conditions of workplaces, while within more recent years a higher standard of living, increased out-door exercises among school children and adults, and the increased attention to sobriety, personal health and fresh air must all be powerful factors in giving a healthier stock to breed from. Any good effect also of the medical inspection of school attendants may also be instanced as a cause, for some of the children who were scholars a dozen years ago are now at the child-producing age, and any improvement brought about then must have some effect on the physique of the present father and mother. A homely illustration may be seen in the condition of teeth, apart from the dental exhibitions seen in the illustrated newspapers. Wherever one travels in London one is struck by the great improvement that has taken place, especially within the last few years. The old condition of decayed and tartar-crowned teeth, judging by what one can see by a casual glance, has practically disappeared, and even where artificial dentures are not worn much care is evidently bestowed on the mouth. Apart from this there is the noticeably improved physique of the girls and young women. The distribution of milk, whether by the Milk Orders or in the form of dried milk, as an assistance to many a struggling home must also take its place. It is my opinion that the reduction in infant mortality, so marked during the last three years, is largely due to this Order. A favourite argument in favour of the appointment of health visitors is based on the assumption that she will dispel the ignorance of the mother, said to be a potent cause of a high infantile mortality. If this be so one must be driven to the conclusion that the mothers in many Yorkshire and other Northern districts are much worse instructed than those of the agricultural districts of the more southerly counties. Proper and sufficient food is often far more necessary than advice or medicine, and any scheme whereby the administrative expenses for professional help are diminished, and the money thus saved applied as a contribution to the supply of nourishment in the really necessitous cases, may well be thought of when the idea of new appointments and fresh centres comes under consideration. It is usually claimed that they should be used as advisory and preventive, although how these two can be divorced from treatment, except theoretically, I know not. Their being used as treatment centres, of course, tends to make people take the easier path and come to depend on the municipality rather than going to their own doctor, particularly when such benefits as dried milk, etc., at cost or reduced price can be obtained. This can hardly fail to pave the way for a policy of spoon-feeding and for a State medical service for all—a consummation little enough to be desired. It is contended that those who attend the centres are those who could not afford a private doctor; but my impression is it is just the class who could do so if they wished, that form the bulk of their clients; but if my opinion be wrong, other and less expensive methods are possible in aid of those who, by reason of poverty, cannot help themselves but who need a helping hand. Maternity centres have decided advantages, in that they are a social meeting place for mothers, and the mild dissipation of a cup of tea and a talk under comfortable conditions may well be a pleasant interlude in an otherwise drab life. The social intercourse, in the voluntary ones especially, with a number of self-denying women who esteem it a pleasure to do work without fee, reward, or political advantage has an immense moral and intellectual benefit, and this is a strong plea for the policy of subsidising voluntary centres rather than the establishment of municipal ones with thenpaid staff. A complete volte face in the policy of this Council as regards the employment of health visitors took place in February, 1921. As stated in the 1920 Keport, this matter came before the Public Health Committee in December, 1919, on which I addressed to that body a statement adverse to the appointment. The matter was then proceeded with no further, but in January, 1921, the Maternity Committee, surrendering a position which had so long and so successfully resisted attacks, both official and non-official, from within and without the Council, passed a resolution, which was affirmed by the Council, to appoint a visitor. The final success of those who worked so energetically for this appointment now gives them a strategic advantage. The infantile mortality of Camberwell in past years obstinately refused to show the "damaging effects" of the remissness of the Council in not obediently falling into line as regards the appointment so often urged on them. Now their old opponents hold the field, in that a diminishing mortality can be pointed out, and since health visitors are universal no contradictory evidence in the way of a district which has no exceptional mortality and has no health visitor on its staff can be adduced. However, my views are no longer in accord with those of the Council, and I will not weary them with the arguments they have heard so often, but will content myself with giving a table brought up to date, as shown by the statistics of the Medical Officer of Health of the London County Council, showing Camberwell's position among its compeers. The advocates of the appointment may well be left to derive any satisfaction they can from the figures. But to those who have not yet made up their mind I am bound to point out that there is an enormous mass of opinion in their favour among those who have nothing to gain by Welfare Centres. The fact of practically all Medical Officers of Health being in their favour is a tremendous argument against the views set out above. Fashions however change and I can remember when to doubt the absolute necessity of an intercepting trap was an unpardonable sin outside Camberwell. The infantile mortality in No. 1 Ward calls for some special comment, for it was here that the first Maternity Centre was established in May, 1921, and where the first health visitor of the Council inaugurated its new policy. The rate last year reached the low figure of 62, compared with 111 in 1920, a notable accompaniment to the appointment of a visitor. It is, however, somewhat discounted by the fact that in No. 12 Ward the rate went from 100 to 59 and in No. 14 Ward from 96 to 60. It is fairly obvious, then, that there are more important causes at work than an official health visitor. INFANTILE MORTALITY. Year. Year Health Visitor was appointed. District. 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 100 109 99 103 73 99 102 82 71 74 104 83 106 Camberwell 130 115 94 1921 138 Bermondsey 153 123 126 156 111 132 125 149 101 130 134 92 85 93 144 1909 129 Bethnal Green 155 138 132 123 151 96 118 137 122 106 112 129 85 95 100 1906 Hammersmith 138 117 120 120 90 103 94 102 86 111 99 146 102 99 67 88 1905 Hampstead 77 69 69 75 60 78 62 73 80 78 65 82 77 83 48 66 1909 Kensington 132 119 113 91 127 102 128 106 133 112 94 118 86 91 83 107 1906 109 Lambeth 131 120 104 94 123 86 102 104 105 90 101 97 86 69 76 1907 Woolwich 82 73 109 112 94 85 97 79 85 94 69 79 106 86 61 62 1906 107 Battersea 126 114 106 97 124 81 111 93 112 84 101 99 74 83 74 1907 108 London 104 131 116 113 103 129 91 105 104 112 89 108 85 76 81 I—14 I—15 TABLE III.—RETURN OF WORK PERFORMED IN THE SANITARY DEPARTMENT DURING THE 52 WEEKS ENDING 31st DECEMBER, 1921. Inspectors. Groom. Eagle. Scudamore Description of Work. Collins. Totals. Farmer. Malins. Green. Worsfold. Glenday.* Miss O'Riordan. Miss Butcher. Miss McKenzie. Morley. Jones. Nash. 50 396 340 293 Visits to complaints 71 239 House inspections following complaints 1 331 342 305 565 696 119 556 25 2 3,657 47 - 186 139 - House to-house inspections 16 171 315 21 454 444 207 470 14 2,656 6 - - - Tenement inspections - 245 326 98 298 231 1,773 - 62 5 - - - - - - 38 231 Houses let in lodgings inspections - - - - 101 - - - 63 - - - - - - Housing and Town Planning inspections - - - 69 - 71 2 - - - - - - - - - 314 41 - Visits to new buildings 11 195 - - - - - - - - - 11 17 - No.of inspectons re overcrowding - - 978 25 1 98 28 1 - 1,709 - - - - 4 Do. do. of slaughterhouses 7 5 1 - - 13 1 12 6 10 - - 28 - - - - - Do. do. bakehouses 37 27 38 7 - 39 27 - - - - - - Do. do. cowhouses 38 22 4 - 65 25 34 14 44 375 2 1 - - - - 49 2 - 9 Do. do. milk shops and dairies 78 128 58 - 4 - - - - - - - 13 64 63 66 16 Do. do. eating houses 2 159 38 72 83 874 16 5 - - - Do. do. ice cream shops 16 40 17 2 24 20 13 16 38 5 - - - - 116 - 1 33 22 34 14 31 293 Do. do. railway stations 1 - 33 47 1 - - - - 1 - Do. do. workshops 47 81 147 123 1 - - 160 28 - - - - - 1 Do. do. factories 14 - - 74 32 143 86 94 56 103 69 120 1,081 25 - D9. do. urinals, public 5 1 58 12 49 54 - 96 21 101 431 17 4 3 - - 19 2 6 - Do. do. do. private 30 122 73 39 42 9 62 8 177 - - - 2 100 86 Do. do. schools, L.C.C. - 12 281 407 20 66 118 2 4 - - 1,344 - - 25 6 5 7 43 38 194 Do. do. do. private 5 1 24 5 8 6 33 - 2,902 3,885 3,727 6 - - 8 151 Re-inspections 409 11 - 2 94 - - - 2,947 Miscellaneous 91 169 90 3,451 4,828 3,030 3,891 2,771 141 27 1 38,343 92 2,606 45 Infectious cases visited and houses inspected 230 264 283 109 328 503 358 103 5 1,044 1,308 177 72 369 1,862 6,503 Do. do. or enquiries 282 273 111 43 67 25 205 176 210 310 170 23 15 44 19 2,681 10 Tuberculous cases visited and houses inspected 11 61 69 92 115 41 104 14 7 821 - - 6 58 4 Do. do. or enquiries 2 - - 3 4 2 - - 884 663 835 2,405 - - - - Visits to verminous premises 1 282 - 2 - 4 1 - 268 379 - - - - - 941 Intimations 450 690 703 - 27 3 60 452 - - - 29 - - - - Statutory notices 235 380 970 604 654 751 24 227 360 563 496 908 32 22 7,319 - Notices, houses let in lodgings 5 147 386 - - 225 197 425 368 193 3 1 3,147 - - - Infectious disease contacts - 21 62 2 - 3 - - - - 69 - - - - - Seizures of unwholesome food - 3 - 1 - - - - - - - - - - - 25 Outworkers - - 2 11 4 17 1 38 - - - - - - - - Measles - - - 1,898 - - - 584 865 449 - - - - - - Scabies - - - - 58 127 64 249 - - - - - - - - - 45 29 108 - - - - - - - 34 4,951 6,338 6,667 6,055 6,064 6,798 6,317 7,705 5,234 5,171 267 4,076 3,407 3,331 79,846 7,465 * From December 19th to 31st only. Hospital Accommodation. The amount expended in Poor Law Belief was £61,216 2s. 0¼ o|d. The Infirmary in Brunswick Square, with its 828 beds, is the chief institution for gratuitous in-door medical relief. To this are usually admitted the more serious and acute cases, and a large amount of surgical work is carried out there. It is usually well filled, 4,688 patients having been admitted during the year. Constance Road Institution, 906 beds, and Gordon Road Institution, 867 beds, are used more especially for the young, the aged and infirm, and for the chronic cases. St. Thomas's, Guy's, and King's College receive a considerable proportion of the sick people, especially the latter, situated as it is in a part easily accessible from the poorer parts of the Borough. The special hospitals, near and far, also receive their quota; in fact it may be said that there is no difficulty in getting advice for any one unable to pay, and it is only where circumstances demand treatment as an in-patient that difficulties arise. Closet Accommodation. A certain amount of work which calls for no special mention has been carried out chiefly as a result of inspections of factories and workshops. The water-carriage system being practically universal, no trouble has arisen in the way of conversion of privies, etc. The point has arisen as to how far it is possible to insist on the provision of sanitary conveniences in the various sports grounds of the Borough where at the present time there may be no sanitary nuisance, but where at the same time no accommodation is provided. The subject is really a legal one, and it is possible that a case may be decided in the Courts which will clearly define the position. Scavenging. There is no great difference from last year as regards scavenging, but I would still urge on the Council the great desirability of trying the effect, certainly in the summer months, of a daily collection in the poorest parts of the Borough, where the facilities for dust disposal are of the crudest and most unsatisfactory nature and the means of storage of food are of the most meagre description. For this purpose I would advise the selection of the Secretan Boad area as a most promising spot for the experiment. Boxes could be deposited outside the houses and removed with the least possible delay, and without the loss of time to the dustmen in going through the houses (itself undesirable). This would run counter to the by-laws, but I doubt if the condition of the boxes would be much worse than the galvanized iron bins after a couple of months' wear. The discussion of scavenging may be humdrum and unsensational, but its importance to the well-being of the community is such that it merits a word in favour of this means of collection from boxes as practised in many places here and abroad. Sanitary Inspections of the District. The visits to complaints have increased from 2,775 to 3,657. This does not necessarily mean that causes for complaint have increased, but rather that people are more ready, either with or without cause, to call in the help of the local authority. With this there has been an increase in the house inspections arising from such complaints, a visit to the premises complained of often leading to a further inspection of its neighbours. The great increase of " visits to new buildings," which show a twenty-fold growth, is largely the reflection of the Council's activity in forming the new residential districts at Nunhead and on the Casino estate. The over-crowding figures remain about the same, but I do not think they have ever given a true picture of the condition of things in the northern part of the Borough. The desire of so many people to live near their work has to be reckoned with, and when one sees the storming of the buses and tramcars which takes place morning and evening at many centres, and the loss of time it entails, it is one that can well be understood. Hence, those parts which are nearest to the centre will always remain crowded. The condition can only be altered by greater decentralisation and the building up of small subsidiary areas round London where the factories could be put up with ample spaces round them for dwelling purposes. Another factor which is increasing the congestion is the gradual substitution, almost unnoticeable in its progress, by the workshop of the private dwellings in whole or in part. Most of the other routine inspections call for no comment, inasmuch as they differ little from last year. The most notable difference is seen in the workshops inspected, over 200 more visits having been paid than in 1920. Although nearly 500 fewer intimations were served, the number of statutory notices remained about the same, indicating the continuance of the policy of speeding up, and it is well that it is so. The difficulties encountered during the war have practically disappeared, and there is no lack of labour to execute the demands in the generous period usually allowed by the Authority. The number of visits to houses let in lodgings has shown a noticeable increase, but we are still a long way behind pre-war figures. Schools. All the schools, both public and private, have been kept under observation during the year, there having been 194 inspections of the former and 151 of the latter. In addition, there were the usual inspections of Dulwich College and the Datchelor Schools, which are made at the instance of the authorities of those institutions. These, especially the former, take up a very large proportion of the Inspector's time, for here not only the school buildings but also the masters' houses are inspected and the drains examined. Indeed, the Council does for nothing what a sanitary surveyor would charge a fee for, and for these schools acts on lines it does not follow for other ratepayers. No occasion has arisen for this Authority to act in the way of closure of schools; where any such action has been taken it has been done by the School Medical Officers of the London County Council, and has then ordinarily been limited to the closure of either a department or one or more classrooms, and the cause has usually been measles. As heretofore, all absences of children from school which might be due to infectious disease are visited, appropriate action being taken when necessary. Difficulty, however, has arisen where a definite notification of infectious disease has been made by a school medical officer when examining children at school. The child often is apparently well, and the parents, backed up by their own doctor, come down to know the reason of exclusion. It has sometimes been a delicate matter to decide and to keep the peace, and it would certainly make for smoother working if information of such cases were given to the Borough Council in another way than by a formal notification. The cleansing station continues in its work, but, owing to a change of method of dealing with verminous children, the London County Council has pressed for the appointment of an additional woman help. The expense of this is almost certain to lead to such expenditure by the Borough Council that the station will be run at a loss to the ratepayers of Camberwell. It will naturally be said that, whether from the central or whether from the local authority, the money comes out of the ratepayers' pocket, but here it comes from Camberwell only, and in the former from the common purse of London. The matter is at present still under discussion, but it is to be hoped that it will not be decided without considering whether the old agreement, which involved a considerable expenditure, was not made on the understanding that the circumstances then obtaining would continue. Milk Supply. The conditions of the milk supply remains much the same; if anything, the position of the combines is strengthened and the greater bulk of the milk coming into Camberwell is distributed through their agencies. Having dealt with this subject in previous reports it is unnecessary to make more than a passing reference to it. Samples of milk were taken by your inspector for the purpose of bacteriological examination and several of them were found to show evidence of serious contamination. The results obtained by no means accorded with others taken by the firms concerned. One of these, indeed, went so far as to suggest that notice be given of the time and place at which it was intended to take a sample, ostensibly that they could bring sterile bottles and take a sample at the same time. There were 874 inspections of milkshops during the year compared with 779 in 1920. If only the simple precautions were adopted by milkers, which really amount to nothing more than strict cleanliness, one would certainly be able to get some improve- ment in the purity of milk, an event for which a casual examination of the bottom of many vessels containing it will emphasize the necessity. Milk, Mother and Children. The Committee which commenced operations in the early part of 1920 continued its good work during last year, and the circumstances of each applicant were the subject of strict yet sympathetic consideration. It is argued out that all the milk granted did not find its way to the persons to whom it was allowed, and this point must be conceded, for one can hardly imagine a mother consuming all that supplied with hungry children watching every mouthful. Still, so far as it was in the Committee's power, it may be fairly claimed that no genuine case went unrelieved. That some unworthy persons profited is possible, but to avoid this entirely is beyond the limit of human endeavour. Towards the end of the year the calls on Dr. Barnes' time were so much increased by the necessary visiting at maternity centres, and also by Police Court attendances to give evidence, that it was necessary to cut down the Committee to a weekly meeting. The number of applications during the year was 10,804 and those in which some relief was granted was 10,152. The monetary value of the work of the Committee can be, therefore, appraised and appreciated. Whether the distribution of milk has led to a greater dependence on the authorities as a means of support and less on their own individual effort is a question beyond the province of a Medical Officer of Health to discuss ; but I do think, from the point of physical welfare of the children concerned, the Order has been of great benefit. The approximate gross cost of this milk supply was £7,342 18s. 5d., leaving the net amount to be defrayed by the Borough as £3,671 9s. 2|d. Meat. No public abattoir has been established, but there is only a very small proportion of slaughtering in Camberwell, nearly all the meat consumed therein being bought wholesale in the Central Markets. There is not much danger of diseased meat being obtained from this source, and, judging from the experiences of other Boroughs, dealings in bad stuff are carried out by importation from country districts. Unwholesome Food. There were 11 more seizures of unwholesome food than in 1920, some of them being on an extensive scale. These numbers however give no indication of the enormous amount of work they often entail. Visits at all hours and to all parts of London are often necessary, in addition to the hunting up and questioning of persons whose interest is often to conceal the truth rather than to further the administration of justice. This naturally takes the inspector from his district, with the resulting loss of inspections, besides the inconvenience to those who may be carrying out work under his directions. Urgent cases are of course dealt with by another inspector, but the routine duties of both districts are thrown sadly out of gear. The difficulty can of course be met by the appointment of a special food inspector , but unless several were appointed the patrolling of the Borough for this purpose could not be so complete as it is with all the inspectors on the look out, while if the duty is still left to the district inspector in addition to the special officer the difficulty referred to above is still likely to arise, although, perhaps, in a less aggravated form. As a sort of aftermath of the war an active trade has been carried out by the vendors, chiefly of a more or less itinerant description, of tinned food, with the accompaniment of increased vigilance in its examination on the part of your Inspectors. A great many tins were seized and condemned ; but it is quite possible that a large number escaped seizure, for only those could be taken in which there was prima facie evidence of unsoundness. But there is evidence to show that a tin may contain meat of a harmful character without showing any sign of going wrong, and such cases would naturally escape seizure. The Inspectors chiefly concerned in such seizures were Collins, Malins and Nash, and they deserve special mention for the energy and zeal they displayed in bringing the offenders to book. The subject of Street Trading also led to some discussion. It was alleged that serious danger arose from this source, and a report is appended which was made to the Works Committee. Whenever it was possible, e.g., in the case of meat, we insisted as far as possible on as many safeguards as we should in the case of shops, and also took into account the facilities for storage the applicants possessed. The report of the Food and Drugs Inspector, who has shown great zeal during the year, is appended. Public Health Department, 35, Brunswick Square, Camberwell, S.E. 5, 35, Brunswick Square, Camberwell, S.E.5, March 30th, 1922. To the Medical Officer of Health, Camberwell. Sir,—l herewith submit a report of the work carried out under the Sale of Food and Drags and other Acts for the year ending December 31st, 1921. The number of official samples taken was 1,089. The number of official samples taken was 1,089. Of these, 6 were taken under the Public Health (Milk and Cream) Regulations, 1912, and 37 under the Sale of Food Order, 1921. The number of informal or test samples purchased was 215, including 25 informal samples of margarine, which were obtained in order to ascertain whether the requirements were being complied with. A table is attached hereto showing the variety of official samples purchased and the results of analysis. Eleven samples of butter were taken with a view to ascertaining whether the 16 per cent,limit of moisture permitted was exceeded. In no case was there found to be any excess. The 37 samples taken under the Sale of Food Order are made up of the following:—Margarine, 21 : dripping, 12 ; jam, 3; and marmalade, 1. All the margarine complied with the requirements of the Order. Two samples of dripping failed to comply with the Order. One sample of jam, sold as "apricot," was found to be " peach." Proceedings were taken in respect of one of the drippings and a conviction wasobtained, while in the other a caution was given to the vendor. The purchase of the apricot (peach) jam led to proceedings being taken under the Public Health Act, 1891, in respect of a consignment of jam found to be unsound at the premises wherethis particular sample was purchased. Of the cases that were heard at the Lambeth Police Court the following may be worth noting : — (1) A vendor of watered milk was sent to prison on two occasions, viz., in March and July, the first period being for two months and the second for the maximum sentence of three months with hard labour. (2) In another case milk was being supplied to the outdoor poor by a vendor under a contract with the Camberwell Board of Guardians ; a fine of £20 and £7 7s. costs was inflicted by the Magistrate for supplying milk adulterated with 1 2 per cent, of added water. (3) Under the Mother and Infant Welfare Order milk was being supplied to a recipient by a vendor under a contract with the Borough Council. By means of informal sampling it was discovered "that the milk was badly adulterated; on this occasion the offence being aggravated by the fact that the milk was delivered to a child. An official sample taken at the shop in the course of delivery to the recipient (the child's mother) was found to be genuine, but the suspicious actions of the vendor on this occasion were such that the matter was followed up. After many weeks of informal buying, by a young girl, it was found, as anticipated, that when the milk was served from a certain receptacle, it always showed that it had been tampered with. When the official sample was purchased and found to be badly adulterated, proceedings were taken and the vendor was fined £25 and £10 costs. (4) A sample of milk purchased from an old offender was found to be adulterated. A summons was issued. On behalf of the defendant it was stated that his portion of the sample had been certified as genuine, and at his request the third portion was sent to the Government Laboratory. Though this analysis practically agreed with that of the Public Analyst, the Magistrate dismissed the summons. (5) In a summons for adulterated whisky the licensee was fined £2 and £6 6s. costs, and in a (6) Summons for selling sausages containing an excessive amount of boric acid the vendor was fined £2 and £4 4s. costs. With regard to vinegar, the percentage of adulteration in 1920 was nearly 19, while this year it fell to 2.5. Six official samples of cream were purchased, four containing preservatives. In two cases the purchaser's receptacle was wrongly labelled and the receptacle containing the bulk unlabelled. In the other two instances both the customer's vessel and that containing the bulk were unlabelled. Cautions were given by order of the Public Health Committee in each case. The remaining two creams were free from preservatives and complied with the requirements in all other respects. Informal or Test Samples. The number of samples obtained under the above heading amounted to 190. They include the following:—Butter, 96; milk, 80 ; whisky, 5; margarine, 4 preserved peas, 1; preserved cream, 1; gin, 1; and dripping. 1. Of the samples submitted to the Public Analyst the following were reported against:—Milk, 14; gin, 1; and whisky, 1. None of the butters submitted to the Public Analyst were reported against. (Signed) GEORGE T. DEWEY, Food and Drugs Inspector. There is little to add by way of comment to the above report except to express the opinion that the cruel fraud perpetrated by the sellers of the milk to which Mr. Dewey draws attention called for severer punishment than was meted out. I—22 Summ onses. (6) Genuine or complied with requirements (3) Not genuine or failed to comply with requirements. (4) percentage not genuine etc. (5) Cautions (7) Number taken (2) Sample. (1) Other Remarks (8) Milk 664 651 13 1.95 12 1 See footnote. 3.05 Vinegar 3 98 95 3 - 48 Butter 48 - - - - 28 28 Pepper - - - - 27 Cocoa 27 - - - - Mustard 27 26 1 3.7 1 - Margarine 24 20 4 16.6 2 2 Wrappers unstamped. 1 15 2 13.3 Taken in connection with Sale of Foods Order. Dripping 13 1 Separated Milk 14 13 1 7.1 Contained preservative. - - 13 Custard Powder 13 - - - - 13 13 Lard - - - - Camphorated Oil 11 11 - - - - Baking Powder 11 11 - - - - Coffee 9 9 - - - - Self-raising Flour 8 8 - - - - 7 6 1 14.3 1 Excessive amount preservative. Sausages - Arrowroot 6 6 - - - - Cream 6 2 4 66 4 see report. - - 5 Preserved Peas 5 - - - Golden Syrup 5 5 - - - - Rice 5 5 - - - - 4 Ground Rice 4 - - - - Full Cream Condensed Milk 4 4 - - - - 4 Malt Vinegar 4 - - - - Fish Paste 4 4 - - - - 3 Flour 3 - - - - 3 3 Olive Oil - - - - Lemonade Powder 3 3 - - - - 33 1 Proceedings under the Public Health Act (Unsound Food) Jam 3 2 1 - Crushed Linseed 2 2 - - - - Egg Substitute Powder 2 2 - - - - Brawn 2 2 - - - - Sausage Meat 2 2 - - - - Whisky 2 2 100 1 1 - 1 1 Ground Ginger - - - - Cream of Tartar 1 1 - - - - Sago 1 1 - - - - Cornflower 1 1 - - - - Sweets 1 1 - - - - Marmalade 1 1 - - - - Returned by Analyst as "Not Genuine." Strength complied with that stated on notice exhibited in the bar. No action taken. Gin 1 1 - - - - Totals 1,056 33 3.03 22 10 1,089 1918. 1919. 1920. Milk, previous years' percentage of adulteration 11.7 6.9 2.8 Prevention and Control of Infectious Disease. Last year it was incumbent on me to report a great and widespread prevalence of scarlet fever. One would have expected and hoped that in 1921 there would have been no necessity to repeat this, but rather to have been able to say there was much less of this disease. Instead of this, however, scarlet fever prevailed among us to a considerably greater extent than in 1920, there being notifications instead of 1,308. A large proportion of these (1,752) were removed to hospital. The epidemic started in the early part of July, reached its maximum at the end of September, but it was not until January, 1922, that the number of cases fell to the level of July, 1921. There were 23 return cases of this illness, compared with 12 in 1920, and these were referred to their own doctors. The continued prevalence, although with a diminished mortality, of this disease, in spite of the measures of notification, removal, and disinfection, has naturally given rise to doubts, perhaps vague and ill-defined, but certainly existent, as to whether the existing practice is a costly mistake. It has gone on with little question for some thirty years, but when one meet's with a continued high prevalence a justifiable and well-grounded suspicion may arise as to the necessity for some radical change. Allowing for differences in the amount of susceptible material and alterations in the population, it certainly seems strange that in the year 1893 there were 1,886 notifications, and in 1921,59 the differences in the population being 1893, population 247,950, and 1921,600 and this followed 1920, also a year of exceptionally high notification. Some observations were made as to the results of the ordinary methods of disinfection carried out after this disease. Without an extended enquiry in many different localities it would be unwise to make any alteration, but so far as one went it was enough to show the advisability of further and critical enquiry in order to confirm or do away with any doubt as to its value. There were 870 notifications of diphtheria, and of these 829 were removed to hospital. No series of cases occurred which might have aroused the suspicion of any local outbreak. The continued prevalence and fatality of this disease is difficult to understand. For there is a well-recognised means for its control and prevention, and this has been in universal use since its discovery in 1894. That by this time the disease has increased in its virulence and consequent high mortality, just as scarlet has diminished, is possible, but it i 3 not likely that the antitoxin which formerly was so potent has now lost its power. It is far more probable that antitoxin is not used to the extent that it should be, not only among the sufferers, but on those who are exposed to massive infection. The injection of antitoxin should be made directly strong suspicion is aroused and before the diagnosis is confirmed by bacteriological diagnosis. Instead of that, the injection is often delayed until this is received, and bacteriology, which might be so helpful, becomes a hindrance. No doubt the necessary inconvenience associated with injection does form a difficulty to the busy practitioner in the poorer districts, and in the near future it may be that the operation on request may be done by the Medical Officer of Health as a measure for the protection of the contacts in the same way he vaccinates as a matter of urgency when smallpox has appeared in a household. CASES OF INFECTIOUS DISEASES NOTIFIED DURING THE YEAR 1921 Total Cases Removed To Hospital. E. Dulwich. N.W. Camberwell. Peckham. Returned Cases. North Camberwell. Dulwich. Notifiable Disease. Smallpox ... ... ... ... ... ... Cholera ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... Diphtheria (including Membranous Group 23 111 215 274 247 5 829 Erysipelas 11 33 42 38 1 34 ... 40 265 463 652 539 23 1,752 Scarlet Fever Typhus Fever ... ... ... ... ... ... ... 4 15 Enteric Fever 5 3 5 2 ... Relapsing Fever ... ... ... ... ... ... ... Continued Fever ... ... ... ... ... ... Puerperal Fever ... 3 3 ... 5 3 13 ... Cerebro-spinal Meningitis 1 2 ... 1 ... 1 ... Poliomyelitis 3 1 1 ... ... ... ... Ophthalmia Neonatorum 4 12 5 11 ... 15 ... 147 211 Pulmonary Tuberculosis 21 59 157 ... ... Other forms of Tuberculosis 2 8 40 56 49 ... ... Pneumonia 3 7 10 36 50 ... 36 1 9 Encephalitis Lethargica ... 5 2 4 ... 3 23 14 Malaria ... ... ... ... Dysentery 1 4 6 ... ... ... ... Anthrax ... ... ... ... ... ... 1 ... Trench Fever ... ... ... ... ... The notifications of enteric fever in its various divisions showed an increase from 5 to 15. In 1920 there were no notifications either from Dulwich or North Camberwell, yet in the year now under consideration there were six cases, but in London taken as a whole the disease does not seem to have been so prevalent. To this result the strict supervision of the sources of food, and especially to the more careful supervision to that of fish supply, has probably largely contributed. As mentioned in the early part of this report, no genuine case of smallpox was reported; but there were several false alarms, and the aid of the County Council Consultant was sought on more than one occasion. Nothing more has been done in the way of providing a house in which persons might be kept in quarantine after the occurrence of a case of smallpox in their home: a subject in which the decision of this Council to take no action has been defended in previous reports. There were 32 notifications of ophthalmia neonatorum, and of these 15 were taken to hospital. It is gratifying to be able to report that so far as could be seen at present none of the children showed any sign of permanent injury to the eyes. Tuberculosis. Material alteration has taken place in the adminstration of the arrangements for this disease. At the end of 1920 it was intimated to this authority that the Committee who had so long carried out the work could no longer be responsible for its continuance. The Council, therefore, had no alternative between dropping the scheme altogether or of continuing it under their direct control and being themselves responsible for the cost. A scheme was prepared and approved by the Committee, and subsequently by the Council, to this end, and it is now directly under municipal control, the Tuberculosis Officer, Dr. Brand, being an officer of this Authority. The staff at the end of 1921 consisted of: — Tuberculosis Officer Dr. Brand. Assistant Tuberculosis Officer Dr. Gorrie. Nurses Miss Chambers, Miss Thistleton. Clerk Miss Fry. Dispenser Miss La Croix. Potter Mr. W. J. Cripps. Cleaner Mrs. Martin. The work is carried on from the old premises in Brunswick Square, there being also a day sanatorium and school at Grove Hill Road. Cases requiring institutional treatment are sent to the Infirmary, to various homes under the control of the London County Council, and to a lesser extent become inmates of the various hospitals, general or special. Formerly it was the custom for the women sanitary inspectors to keep in touch with patients and contacts, and while the Dispensary was under outside control it was probably the best plan, in spite of the extreme likelihood of overlapping, for the Dispensary nurses did a considerable amount of visiting. Now, however, that the Dispensary has come under the direct control of the Borough Council it is much to be desired that nurses alone should visit, leaving the Sanitary Inspector to come in when there Sire unhealthy conditions which can be remedied under statutory powers. This will avoid the not unnatural irritation caused by visits from many persons, particularly noticeable where it is impossible to offer any material advantage either in the way of food or treatment. A dental scheme for giving dental treatment was in operation during the year. No provision has been made in the way of providing some shelter whereby the last days of a dying consumptive might be rendered easier to bear, and by such means to aid a poor household already hampered by the incapacity to Work of one who had been a material help. It has been suggested that such homes might lose much of their usefulness through being known as " Homes for the Dying." This is a matter for individual opinion, but I know of one such institution which has such a title to which patients feel no repugnance, and removal to which is often a melancholy satisfaction to their friends. Cases in which tuberculous mischief is suspected by the School Medical Officer continue to be referred to the Dispensary, and the Care Committee has continued its work during the year. But it is obvious that the connection between Tuberculosis and Housing is of the closest, for the main difficulty that has arisen has been due to the lack of proper accommodation. This may often be sufficient for ordinary needs, but there is no margin available for the extra requirements of the tuberculous patient. Many a one who has derived benefit from the extra care and salubrity of a sanatorium when he returns to his old unsuitable home loses all the advantage that he gained while away. The number of cases attending the Dispensary in 1921 was— (a) insured, 1,249; (b) uninsured, 2,198; (c) contacts examined, 1,310. There were 44 deaths reported from phthisis, of whose existence we only became aware through the Registrar's return of deaths, and 44 from other forms of tuberculous diseases. To be consistent, there can be no reason for treating a nonnotification of a case of tuberculosis different to one of scarlet fever. It is always possible for the notifying practitioner to express a wish that it should not be visited, and unless serious and grave reason existed, such a desire would always be respected. Of late years a tendency has grown up to regard the raising of the resistance of the individual to infection as more important and likely to give better results than the attempted destruction of infective material. On account of the stress laid on the latter policy I was never able to give whole-hearted support to the notification of phthisis, which is so bound up with it. One of the great arguments in general use some ten years ago in support of notification was summed up in something of these terms. Here is an infectious disease admitted to be about as fatal as all the notifiable diseases, and yet it is not included among them. Notification seemed then to imply an analogy between tubercle and the ordinarily notifiable diseases, which does not unquestionably exist, and that similar lines of administrative action should be followed, thereby relegating to a subordinate position the indirect methods which are so valuable and which exerted their efforts long before the famous question of 1898, ascribed to one of very high position, and which was expressed as "Consumption is a preventable disease; why is it not prevented ?" Judging from the disastrous ravages of the tubercle bacillus in a virgin population, unless the impossible task can be accomplished of destroying every one of its varieties, it is surely far better to have a population with a resisting power raised by the previous slight infection to which we have all been subjected to, and which can be further raised by improvements in housing, better nourishment, and healthier habits of life. It is no use crying over spilt milk, but one is impelled to ask if all the money that has been spent on tuberculosis had been used for housing and more generous supply of food to those who, under their existing circumstances, could not obtain it, whether the results to the public health would not have been much better than they are. It is quite possible that in the near future it may be possible to effect a further increase of the resistive power by the employment of inoculation of suitable material. Anyway, the lessening of tuberculosis must be a slow process, and the utterers of the bombastic phrases of consumption being stamped out in a score or so of years are, I fear, likely to be disappointed. The number of deaths from tubercle in Camberwell was 353, compared with 352 in 1920 and 373 in 1919. The figures for the pulmonary form were 273, 274, and 294, respectively. For the County of London for the same years the figures are 5,332, 5,746 and 5,777 respectively. 964 deaths in 1921 and 1,071 in 1920 were assigned to the non-pulmonary forms. MATERNITY AND CHILD WELFARE. The Borough Council established two Municipal Infant Welfare Centres during the year, No. 140, Camberwell Road and No. 114, Lordship Lane. East Dulwich (the former was opened on 27th May, 1921, and the latter 24th November, 1921), appointed two health visitors, and, in addition, continued to subsidize the following schools for mothers working in the Borough, viz.:— St. Luke's School for Mothers, 2, Commercial Road, Peckham; The Camberwell (Cambridge House) School for Mothers, 6, Addington Square; The United Girls' School Settlement School for Mothers, 19, Peckham Road; The Nunhead Mothers' Welcome, 31, Nunhead Grove, and the Bird-in-Bush School for Mothers, 601, Old Kent Road. All these do health visiting, and in accordance with the established practice I give below a summary of their work for the year ended 31st December, 1921. Attendances of Children 23,811 Do. Expectant Mothers 544 Do. Post-Natal Do. 548 Do. at Mothercraft Classes 5,974 Visits to Expectant Mothers 2,137 Do. to Children and Mothers 22,717 Total No. of Staff Visits 25,364 During the year three mothers and three children were sent away for convalescent treatment. The grants to the following have been increased since 1919, that of St. Luke's from £150 to £350, of the United Girls' School Settlement from £150 to £350, of the Nunhead Centre from £200 to £300, of the Cambridge House from £150 to £250, and that of the Bird-in- Bush Centre from £187 10s. to £-300. The grant to the Peckham Day Nursery was not renewed, but one of £50 for the Cheltenham College Day Nursery was sanctioned. There is no change to report in the way of provision of lying-in homes beyond the three mentioned below, which are designed for the reception of unmarried mothers—-The Moorings, Champion Park; Home of Hope, Grove Lane; 24, De Crespigny Park ; and also the Home of Help, Camberwell Grove, for the mother and her infant. Although no other provision has as yet been made, several homes were surveyed, but for one reason or another were not considered suitable. The nursing arrangements are not carried out by the Borough Council direct, but by the various nursing associations, or else by nurses who are connected with one or other of the philanthropic agencies in the Borough, and by arrangement with Bermondsey it is possible to secure attendance in a small district which is not covered by the above agencies. The amount expended for the year was £104 16s. 4d., but prejudice against a nurse's help I fear still lasts, and usually exists in homes where they are most needed. This will in time, when the people at large have come to recognise their value, no doubt disappear. There were 14 notifications of puerperal fever, compared with 20 in 1920, with 9 deaths, as opposed to 8 in the previous year. Ophthalmia neonatorum has already been referred to. HOUSING. During 1921 progress was made in improving the housing conditions in the Borough. It cannot be urged too strongly that proper accommodation in this regard is the surest way to reduce mortality, both infantile and general, and only one thing takes precedence ; this being proper and sufficient nourishment. All others come a long way behind these, and it is on food and housing first, second and last on which reliance will have to be placed, and I feel sure that any administration which concentrates on these two will reap the greatest reward. During the year the Casino Estate and ground in Nunhead have been utilized, the former being completed in December, 1921, and the latter in September, 1921. Much, however, remains to be done in the provision of accommodation, perhaps simpler and less ornate in character, but so far as rent is concerned at a level to suit the pockets of the "bottom dog." An advance in the way of provision for this class is seen in Hampton's Avenue, which was the subject of anxious and careful consideration by the Housing Committee. At the end of 1920 matters indeed seemed to have reached a deadlock; the owners could not pay for the repairs ; to have spent unaided any money on the property did not appear justifiable to the Council; and no help was forthcoming from the Central Authorities to assist in the carrying out of a reconstruction scheme favoured by some members. At the same time the condition of the place was deplorable. At the end of the year, however, the homes were acquired by a private firm with considerable interests in the neighbourhood, and now, although much still remains to be done, and the result will not have the eclat of a big scheme, definite progress has been made towards its improvement. The Committee has, of course, all along been hampered by the difficulty of finding accommodation for those persons displaced and has had to go very slow lest worse evils might supervene. The house occupied by one family is, of course, the ideal, but Utopian so long as the present relations exist between work place and dwelling place, consequently it seems necessary to crowd more persons on a given site than one would welcome, but given strict attention to planning and to the provision of light, air and refuse disposal, three-floor buildings offer the best solution. Nothing further has been done in the way of improving the conditions of Carpenters Place or Blue Anchor Lane, but the Report for 1922 will probably show substantial progress in the treatment of other areas such as Tiger Yard, which have been considered by the Committee, and with the fall in prices there are other areas which are now quite fitted for their present occupying families, but which by some rebuilding could be adapted for a larger number. Considerable trouble was caused by a certain number of families who seized an unoccupied brewery in the Borough. From this they were ejected by order of the Court, but then proceeded to camp out in the yard of the building from which they had been expelled. They managed somehow to obtain closet accommodation and water, thus rendering it difficult to take any legal action, and at the end of the year were still in possession. Difficulty also arose in the case of two older houses in the northern part of the Borough of Camberwell where the outside wall was removed on account of its dangerous condition. The hardships were alleviated by the provision of stoves, tarpaulins, &c. APPENDICES. Housing Conditions. STATISTICS, YEAR ENDED 31st DECEMBER, 1921. 1. General. (1) Estimated population 269,600 (2) General death rate 2.1 (3) Death rate from tuberculosis 1.3 (4) Infantile mortality 74 (5) Number of dwelling-houses of all classes) (6) Number of working-class dwelling-houses Provisional figures 41,018 (7) Number of new working-class bouses erected 236 2. Unfit Dwelling-Houses. I. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 9,687 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 Nil (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 46 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably lit for human habitition 7,265 II. *Remedy of Defeats without Service of formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers — III. Action under Statutory Fowers. (a) Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919:- (1) Number of dwelling-houses in respect of which notices were served requiring repairs 13 (2) Number of dwelling-houses which were rendered fit — (a) By owners 13 (b) By Local Authority in default of owners Nil (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil (6) Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 3,134 (2) Number of dwelling-houses in which defects were remedied:— (a) By owners All (A) By Local Authority in default of owners Nil (c) Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc., Act, 1909. (1) Number of representations made with a view to the making of Closing Orders Nil (2) Number of dwelling-houses in respect of which Closing Orders were made Nil (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit Nil (4) Number of dwelling-houses in respect of which Demolition Orders were made Nil (5) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil 3. Unhealthy Areas. Areas represented to the Local Authority with a view to Improvement Schemes under (a) Part I., or (b) Part II., of the Act of 1890: — (1) Name of area — (2) Acreage — (3) Number of working-class houses in area — (4) Number of working-class persons to be displaced — 4. —Number of houses not complying with the building bye-laws erected with consent of Local Authority under Section 25 of the Housing, Town Planning, etc., Act, 1919 - 5.—Staff engaged on housing work with, briefly, the duties of each officer - This work is carried out, along with their other duties, by the Sanitary Inspectors. * If by formal notice is meant statutory notice, there were 4,172 premises dealt with in the terms of this enquiry. STAFF. The Council sustained a considerable loss through the death in January, 1921, of Dr. E. C. Bousfield, who was appointed bacteriologist in the far away days of 1898, when the then Vestry was one of the earliest, if not actually the first, to recognise the value of this branch of medicine in the prevention of infectious disease. In 1899 he was concerned with others in pointing out the practical importance of the examination of apparently healthy throats. This was largely made use of in the investigation of an outbreak of diphtheria in a certain school and a reference to the Minutes of that time will give an idea of the stir then caused by that long-forgotten episode. Its effect, however, remains in the word " carrier,'' which has now become such a much used word in the public health vocabulary. He was a man well known and his opinion was largely sought by many practitioners in the Borough, especially at a time when so few authorities provided the opportunities he then gave to Camberwell. On many occasions he acted as my deputy, the last time being during the war, when I was engaged abroad for over six months, and on many occasions the Council thanked him for his services. After much consideration and discussion, the Council finally decided that the work formerly done so well by Mr. Chadderton, the chief clerk, should be extended and it was decided to appoint two sectional clerks; Mr. Wright in the main to look after the general correspondence and management of the office, while Mr. Jones, a former inspector, had charge of the work of the Inspectors. It speaks highly for the public spirit of these two members of the staff that they have managed so well in an arrangement which, I am equally bound to say, I thought would never work smoothly and of which I could not altogether approve. Coincident with this was the transference of a good deal of clerical work from the inspectors to the clerks with the idea that the former by being relieved of some of their duties in this regard would be able to devote more attention to their out-door work. Various other recommendations were made, but were held over in view of the changes that would ensue on my resignation in March, 1922. To fill Mr. Jones' position Mr. Donald Glenday was appointed a temporary sanitary inspector. The appointment of health visitors is referred to elsewhere. The two appointed were Miss Stoddart, a trained nurse and midwife, formerly superintendent of the Bird-in-Bush Voluntary Maternity Centre, and Miss Agnes Duffield, who had formerly had a large midwifery experience in the Borough, and who at the time of her appointment was engaged temporarily by the Council. The use of a house belonging to the Council for the purpose of a Tuberculosis Dispensary was not unexpectedly vetoed by the Central Authority, and a proposal was then made that it should be used as offices for the Public Health Department. The separation of such an integral part of the administration of the Council is unfortunate, and this opinion was at one time shared by my colleagues. At the same time no serious opposition could be made, on account of the condition of things in the old sanitary department of the Town Hall in the way of light, ventilation and heating being prejudicial to the health of those who were working there. After various structural alterations had been carried out, the department was transferred to Brunswick Square in September, 1921, and up to the time of writing neither anything nor anyone has suffered in consequence. CONCLUSION. This report is, I am sorry to say, very belated, but illness, labour difficulties among the printers, and press of other Council work, coupled with the disadvantage of writing it far removed from sources of information, must be at once my explanation and my apology. To Dr. Bousfield I have already referred, but this report would not be complete were I to omit a tribute to Mr. Cbadderton, the former Chief Clerk, who retired in 1921. In the difficult days of the war, when we were relying a good deal on temporary help and I was sometimes busy on other duties, so long as he was in his accustomed place I never felt the slightest anxiety about the work of this department. Dr. Barnes has been of great assistance to me, both by his work and his opinions. I rejoice to think that the Council appointed him my successor, for I feel sure that the administration of the most important department of the Council is now in able hands. To Mr. Wright and his juniors, to whom I am indebted for much help in the statistical part of this report, work ably seconded by Mr. Jones in that which relates to the inspectors, I tender my grateful appreciation. The closer association with the work of the latter in great measure passed to Dr. Barnes, but when I had need the help was given with the same readiness and intelligence as of old. In commending the Superintendent Disinfector for the way he has assisted me and the zeal displayed in his work, I have to place on record the fact that during the whole of my service with the Vestry and Council I have never received any complaint of the conduct of any of his staff when engaged in work which must bring temptation in its way. In conclusion, with all my heart I thank the Council, the Chief Officers and the whole Staff, ever changing in membership but unchanging in the kindness and consideration they have shown me, and wish them, one and all, God speed in their work. Good-bye. Your obedient servant, FRANCIS STEVENS. February, 1923.