CAM 23 London Metropolitan Borough of Camberwell REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1923 HOWELL W. BARNES, B.A., M.B., B.Ch., D.P.H. Printed by HENDERSON & SPALDING Ltd. Sylvan Grove, Old Kent Road, S.E. 15 Report of the Medical Officer of health. Public Health Department, 35, Brunswick Square, S.E.5. June 30th, 1924. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Camberwell. Ladies and Gentlemen, —I have the honour to submit to you the annual report on the health and sanitary condition of the Borough for the year 1923. It is compiled in accordance with the Ministry of Health's directions conveyed in their circular No. 451, issued December 15th, 1923. The health of the Borough continues to be satisfactory. There is a 2·4 decrease in the death rate, which is 11.0 as compared with 13.4 in 1922. During the first 9 months of the year the number of deaths was remarkably low, and the increased number of deaths during the last quarter is accounted for by the number of deaths from respiratory diseases which cold and fog always bring. The infantile death rate showed a marked decrease of 22 points, 56 as compared with 78 in 1922. This is the lowest rate ever recorded in the Borough. Although economy has been the watchword during the year, this economy has not been allowed to interfere with efficiency and progression relating to health services. It is generally agreed that economy in Public Health administration would be a false economy and might lead to a loss in human health and life. The outstanding event during the year was the provision of a Municipal maternity ward in the St. Giles' Hospital, Brunswick Square. I should like to take this opportunity of expressing my thanks to the Chairmen and Members of the Public Health, Maternity and Child Welfare and Housing Committees for the assistance they have afforded me. I desire also to place on record my appreciation of the work of the staff of the department, who have at all times under difficult circumstances, accorded to me their loyal and unselfish co-operation. I am, Ladies and Gentlemen, Your obedient Servant, H. W. BARNES. Medical Officer of Health. Staff of the Public Health Department at the end of 1923. *Medical Officer of Health and Medical Officer, Maternity and Child Welfare. H. W. Barnes, B.A., M.B., B.Ch., D.P.H. Hon. Consulting Medical Officer of Health Francis J. Stevens, D.M. W. Brand, B.A., M.B., C.M. *Tuberculosis Medical Officer Eleanor A. Gorrie, M.B. *Assistant Tuberculosis Medical Officer *Medical Staff at Municipal Infant Wellfare Centres. The Medical Officer of Health (Dr. Barnes), (Mrs.) Margaret Dunstan, M.B., B.Ch., D.P.H., and J. H. Clatworthy, M.D. E. A. Pinchin, B.Sc., F.I.C., F.R.M.S., certified bacteriologist. Public Analyst *Inspector under the Food and Drugs Acts. George T. Dewey. § *Sanitary Inspectors—Male. Dist. Dist. 1. Maurice Malins. §§† 7. William R. Farmer. § 2. William T. Worsfold. §§ 8. William Eagle. 3. Richard F. Nash. §§† 9. George G. Morley.§ 4. George W. Scudamore. § 10. William E. Groom. § 5. Henry C. Green. §§† 11. Edwin R. Collins. § 6. Donald Glenday. §§ *Women Sanitary Inspectors. Miss F. O'Riordan. §§† Miss M. Butcher. §§ * Health Visitors. Miss A.M.Stoddart, ‡ Miss A. Duffield ‡ and Miss K. Jerrard. ‡§§ Clerks. H. K. Wright. H. N. Jones. §§† H. J. Hurst. F. T. Harman. A. J. Hardiman. F. H. Wetherall. *C. T. Wilson (Temporary). A.J. Baker (Temporary). L.A. Westacott (Temporary). *Miss M. L. Thompson (Temporary), part-time Milk Inquiries and part-time at Infant Welfare Centres. A. Beeson (Temporary). Tuberculosis Dispensary. Miss H. Chambers‡‡ and Miss M. Thistleton.‡‡‡ *Tuberculosis Nurses. Miss J. M. Fry and H. W. Leonard. *Clerks. Miss P. La Croix (part-time). *Dispenser. Disinfecting and Cleansing Station. Foreman Disinfector. Assistants. A. Franklin. J.Knappett, E.Corby, A. Peppler (motor driver), F. Hickey, J. Smith, J. Conner. Women Assistants. For Cleansing of Children, etc. Mrs. A. Cork (temporary). Mrs. S. Herd (3 days per week) (temporary) Mortuary Keeper. A. E. A. Dennison. *Officers to whose salary contribution is made under the Public Health Acts, or by Exchequer grants. † Meat and other Foods Certificate. § Royal Sanitary Institute Certificate. §§ Certificate Sanitary Inspectors' Examination Board. † Central Midwives Board Certificate and Health Visitor's Diploma. †† General Training Certificate and Central Midwives Board Certificate. ††† General Training Certificate and Certficate Special Course in Tuberculosis. SECTION 1. General Statistics. Area (acres) 4,480 Population (Census 1921) 267,198 Do. (estimated 1923) 272,300 Number of inhabited houses (Census, 1921) 41,419 Do. do. do. (approximately, 1923) 41,780 Number of families or separate occupiers, 1921 66,104 Rateable value £1,406,254 Sum represented by a penny rate, about £5,700 Population.— The Registrar-General has estimated the population of the Borough at the middle of 1923 to be 272,300, and it is upon this figure that the death and birth rates are calculated. The estimated population of the different wards is as follows: — SECTION 2. Extracts from Vital Statistics of the year. Births Legitimate Illegitimate Total. 5,522 135 M. 2,810 72 F. 2,712 63 Birth Rate, 20.7 Deaths 3,000 Death Rate, 11.0 Number of women dying in, or in consequence of, Childbirth:— From Sepsis 9 9 From other causes 11 Deaths of infants under one year of age per 1,000 births 56·7 Legitimate, 308; Illegitimate, 13. Total 321 Deaths from Measles, all ages 35 Deaths from Whooping Cough, all ages 30 Deaths from Diarrhœa, under 2 years of age 49 272,300 3,980 12,369 16,335 14,922 14,844 12,361 10,916 10,860 14,293 11,654 9,146 16,548 15,844 16,540 13,495 16,406 16,878 14,472 14,695 15,736 Estimated 1923. 270,300 3,951 12,278 16,215 14,812 14,735 12,267 10,836 10,786 14,188 11,571 9,079 16,426 15,728 16,418 13,396 16,286 16,754 14,366 14,587 15,621 Estimated 1922. 267,198 3,906 12,137 16,029 14,642 14,566 12,126 10,712 10,662 14,025 11,438 8,975 16,238 15,548 16,230 13,243 16,096 16,562 14,201 14,420 15,442 Census 1921. 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Ward. Population. Births.— The total number of births registered in the Borough was 5,052. The corrected number of births arrived at by adding 690 births which occurred outside the Borough of persons belonging to the Borough, and deducting 85 births which occurred in the Borough of persons not belonging to the Borough, amounted to 5,657 — 2,775 females and 2,882 males. The birth rate for 1923 was 20.7 births per thousand population. The following table gives the births and birth rates since 1919:— Year. Population. Births. Birth Rates. 1919 285,220 5,183 18.2 1920 284,712 7,505 26.0 1921 269,600 6,301 23.3 1922 270,300 5,802 21.4 1923 272,300 5,657 20.7 The effect of the declining birth rate, which is viewed with great concern in some quarters, is counterbalanced by the preservation of infant life. In these days of unemployment and overcrowding a decrease in the birth rate could be viewed with equanimity if it were spread equally throughout the Borough. There is reason to believe that this is not the case, as the fall is most marked in the most virile part of the population. Illegitimate Births. —The number of Camberwell births reported as illegitimate was 135, equal to a rate of 23.8 per 1,000 registered births. Notification of Births Act.— During the year 5,054 births were notified as follows:— Notified by Midwives 2,829 Notified by Medical Practitioners 1,330 Notified by Parents 895 Still-Births.— Of the 5,054 births notified, 144 are returned as born dead. There is no doubt that a large number of still-births could be prevented, if only pregnant women would realise the value of ante-natal supervision, in order that any complications in the management of the labour might be foreseen, and the risks avoided or minimised. Effective supervision of pregnant women, especially primagravidæ, has resulted in the saving of many mothers and children from the danger of obstructed labour, and other risks occurring during the actual birth. The difficulty is to educate the public as to the advantages of ante-natal care. This education can only be given with profit to women who place themselves under professional care from the early days of pregnancy, and who continue to be supervised up to the time of birth of the child. We know that if expectant mothers were healthy, and if their offspring were kept healthy until they had a good start in life, the amount of invalidism would be very materially diminished. We also know that the death of a newly born child is a loss, because of the loss of working capacity of the mother immediately before and after birth. Further, if a child suffers from an ailment which does not kill, but which causes crippling or chronic invalidism, the loss to the country is even greater, for the parents or the community have to assume the heavy financial responsibility of supporting an unproductive member of society. Deaths.— The number of deaths registered during the year as having taken place in the Borough was 3,227. The corrected number of deaths, found by deducting 765 deaths of non-residents who died in the Borough, and adding 538 deaths of inhabitants of Camberwell who died elsewhere, is 3,000. The corrected death rate for 1923 is 11.0, as compared with 13.4 for 1922. The sub-joined tables show the total deaths registered, redistributed, and the death rate for each sub-district and for the whole Borough since 1921:— Deaths Registered in the Sub-Districts of Camberwell. Year. Borough. Dulwich. East Dulwich. North-West Camberwell. Peckham. North Camberwell. Unattached. 1921 1922 1923 3,245 3,635 3,000 160 183 189 493 515 419 819 989 799 940 1,028 881 801 893 696 32 27 16 Deaths Redistributed in Sub-Districts. Borough. East Dulwich. North-West Camberwell. North Camberwell. Year. Dulwich. Peckham. 1921 3,245 162 498 827 949 809 1922 3,635 519 184 996 1,036 900 1923 3,000 190 421 803 886 700 Year. Borough. Dulwich. East Dulwieh. North-West Camberwell. Peckham. North Camberwell. 1921 11.08 12.3 12.3 12.02 12.0 10.07 11.4 1922 13.4 11.3 14.8 13.3 14.3 1923 11.0 11.6 9.1 11.7 11.3 11.0 TABLE No. I.—CAUSES OF, AND AGES All ages. Causes of Deaths. Enteric Fever 3 Small Pox - Measles 35 Scarlet Fever 7 Whooping Cough 30 72 Diphtheria and Croup 25 Influenza Erysipelas 2 252 Phthisis (Pulmonary Tuberculosis) 22 Tuberculous Meningitis 31 Other Tuberculous Diseases 333 Cancer Rheumatic Fever 16 22 Meningitis Organic Heart Disease 301 Bronchitis 276 Pneumonia (All forms) 244 Other Diseases of Respiratory Organs 31 49 Diarrhoea and Enteritis Appendicitis, Typhilsitis 9 Carrhosis of leaver 20 1 Alcoholism 72 Nephritis, Bright's Disease Puerperal Fever 9 Other Accidents and Diseases of Pregnancy and Parturtion 11 Congenital Debility and Malformation, including Premature Birth 146 Violent Deaths 76 27 Suicides 867 Other Defined Diseases 9 Diseases ill-defined or unknown 2 Encephalitis Lethargica 3,000 Total AT, DEATHS DURING THE YEAR 1923. 2 to 3. 3 to 4. 4 to 5. 5 to 10. 10 to 15. 20 to 35. 45 to 65. Total Deaths whether residents or non-residents in Institutions in the Borough. 15 to 20. 35 to 45. 65 and up. - - - - - 2 1 _ - - - - - - - - - - - - - - 4 6 4 3 - 15 - - - - - - 1 - 1 1 - - - - - - 5 1 1 4 - - - 11 14 - - - 9 8 15 7 3 - - - 1 - - - - 1 - - 1 5 - 15 3 - - - - - - - 5 1 1 1 1 - 1 1 5 28 85 57 18 88 55 1 1 5 85 2 3 1 - - 11 - 3 - - 1 1 9 10 - 14 2 2 - - - 2 8 18 170 134 - 1 107 - 2 3 1 - - 4 2 3 1 5 3 2 - 1 1 3 - 1 3 1 9 - 1 1 - 4 9 16 103 15 151 78 1 1 1 4 3 - - 5 62 185 74 6 7 1 3 2 5 16 64 59 84 23 6 - - 1 - 2 3 11 7 - 11 - - 3 - - - - - - - 18 - - 2 - 4 3 - 5 - - - - - - - 10 8 1 - 1 1 - - - 1 8 - - - - - - - - - 2 1 2 3 29 31 - 4 21 - - - 1 5 3 3 - - - - - 5 - - - - 6 9 - - - 1 - - - - - - - 21 - - 4 3 4 11 2 4 6 9 6 22 15 3 - - - - 1 6 3 5 14 - 33 6 2 3 4 9 46 196 516 328 9 - - - - 1 - - 1 3 2 1 - - - - - - - 1 - 1 - 40 31 58 41 74 211 198 1,149 34 763 935 The following comparative death rates are of interest:— Death Rates, 1923. England and Wales 11.6 London 11.2 Camberwell 11.0 105 Great Towns 11.6 157 Smaller Towns 10.6 Seasonal Mortality.— The mortality in the four quarters of the year was:— Deaths. Death Rates. First Quarter 781 2.8 Second Quarter 796 2.9 Third Quarter 631 2.4 Fourth Quarter 792 2.9 Causes of Death.—It will be seen from Table 1 that cancer has been the cause of the largest number of deaths. Cancer and Malignant Disease.—The deaths ascribed to cancer or malignant disease each year since 1919 are shown in the following table:— Year. Males. Females. Total. Percentage of total deaths. 1919 153 183 336 0.9 1920 132 186 318 0.9 1921 175 168 343 1.0 1922 148 178 326 0.9 1923 136 197 333 1.1 During the year the following pamphlet was issued in connection with this disease:— CANCER. This disease is increasing in this country. In 1921 in England and Wales 1.21 deaths of every 1,000 of the population was due to cancer. Quack remedies at the present moment play a prominent part in the treatment of this condition, and the object of this leaflet is to instruct the public as to the signs of its beginning in sites of the body commonly affected, and the importance of an immediate examination by a medical man, for the purpose of recognition in the most favourable stage for a cure. A few hints as to the causation of the disease are also added for guidance. Cancer frequently follows on chronic and prolonged irritation of certain parts of the body. Cancer of the Lip is caused by irritation from a pipe stem, particularly a clay pipe, carried from day to day on the same place. This irritation gives rise to a sore. Cancer of the Mouth is often due to the result of irritation from a broken tooth, or badly fitting dentures, and any ulcer or swelling in the mouth should be viewed with suspicion. Cancer of the Breast usually shows itself as a lump in the breast, and it is frequently caused by wearing clothes which irritate the nipples and breast. Cancer of the Bowels sometimes results from chronic constipation, and any bleeding or mucus passed with the stools should at once be brought to the notice of a doctor. Cancer of the Womb. As this disease often occurs at the change of life, any abnormal signs should not be treated with indifference, but medical advice sought. Cancer of the Skin. A tumour involving the skin, or an ulceration lasting some time, suggests this disease. Remember that cancer in its early stages is almost invariably unaccompanied by pain. Immediate Recognition is most important. Don't wait for pain. (Signed) H. W. BARNES, Medical Officer of Health. Respiratory Diseases.—276 deaths were due to bronchitis, 244 to pneumonia (all forms), and 31 to other respiratory diseases, as compared with 417 bronchitis, 434 pneumonia (all forms), and 26 other respiratory diseases during 1922. Violent deaths (excluding Suicide). —76 deaths are classified under this heading. Suicide.—27 persons committed suicide, as compared with 19 in 1922. INFANTILE MORTALITY. The number of deaths under one year for the year 1923 was 321. It is very satisfactory to note that the infantile mortality rate was 56 per 1,000 births. This low mortality was largely due to the small number of deaths from the respiratory diseases. The number of deaths, however, from congenital malformation, premature birth, atrophy and other allied conditions still remains at a high level. The number of deaths amongst illegitimate infants was 13. Comparative Table Infantile Mortality. Infantile Mortality Rate. Year. Camberwell. England and Wales. 1919 89 82 1920 71 80 1921 74 83 1922 78 77 1923 56 69 It is customary to consider the value of Infant Welfare work from the standpoint of the infantile mortality rate, and, although I do not agree that this work has been the one and only cause responsible for diminishing the infantile mortality rate, I do submit that it has played an important part. It is worthy of notice that there is a striking coincidence in the increase in the number of Health Visitors and the decrease in the infantile mortality rate. But, apart from the infantile mortality rate, the value of the Infant "Welfare Centre and the Health Visitor lies in the prevention of disease and the deformities arising from diseases. Those who work at Infant Welfare Centres have seen wasting children improve visibly week by week; have seen incipient cases of diarrhoea and pneumonia caught in the early stages and readily cured, instead of slowly but surely developing into the serious cases. A further example may be quoted, that of rickets, which with organised supervision yields to treatment. We are consequently faced with the alternatives of the prevention of children coming into the world, or when they are born they must be placed on such a basis that they are not a dead weight on the community as a whole. TABLE No. 2.—INFANTILE MORTALITY DURING THE YEAR 1923. Deaths from Stated Causes at Various Ages under One Year 0f Age. Under 1 week. 1 to 2 weeks. 2 to 3 weeks. 3 to 4 weeks. Total under 1 month. 1 to 3 months 3 to 6 months. 6 to 9 months. Total under 1 year. Cause of Death. 9 to 12 months. Small-pox - - - - - - - - - - Chicken-pox - - - - - - - - - - 3 Measles - - — - - 1 2 - - Scarlet Fever - - - - - - - - - - Whooping Cough 5 - - - - 1 2 2 10 - Diphtheria and Croup - - - - 1 1 2 4 - - Erysipelas - - - - - - - - - - Tuberculous Meningitis 5 - - - - - 1 - 6 - Abdominal Tuberculosis 1 - - - - - - - - - Other Tuberculous Diseases - 1 - - - - - 1 2 - Meningitis - 1 - - 1 1 1 2 1 6 1 - - Convulsions 5 6 2 1 1 10 - Laryngitis - - - - - - - - 3 10 3 1 Bronchitis - 2 1 1 2 3 10 - Pneumonia 1 1 - 2 4 11 6 11 14 46 Diarrhoea 1 1 2 2 1 - 6 - - - Enteritis 1 12 12 6 35 1 - 2 3 - Gastritis - - - - 1 - - - - 1 Syphilis - - - - - - - - - - Rickets - - - - - - - - - - Suffocation 1 1 2 - - 2 - - - - Injury at Birth 2 - 2 - - - - - 2 Atelectasis - - - - - - - - - - - Congenital Malformation 26 23 - 5 2 3 - - 1 34 Premature Birth 50 5 4 64 6 2 5 - - 72 2 1 18 Atrophy, Debility 14 7 5 2 2 34 1 Other Causes 10 2 6 3 21 2 6 5 4 38 150 107 15 42 40 47 321 Totals 15 13 42 12 13 TABLE No. 3.—DEATH AND INFANTILE MORTALITY RATES OF PRINCIPAL DISEASES. Deaths from All forms Tuberculosis. All forms Pneumonia. Cancer. Birth Rate. Scarlet Fever. Population. Death Rate. Infantile Mortality Rate. Diphtheria. Measles. Whooping Cough. Whole Borough Ward. 272,300 20.7 11 57 7 35 72 30 305 246 333 23.5 12.5 15,736 64.8 - No. 1 59.1 5 7 20 24 17 - 23.0 12.2 2 14,695 - 5 2 28 15 17 48.7 8 23.3 10.9 3 14,472 - 1 17 12 76.7 5 3 12 24.7 11.2 1 4 16,878 12 5 3 12 17 12.4 - 16,406 23.7 84.6 1 22 5 7 1 4 24 22 8.1 69.4 13,495 21.3 - 4 1 1 6 17 13 12 77.4 7 16,540 25.7 11.0 - 9 4 6 32 21 15 65.6 1 8 15,844 23.1 12.8 6 3 14 16 24 11.4 49.0 1 - 9 16,548 21.0 3 2 15 84.5 1 29 16 12.4 - 10 9,146 21.9 5 1 1 6 10 16 1 11,654 17.5 9.6 49.0 11 4 1 14 6 17 - - 10.9 41.5 12 14,293 20.2 3 2 11 3 8 21 54.0 - 10,866 13.6 9.4 13 3 9 5 12 - - 10,916 18.4 11.4 34.8 - 14 5 1 22 15 14 16.4 11.0 44.3 - - 15 12,361 4 1 6 8 17 42.0 - 16 17.6 10.1 - 3 14,844 17 10 23 25.2 1 - - 14,922 26.5 7.1 17 3 - 6 9 13 45.0 14.9 - 18 16,335 8.9 - - 13 9 18 11.7 34.4 - - 12,369 11.2 - 19 1 5 7 16 10.8 69.7 1 - - 13 .3 20 3,980 - 4 4 10 - - - - Unknown Locality - - - - 4 1 3 - - SECTION 3. NOTIFIABLE INFECTIOUS DISEASES. Small-pox. One case of this disease was notified in the person of a young woman aged 23. The history of the case is as follows:— The patient was employed at a hotel in the Borough of Westminster, and was first taken ill on Sunday, September 2nd, with a cold and a headache. On Monday, September 3rd, she had a temperature, and stated that the headache was worse, and complained of pains in the back. She was unfit for work, and was sent to her home in East Dulwich. The rash appeared on Wednesday morning, September 5th. I was called in consultation by the private practitioner in charge of the case, and diagnosed it as small-pox, which was confirmed by the London County Council Consultant. The patient gave a history that she attended a visitor at the hotel during the period August 13th to 19th, and, according to her statement, the visitor was ill and had " spots." This visitor did not receive any medical attention during her stay at the hotel. The Medical Officer of Health for Westminster was advised as to the necessity of tracing this woman, and the probability of other cases arising. The usual procedure of advising vaccination of all contacts, keeping them under daily observation, and the disinfection of the clothing of persons in contact with the patient was carried out. I am pleased to state that no further cases developed in Camberwell. Diagnosis.—ln view of the difficulty in diagnosing small-pox, and the few opportunities general medical practitioners have of seeing this disease, I am of the opinion that facilities should be available for medical men and students seeking an intimate acquaintance with small-pox. Although many books have been written on the subject as an aid to the successful diagnosis of small-pox, it must be conceded that bedside study of the disease in an isolation hospital would be of greater assistance. So far as London is concerned, this could only take place at the London County Council Small-pox Hospital. I have no doubt that there would be administrative difficulties to overcome, but these should not weigh against a suggestion of this kind if it were productive of an increased knowledge of the disease in its various phases. Vaccination. The value of vaccination and re-vaccination cannot be too strongly urged as a protective agency, and public indifference to the need is causing much concern to those responsible for staving off outbreaks of small-pox. The number of cases in England has increased since the cessation of the war, with the exception of one year, as will be seen from the following figures: — Year. No. of Small-pox Cases Notified. 1918 63 1919 311 1920 280 1921 336 1922 973 In 1923 over 2,000 cases of smallpox were notified, and I have no hesitation in saying that the present situation is grave. The danger of a serious epidemic of this disease occurring in England is always possible, due to the absence of systematic vaccination, and until the people of this country realise the value of it there will always remain a large section of the community susceptible. It is only by the vigilance of the medical profession that an epidemic on a large scale has not occurred. In London the services of' Dr. McConnell Wanklyn, L.C.C. Consultant, and the Medical Officer of Health of each Borough are available to assist the private medical practitioner where a doubt exists as to diagnosis. I am certain there is not so great an objection to vaccination as the number of exemption certificates obtained each year would make it appear. There is still a settled conviction in the minds of some that arm to arm vaccination is still in progress, and that certain diseases are transmitted from one individual to another by vaccination. These stories have been handed down and enlarged, with the result that the present generation, who have not taken the trouble to enquire into the method at present in use, develop conscientious objections. To-day lymph is obtained from specially selected calves and before it is distributed for use the animal from which it was derived is slaughtered and the body subjected to careful examination. No lymph is used if there is the slightest cause for doubt as to its purity. Further, vaccination is carried out nowadays with aseptic precautions. In all cases of primary vaccination the vaccinator should aim at procuring four good-sized vesicles, in order to obtain the maximum result, and the total area of vesiculation should not be less than half a square inch. Diphtheria. During the year this disease was very prevalent in Camberwell, the notifications numbering 875. Of these 860 were removed to isolation hospitals. Although the number of cases notified is high, yet the death rate from diphtheria has remained more or less stationary, there being 72 deaths. Deaths from Diphtheria in the Borough from the Year 1919. Year. No. of Notifications. No. of Deaths. 1919 483 35 1920 937 62 1921 875 64 1922 821 63 1923 875 72 It is possible to reduce the death rate from diphtheria by the early administration of anti-toxin and the incidence of the disease by the practice of inoculating toxin and anti-toxin. Progress in the direction of active immunisation, however, is slow. Health propaganda and the education of the public in the value of such prophylaxis should, in time, bear fruit, and result in the eager acceptance of this agency for the protection of children against diphtheria, with its accompanying mortality. The extreme prevalence of this disease is probably due to a large extent to "carrier cases." It is known that virulent diphtheria bacilli may be present in large numbers in the throat and nose of an individual without there being any clinical symptoms of the disease present. It can be understood that cases of this type are a distinct menace to the health of the community as a whole, and it requires no further comment to demonstrate the importance of the adoption of means which would prevent the spread of this disease, particularly in a Borough like Camberwell, with its densely populated areas. Until something is done on these lines it is doubtful whether any appreciable decrease in the number of cases of diphtheria can be looked for. Scarlet Fever. During the year 1923, 521 cases were notified; of these 479 were admitted to the Isolation Hospitals, and the number of return cases was 19. The number of deaths from scarlet fever during the year was 7. In the following table is set out the corresponding figures for 1919 to 1923:— Number of Notifications. Number of Deaths. Death Rate per 1,000 Population. Case Mortality per cent. Percentage of cases removed to Hospital. Year. 1919 700 12 0.04 1.7 - 1920 1,308 13 0.04 0.9 81.1 1921 1,959 19 0.07 0.9 89.4 1,083 2.0 1922 22 0.08 82.2 520 1923 7 0.02 1.3 92.1 The table on pages 18 and 19 shows the house distribution of cases of scarlet fever in Wards. Typhoid Fever. 10 cases were notified during 1923, as compared with 11 in 1922. 9 of these were removed to hospital. 3 of the 10 cases notified died. All the cases in question occurred in separate houses, and enquiries proved that two of the cases were infected outside the Borough. Of the remainder two gave a history of eating shell fish, and three others of eating watercress. Puerperal Fever. During the year 16 notifications of this disease were received; 11 of these were removed to Institutions. The deaths numbered 9. Every case was investigated, with a view of discovering the source of infection, and the necessary disinfection carried out. The notifications received, and deaths from this cause for the years 1919 to 1923 are as follows: — Notifications Received. Deaths. 1919 17 9 1920 20 8 1921 14 9 1922 10 7 1923 16 9 TABLE No. 4.— SCARLET FEVER. Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8 Ward 9 Ward 12 Ward 13 Ward 14 Ward 15 Ward 16 Ward 17 Ward 10 Ward 11 Number of Houses in which— I case occcurred 25 15 9 19 24 25 24 21 25 2 cases do. 10 11 19 27 - 4 7 28 16 17 2 2 4 2 1 2 3 3 cases do. 2 1 - 4 5 3 1 - 1 1 4 2 2 2 1 - - 4 cases do. - 1 - 2 3 - 1 - - - - - - 1 - - - 5 cases do. - 1 - - - - - - - - - - - - - - - Total Houses 1 1 - - 26 20 12 - - - 23 30 29 27 - 23 28 30 8 32 18 19 12 18 26 Number of Cases notified from Local Institutions - - - - - - - - - - - - - - - - - A umber of Cases which were notified as suffering from Scarlet lever after removal to Hospital for another Infectious Disease - - - - - - - - - - - - - - - - Total Notifications Puerperal Fever — Contd. The mortality rate of this disease remains high. The necessity for the early removal of cases to Institutions cannot be too strongly advocated. In the majority of homes there are not facilities for the successful treatment of this disease, and I am certain that, where a doubt exists with regard to the diagnosis, it would be better to remove the patient to an Institution, in order that she may be placed in the most favourable circumstances for treatment. The number of deaths due to, or associated with, childbirth is extremely disquieting, as will be seen from the following table:— Maternal Mortality. Deaths per 1,000 Births. Total No. Deaths. From Sepsis. Other Causes. Total Childbirth. Year. Sepsis. Other Causes. 1919 21 9 12 1.73 2.31 4.04 1920 14 8 6 1.06 0.79 1.85 1921 16 9 7 1.42 1.11 2.53 1922 15 7 8 1.29 1.47 2.76 20 1923 9 11 1.59 1.94 3.53 When one considers the above figures, no other conclusion can be drawn than that there has been no improvement in the death rate of women in childbirth. In fact, last year's figures show an increase over the three preceding years. In my opinion, improvement can only be obtained by the proper care of the expectant mother. Further, apart from the deaths from this cause, it must not be forgotten that a large number of women who survive a pregnancy suffer some permanent injury or impaired health, which, in all probability, could have been prevented by treatment during the period of pregnancy. Pneumonia. 32 cases of acute influenzal and 52 of acute primary pneumonia were notified during the year. Nursing services were provided in all cases where assistance was sought. Cerebro-spinal Meningitis.—No cases of this disease were notified. Acute Polio-Myelitis and Encephalitis.—Four cases were reported during the year. Each case was followed up, to ensure that treatment was carried out to prevent the development of permanent deformities. Malaria.—There were 20 cases of this disease notified, and the whole of them were infected in the Army during the war. Dysentery.—Only one case of this disease was notified, the patient developing the disease in Mesopotamia during the war. Encephalitis Lethargica.—Three cases were notified during 1923. Two were removed to Institutions. All three cases died. One death was certified as cerebral abscess. Ophthalmia neonatorum.—Thirty-three notifications of cases of ophthalmia neonatorum were received during 1923. Ophthalmia neonatorum. Cases Treated Notified. Vision Unimpaired. Vision Impaired. Total Blindness. At Home. In Hospital. 33 24 9 32* Nil Nil *One case moved out of Borough, address unknown. No cases of cholera, plague, typhus, trench fever, anthrax, relapsing fever, glanders, rabies, or continued fever were reported in 1923. TUBERCULOSIS. During the year 1923, 657 new cases of tuberculosis were notified, 505 representing pulmonary tuberculosis and 152 other forms of the disease. The deaths of non-notified cases of tuberculosis numbered 73, and the total tuberculosis deaths 305; the proportion of non-notified tuberculosis deaths to the total deaths from this disease being approximately one in four. Hospitals and other Institutions are the principal offenders in the matter of failure to notify cases. Reasons for the failure may be found in the fact that a large percentage of cases arrive in a moribund condition, and sometimes the actual nature of the disease is only discovered after death. No instances of wilful neglect or refusal to notify have been discovered. It cannot be said that any one occupation has caused an excessive incidence of, or mortality from, tuberculosis in the Borough. A full report by the Tuberculosis Medical Officer, Dr. W. Brand, will be found on pp. 27-38. Table Showing Occupation of Men who Died from Tuberculosis in 1923 Barmen 3 G.P.O. sorter 1 Bicycle repairer 1 Helmet maker 1 Boot maker 1 Hotel waiter 2 Boot repairer 1 Hairdresser 1 Basket maker 1 Hawker 2 Blacksmith 1 Insurance agent 1 Builder and decorator 1 Jeweller's traveller 1 Bricklayer 3 Leather salesman 1 Brass finisher 1 Labourer, leather-dresser's 1 Bus conductor 2 Manager, wadding manufacturer 1 Billposter's assistant 1 Clerk, Civil Service 1 Messenger, tailor's 1 do. Inland Revenue 1 Musical director 1 do. Met. Water Board 1 Mechanic, monotype 1 do. Law Courts 1 Machine minder, printer's 1 do. Gas Company 1 No occupation 3 do. printer's 1 Newspaper, job hand 1 do. Commercial 8 Publisher's manager 1 Carman, Municipal 1 Porter, Public Record Office 1 Carman and contractor 1 do. Lodging house, L.C.C. 1 Comb maker 1 Packer, general stores 1 Compositor 1 Packing case maker 1 Commercial traveller 3 Pattern maker, engineer's 1 Coachman 1 Printer's assistant 2 Carmen 2 Polisher, gold and silver 1 Coach painter 1 Plumber, journeyman 1 Postman 1 Chemist's assistant 1 Civil Servant 1 Porter, railway 2 Decorators 3 Packer 1 Driver, electric car 1 Plasterer 1 Dispatcher, cinema films 1 Restaurant proprietor 1 Driver, motor cab 2 Secretary, company 1 Dock labourer 1 Storekeeper, clocks and watches 1 Electric railway porter 1 do. superintendent 1 Stone mason 1 do. switchboard attendant 1 Electrician 1 Sheet metal worker 1 Engineer's turner 1 Seaman, R.N. 1 do. storekeeper 1 Stoker 1 French polisher 2 Shunter, railway 1 Fish hawker 1 Scientific instrument maker 1 Fuse maker, Royal Arsenal 1 Stonemason 1 Firewood merchant 1 Timber merchant 1 General Labourer 13 Timekeeper, printer's 1 Gauger, licensed victualler's 1 Van boy 1 Gas meter tester 1 Warehouseman 4 do. repairer 1 Watchmaker's assistant 1 Gas fitter 3 Window cleaner 1 Glazier 1 Ginger beer brewer 1 Total 139 Gardener 1 Greengrocer's assistant 1 Table Showing Occupations of Women who Died from Tuberculosis in 1923. Book-keeper 1 Needlewoman 1 Barmaid 1 No occupation 20 Children's nurse 1 Patent medicine labeller 1 Confectioner's assistant 1 Pin driller 1 Cigarette machine minder 1 School teacher 1 Chocolate packer 1 Saleswoman 1 Draper's clerk 2 Shorthand typist 5 Domestic servant 1 Shop assistant, news 1 Factory hand, soap 1 Shop assistant 1 do. biscuit 1 Silk weaver 1 Fancy feather worker 1 Toilet requisite packer 1 Theatre attendant 1 Gas meter repairer 1 Housewife 36 Widow 22 Hairdresser's assistant 1 Laundry woman 1 Total 113 Lady's maid 1 Machinist 2 NON-NOTIFIABLE DISEASES. Measles and German Measles.—These diseases' are not notifiable in Camberwell. The principal means of obtaining information with regard to them is through the medium of the school absences returns and the health visitors. The number of cases that came to our notice during the year was considerably less than in 1922. The number of deaths recorded was 35, as compared with 84 in 1922. Every case that comes to the knowledge of the department is visited, and the parents advised of the necessity of seeking the assistance of a doctor. Strict isolation as far as possible is insisted on, and where necessary the services of a district nurse are provided. Whooping Cough.—The number of deaths from this disease was 30, as compared with 80 in the previous year. It is satisfactory to record a decrease in the number of deaths from this cause, but, as will be observed from the following table, the mortality rate is still very high among children under 5 years of age. Table of Deaths. Under 1 year. 1 to 2 years. 2 to 3 years. 3 to 4 years. 4 to 5 years. 1923. 30 12 8 5 1 4 As to how far the incidence rate of this disease is capable of reduction is a matter of speculation. 24 25 TABLE No. 5.— NOTIFIABLE DISEASES, 1923. Age Distribution, Notifications and Deaths. Total Cases Notified. Admitted to Hospital. 3 to 4. 4 to 5. 5 to 10. 15 to 20. 20 to 35. 35 to 45. 45 to 65. 65 and up. Under 1. 1 to 2. 2 to 3. 10 to 15. Disease. Total Deaths. Deaths. Notifications. Deaths. Notifications. Notifications. Notidcations. Notifications. Notifications. Notifications. Deaths. Notifications. Deaths. Notifications. Notifications. Deaths. Notifications. Deaths. Notifications. Deaths. Deaths. Deaths. Deaths. Deaths. Deaths. 1 1 - - - - - - Small-pox - - - - - - - - - - - 1 - - - - - - - - - Cholera, Plague - - - - - - - - - - - - — — - - - - - - - - - - - 72 Diphtheria and Croup 875 860 23 3 54 13 77 9 13 14 61 8 286 15 147 7 43 3 54 13 - 4 - - - - 521 479 7 3 28 4 44 44 29 Scarlet Fever - - 1 - 215 1 94 - 24 - 35 1 3 - 2 - - - 3 Enteric Fever 10 8 - - - 1 2 - 3 - 2 2 1 - - - - - - - - - - 1 1 - Puerperal Fever 16 12 - 4 10 2 - - - - - - - - - - - - - - - - - - - - - 32 11 7 - 2 Acute Influenzal - - — - 1 - - - - - 2 2 6 2 7 1 12 1 2 - - 1 Pneumonia 14 - 12 7 Acute Primary 52 2 — - 7 3 - 13 2 - 1 - 1 1 1 2 - - - - - - 25 - - - 75 2 1 1 1 1 7 12 18 Erysipelas - - 4 14 14 - - - - - - - - - - Cerebro-spinal Meningitis 4 - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - Poliomyelitis 4 - - - 1 1 1 - - - - - - - - - - - - - - - - - - Malaria 20 - - - 12 5 3 - - - - - - - - - - - - - - - - - - - - Dysentery 1 - - - - - - - 1 - - - - - - - - - - - - - - - - - 5 - 9 - Chicken-pox 107 15 - 2 12 17 52 8 1 1 - - - - - - - - - - - - - - 3 - 1 - - 1 1 Encephalitis Lethargica - - - - - - 2 - - - - - - - - - - - - - - - - Typhus Fever - - - - — - - - - - - - - - - - - - - - - - - - - - Relapsing Fever - - - - - - - - - - - - - - - - - - - - - - - - - Continued Fever - - - - - - - - - - - - - - - - - - - - - - - - - - - 33 9 33 Ophthalmia Neonatorum - - - - - - - - - - - - - - - - - - - - - - - - - Anthrax - - - - - - - - - - - - - - - - - - - - - - - - - - Glanders - - - - - - - - - - - - - - - - - - - - - - - - - - - Tuberculosis :— 142 M. 298 297 - 1 8 5 2 22 8 125 40 67 41 64 39 6 - - - - - - - - - 12 F. 207 183 115 - 1 1 1 6 2 10 3 33 21 87 49 33 - - - 13 34 22 2 4 Pulmonary - - - Total 2 490 257 - 1 29 505 1 - - - 14 2 15 5 55 212 89 100 54 98 61 - - - 8 16 3 24 5 5 3 2 1 1 5 M. 87 51 1 5 - 15 2 16 1 14 2 14 7 3 5 1 - - 24 2 4 F. 65 33 4 1 - 2 1 3 2 11 3 5 13 2 5 3 2 - 19 4 - 3 - Non-Pulmonary - 1 84 48 5 9 4 4 5 7 Total 152 5 2 8 2 26 5 35 5 19 2 27 12 3 8 1 - 5 NOTIFIABLE DISEASES, 1923. Notifications and Deaths. 3 to 4. 4 to 5. 5 to 10. 10 to 15. 15 to 20. 20 to 35. 35 to 45. 45 to 65. 65 and up. Notifications. Notifications. Notidcations. Notifications. Notifications. Notifications. Deaths. Notifications. Notifications. Notifications. Deaths. Deaths. Deaths. Deaths. Deaths. Deaths. Deaths. Deaths. - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 13 61 286 15 147 3 54 - 14 8 7 43 13 4 - - - - 44 1 29 215 1 94 24 35 1 3 2 - - - - - - - - 1 2 3 2 2 1 1 1 - - - - - - - - - 4 10 2 - - - - - - - - - - - - - - - 6 1 1 2 2 2 7 1 12 2 1 - - - - - - - 1 7 3 13 2 1 1 - 1 2 - - - - - - - - 1 4 1 7 12 18 14 - - - 14 - - - - - - - - - - - - - - - - - - - - - - - - - 1 1 1 - - - - - - - - - - - - - - - 12 - 5 3 - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - 12 17 52 8 1 1 - - - - - - - - - - - - - 1 1 2 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 41 1 8 5 2 22 8 125 40 67 64 39 6 - - - - 12 1 6 2 10 3 33 21 87 49 33 13 34 22 2 4 - - - 89 2 14 2 15 5 55 29 212 100 54 98 61 8 - - - 16 2 14 2 14 5 - 3 1 5 15 16 1 7 3 5 1 - 1 5 2 - 2 3 2 11 3 19 4 13 2 5 3 3 - - - 26 35 19 27 7 5 2 8 2 5 5 2 12 3 5 8 1 - Whooping Cough—Continued. Home nursing is valuable, provided that contacts of the patient are supervised for the detection of the disease at any early stage, and institutional treatment is essential for those whose home conditions are unfavourable for proper treatment and care. Limited accommodation is available in the Metropolitan Asylums Board Institutions for the reception of those cases unable to obtain adequate care at home, but I understand the demand on their hospitals for the reception of scarlet fever and diphtheria cases does not permit of more cases being accommodated. Venereal Diseases.— The treatment of venereal disease in Camberwell is in the hands of the London County Council. The nearest Hospital for Camberwell residents requiring treatment is King's College Hospital, Denmark Hill. Although there was no local Propaganda Committee functioning in Camberwell during 1923, the National Council for Combating Venereal Diseases carried on propaganda work in Camberwell by giving a certain number of lectures during the year, these lectures being illustrated by suitable films. Foot-and-Mouth Disease.— There have been rare instances in which this disease has been communicated to man through the secretions from the mouth of the infected animal to cowkeepers and other persons in close contact with the animal. Under the present system, by which infected animals are immediately slaughtered, there is little probability of an extension of the disease to man. Further, this policy of slaughtering, under efficient supervision, all animals found to be suffering from the disease or to have been in contact with diseased animals dispenses with the question of milk or meat from infected animals reaching the public. Every step is being taken by the Authorities to prevent the sale for human consumption of milk from animals so infected, the sale of which, or consumption for human food, is prevented by Article 15 of the Dairies, Cowsheds, and Milkshops Order of 1885. REPORT OF THE TUBERCULOSIS MEDICAL OFFICER FOR THE YEAR 1923. The Notification of Tuberculosis in Camberwell. In a perfect system the number of Primary Notifications of Tuberculosis in any year should represent the total number of new cases of the disease in that year and should thus be an index of increase or diminution of incidence. In reality the number of primary notifications represents the cases of tuberculosis that are discovered and after discovery notified, Many new cases are not discovered, and many although discovered are not notified. On the other hand, cases are sometimes notified in which a reasonable difference of opinion as to the diagnosis may exist. In judging of the progress of anti-tuberculosis efforts by a study of the number of new notifications errors may creep into our calculations unless we remember these factors. It may, moreover, happen that an increase in the notification rate in an area is not an indication of an actual increase of tuberculosis, but rather of an improvement in the working of the local scheme. The number of primary notifications of tuberculosis in all its forms in 1923 was 657. The number of primary notifications of pulmonary tuberculosis was 505, and the number of primary notifications of non-pulmonary tuberculosis was 152. On Table I is given the number of primary notifications of tuberculosis for 1921, 1922, 1923. TABLE I. (CAMBERWELL). Primary Notifications of Tuberculosis. Year. All Forms. Pulmonary Tuberculosis. Other Forms. 1921 750 155 595 1922 653 506 147 1923 657 505 152 On Table II is given the primary notification rate (per 1,000 population of Camberwell) for the years 1921, 1922, and 1923. TABLE II. (CAMBERWELL). Notification Rate (per 1,000 population). Pulmonary Tuberculosis. Other Forms. Year. Population. All Forms. 1921 267,198* 2.80 0.58 2.22 1922 2.41 270,300a 1.87 0.54 1923 272,300a 2.40 1.85 0.55 * Census 1921. a Estimated. Total Notifications on Form A. Total Notifications on Form B. Poor Law Institutions. Total Primary Notifications. Total Primary Notifications. Under 5 Sanatoria. 65 and upwards. 0 - 1 5 - 10 10 - 15 15 - 20 20 - 25 25 - 35 35 - 45 45 - 55 55 - 65 10 - 15 1 - 5 5 - 10 83 - - 8 42 67 42 22 386 - 1 243 1 5 22 6 298 - 109 - 6 17 33 37 50 33 17 2 207 276 - - - 107 107 2 10 - - - 15 - - - 5 12 16 14 7 7 7 - 3 1 87 100 - 2 2 42 - - 11 19 6 7 5 2 - - 65 70 - - 1 35 10 5 - - Table showing the notified cases of tuberculosis during 1923 allocated to the wards of the Borough. Pulmonary. Non-Pulmonary. Wards. Grand. Total. Males. Females. Total. Males. Females. Total. 1 31 21 10 6 5 11 42 15 2 15 30 6 4 10 40 3 21 9 30 5 5 10 40 10 24 6 1 7 4 14 31 18 12 30 8 5 13 43 5 16 15 31 8 2 10 41 6 30 7 27 57 9 5 14 71 5 5 48 8 23 15 38 10 11 38 3 5 8 9 27 46 10 4 5 9 4 3 7 16 11 8 9 17 2 2 4 21 12 17 8 25 3 4 7 32 14 1 5 6 13 10 4 20 14 19 8 27 3 3 6 33 15 14 15 29 2 2 4 33 4 6 16 10 6 16 2 22 11 20 2 17 9 5 7 27 9 23 4 4 8 18 14 31 1 19 6 8 14 3 4 18 20 - 2 2 - 2 - - In the accompanying Table the non-notified cases ascertained through the certificates of death have been added to the primary notifications, thus making the total of new cases found in 1923. New Cases. Deaths. Age Periods. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. - - 0 - 8 4 - 5 4 1 13 1 3 14 - 1 4 2 5 3 5 8 6 15 2 18 - 4 10 7 22 10 16 20 2 3 1 8 15 35 16 5 21 2 - 20 43 40 9 6 14 20 3 - 86 53 7 29 25 8 26 2 2 69 35 8 6 41 13 3 35 - 45 45 18 1 5 23 13 1 2 9 55 27 20 6 16 4 1 - 65 & up 12 4 4 1 - 12 - - 320 24 Totals 224 105 81 142 115 24 Deaths from Tuberculosis (Camberwell) in 1923. The number of deaths from tuberculosis in 1923 was 305. Of these 257 were from pulmonary tuberculosis and 48 from other forms of the disease. 73 cases were not notified as suffering from tuberculosis during life. Non-notified fatal cases. 1923. All forms of Tuberculosis. Proportion of non-notified fatal cases in 1923 to total number of deaths. 24 per cent, Pulmonary Tuberculosis. Proportion of non-notified fatal cases in 1923 to total pulmonary deaths. 16 per cent. Non-pulmonary Tuberculosis. Proportion of non-notified fatal cases in 1923 to total non-pulmonary deaths. 64 per cent. Proportion of non-notified cases who died in Institutions to total of non-notified fatal cases. 74 per cent. Proportion of non-notified cases who died at home to total of non-notified fatal cases. 26 per cent. Of 26 deaths from tuberculous meningitis 19 (73 per cent.) were not notified before death. Of these 16 (84 per cent.) died in hospitals and 3 (16 per cent.) at home. Death rate from tuberculosis (Camberwell, 1923) per 1,000 population (estimated): — Pulmonary 0.94 Other Forms 0.18 Contrast this with the figures of a decade ago. Death rate from tuberculosis (Camberwell, 1914) per 1,000 population (estimated): — Pulmonary 1.44 Other Forms 0.34 1.78 Put in another way—without taking into consideration the increase of population:— 1914. 1923. Deaths from all Forms of Tuberculosis 468 305 Deaths from Pulmonary Tuberculosis 378 257 Deaths from Non-pulmonary Tuberculosis 90 48 The deaths among Camberwell clerks, working in different parts of London, from tuberculosis, in 1923, was at the high rate of 2 per 1,000 clerks living in this Borough. Caution is needed, however, in interpreting these or any figures that view tuberculosis mortality among clerks from an occupational standpoint. It is well known that many parents look upon the clerical profession as a sheltered one, and urge or put the more delicate members of their family into it on that account. In that way many latent cases of tuberculosis may enter. Dr. Brownlee reported to the Medical Research Committee as follows:— " . . . after the age of 35 the mortalities from phthisis among the persons included in the class of commercial clerks and in the class of carmen, carrier, etc., are practically identical, and also identical with the mortality of males in general. Before this age there is a considerable excess of phthisis among commercial clerks, and a corresponding defect of phthisis among carmen, etc. It is hardly likely that these variations are to any extent occupational. It is much more probable that the occupations have been originally selected for reasons of physical fitness or the reverse." Nevertheless, it cannot be urged too strongly that offices in which clerks work should conform to the standards of health. Nor, while pushing that point, should we forget that, while clerks spend 44 hours of the week in their office environment, they have to spend over 100 hours of the week in the environment of the tram, train, and bus, and finally of their home. Table showing the number of deaths from tuberculosis in 1921, 1922, and 1923 allocated to the different Wards of the Borough, and giving the number and density of population:— Deaths. Number of Wards. Population of Wards. Census 1921. Density of Population 1921.* 1921. 1922. Total of 1921, 1922 and 1923. 1923. 124 1 15,442 22 31 18 71 2 14,420 170 17 24 27 68 24 3 14,201 108 21 19 67 4 16,562 35 159 22 13 70 5 16,096 163 21 25 22 68 6 13,243 107 15 20 18 53 7 16,230 99 25 29 28 82 8 15,548 125 22 26 16 64 9 16,238 113 24 13 29 66 10 8,975 81 18 7 7 32 11 11,438 83 21 11 48 16 12 120 14,025 17 19 7 43 13 10,662 20 19 11 11 41 14 10,712 83 12 8 19 39 8 15 12,126 49 13 7 32 16 16 14,566 88 21 17 54 17 14,642 64 10 12 6 28 18 16,029 36 12 15 13 40 19 12,137 22 5 8 5 18 20 3,906 6 1 3 4 8 5 Homeless cases are not included in above table. * Density of Population Per Acre. The object of the accompanying Tables is to show, in relation to certain sex-age groups in Camberwell approximately calculated on the basis of the Census of 1921, the number of primary notifications of and deaths from pulmonary and other forms of tuberculosis during 1923. OTHER FORMS OF TUBERCULOSIS. Males. Females. Totals. Age Period. Persons. Cases Notified. Deaths. Persons. Cases Notified. Deaths. Persons. Cases Notified. Deaths. 10 0 — 5 12,248 17 9 11,952 9 24,200 27 18 5 — 15 26,419 31 3 25,962 30 7 52,381 61 10 15 — 25 21,325 21 5 25,378 11 46,703 32 5 - 18,357 22,734 25 — 35 7 2 7 2 41,091 14 4 20,175 35 — 45 17,217 7 - 5 3 37,392 12 3 14,302 1 15,712 3 45 — 55 - 2 2 30,014 2 1 55 — 65 9,267 3 4 10,322 19,589 3 - 5 15,828 65 — up 6,413 1 - 9,415 - 1 - - The Work of the Tuberculosis Dispensary. The aims of the Tuberculosis Dispensary were outlined in the 1922 Report. One point should be emphasised again. Close co-operation with the local medical practitioners is the most important element in our organisation. During 1923 medical men sent 698 new patients for diagnosis or consultation, as compared with 607 in 1922 and 602 in 1921. Further, they sent for renewed consultation about 100 patients who had attended in previous years. The function of the Dispensary as a centre of diagnosis may be noticed further. The total number of new patients in 1923 was 1,904, as compared with 1,817 in 1922. In addition, 86 patients were under observation on 1st January, 1923, pending diagnosis. Of a total of 1,990 examined for diagnosis 409 were found to have active tuberculosis, 1,498 were discharged as not tuberculous, 39 ceased attendance before completion of diagnosis, and 44 remained under observation on 31st December pending diagnosis. Summary of the Work of the Tuberculosis Dispensary in 1923. Number of new patients examined 1,904 Number of old patients examined 1,638 Number of new patients sent by medical men for consultation 698 Number of old patients sent by medical men for consultation about 700 Total attendances of patients at the Dispensary 10,716 Number of new contacts examined 831 Number of patients referred to hospital for consultation 197 Number of specimens of sputum examined in connection with the work of the Dispensary 1,925 Number of Home visits paid by Tuberculosis Officers 1,103 Number of Home visits paid by Nurses 5,914 The Care Work of the Dispensary. The aim is constructive work—i.e., an attempt to preserve or to improve the social and economic position of every family affected by tuberculosis. Items of assistance, such as food, money, sanatorium treatment, etc., cannot attain to even a moderate measure of success as long as the family standard of living remains below that compatible with health, or if a standard, normal at the onset of tuberculosis, is allowed to pass step by step to lower levels. Housing, employment, and education enter largely into this matter. Until housing and employment are brought nearer a normal level we cannot expect to carry out a large constructive policy in Care work, although we may accomplish much in lesser ways. Under employment reference is made not so much to the employment of the consumptive as to the employment of any members of his family who may be out ANALYSIS OF PATIENTS DEALT WITH BY THE DISPENSARY FOR DIAGNOSIS IN 1923. Found to be Under observation at the Dispensary on Dee. 31st pending diagnosis. Examined for the first time during the year. Total. Ceased attendance before completion of diagnosis. Number of Under observation at the Dispensary on Jan. 1st pending diagnosis. Suffering from Tuberculosis Not suffering from Tuberculosis. Non-Pulmonary. Pulmonary. 12 266 19 (a) All persons (in-cluding "Contacts.") M. 32 472 504 184 23 Adults 114 20 F. 37 527 564 19 393 18 467 477 10 24 433 7 3 Children under 15 M. 10 F. 406 4 7 438 445 17 18 - 1,904 1,990 325 84 1,498 44 39 Total 86 4 M. 7 74 81 8 4 62 3 (b) "Contacts" (included in (a) ). Adults 219 7 1 206 4 1 F. 8 211 Children under 15 264 3 1 M. 5 268 273 1 4 F. 7 278 285 4 4 277 - - c) Insured persons (included in (a)). M. 406 143 17 220 16 10 32 374 136 13 8 F. 24 185 209 47 5 of work. Every effort should be made to assist in finding work in such cases. The employment of the consumptive is a special matter in the majority of cases. Many patients are, on the completion of treatment, employable in a normal or almost normal sense. In the case of others, probably in the case of the majority of consumptives, the primary conception of work must be specialised. It must be of such a nature and of such an amount that its natural mental and physical tonic qualities are not exceeded to the extent of making it a poison to the tuberculous constitution. It may be considered a fine thing that his job should make a consumptive self-supporting. In the majority of cases such an aim will defeat its purpose. Much help can be given to the consumptive or to members of his family in lesser matters. The aim is to make the whole period of treatment as smooth as possible for all immediately concerned and to lessen as far as possible the risks of relapse in the "testing period which follows the " completion of treatment." As this period may run into years, the value of constructive action is apparent. An entertainment was given at Dulwich Baths on 11th December, 1923. under the patronage of the Worshipful the Mayor of Camberwell (Councillor H. F. A. Edmonds, J.P.). The proceeds were given to a voluntary fund for assisting in the dental treatment of patients in Camberwell who are suffering from tuberculosis. The entertainment was organised by Mrs. E. R. Morrogh, Hon. Secretary of the London County Council Interim Tuberculosis Care Committee, and, thanks to her indefatigable efforts and to the distinguished artists who gave their services, a clear profit of £65 was made. Awaiting residential treatment at 31st December, 1923 8 Failed to enter 15 Not recommended 33 Number who did not receive residential treatment:— Number who received residential treatment for the first time 193 Total number who received residential treatment 223 Total number of applicants 279 Number of applicants who. had received previous residential treatment 30 Number of applicants who had not received previous residential treatment 249 1. Adult Males:- A. Through the London County Council. Institutional (Residential) Treatment of Camberwell Patients in 1923. Classification of Adult Male Patients who received, Residential Treatment for the first time. Pulmonary cases in which tubercle bacilli had not been found in the sputum 21 Cases of pulmonary tuberculosis in which tubercle bacilli had been found in the sputum 136 Early pulmonary tuberculosis 15 Moderately advanced pulmonary tuberculosis 83 More advanced pulmonary tuberculosis 38 Surgical tuberculosis 21 Diagnosis of tuberculosis 7 Not classified 8 Total 193 2. Adult Females. Number of applicants who had not received previous residential treatment 109 Number of applicants who had received previous residential treatment 3 Total number of applicants 112 Total number who received residential treatment 83 Number who received residential treatment for the first time 80 Number who did not receive residential treatment: — Not recommended 18 Failed to enter 6 Awaiting residential treatment at 31st December, 1923 5 Classification of Adult Female Patients who received Residential Treatment for the first time. Pulmonary cases in which tubercle bacilli had not been found in the sputum 12 Cases of pulmonary tuberculosis in which tubercle bacilli had been found in the sputum 52 Early pulmonary tuberculosis 4 Moderately advanced pulmonary tuberculosis 39 More advanced pulmonary tuberculosis 9 Surgical tuberculosis 7 Diagnosis of tuberculosis 2 Not classified 7 Total 80 3. Children. Number who received residential treatment Classification of Residential Treatment Cases. Early pulmonary tuberculosis 9 Moderately advanced pulmonary tuberculosis 4 Advanced pulmonary tuberculosis 3 Tuberculosis of knee joint 8 Tuberculosis of glands 7 Tuberculosis of bone 6 Tuberculosis of hip joint 5 Tuberculosis of spine 3 Tuberculosis of peritoneum 2 Tuberculosis of wrist joint 1 Tuberculosis of elbow joint 1 Tuberculosis of kidney 1 Tuberculosis of ankle joint 1 Tuberculosis of iris 1 52 36 The average duration of treatment given by the London County Council in 1923 to 306 adults was 14 weeks. The average duration of residential treatment given to 52 children by the London County Council in 1923 was 18.65 weeks. This refers only to treatment given in 1923 to patients who commenced treatment in that year, and, as many of these patients continued treatment during varying periods of 1924, the ultimate averages are to be reckoned as considerably higher. Institutional (Residential) Treatment of Camberwell Patients in 1923. B. Through the Guardians. 249 cases of tuberculosis received treatment in the wards of St. Giles' Hospital during 1923. Of these 129 were males and 120 females. Residential treatment was arranged for children out of London as required. C. Through Private Arrangements. A considerable number of patients did not ask the above-named Public Bodies to assist them in arranging for residential treatment. The Residential Treatment of Advanced Cases of Tuberculosis in Camberwell in 1923. During the year 173 Camberwell patients died of tuberculosis in Institutions and 132 died at home. 114 died in St. Giles' Hospital and 59 in other Institutions. The Camberwell Day Sanatorium, 6, Grove Hill Road. This is an After-Care scheme primarily intended for children who have completed residential treatment in Institutions out of London. All cases are non-infectious. A strong effort is made to find suitable jobs for the children on the completion of their school life. Number on roll on December 31st, 1923 26 Number admitted during 1923 9 Number discharged during 1923 9 Reasons for Discharge. Number fit for elementary school 1 Number fit for work 6 Namber transferred to hospital or sanatorium — Number removed from district - Number discharged for other reasons 2 Gain or Loss of Weight of Children who have been in the School more than 12 Months. Number of children who showed a gain in weight 25 Average gain in kilos. 3 Number of children who lost weight or whose weight was stationary - Average loss in kilos. - WILLIAM BRAND. SECTION 4. There were no specific causes of sickness or invalidity calling for special mention during the year 1923. SECTION 5. MATERNITY AND CHILD WELFARE. Infant Welfare Centres. It is fair to state that the growth in the number of Infant Welfare Centres emerged from a genuine public desire for enlightenment in the care and management of infants. Indeed, their establishment may be regarded as a concrete expression of an attempt to improve the physical standard of the children of this country. Nevertheless, there still remains a considerable section of the public who view the Infant Welfare Centre as another example for encouraging those who are alleged to seek to be relieved of full parental responsibility. On the contrary, the function of the Infant Welfare Centre is to advise mothers what to do, and how to do it. The ante-natal clinic, doctor's clinic, and mothercraft class are definite agencies for instruction in matters relating to the health of the mother and her infant. The well-being of the child depends upon her own efforts in carrying out this advice. It must be recognised that the promotion of all official schemes is usually the result of pressure in a greater or lesser degree on the part of those who desire an improvement in existing conditions, and their establishment directs public attention to the need for the services. Therefore, so long as the community as a whole are indifferent to the advantages of taking an intelligent interest in their welfare, so long will they be deprived of the benefits of progressive measures. This is particularly true with regard to preventive medicine. Much could be accomplished in the realm of public health by an intensive propaganda campaign in the form of simple lectures and demonstrations in the causation of diseases. It is, however, exceedingly difficult to get the people out of the habit of evincing an interest in such questions at any other time than when laid aside with sickness, and consequently progress in the reduction of the incidence rates of disease is slow. The infant welfare work in Camberwell is divided between 6 Voluntary and 3 Municipal Centres, and each is doing remarkably good work. The question of the staff, situation of the premises, and areas will sooner or later have to be considered. I have long held the view that in some cases the existing premises are far from ideal for the purpose for which they are used, and a re-distribution of areas would enable all the children needing health visiting to be kept under constant supervision until they reach school age. The table which appears on page 40 records the work of the Municipal and subsidised Infant Welfare Centres, and it is gratifying to note that the attendances and visits show an improvement in the figures for the previous year. The increase in the attendances at the ante-natal clinics is deserving of special mention, and encourages the hope that as time goes on the educational work of the Centres will reach many to whom pre-natal advice would he of inestimable benefit. Infant Welfare Centres Conference. With a view of co-ordinating, correlating, and consolidation the Maternity and Child Welfare Services in the Borough, the Maternity and Child Welfare Committee appointed a Special Sub-Committee to consider and report on the whole of the services. The first meeting of the Committee was held in September, and it was decided that, in order to assist them in their consideration of the matter, a Conference be convened of representatives from each of the Voluntary Infant Welfare Centres in the Borough, the Ministry of Health, the Borough Council, and the Medical Officers at the Municipal Centres. The Conference in question, which was well attended, was held at the Town Hall on October 25th, and the following Resolution was adopted:— "That a Joint Advisory Committee be appointed consisting of four members of the Maternity and Child Welfare Committee of the Council and the various Chairmen of the Voluntary Infant Welfare Centres in receipt of grants from the Council, such Committee to meet once a quarter and to report to the Maternity and Child Welfare Committee." MUNICIPAL AND SUBSIDISED INFANT WELFARE CENTRES. RETURN OF WORK, 1923. Consultations. Children —Attendances at Consultations. Mothercraft Classes. Analysis of Visits. Infant Welfare Centre. Expectant Mothers. Post-Natal Mothers. First Attendances. Subsequent Attendances. Superintendent's Consultations. Doctor's Consultations and Weighings. Total. After Notification of Birth. Before attending Centre. Miscellaneous and other Visits not defined. Visits by Voluntary Helpers. Visits to Mothers & Children not attending the Centre. Attendances— Dental Clinic. Total Attendances. Doctor's Consultations. Sewing Class. Health Talk. Sewing Class and Health Talk. Expectant Mothers. Children Attending Centre. Weighing only. Total Visits. Under 1 year. Over 1 year. First Visits. Subsequent Visits. First Visits. Under 1 year. Over 1 year. Subsequent Visits. — 2165 479 158 31 106 239 1830 Camberwell Municipal, 140, Cmberwell Road. 36 180 88 1296 601 2165 419 1585 161 546 468 282 - - - - - 3099 454 217 81 54 1569 - 718 3099 266 - 2379 86 544 588 150 66 Dulwich Municipal, 114, Lordship Lane 280 68 2033 - - - - - 411 343 558 1668 122 Peckham Municipal, St. Jude's Hall, Meeting House Lane. 210 51 1142 265 1668 72 1185 101 108 900 58 203 2050 - - - - - — - 1589 699 910 602 6215 760 4222 Bird-in-Bush Voluntary, 601, Old Kent Road 172 312 371 36 4337 1471 6215 3232 158 - 2825 69 222 70 - - - - 2755 1545 305 724 4583 239 998 715 - 115 211 Cambridge House, 6, Addington Square. 21 169 44 1474 2755 1964 408 383 571 182 1501 - - - - 663 - 202 2242 1534 307 70 500 214 - Cobourg, Kempshead Hall, Kempshead Road. 47 202 12 1826 2242 *- 522 3147 229 - - - - - 4755 153 275 1897 587 6 4755 2450 34 2265 164 - 172 1 2744 5829 Nunhead, 31, Nunhead Grove 78 288 70 2838 1559 527 - - - 124 3675 St. Luke's, 2, Commercial Road 67 177 32 1899 1567 3075 1312 2363 337 519 - 132 117 61 1573 589 284 1135 3891 - - - - United Girls' School, 17, Peckham Road 99 314 405 65 4082 1614 6160 2193 3973 6166 654 825 133 242 358 643 7519 626 - 9388 - - - - - 925 12835 2534 1754 Totals 520 2352 466 20927 8995 32740 11914 600 5149 32740 2233 2079 1140 1759 16626 4972 490 2598 7170 36509 229 * Information not available, Not subsidised by the Council, Homes for Unmarried Mothers. Southwark Diocesan Association for Preventive and Rescue Work, 24, De Crespigny Park, Camberwell. The Home is for unmarried mothers before and after the birth of the first child. They can remain as long as is considered necessary to give them a good start in life again. Their general health is thoroughly attended to, and if necessary clothing is provided. During the year 29 mothers and 22 babies were received into the Home. A great deal of visiting and after care is also carried on. All unmarried mothers in the Borough Institutions are visited after they leave. In this and other ways 51 cases have been dealt with in addition to those in the Home. National British Women's Temperance Association " House of Help," 201, Camberwell Grove, S.E. The number of cases dealt with during the year in this Hostel was 30 mothers and 30 babies, and the average length of stay was 23 weeks. The health of both mothers and babies, was excellent; only one baby failed to benefit, and was sent to the Infants' Hospital, Vincent Square. Maternity Ward. Further negotiations proceeded during the year for the provision of a Municipal Maternity Ward, and it is gratifying to record that the Council were successful in their efforts to meet the need for the accommodation of patients whose domestic conditions are unfavourable for confinement in their own homes, and also for patients showing some abnormality either during pregnancy or at the time of labour. The accommodation consists of a Ward containing six beds and a labour room equipped with all modern appliances at the St. Giles' Hospital, Brunswick Square, Camberwell. I am satisfied that the establishment of this Ward will be welcomed, not only by the residents in the Borough, but also by the medical practitioners, who will appreciate the facilities offered for sending patients to the Ward, thus avoiding the necessity of carrying out obstetric operations under circumstances which, in many instances, can only be described as appalling. Nursing. The Council have continued to provide nursing assistance for the treatment of maternity cases and infectious disease cases arising out of maternity, and for illness in children under 5 years of age, and also for patients suffering from pneumonia, malaria, dysentery, and other diseases specified in the Public Health (Pneumonia, Malaria, Dysentery, etc.) Regulations, 1919. Such nursing is carried out by the Ranyard Nursing Association, Camberwell District Nursing Association, The Rotherhithe District Nursing Association, and the East Dulwich and Dulwich Village District Nursing Association. The two former Associations are paid Is. a visit by the Council, and the following records the number of cases, visits, and cost of such cases during the year:— The Camberwell District anil Ranyard Nursing Associations. No. of Cases. No. of Visits. Quarter ended. Cost. £ s. d. 82 954 47 14 0 March 0 June 69 897 44 17 80 864 43 4 0 September 1,158 57 18 0 December 103 Total 3,873 193 3 0 334 Milk. Grants of milk in accordance with the following conditions provided by the Ministry of Health Circular No. 185 were continued to be made to (a) Nursing mothers, (b) Expectant mothers in the last three months of pregnancy, and (c) Children up to 3 years of age, and exceptionally to children between 3 and 5 years of age. The quantity of milk to be supplied at less than cost price must not ordinarily exceed one pint per day per person, but in the case of infants between 3 months and 18 months in exceptional cases 1½ pints a day may be supplied. The approximate gross cost of the grants during the year amounted to £4,400, representing the distribution of upwards of 900 lbs. of dried milk and 336,000 pints of milk. Every individual application was carefully examined by the Milk Applications Committee, and in cases where a doubt existed regarding the applicant's statement of his earnings enquiries were made before a grant was authorised. In four instances only was it necessary to request the attendance of the applicant before the Committee to offer an explanation of the conflicting information relating to circumstances. Convalescent Treatment. The practice of sending approved cases for convalescent treatment was continued, and during the period under review 18 children received treatment for one month, 2 for six weeks, 1 for a term of five weeks, and one mother and her infant for a period of one month. Peckham, Nunhead and District Day Nursery. A marked increase in the number of attendances of children at the above Institution during the year was recorded, there being 4,195 attendances, as compared with 2,657 for the year 1922. The nursery was open on 246 days, and the average daily attendance was 17. From October 26th to November 23rd the Institution was closed, owing to an outbreak of measles. Midwives' Fees. In three instances authority was given for the payment of the midwife's account for services rendered to indigent mothers in confinement. Midwives. For the year under review there were 44 practising midwives in the Borough. Hospitals Provided or Subsidised by the Local Authority. Maternity. A private ward containing six beds at the St. Giles' Hospital, Brunswick Square, Camberwell, subsidised by the Borough Council. Hospitals available for the District. King's College, Denmark Hill, S. E. 5. Camberwell Board of Guardians Institutions. Institutional Provision for Unmarried Mothers, etc. Southwark Diocesan Association for Preventive and Rescue Work Home, 24, He Crespigny Park, Camberwell, S. E. 5, subsidised by the Camberwell Borough Council. National British Women's Temperance Association " House of Help," 201, Camberwell Grove, S. E. 5, subsidised by the Camberwell Borough Council. Ambulance Facilities. (a) For infectious cases. The Metropolitan Asylums Board. (6) For non-infectious and accident cases. London County Council for accident cases. Maternity and Child Welfare Centres. Bird-in-Bush, 601, Old Kent Road Shop and dwelling house Voluntary Mondays & Thursdays; antenatal, 2nd & 4th Fridays. Cambridge House, 6, Addington Square Private rooms Waiting room ; consultation and dental work room ; disrobing room. do. Tuesdays & Thursdays. Cobourg, Kempshead Hall, Kempshead Road. do. Help and advice daily (except Saturday) ; ante-natal, Ist Monday; dental clinic Ist and 3rd Friday. Nunhead, 31, Nunhead Grove Waiting room; weighing room; consultation room. 3 rooms do. Thursdays & Fridays. St. Luke's, 2, Commercial Road do. Wednesdays & Fridays; ante- natal, 1st & 3rd Monday. Tuesdays & Fridays. Waiting room; weighing room; consultation room. do. United Girls', 17, Peckham Road Rented by Camberwell Boro' Council. Mondays & Fridays; antenatal, 2nd & 4th Thursdays. Camberwell Municipal, 140, Camberwell Road. do. do. SECTION 6. BACTERIOLOGY. The bacteriological examinations required by the Borough of Camberwell were continued to be carried out by King's College Hospital, and the following is a summary of this work for the year 1923:— Swabs for examination for Diphtheria. Positive 216 Negative 1,079 Examination of Sputa for T.B. Positive 333 Negative 2,367 Widal Reactions. Positive 8 Negative 5 Examinations for Gonococci. Positive - Negative 9 Examinations of Miscellaneous Material., e.g., Ice Cream, Tinned Meat, etc. 10 SECTION 7. SANITARY ADMINISTRATION. Sanitary Inspection of District. Visits to complaints numbered 3,870 in the year, compared with 3,843 in 1922, whilst house inspections following complaints increased to 2,652. The number of house-to-house inspections was 2,066, compared with 2,129 in the previous year. Tenement inspection increased from 466 in 1922 to 519 in 1923. Inspections after infectious disease dropped to 1,509, owing to the smaller number of notifications received during the year. Inspections of houses-let-in-lodgings increased to 169. The new by-laws for this type of house, which were made by the London County Council in 1922, had not received the approval of the Ministry of Health at the time of writing. The total number of inspections for all purposes made by the Sanitary Inspectors in 1923 was 79,174. Detailed statistics of the Inspectors' work will be found in the tables on pages 56-59. The following is a summary of the summonses heard at Lambeth Police Court in connection with the work of the inspectors:— No. of Summonses. No. of Magistrates' Orders. Fines. Costs. For defects 56 16 £3 15 0 £37 14 6 For disobedience of Magistrates' Orders 5 - 8 0 0 2 8 0 61 16 £11 15 0 £40 2 6 In a large number of cases the work required was done and the costs paid before the date of hearing. Two summonses, in respect of 64/66 Acorn Street were adjourned sine die, the London County Council having obtained an Order on account of the dangerous condition of the structures. These houses have since been demolished. Drainage and Sewerage.—The water carriage system is universal in the Borough, with the exception of a few earth closets in connection with sports grounds, and cesspools in use at premises in outlying parts of the Borough, where the nearest sewer is at too great a distance for connection to be insisted upon. With regard to reconstruction of drains, 102 plans were submitted for the total reconstruction of private drains, and 146 for the partial reconstruction thereof. When the plans have been approved by the Public Health Committee, this work of reconstruction, as well as new drainage work on private premises, is supervised by the Sanitary Inspectors. During the year the Borough Engineer reconstructed sewers in Dorton Street and Lansdowne Place and also the sewer running from Ann's Avenue to Malt Street. An amendment of the Drainage By-laws, permitting the use of iron soil-pipes inside buildings, was drafted by the London County Council, but did not receive the approval of the Ministry of Health till after the close of the year. Scavenging.—A weekly collection of house refuse is made generally in the Borough, but in certain congested areas, as also from numerous blocks of tenements, boardinghouses, etc., the refuse is collected more frequently. It cannot be too strongly emphasised that the frequent collection of refuse from crowded areas is essential from the public health point of view. The removal of house and trade refuse is carried out by the Borough Engineer's Department. Offensive Trades.—In my report for 1922 the number of offensive trade premises was given as eight, one occupied by a soap-boiler, and the other seven by dressers of fur skins. Fur Skin Dressers.—The question whether the trade carried on at the premises occupied by the skin dressers in Camberwell came within the definition given in the By-laws for regulating the conduct of the business of a dresser of fur skins was put to the London County Council, and that body caused a careful investigation to be made throughout London, with the result that in March, 1923, a communication was received stating that inspections had been made by the County Council's officers, and it had been decided that only four of the businesses reported by this Department were subject to the By-laws. This will explain the reduction in the number of offensive trade premises to five, comprising four dressers of fur skins and one soap-boiler. To these premises the Inspectors made 30 visits during the year. Rag and Bone Dealers.—By-laws were made by the London County Council in June, 1923, and confirmed by the Ministry of Health in September last, for regulating the conduct of the business of a rag and bone dealer, and with respect to the premises, apparatus, etc., used for such business. These By-laws were made under Section 9 of the London County Council (General Powers) Act, 1908. All these premises are being inspected and a register prepared. In the case of premises existing and in use at the date of the confirmation of the By-laws, the sections dealing with the construction of the premises do not come into force until September, 1924. These sections require the premises to be so constructed as to prevent the harbouring of vermin and to be capable of being readily cleansed, in addition to certain requirements regarding light and ventilation. Other provisions require the removal of offensive articles within 24 hours, and prescribe the nature of receptacles for bones, etc., and also provide for the removal thereof at stated intervals. Factories and Workshops.—Particulars of the factories and workshops on the register, of inspections, and other matters will be found on pages 55 and 60. FOOD PREMISES. Cowhouses.—As in 1922, I have to report that there is in Camberwell only one licensed cowhouse, practically the whole of the milk supply coming from outside the Borough. Five inspections were made, and the premises were found to be well kept. Milkshops and Dairies.—At the close of the year there were 415 milkshops and dairies on the register. 1,220 visits were made by the Sanitary Inspectors. 12 notices were served, and complied with. The premises occupied by persons applying for registration were inspected and the drains tested. No registration was granted until the defects, if any, had been remedied. Included in the number of milkshops and dairies are 20 premises in respect of which licences, under the Milk (Special Designations) Order, were issued for the sale of "Certified" milk and one place which was licensed for the sale of "Grade A Tuberculin Tested" milk. Slaughterhouses.—The number of private slaughterhouses in the Borough remains five. These premises were visited frequently, and as often as possible when killing was taking place, and altogether 142 visits were made by the inspectors. There is no public abattoir in the Borough. In March, 1923, the London County Council made a By-law under Section 19, Sub-section 4, of the Public Health (London) Act, 1891, requiring the use of a mechanically operated killer in slaughterhouses. This By-law duly received the approval of the Ministry. The London County Council also made By-laws for regulating the business of a slaughterer of poultry. These by-laws were confirmed by the Ministry, but it does not appear that there are in the Borough any persons who could be properly described as slaughterers of poultry. Butchers' and. Provision Dealers' Shops.—It is pleasing to be able to record that there is a slight but increasing tendency for the fronts of these shops to be closed by windows. It appears to be dawning upon the people engaged in these trades that protection, from dust and flies, of meat, bacon, etc., is beneficial to their pockets, by reason of the improved keeping qualities and appearance of their stock. The benefits to the consumer hardly need emphasis. Restaurants, Eating-Houses, and Frierd Fish Shops.—At the end of 1923 there were 147 of these places on the register, to which the Inspectors paid 210 visits. Special attention is paid to the kitchens and other places where food is prepared. 18 notices were served, and complied with. Bakehouses. —At the close of the year there were 137 bakehouses in use, 50 of which are underground bakehouses. The Sanitary Inspectors made 515 visits, and 21 notices were served, and duly executed. Ice-Cream Vendors' Premises.—The number on the register was 323. 458 visits were made by the Sanitary Inspectors. 7 notices were served, and the complaints were remedied. The number of visits recorded includes inspections of stalls. FOOD. Milk.—The Milk (Special Designations) Order, 1923, was issued by the Minister of Health in May, 1923. This Order revoked the previous Order (1922), embodied certain amendments considered desirable, in the opinion of the Minister, in the light of experience gained of the working of the original Order, and came into force on the 1st July, 1923. The general scheme of grading was not altered, but changes were made in the conditions under which licences might be granted for the sale of "Grade A" and "Pasteurised" milk. With regard to "Grade A" milk, conditions were not greatly altered, the alterations affecting the conditions of production only. The standard laid down in the 1923 Order for Grade A Milk —Pasteurised, was that originally set for "Pasteurised" milk in the Order of 1922, it being stated that such milk" shall be produced and treated under such conditions that, on a sample being taken before delivery to the consumer, the milk shall be found to contain (a) in the case of a sample taken at any time before 1st January, 1924, not more than 50,000 bacteria per cubic centimetre and no coliform bacillus in one-hundredth of a c.c., and (b) in the case of a sample taken at any time after 1923 not more than 30,000 bacteria per c.c., and no coliform bacillus in one-tenth of a c.c." In the case of "Pasteurised" milk other than "Grade A" the standard was considerably relaxed by the 1923 Order, it being laid down that up to December 31st, 1923, a sample must not contain more than 200,000 bacteria per c.c., and, after that date, not more than 100,000 bacteria Tier c.c. (The previous Order permitted only 50,000 and 30,000 per c.c. respectively.) The test for coliform bacillus was also removed. The general effect of the Milk (Special Designations) Order is to ensure that certain special varieties of milk which are sold at high prices are of a good standard of purity. Milk being such an important article of diet for infants and invalids, it is of the greatest importance that all milk should be of the highest quality and purity obtainable. A bacteriologically clean milk supply, apart from its benefit to the consumer, would also be advantageous to the vendor by reason of its improved keeping qualities. The milk question received considerable attention at the meeting of the Royal Sanitary Institute at Hull in July, 1923, and again at a meeting of the Institute in December last, and it is sincerely to be hoped that the interest that has been aroused in the matter will continue until a really pure milk supply is ensured for the public. The legal powers of the local authority for dealing with the unsatisfactory conditions under which milk is sometimes kept in retail shops (more particularly "general" shops) were not really adequate, but the powers given to the local authority under the Milk and Dairies (Amendment) Act, 1922, in the matter of refusing or cancelling registration where conditions are not satisfactory, represent a distinct advance. These additional powers must be used with discretion but firmness, and should be the means of securing improved conditions. It would undoubtedly be a great improvement if all milk could be supplied by the dairymen in bottles—both that delivered directly to the consumer and that supplied to the small shops. This would largely overcome the possibilities of contamination, both in the shop and in the home of the consumer. A difficulty arises, more particularly in the case of the "general" shop, and especially in cases where these shops supply employees in factories—these mostly buy in very small quantities. Nevertheless, if the bottle were the smallest quantity purchasable, these people would probably soon arrange to share a bottle between them. In connection with the retail sale of milk, a report was presented to the Public Health Committee in November last. This report dealt more particularly with the sale of milk in "general" shops in the Borough. Certain conditions to be observed by the shopkeepers were suggested:- 1. The milk container to be kept covered (to exclude flies and dust) when not serving. 2. The milk container and its cover, and the measures, to be scalded daily before use. 3. The floor and fittings of the shop to be kept clean and free from dust at all times. 4. If jams, syrups, and/or pickles are sold from open jars, a closely fitting cover must be kept in position when not serving. 5. No paraffin, or similar oil, vegetables, fish, raw meat or offal to be sold from the premises. The Council passed a resolution that persons registered as Purveyors of Milk, and those applying for registration, he informed that the foregoing conditions must be observed, and that, in the event of non-compliance, steps be taken to cancel the registration, or, in the case of a new application, that the same be refused unless the conditions are agreed to. Bread. —In February, 1923, the attention of the Public Health Committee was drawn to the practice of selling bread entirely unprotected from dirt and other impurities. The Committee recommended that the Metropolitan Borough Councils be asked to support representations in favour of legislation being promoted to deal with this question. In October, 1923, the Metropolitan Boroughs' Standing Joint Committee, after giving the matter careful consideration, addressed a communication to the Minister of Health, asking that legislation be promoted when opportunity arose. Another practice which, though not so common as formerly, is extremely objectionable, is that of taking back unused stale bread and exchanging it for new. This custom should be entirely prohibited, and the representation included a note on this matter. Ice-Cream. —6 samples of ice-cream were submitted for bacteriological examination during the summer of 1923. The reports in the case of 2 of the samples were far from satisfactory. The necessary steps were taken to improve the conditions under which the ice-cream was prepared and stored, and further samples will be taken during the coming season. Preservatives in Foodstuffs. —The widespread use of preservatives in foodstuffs was considered by the Council, and it was decided to support a resolution of the Paddington Borough Council urging the Ministry of Health to prescribe, pursuant to the powers vested in the Ministry by Section 1 of the Public Health (Regulations as to Food) Act, 1907, the limits of the amount of chemical preservatives sanctioned, and to regulate the conditions of sale of foodstuffs containing preservatives. Representations to this effect were made to the Ministry of Health. Inflation (of Meat and Fish). —It having been suggested to the London County Council that that body should promote legislation prohibiting this practice, the Metropolitan Borough Councils were circularised by the County Council on the matter, and your Council expressed the opinion that such legislation should be promoted. Unsound Food.—The systematic inspection of street markets, and shops, on Saturday nights was maintained during the year. The total number of inspections was 1,301, including the Saturday night visits. I should like to see greater activity in this matter of food inspection, but the routine duties of the Inspectors render any great extension in this direction impossible. One seizure of meat from a retail shop was made by Inspector Nash in July. The matter was duly reported to the Public Health Committee, and an explanation was submitted by the owner, who was cautioned by the Committee. Disinfection and Disinfestation. The total number of articles disinfected at the Council's. Disinfecting Station at Peckham Park Road Depot was 40,222, whilst the number of articles destroyed was 1,151, the latter mostly mattresses. 966 mattresses and cushions were re-tabbed. Visits to infected houses numbered 3,976, and 1,977 rooms were disinfected. The duties of the disinfecting staff under the control of Mr. A. Franklin include the destruction of unsound food. 3,248 verminous children and 58 adults were cleansed, and 961 children and 19 adults were treated for scabies at the Cleansing Station during 1923. 135 verminous premises were sprayed. SECTION 8. (See page 2 —Staff.) SECTION 9. HOUSING. During 1923 the remaining 12 houses under the Camberbell well Housing Scheme, which were in course of erection at the time of the last Annual Report, were completed. Private enterprise was responsible for the construction of two fiats on the North Side of the Borough and 94 houses on the South Side of the Borough. These new houses were built for sale, and were of a type that could not be described as working-class houses. It will thus be seen that my remarks on the subject of overcrowding in last year's report still hold good. Indeed, the fact that births in Camberwell in 1923 exceeded deaths by 2,657 obviously makes the present position more difficult than before. I can only repeat that, in my opinion, the present unsatisfactory state of affairs cannot be substantially ameliorated until the overcrowding of London is dealt with as a whole. Notices were served in 27 cases of overcrowding, 15 of which were abated by a re-arrangement of the sleeping quarters. No legal proceedings were taken, for obvious reasons. Unhealthy Areas.—The five areas represented in 1922— viz. : Woodland Cottages, Tiger Yard, Joiners' Arms Yard, Mayhew's Buildings, and Levant Street (Island Site)—were the subject of a Local Enquiry by the Ministry of Health in the early part of the year, with the result "that all the areas were condemned as unfit for habitation. The form of the Order confirming the Council's Improvement Scheme is still under discussion. Housing Act, 1923.—The important section of the Housing Act of 1923, from this Department's point of view, is Section 10, which gives the owner the right of appeal to the Minister of Health against any notice under Section 28 of the 1919 Act, or against any demand for the recovery of expenses from him under that section, or an order made by the Local Authority regarding such expenses. It is provided that no appeal against a demand for expenses or an order of the Local Authority shall lie if and so far as the appeal raises any question that might have been raised on an appeal against the notice. Only three notices were served under Section 28 of the Housing Act of 1919, and these were duly complied with by the owners of the property concerned. Rent and Mortgage Interest Restrictions Act, 1923.— This Act prolonged the operation of, and amended, the Act of 1920. Certificates that certain premises were not in all respects in a reasonable state of repair were issued in 19 cases. STATISTICS.—HOUSING CONDITIONS. Number of New Houses Erected during the Year 1923. (a) Total 108 (b) As part of a Municipal Housing Scheme 12 Unfit Dwelling Houses. I. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 6,963 (2) Number of dwelling-houses inspected and recorded under the Housing (Inspection of District) Regulations — (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation —* (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 5,399 II. Remedy of defects without service of formal notices. Number of dwelling houses rendered fit in consequence of informal action by the local authority or its officers 3,274 III. Action under Statutory Powers. (a) Proceedings under Section 28, Housing, Town Planning, etc., Act, 1919:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 3 (2) Number of dwelling-houses which were rendered fit— (a) By owners 3 (b) By Local Authority in default of owners — (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declaration by owners of intention to close — III. (6) Proceedings under Public Health Act:— (1) Number of notices served requiring defects to be remedied (dwelling-houses):— Intimations 5,399 Statutory Notices 1,898 Notices—houses let in Lodgings 224 (2) Number of dwelling-houses in which defects were remedied— (a) By owners all except 6 (b) By Local Authority in default of owners 6 111. (c) Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc., Act, 1909 Nil * Two houses were closed following action by the District Surveyor of the London County Council, and have since been demolished. The stuctures were in a dangerous condition. INSPECTION OF FACTORIES AND WORKSHOPS. Inspections made by the Sanitary Inspectors during 1923. Number of Premises. Prosecutions. Inspections. Written notices. Factories (including laundries) Workshops (including laundries) 677 1,624 1 106 2,301 106 1 Bakehouses. Number in use. Inspections. Written notices. Prosecutions. 137 515 24 - Defects Found. Number of Defects. Particulars. Referred H.M. Inspector. Found. Remedied. Prosecutions. Nuisances under the Public Health Acts: Want of cleanliness 39 28 1 - Want of ventilation 2 2 - - Overcrowding 3 3 - - Want of floor drainage 1 1 - - Other nuisances 48 Sanitary accommodation— 32 1 1 Insufficient 3 2 - - Unsuitable or defective 42 32 - - Not separate for sexes 3 Offences tinder Factory & Workshop Act:— - 1 - - Illegal occupation of underground bakehouse (sec. 101) - - - Breach of special sanitary requirements for bakehouses (ss. 97-100) 23 23 - - - Other offences - - - 1 164 124 2 Outworkers. In accordance with Section 107, lists of outworkers were received from 74 persons carrying on business in Camberwell, in addition to those forwarded by 57 56 SUMMARY OF INSPECTIONS, ETC., 1923. Inspectors. G. G. Morley. W. R. Farmer. M. Malins. H. C. Green. R. F. Nash. W. T. Worsfold. D. Glenday. Miss F. O'Riordan. Miss M. Butcher. Totals. W. Eagle. G. W. Scudamore. E. R. Collins. W. E. Groom. Description of Work. 429 3 528 299 468 9 3,870 250 315 288 353 423 Visits to complaints 196 309 246 255 115 237 377 183 225 357 - - 2,652 183 355 133 56 125 427 119 170 232 191 137 2,060 House inspections following on complaints - - 141 287 167 100 272 98 House-to-house inspections - - - - - 519 - - 49 169 - Tenement inspections - - - 169 - - - - - - - - - 19 19 - 48 Houses let in lodgings inspections - - - - - - - - 20 Housing and Town Planning inspections 10 1,454 658 469 54 20 127 - - - 3,080 - 102 166 10 2 Visits to new buildings - 16 6 9 1 11 - 56 - - - 11 - 19 31 142 Visits re overcrowding - - - - - - - - - 43 59 33 54 95 29 48 22 32 46 Slaughterhouses - - 515 25 44 77 1 Bakehouses - 5 - - - - - - - - - 105 - 4 62 115 196 123 74 104 83 - 1,220 Cowhouses ... ••• ••• | - 176 74 83 99 5 11 37 25 16 27 30 Milkshops and dairies - 210 if a 13 - 11 18 43 89 30 33 37 Eating houses 12 63 57 458 - - 9 52 Q 33 43 112 - - - - - 176 Ice cream shops and stalls - - - 10 8 45 65 91 137 143 71 112 94 Railway stations 3 158 303 1,624 43 112 250 58 54 Workshops 39 3 50 55 80 164 80 677 - 78 16 1 2 - - - - - - - - 30 Factories 19 12 - 8 7 39 3 84 35 39 41 Offensive Trade Premises —Visits 39 24 23 392 34 12 296 139 196 - Urinals, public 39 150 441 162 167 193 - 2,309 230 107 168 3,947 3,375 4,404 3,335 4,380 3,537 3,295 5,564 37 1 42,090 Do. private 2,353 3,980 3,882 648 516 963 782 837 356 454 787 1,597 8,344 Re-inspections 182 619 68 535 117 189 128 230 Miscellaneous 60 100 103 140 - 1,509 - 68 225 45 143 63 49 57 55 24 70 44 409 Infectious cases visited and houses inspected 371 1,317 41 1 18 71 68 54 6 7 214 Infectious cases, inquiries 1 3 391 - - 6 25 6 36 501 Infectious disease contacts visited 47 14 78 210 132 174 1,301 - - 58 4 47 4 4 1 24 17 8 6 29 122 Inspection of foodstuffs 15 14 - - - - Smoke observations - - 9 - - 10 - 24 - - 5 - Schools, L.C.C. 9 1 4 1 8 128 153 - - - - - 2 1 - - Do. private - - - - - - - (71)* - - - - - - 1 Tuberculosis, houses inspected - 309 4 314 - - - - - - - - Tuberculosis Cases visited or Inquiries - - 747 1,915 2,662 - - - - - - - - Outworkers visited - 194 - - - - 276 470 - - - - - - - - 59 25 84 Measles - - - - - - - - - - 53 22 75 Scabies - - - - - - - - - - Ophth. Neonm. - - - - - - 86 14 100 - - - - - 7,425 Verms. Cplts., visits - 6,329 7,981 6,209 7,002 5,803 6,017 8,648 3,957 3,265 79,174 3,552 6,260 6,726 Total number of visits Seizures of foodstuffs - - - - - - 1 1 - - - - - - 1 3 3 1 17 - - - - - - 4 5 394 469 371 690 484 535 616 594 58 - 16 5,563 Smoke nuisances 496 376 464 134 153 154 283 225 91 Intimations 146 175 1 1,898 188 - 165 2 183 - 1 Statutory notices, Public Health - - - - - - - 3 - - - 10 4 2 9 7 3 18 10 Notices, Section 28, Housing and Town Planning Act 78 6 3 - - - 224 Do. Section 29 do. do. - - - 224 6 3 - - - - - - Do. houses let in lodgings - * This figure is included in the number of House Inspections following complaints in Column 2, and represents complaints received from the Tuberculosis Officers. 58 59 SUMMARY OF SANITARY ORDERS FOR THE YEAR 1923. Inspector. G. W. Scudamore. H. C. Green. W. T. Worsfold. D. Glenday. W. E. Groom. R. F. Nash. W. R. Farmer. E. R. Collins. G. G. Morley. Totals. Description' of Work. W. Eagle. M. Malins. Cleanse and repair walls and ceilings 220 218 280 Repair roof, guttering, etc 103 254 124 250 455 361 533 383 3,385 307 78 176 118 287 149 303 Provide damp-proof course, etc. 100 191 148 176 195 1,924 Abate overcrowding 2 64 49 104 94 59 47 102 129 141 1,055 166 4 1 1 14 2 8 2 4 41 Abate smoke nuisance - 3 - Repair stoves, coppers, etc 20 4 5 1 3 3 16 - - - - - Repair windows, sashlines, etc. 23 42 20 54 49 178 50 90 79 130 759 47 Repair flooring, stairs, etc 22 48 24 76 68 260 47 99 232 190 1,103 36 33 68 Light and ventilate staircase, etc. 10 28 42 27 41 140 61 133 170 765 Provide dustbin 45 51 1 3 1 11 2 2 2 1 84 - 18 12 63 46 129 64 69 74 75 719 Remove accumulation 53 29 13 28 3 11 6 Pave, level and drain yard 78 5 13 3 8 9 117 5 130 59 38 46 56 92 94 63 92 129 877 Provide or repair manure pit 1 7 1 1 4 5 31 Provide sufficient water supply 6 3 4 - - 9 Provide receptacle or render accessible 2 10 5 10 4 5 7 1 10 69 - Repair cover or cleanse receptacles, etc 2 1 1 2 - - - - - - - - 4 10 18 31 21 14 4 26 165 Clear premises of rats, etc. 19 12 8 2 28 7 10 1 3 10 9 15 16 9 86 Provide, cleanse, repair or remove closets, pans, etc. Provide water supply to closet, repair flushing apparatus 18 46 38 28 23 53 78 29 58 58 63 502 Ventilate and remove outside soil pipes, cleanse, repair and trap drains 62 40 29 29 86 429 57 40 10 23 54 43 1 Cleanse, repair or trap pinks, waste pipes, etc. 57 64 41 69 63 113 75 74 62 82 762 6 3 3 11 10 4 8 4 63 Animals to be kept clean or removed 11 3 5 Public conveniences, cleanse, supply with water, etc. - 6 5 3 3 2 3 1 1 30 - - Private conveniences, cleanse, supply with water, etc. 6 - - - - - - - - - - - Miscellaneous 16 3 5 2 28 3 9 - - - - - 139 708 36 40 17 31 63 138 57 96 7 3 Outworkers—Continned. other Boroughs from persons in business therein. 2,662 visits were made by the Women Sanitary Inspectors to the homes of outworkers. Factories, Workshops, and Workplaces on the Register at the end of 1923. Wearing apparel 218 Engineering and allied trades 175 Eating-houses 147 Bakehouses 137 Building trades 97 Preparation of foodstuffs 87 Sawmills, joinery works, etc. 63 Printing and lithography 41 Laundries 39 Farriers and smiths 23 Chemical works, manufacturing chemists 11 Brush trades 10 Toy makers 8 Varnish and colour works 6 Offensive trades 5 Glass blowing 3 Celluloid works 1 Gas works 1 Miscellaneous 482 1,553 Other Matters. Matters notified to H.M. Inspector of Factories — Failure to affix Abstract of the Factory and Workshop Act 7 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Act, but not under the Factory and Workshop Act— Notified by H.M. Inspector 17 Reports of action taken sent to H.M. Inspector 9 Other matters reported to H.M. Inspector 2 Underground Bakehouses:— Certificates granted during the year Nil In use at the end of the year 50 ADMINISTRATION OF THE FOOD AND DRUGS ACTS. The Report of the Food and Drugs Inspector for the year 1923 is appended. It will be noticed in this Report that a greater amount of informal sampling was carried out in 1923 than in any other year. The results were highly satisfactory, as out of 92 samples of butter taken only six were found to be adulterated, four of which were taken from one shop and the remaining two from other shops. Additional work was thrown on the Food and Drugs Inspector by the Council appointing him to carry out the duties under the Public Health (Condensed Milk) Regulations. Public Health Department, 35, Brunswick Square. April 2nd, 1924. To Dr. Barnes, Medical Officer of Health, Camberwell. Sir,—I leg to report herewith on the work carried out under (1) the Sale of Food and Drugs Acts; (2) the Margarine Acts; (3) the Public Health (Milk and Cream) Regulations; (4) the Sale of Food Orders; and (5) the Public Health (Condensed Milk) Regulations. The formal or official samples obtained under the Sale of Food and Drugs Acts and Margarine Acts total 1,076. These are set out in detail under Table "A," which, also shows, against the adulterated articles, the percentage of adulteration and action taken. The extent and nature of the adulteration and the result of the proceedings, or other action taken, are set out in Tables "C" and "D." Fifteen official samples of cream taken under the Public Health (Milk and Cream) Regulations are dealt with under Table "E." Three official samples were taken under the Public Health (Condensed Milk) Regulations, 1923, making a total of 1,094 official samples. Table "F" shows the number of summonses and the amount of the fines and costs. Yours obediently, GEORGE T. DEWEY, Food and Drugs Inspector. TABLE "A." OFFICIAL SAMPLES, Number taken. Percentage not Genuine. Summonses. Cautions. Not Genuine. Article. Remarks Genuine. Milk 682 672 10* 1.46 6* 4 Including one milk, proceedings in respect of which were taken under the Milk and Dairies Amendment Act, owing to the presence of colouring matter. Butter 77 76 1 1.39 1 - 48 46 2 4.16 1 1 Vinegar Mustard 33 33 - - - - 2 8.33 2 Malt Vinegar 24 22 - 2 1 16 13 3 18.75 Golden Syrup Rice 15 15 - - - - Arrowroot 14 14 - - - - 62 14 Lard 14 - - - - 14 Cocoa 14 - - - - 2 16.66 1 1 Prescription 12 10 Self-Raising Flour 11 - 11 - - - 1 11.11 1 Sponge Cakes 9 8 - 8 8 - Pepper - - - 7 6 1 14.39 1 Separated Milk - 4 Articles sold in an unstamped wrapper. Margarine 7 7 - - - Coffee 7 7 - - - - 6 6 Beef Sausages - - - - Fish Paste 5 5 - - - - Custard Powder 5 5 - - - - Cornflour 5 5 - - - - Black Currant Jam 4 4 - - - - 4 4 Baking Powder - - - - 3 Olive Oil 3 - - - - Lemonade Powder 3 3 - - - - 3 3 - White Pepper - - - 2 2 Dripping - - - - Plum Jam 2 2 - - - - Raspberry Jam 2 - 2 - - - Lemon Curd 2 2 - - - - Sherbet 2 2 - - - - Mincemeat 2 2 - - - - Brawn 2 2 - - - - Cornbeef 2 2 - - - - Blancmange Powder 1 1 - - - - Honey 1 1 - - - - Curry Powder 1 1 - - - - Ground Ginger 1 1 - - - - Strawberry jam 1 1 - - - - Cane Syrup 1 1 - - - - Raisin Wine 1 1* 100. 1 * *Preserved with 31 grains of salicylic acid to the pint. - - Orange Marmalade 1 1 - - - - Madeira Cake 1 1 - - - - Sponge Fingers 1 1 - - - - Camphorated Oil 1 1 - - - - Treacle - 1 1 - - - Citrate of Magnesia 1 1 - - - - Ginger Beer Powder 1 1 - - - - 63 Plum Jam, with added Fruit Juice 1 1 - - - - Lemon Cheese 1 1 - - - - Lemon Phosphate 1 1 - - - - Pineapple Phosphate 1 1 - - - - Lime Juice Cordial 1 1* 100. 1* *Preserved with 3*5 grains of salicylic acid to the pint. - - Ground Almonds 1 1 - - - - Tinned Peas 1 1 - - - - Dried Milk 1 - - - - - Lemon Squash ... 100. 1* *Preserved with 5-7 grains of salicylic acid to the pint. 1 1* - - Lemon Squash Powder 1 1 - - - - Total 1,076 1,051 25 2.32 12 17 In addition to the above, fifteen samples of Cream were taken under the Public Health (Milk and Cream) Regulations (see Table) and three samples of Condensed Milk were taken under the Public Heilth (Condensed Milk) Regulations, 1923, miking a tatal of 1,094 official samples. MILK. Six hundred and eighty-two formal samples of milk and seven samples of separated milk were taken for analysis, making a total of 689. Eleven samples were reported against, giving a percentage of 1.59. Table "B" shows the percentage of milk adulteration for the past six years. TABLE " B." Year 1918. 1919. 1920. 1921. 1922. 1923. Percentage 11.7 6.9 2.8 1.95 1.95 1.59 Table "C" gives the particulars of the adulterated samples of milk and the result of legal proceedings or other action taken. TABLE "C." Deficiency of Fat. per cent. Added Water, per cent. Sample No. Result of Proceedings. No. 895 5 - Dismissed under the Probation Act, Costs payable to Council £2 2s. No. 916 18 - Fined £25 and £5 5s. Costs (previous convictions). - No. 921 - This sample was a genuine milk, but coloured with annatto. A summons was issued under the Milk and Dairies Amendment Act. Same was dismissed under the Probation Act, the defendant paying £2 2s. Costs. - No. 930 6 Fined £25 and £5 5s. Costs (previous convictions). No. 978 31 - Fined £2 2s. No Costs. No. 14 11 - Dismissed under the Probation Act. Costs payable to Council £1 1s. - No. 144 6 Caution, Public Health Committee. No. 319 8 - Do. No. 322 - 4 Do. No. 365 6 Do. - 7 Dismissed under the Probation Act. Costs payable to Council £1 1s. - No. 666 (Separated milk). It will be noted that eight of the above samples were deficient in fat, and only two contained added water. Sample No. 930. —With regard to this sample, the defendant requested that the third portion should be sent to the Government Laboratory. The analysis bore out that of the Public Analyst. Appeal to Cow Sample.—No "Appeal to Cow" samples have been taken, the necessity never having arisen. Milk and Dairies (Amendment) Act, 1922.—0ne summons was issued under this Act, in connection with the sale of a sample of milk containing colouring matter. (Sample 921, Table "C.") 81 Prescription 4.7 per cent, deficiency in Ammonium Carbonate Dismissed under the Probation Act. Costs payable to Council, £2 2s. Caution. Public Health Committee 129 Prescription 40 per cent, deficiency in Ammonium Carbonate 140 Lemon Squash 5.7 grains of Salicylic Acid per pint do. 150 Fine £5. Costs £4 4s. Butter 60 per cent, of Margarine The sample of butter No. 150 referred to in Table "D" was the outcome of informal buying. Four informal samples previously purchased of this vendor were reported as containing 50, 50, 65 and 50 per cent, respectively of foreign fat. Six samples of butter and three samples of margarine were analysed to ascertain whether they exceeded the amount of moisture permitted. In no case was there found to be an excess. INFORMAL SAMPLING. The informal samples purchased and submitted to the Public Analyst were as follows :— Butter 92 6 adulterated Milk 58 All genuine Blancmange Powders 2 Genuine Peach Jam 1 Genuine Glycerine and Black Currant Pastilles 1 Genuine Sherbet 1 Genuine Coffee 1 Genuine The six butters reported against were adulterated to the extent of 50, 50, 65, 50, 95 and 35 per cent, respectively of foreign fat. Samples subsequently purchased at the shops supplying the two latter failed to disclose any further adulteration, and, as previously stated, the vendor of the other four samples was convicted in respect of the official sample that was afterwards taken. MARGARINE. Eighty-seven informal samples of margarine were purchased. Of this number 74 complied with the requirements as to stamping the wrappers, etc., 9 were sold in wrappers indistinctly stamped, and 4 were sold in wrappers uot bearing the word margarine. Most of the informal buying was done during the evenings. SALE OF FOOD ORDER, 1921 In connection with that part of the above Order dealing with the labelling of imported meat at butchers' shops, it was found necessary to caution eleven tradesmen who had omitted to exhibit the required labels. With respect to the marking of imported eggs, cautions were given to fiftyseven traders, on whose premises imported eggs were found exposed for sale, not marked in accordance with the requirements of this Order. Proceedings were instituted against one tradesman who had been previously cautioned, and resulted in a fine of £2 and £2 2s. costs. There seems to be a tendency on the part of salesmen to defeat the object of the Section of this Order dealing with imported eggs, inasmuch as during the last year many labels were found with the words "new laid" or "fresh" in large letters and the "imported " or words dealing with the country of origin in minute letters and not entirely discernible. PUBLIC HEALTH (CONDENSED MILK) REGULATIONS, 1923. The above Regulations came into operation on November 1st last. On this date a standard for full cream condensed milk and machine skimmed condensed milk came into force. Regulations were also framed concerning the wording of the labels on the tins. From the above date to December 31st, 1923, two hundred and ninety-seven shops were visited and the labels of the various brands of milk examined. At thirty-one shops tins of condensed milk were found bearing the old form of labels. In accordance with the instructions of the Public Health Committee, the tradesmen were in each case advised as to the requirements of the Regulations, and cautioned. The stock in every instance was withdrawn from sale. Two tins of condensed machine skimmed milk sweetened, and one tin of condensed full cream milk sweetened, were submitted to the Public Analyst to ascertain whether the equivalent amount as stated on the labels was correct. The statements on the tins of machine skimmed milk were found to be in order, but the full cream milk (Sample No. 761) was reported to be of a pint short of the equivalent amount (viz., 1¾ pints) ; that the contents should have made according to the wording of the label on the tin. As this brand of condensed milk was an imported one, the facts were communicated to the Ministry of Health, in accordance with the requirements of the Regulations. PUBLIC HEALTH (MILK AND CREAM) REGULATIONS, 1912-1917. Fifteen (15) samples of cream were purchased and submitted to the Public Analyst during the year ended December 31st, 1923, and the details are set out in the following table, in the form prescribed by the Ministry of Health. All samples of milk formally and informally taken are analysed for preservatives. TABLE " E." (1) Milk and Cream not sold as Preserved Cream. Number in which preservative was reported to be present and percentage of preservative found in each sample. (B.) Number of Samples examined for the presence of a Preservative. (A.) Article. Action taken. Milk 689 Formal. 58 Informal. Nil - 747 Cream 8 5 E Sample No. 201 Boric Acid 0-04 per cent. do. 297 0.23 do. Summons, Fined 20s. & 21s. costs Caution, Public Health Committee do. 349 0.21 do. do. do. do. 432 0.38 do. Summons, Fined 20s. and £3 3s. costs do. 460 0.35 do. Caution, Public Health Committee The Vendor of Sample No. 201 had been previously cautioned. The Vendor of Sample No. 432 failed to comply with the Public Health Committee's request for a written or verbal explanation as to the presence of a preservative in the sample, and a summons was therefore ordered to be issued. (2) Cream sold as Preserved Cream— (a) Instances in which samples have been submitted for analysis to ascertain if the statements on the label as to preservatives were correct:— (1) Correct Statement 6 (2) Statements incorrect 1 Total 7 (3) Percentage of Preservatives found in Percentage stated on Statutory each sample. label. Sample No. 124 Boric Acid 0-31 per cent. | Not exceeding 0-4 per cent. do. 188 do. 0-54 do. do. [Boric Acid do. 233 do. 009 do. do. do. 265 do. 0.39 do. do. do. 274 do. 0.20 do. do. do. 379 do. 0.35 do. do. do. 394 do. 0.37 do. do. It will be noted that Sample No. 188 exceeded the Statutory amount. The vendor attended before the Public Health Committee and gave an explanation as to this, and also as to his contravention of the requirements respecting the declaratory labels (see Table "D"), and was duly cautioned. (b) Determination made of milk fat in cream sold as preserved cream. (1) Above 35 per cent 7 (2) Below 35 per cent — Total 7 (c) Instances where (apart from analysis) the requirements as to labelling or declaration of preserved cream in Article V (1) and the proviso in Article V (2) of the Regulations, have not been observed 5. (d) Particulars of each case in which the Regulations have not been complied with, and action taken: — Action taken. Sample No. 188. The receptacle (a 2-quart jug), contain- Caution, Public Health ing the bulk, had the declaration Committee. stamped upon it, in indelible ink, of a smaller type than that required by the Regulations, and the purchaser's receptacle had placed over it a paper bag with the declaratory notice stamped thereon, also in indelible ink. Sample No. 201 Cream vessel, containing the bulk, Proceedings taken (see unlabelled. Table (1). Sample No. 297. do. Caution, Public Health Committee. Sample No. 432. do. do. Sample No. 460. do. do. (3) Thickening Substances.—Thickeners were absent in all the samples. TABLE "F." Summary of Legal Proceedings for the year ending December 31st, 1923. No. of Summonses. Costs. Fines. Summonses under the Sale of Food and Drugs Acts Summons under the Milk and Dairies (Amendment) Act Summonses under the Public Health (Milk and Cream) Regulations Summonses under the Sale of Food Order, 1921 11 1 2 1 15 £ s. d. 57 2 0 - 2 0 0 2 0 0 61 2 0 £ s. d. 25 4 0 2 2 0 4 4 0 2 2 0 33 12 0 Total Cost and Fines, £94 14s. INDEX. PAGE Ambulance Facilities 43 Ante-natal 4-5 Bacteriology 45 Bakehouses 49 Births— Birth Rate 4 Illegitimate Births 4 Number of Births Notified 4 Number of Births Registered 4 Still-Births 4 Bread 51 Butchers'and Provision Dealers' Shops 48 Cancer 8,9 Cerebro-Spinal Meningitis 20 Clinics and Treatment Centres 44 Convalescent Treatment 43 Cowhouses 48 Day Nursery: Peckham, Nunhead and District 43 Day Sanatorium: Tuberculosis 37 Deaths — Death Rate 5-8 Number of Deaths Registered 5 Table, Causes of and Ages at 6-7 Table, Mortality Rates of Principal Diseases 12-13 Diphtheria 16 Disinfection and Disinfestation 52 Drainage and Sewerage 46 Dysentery 21 Encephalitis Lethargica 21 Factories and Workshops 47,60 Factories and Workshops, Inspection of, Tables 55 Factories: Workshops and Workplaces on Register 60 Food— Inflation (Meat and Fish) 52 Milk (Special Designations) Order 49-50 Milk 50-51, 64 Preservatives in Foodstuffs 51 Unsound 52 Food and Drugs Acts—Administration of 61 Adulterated Samples (other than Milk), Table 65 Condensed Milk Regulations, 1923 66, 67 Informal Sampling 66 Milk 64 Milk and Cream Regulations, 1912-1917 67-69 Official Samples, Table 62, 63 Sale of Food Order, 1921 66 Summary of Legal Proceedings 69 Foot and Mouth Disease 26 Fur Skin Dressers 47 Hospitals 43 Housing- 52-60 Summary of Inspections 56, 57 Housing Statistics 54 Ice Cream — 51 Ice Cream Vendors' Premises 49 INDEX—Continued. PAGE Infantile Mortality 9-10 Infantile Mortality, Rate 9 Infantile Mortality, Table of Stated Causes 11 Infantile Mortality, Rates of Principal Diseases 12-13 Infant Welfare Centres 38-39 Infant Welfare Centres, Table of Work 40 Informal Sampling 66 Malaria 21 Margarine 66 Maternal Mortality 20 Maternity and Child Welfare 38-44 Maternity Ward 41 Measles and German Measles 23 Midwives 43 Milk: Circular No. 185 42 Milk—See also under Food Milk Shops and Dairies 48 Non-Notifiable Diseases 23 Notifiable Infectious Diseases 14 Notifiable Infectious Diseases, Table of 24-25 Nursing 41-42 Offensive Trades 47 Ophthalmia Neonatorum 21 Outworkers 55, 60 Pneumonia 20 Polio-myelitis and Encephalitis 20 Population 3 Puerperal Fever 17, 20 Rag and Bone Dealers 47 Rent and Mortgage Interest Restrictions Act, 1923 53 Restaurants, Eating Houses and Fried Fish Shops 48 Sanitary Administration 45-52 Sanitary Administration, Summary of Inspections Table 56-57 Sanitary Administration, Summary of Sanitary Orders Table 58-59 Scarlet Fever 17 Scarlet Fever Table, Ward Distribution of Cases 18-19 Scavenging 46 Slaughterhouses 48 Small-pox 14-15 Staff 2 Statistics, General 3 Tuberculosis— 21 Deaths, Occupational Table 22-23 Dispensary, Work of 33 Report of Tuberculosis Medical Officer 27-38 Table, Analysis of Patients 34 Table, Notifications of Tuberculosis 28 Typhoid Fever 17 Unhealthy Areas 53 Unmarried Mothers, Homes for 41 Vaccination 15-16 Venereal Diseases 26 Whooping Cough 23-26