ANNUAL REPORT on the HEALTH of the Metropolitan Borough of Deptford, by CHARLES S. THOMSON, M.D., D.P.H., B.Hy. O.M.M. (Greece). Medical Officer of Health. 1922 DEPTFORD: Gaylard & Son, 446 New Cross Road, S.E. 14 Public Health Committee. Mayor. Councillor J. TIFFEN, J.P. Chairman. Councillor Mrs. B. M. DRAPPER, J.P. Vice Chairman. Councillor E. C. WOOD. Alderman Mrs. G. E. Green Alderman W. H. Green, J.P. Councillor Mrs. A. A. Cheason Councillor A. G. Howard Councillor Rev. J. Mahoney Councillor W. F. Marchant, O.B.E., L.C.C. Councillor Mrs. G. Tiffen Councillor Miss K. P. Warcup Councillor Mrs. L. E. White Maternity and Child Welfare Committee Chairman. Councillor Mrs. G. Tiffen, Mayoress. Vice-Chairman. Alderman Mrs. G. E. Green Consists of the Members of the Public Health Committee, as above. Staff of the Public Health Department. Medical Officer of Health and Administrative Tuberculosis Officer. Charles. S. Thomson, m.d., ch. b. (University of Glasgow), d.p.h. (Durham), o.m.m. (Greece.) Assistant Medical Officer of Health and Tuberculosis Officer. J. A. Harbison, m.b., d.p.h. Second Assistant Medicai Officer of Health and Maternity and Child Welfare Medical Officer. S. Eleanor Hill, m.d., b.s. Public Analyst. Henry G. Harrison, m.a. (Cantab.), f.i.c. Chief Clerk. Charles A. Chapman, Cert. s.i.e.b. (Lond.) Clerks. Henry J. L. Smith, Henry C. Gardner, H. Green. Sanitary Inspectors Robert D. J. Simpson, Cert. Royal Sanitary Institute. Phillip Shelley, ,, ,, ,, ,, ,, (Meat and other Foods). John V. Snowdon, ,, ,, ,, ,, ,, ,, ,, ,, (Meat and other Foods). Arthur G. Kemp, ,, ,, ,, ,, ,, s.i.e.b. (London). ,, Royal Sanitary ,, (Meat and other Foods). Frederick Hewett, ,, s.i.e.b. (London). ,, Royal Sanitary ,, (Meat and other Foods). Hakry Allam, ,, ,, ,, ,, ,, s i e.b. (London). ,, Royal Sanitary ,, (Meat and other Foods). Albert E. Yates, ,, s.i.e.b. (London). ,, s.i.e.b. (London). (Meat and other Foods). William F. Mayo, ,, s.i.e.b. (London). Health Visitors. Miss E. Clubbe, Certs. General Training ; c.m.b. and Health Visitor (r.s.i.) ,, E. Holland ,, ,, ,, c.m.b. and Health Visitor (r.s.i.) San. Inst, (r.s.i.) ,, H. F. G. Piper ,, ,, ,, c.m.b. and Health Visitor (r.s.i.) ,, E. T. Stowell ,, ,, ,, c.m.b. and Health Visitor (r.s.i.) * ,, W. C. Smart, Cert. s.i.e.b. (London), c.m.b. ,, E. T. White, Cert Gen. Training; c.m.b , i.s.t.m., Health Visitor (r.s.i.) * Appointed as Sanitary Inspector and Health Visitor. Municipal Maternity Home. 52 Wickham Road, S.E. 4. Medical Officer—Dr. S. E. Hill, m.d., b.s. Matron—Miss K, Smith, Cert. General Training and c.m.b. Sister—Miss A. Cross ,, ,, ,, ,, Nurses—A. Packer, Cert. Gen Training and c.m.b. O. Bell S. Wass, Cert. Gen. Training. Tuberculosis Dispensary. Hilary House, 78 Amershain Vale, S.E. 14. Tuberculosis Officer—J. A. Harbison, m.d., d.p.h., Secretary, Tuberculosis Care Committee. Miss A. I. Baird, Cert. Gen. Training, c.m.b., i.s.t.m., r.s.i., Health Visitor. Nurse Visitors—Miss E. M. Porteous. Miss G. L. Le Maitre. Dispenser—Miss G. F. Greig. Caretaker Attendant—G. Abbott. Mortuary and Coroner's Court. Watson Street, S.E. 8. Mortuary Keeper—G. W. j, Wagner, Cleansing Station. Watson Street. Attendant—Mrs. Wagner. Disinfecting Station. Watson Street, S.E. 8. Chief Disinfector—C. F. Dowsett. T. Lyons. F. Smith. J. Lloyd, Metropolitan Borough of Deptford. Public Health Department, Town Hall, New Cross Road, S E. 14. July, 1923. To His Worship the Mayor, Aldermen and Councillors of the Metropolitan Borough of Deptford. Ladies and Gentlemen, I have the honour to present to you my second Annual Report dealing with the Health, Vital Statistics and Sanitary circumstances of the Borough for 1922. In view of your decision to the effect that copies of this Report should be given to so many citizens of the Borough, I have seized the opportunity to increase the public knowledge relative to Cancer, Insulin, the science of milk production, the treatment of Rheumatism, and other matters of moment. The public should weigh carefully the thoughtful preface on Cancer, written for us by Professor Sir Thomas Oliver, the distinguished physician and authority on Industrial Disease. It is in keeping with his life of ceaseless and selfless endeavour for his fellow-men that he should turn aside and write this article for us. Dr. George Allan, Senior Assistant to the Professor of Medicine at Glasgow University, has written a thoughtful article on Insulin, giving us a proper perspective of the possibilities of Insulin in the treatment of Diabetes. Dr. Poynton, Physician to University College and Great Ormond Street Hospitals, has kindly allowed me to write a "popular" article on his lecture on Rheumatism and Heart Disease in Children. His lecture has excited the attention of medical men, and it is time that the public learned of the damage done to London's poorer children by 2 acute rheumatism. What, pray, is there which calls for adverse comment in Deptford? The answer is, Housing. Here are some bad cases:— (1) Mrs. F., has 2 small upstairs rooms. Nine children. Oldest 16 years. Mother expectant. (2) Mrs. C. 2 small rooms. Eight children. Oldest 19 years. Mother expectant. (3) Mrs. A. Bed and sitting room. Fourteen children. Eleven sleep in one room with parents. (4) Mrs. B. (a consumptive). One room. Seven in family. Oldest is 16 years. (5) Mrs. G. One room in basement. Five in family. Oldest 14 years. (6) Mrs. G. Three roomed flat. Fourteen in family. (7) Mrs. J. (a consumptive). Three married couples in this house of six rooms. Seven adults, five children. One couple live in one room night and day with three children. What is to be done ? Your Council has done nobly in building where you possibly could. The next point is Vaccination. In 1921, certificates of conscientious objection were obtained in about one-third of the births. The following are the figures :— Out of 2,778 births returned to the Vaccination Officer as registered from the 1st January to the 31st December, 1921, 1,170 infants were successfully vaccinated, 6 were insusceptible of vaccination, and in 935 instances, certificates of conscientious objection were received. 153 infants died unvaccinated; in 8 instances vaccination was postponed by medical certificate; 19 infants removed from the district, the Vaccination Officers of other districts being duly informed, and in 118 instances, removals took place to addresses which could not be traced. This leaves 369 infants born in 1921 which, on February 3rd, 1923— the date of the Vaccination Officer's report, had not been accounted for. I am indebted to Mr. A. E. Rossiter, the Vaccination Officer for the Greenwich Union, for the above figures, which relate only to that part of the Greenwich Union forming the Borough of Deptford. I solemnly warn and charge your Council to approach the Government to withdraw this conscience clause and to enforce vaccination in infancy and adolescence. I wash my hands of all responsibility if any citizen dies of Smallpox. 3 Turn to the bright side. Deptford is one of the safest places in the world for a baby to be born in. The Infant Mortality rate of 74 per 1,000 born, will fall to 30 within five years. I have said so ! let no dog bark. The Maternity Home keeps full, and the Ante-Natal Centre sessions keep multiplying. The Infant Clinics ring with the cries of happy children, and our excellent voluntary helpers never tire. Our splendid Town Clerk recently advised the public to make more use of the Borough services, to come and see us, to tell us about it, and ask our help. The people are responding. Your Council is largely responsible for this spirit of joy in service. We do want to help the people, and all the time. Gladly do I thank each member of my staff for their devotion to the public weal and their loyal support. The aim of the Deptford Health Department is to stand over the young, and to stand by the old. We seek to create and maintain conditions favourable to the young craft setting sail upon the high seas of life. We aim at comforting the old and soothing their fears when face to face with the dark veil which hides from our common vision— the Shining Dawn. Your obedient Servant, Charles S. Thomson, Medical Officer of Health. 4 Summary of Vital and Mortality Statistics for 1922. 1922. 1921. Area 1,564 acres 1,564 acres Population— Census 1911 109,496 109,496 Census 1921 112,534 112,534 Estimated to middle of 1922 114,100 113,500 Number of inhabited dwellings (Census 1921) 18,122 Average number of persons per dwelling 6.3 Density 16 per acre 73 per acre Length of Public Streets 53 miles approx. miles 53 approx. Rateable Value £657,730 £654,526 1d. Rate produces (approximately) £2,621 £2,522 Cost of administration of Public Health Department £4,248 £4,313 Marriages 976 884 Marriage Rate 8.6 7.8 Births 2,631 2,667 Birth Rate 231 23.5 Birth Rate, average for the last 10 years 24.7 25.1 Deaths 1,574 1,382 Death Rate 13.8 12.2 Death Rate, average for the last 10 years 14.7 15.1 Infantile Mortality 74 per 1,000 births 88 per 1,000 births Infantile Mortality, average for the last 10 years 97 per 1,000 births 103 per 1,000 births Zymotic Death Rate 1.4 0.8 Deaths from Measles (all ages) 59 1 Deaths from Whooping Cough (all ages) 35 14 Deaths from Diarrhœa and Enteritis (under 2 years of age) 11 55 *Structurally separate dwellings occupied by private families, i.e., houses and self contained flats. A. Hendry. Photo. New Cross. Breast Fed. "The Only Way." G.D. age 11 months. Weight 21 lbs. Area and Population. Births and Deaths. 7 Area and Population. Acres. Estimated Population. 1564 114,100 The decennial census was taken on June 19th, 1921, at a time when, owing to abnormally fine weather, holiday movement was in progress. The 1921 census return of 112,534 was therefore not wholly accurate and the Registrar-General recognised this and adjusted the census result by a redistribution of the estimated population on holiday, increasing the census number of 112,534 to 113,500. The population of Deptford to the middle of 1922 has been estimated by the Registrar-General as 114,100. This estimate has been based on the adjusted 1921 figures, after allowing for the varying rate of natural increase as evidenced by the births and deaths, and of migration as indicated from other sources, such as the changes in the numbers on the Parliamentary Register and the migration returns from the Board of Trade. The population for each of the various wards, based on this estimate, was as follows :— East 21,624 South 13,245 North 24,275 South-East 13,276 North-West 24,419 South-West 17,261 As the Borough has an area of 1,564 acres, the density of the population on this estimate is 73 persons per acre approximately. Births. Births. Birth rate per 1,000. 2,631 23-1 The total number of births registered in the Borough was 2,515, and of these 81 were transferred to other districts, as the permanent addresses of the parents were outside this Borough. Similarly, 197 births occurring outside of the Borough, in maternity hospitals, were transferred to Deptford, making a total of 2,631 birchs in all belonging to Deptford. Of these, 1,356 were males and 1,275 were females. This figure gives a birth-rate of 23.1 per 1,000 of the estimated population, as compared with 23.5 for the year 1921. The birth-rate for England and Wales for 1923 was 20.6 ,, „ the 105 County Boroughs and Great Towns was 21.4 ,, ,, the 155 Smaller Towns was 20.5 ,, ,, the County of London was 21.0 The rate for Deptford was therefore considerably higher than the average for the country as a whole. Table I shows the number of births and birth-rates for the past ten years :— 8 Table 1. Year. Estimated population. Births. No. Rate per 1000. 1912 109,377 2896 26.5 1913 109,280 3106 28.0 1914 109,182 3121 28.6 1915 110,299 2955 26.8 1916 110,299 2918 26.5 1917 115,403 2329 20.1 1918 114,328 2093 18.3 1919 115,843 2426 20.5 1920 115,772 3276 28.3 1921 113,500 2667 23.5 Average for 10 years 112,328 2779 24.7 1922 114,100 2631 23.1 Illegitimate Births. The illegitimate births numbered 67 or 2.5 per cent. of the total births. These occurred in the several wards as follows :— East 16 South 13 North 11 South-East 9 North-West 9 South-West 9 As far as can be ascertained, the occupations of the mothers in these cases were :—Domestic servants 7; Factory hands 4 ; Barmaids 3: Shop assistants 3; Drapers' assistants 3: Laundry workers 2; waitresses 2; "No occupation" 4. The remaining births occurred outside the Borough and the information as to occupation is not available. Under the provisions of the Notification of Births Act, 1907, intimations have been received from medical men, parents and others with respect to 2,556 births. Omitting still births, this gives a percentage of births notified to those registered of 97.5. Marriages. Marriages. Marriage Rate 976 8.6 1 he Superintendent Registrar has kindly furnished me with the particulars. There were 976 marriages in the Borough during 1922 as compared with 884 in the previous year. The marriage rate was equal to 8.6 per 1,000 of the population as compared with 7.8 for the year 1921. 9 The marriages were celebrated in the following places :— 633 in Churches of England. 80 in other places of worship. 263 in the Superintendent Registrar's Office. 976 Total Deaths. Deaths. Death Rate. 1,574 13.8 The deaths registered in Deptford numbered 1063 equalling a death. rate of 9.3, as compared with 932 and a death.rate of 8.2 for the preceding year. Of this number, 224 were non.parishioners. The deaths of Deptford residents occurring outside the Borough in public institutions were 735, making a total of 1,574 deaths belonging to this Borough. Of these 829 were males and 745 were females. The death rate was 13.8, compared with 12.2 in 1921. The death.rate for England and Wales was 12.9 „ ,, for the 105 County Boroughs and Great Towns was 13.0 „ „ for the 158 Smaller Towns was 11.7 „ ,, for the County of London was 13.4. The following table shows the number of deaths which have occurred during the past ten years, with the respective rates :— Table II. Year. Estimated Population. Deaths. No. Rate per 1000. 1912 109,377 1442 13.2 1913 109,280 1727 15.5 1914 109,182 1598 14.6 1915 110,299 1962 17.8 1916 110,299 1666 15.1 1917 *103,527 1663 16.0 1918 *102,036 1827 17.9 1919 *111,205 1469 13.0 1920 *115,636 1408 12.2 1921 113,500 1382 12.2 Average for 10 years 109,434 1614 14.7 1922 114,100 1574 13.8 * Civil population. The following table gives the number of deaths belonging to each Ward, and the respective death rates. Deaths of residents occurring outside the Borough are allocated to their respective Wards :— 10 Table III. Ward. Deaths. Death Rate per 1,000. Males. Females. Children under 1 year. Total. East Ward 202 161 66 363 16.8 North Ward 181 169 44 350 14.4 North.West Ward 130 140 24 270 11.1 South Ward 84 77 16 161 12.2 South.East Ward 127 94 19 221 16.6 South.West Ward 105 104 26 209 12.1 The proportion which the mortality at various ages bears to the total number of deaths during 1922 and the previous year is as follows Table IV. Table IV. 1921 1922 Under 1 year 16.9 per cent. 12.4 per cent. 1 to 2 years 3.1 6.7 2 to 5 „ 3.0 6.1 5 to 15 „ 3.4 4.4 15 to 25 ,, 5.4 4.6 25 to 45 ,, 11.9 11.9 45 to 65 ,, 24.2 24.2 65 years and upwards 32.1 29.7 Infantile Mortality. Infant Deaths. Infantile Mortality Rate. 195 74 195 Infants died before attaining the age of one year, i.e., 74 per 1,000 of the births registered. The mortality amongst infants in the various wards is shown in the following table :— Table V. Ward. Births Registered. Deaths under 1 year of age. Infantile mortality per 1000 Births. East 588 66 112 North 636 44 69 North-West 468 24 51 South 376 16 42 South-East 266 19 71 South-West 297 26 88 11 Comparative table of infantile deaths from Diarrhoea and Enteritis. Table VI. RATE PER 1000 BIRTHS. Diarrhœa and Enteritis under two years. Total deaths under one year. England and Wales 6.2 77 105 Great Towns 7.6 82 158 Smaller Towns 5.6 75 County of London 7.1 74 Deptford 4.2 74 Table VII. TABLE SHOWING THE NUMBER OF BIRTHS AND DEATHS IN THE BOROUGH DURING THE YEAR 1921. Births 2631 Deaths 1574 Excess of Births over Deaths 1057 Table VIII. INFANTILE MORTALITY RATE FOR THE PAST TEN YEARS. Year. Deaths under 1 year. Infantile Mortality Rate. 1912 258 89 1913 350 113 1914 309 99 1915 391 132 1916 258 88 1917 239 102 1918 205 97 1919 207 85 1920 259 79 1921 234 88 Average for 10 years 271 97 1922 195 74 12 Table No. IX. METROPOLITAN BOROUGH OF DEPTFORD. VITAL STATISTICS OF WHOLE DISTRICT DURING 1922 AND PREVIOUS YEARS. Year. Population estimated to Middle of each year. Births. Total Deaths Registered in the District. Transferable Deaths Nett Deaths belonging to the District. Uncorrected Number. Nett. Under 1 year of Age. At all Ages. of Nonresidents registered in the District of Residents not registered in the District. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1914 109,182 3,071 3,121 28.6 1,145 10.5 163 616 309 99 1,598 14.6 1915 110,299 2,891 2,955 26.8 1,406 12.7 144 700 391 132 1,962 17.8 1916 110,299 2,838 2,918 26.5 1,126 10.2 135 675 258 88 1,666 15.1 1917 103,527 2,262 2,329 20.4 1,091 10.5 161 733 239 102 1,663 16.0 1918 102,036 2,085 2,093 18.3 1,361 13.3 230 696 205 97 1,827 17.9 1919 111,205 2,396 2,426 20.5 1,051 9.5 202 620 207 85 1,469 13.0 1920 115,636 3,191 3,276 28.3 1,003 87 207 612 259 79 1,408 12.2 1921 113,500 2,549 2,667 23.5 932 8.2 213 663 234 88 1,382 12.2 1922 114,100 2,515 2,631 23.1 1,063 9.3 224 735 195 74 1,574 13.8 Area of District in acres (land and inland water). 1,564. Total population at all ages 112,534. Total families or separate occupiers, 28,007 At census 1921 13 Table No. X. METROPOLITAN BOROUGH OF DEPTFORD. Causes of, and Ages at, Death during the Year 1922. CAUSES OF DEATH. Nett Deaths at the subjoined Ages of "Residents' whether occurring within or without the District. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and upwards. 1 2 3 4 5 6 7 8 9 10 all causes}Certified 1574 195 106 94 70 73 188 380 468 Enteric Fever 2 .. .. .. 1 .. 1 .. .. Small Pox . . . . .. .. .. .. .. .. .. Measles 59 14 26 15 4 .. .. .. Scarlet Fever 11 .. .. 8 3 .. , , .. .. Whooping Cough 35 10 15 10 .. .. .. .. .. Diphtheria and Croup 39 . . 8 13 17 .. 1 .. .. Influenza 6 2 2 2 1 .. 2 14 26 15 Encephalitis Lethargica 1 .. .. .. • • .. .. 1 .. Meningococcal meningitis 1 . . .. • • .. 1 .. . . .. Tuberculosis of respiratory system 133 .. .. .. 4 35 50 38 6 Other Tuberculous Diseases 31 7 4 6 4 4 2 3 1 Cancer, malignant disease 146 .. . , 1 .. . . 10 76 59 Rheumatic Fever 9 .. .. .. 5 2 1 1 .. Diabetes 12 .. .. .. 1 1 3 4 3 Cerebral Haemorrhage, &c. 65 . . . . .. . . . . 1 21 43 Heart Disease 164 .. .. 1 5 4 23 56 75 Arterio.sclerosis 37 .. .. .. .. .. .. 6 31 Bronchitis 111 11 4 1 1 .. 3 19 72 Pneumonia (all forms) 201 50 37 28 4 3 20 37 22 Other Respiratory Diseases 16 1 1 . . 2 1 1 3 7 Ulcer of Stomach or Duodenum 6 .. .. .. .. 1 1 4 .. Diarrhoea, &c. 12 10 1 .. .. . . . . , , 1 Appendicitis and Typhlitis 10 , . . . .. 2 2 3 3 .. Cirrhosis of Liver 8 .. .. .. . . . , 4 3 1 Acute and chronic Nephritis 33 , , .. 1 4 3 7 13 5 Puerperal Sepsis 3 . . . . . . .. .. 3 . . .. Other accidcnts and diseases of Pregnancy and Parturition 5 .. .. .. .. 1 3 1 .. Congenital Debility and Malformation, including Premature Birth 71 69 .. 2 .. .. .. .. .. Suicides 9 .. .. . . 3 3 3 Other deaths from violence 50 3 1 4 3 7 5 15 12 Other defined diseases 230 18 5 3 10 6 29 47 112 Diseases ill.defined or unknown 2 .. 2 .. .. • • .. .. .. 14 Table No. XI. METROPOLITAN BOROUGH OF DEPTFORD. Infantile Mortality, 1922. Nett Deaths from stated causes at various Ages under 1 year of Age. CAUSE OF DEATH. Under 1 week. 1 to 2 weeks. 2 to 3 weeks. 3 to 4 weeks. Total under 4 weeks. 4 weeks and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths under 1 year. All Causes Certified 55 8 7 3 73 30 26 31 35 195 Uncertified .. .. .. .. •• .. .. .. .. .. Small Pox .. .. .. .. .. .. .. .. .. .. Chicken Pox .. .. .. .. .. .. .. .. .. .. Measles .. .. .. .. .. .. 2 5 7 14 Scarlet Fever .. .. .. .. .. .. .. .. .. .. Whooping Cough .. .. .. .. .. 1 5 .. 3 10 Diphtheria and Croup .. .. .. .. .. .. .. .. .. .. Influenza .. .. .. .. .. 1 1 .. 2 Erysipelas .. .. .. .. .. .. .. • • Tuberculous Meningitis .. 1 .. .. 1 .. .. .. 3 4 J Abdominal Tuberculosis .. .. .. .. .. .. .. .. 1 1 Other Tuberculous Diseases .. .. 1 .. 1 .. 1 .. .. 2 Meningitis (not tuberculous) .. .. .. .. .. .. .. .. .. .. Convulsions 2 2 .. .. 4 .. .. .. .. 7 Laryngitis .. .. .. .. .. .. .. .. .. .. Bronchitis .. .. .. .. .. 6 1 .. 4 11 Pneumonia (a11 forms) .. .. .. .. 7 7 3 16 17 50 Diarrhoea .. .. .. .. .. .. 3 1 .. 4 Enteritis .. .. .. .. .. .. 5 1 .. 6 Gastritis .. .. .. .. .. .. .. .. .. .. Syphilis .. .. .. .. .. .. .. .. .. .. Rickets .. .. .. .. .. .. .. .. .. .. Suffecation, overlaying 1 .. .. .. 1 1 .. .. .. 3 Injury at Birth 1 .. .. .. 1 .. .. .. .. 1 Atelectasis 5 1 .. .. 6 .. .. .. .. 6 Congenital Malformations 5 l .. .. 6 2 2 .. .. 10 Premature Birth 33 l 3 .. 37 5 1 .. .. 43 Atrophy, Debility, and Marasmus 4 .. 1 2 7 6 3 .. .. 16 Other Causes 2 .. .. .. 2 1 1 1 .. 5 55 8 7 3 73 30 26 31 35 195 Table Mo. XII. METROPOLITAN BOROUGH OF DEPTFORD. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1922. Notifiable Disease Number of cases notified. Total cases notified in each Ward. Total Cases Removed to Hospital. At all Ages At Ages—Years East Ward North Ward North.West Ward South Ward South.East Ward South.West Ward Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 65 and upwards Small.pox *1 .. .. .. 1 .. .. . . l .. .. .. • • 1 Cholera • • .. .. .. .. .. .. .. .. .. *• .. .. .. .. Diphtheria including Membranous Croup 459 4 121 232 55 42 5 .. 86 96 125 43 55 54 452 Erysipelas 75 .. 3 7 5 41 12 7 25 11 18 7 6 8 . . Scarlet fever 547 19 101 337 66 22 2 128 153 126 36 43 61 530 Typhus fever .. .. .. .. .. . . .. .. .. .. .. .. .. .. Enteric fever 7 .. .. 2 2 3 .. .. . . 2 1 2 .. 2 6 Relapsing fever .. .. .. .. .. .. .. .. . . .. . • .. .. . . .. Continued fever .. • • .. .. .. .. .. .. .. .. .. .. .. .. .. Puerperal fever 7 .. .. .. 2 5 .. .. 2 2 3 .. .. .. 6 Cerebrc.Spinal Meningitis 2 .. .. 2 .. .. .. .. .. .. 1 1 .. .. 2 Poliomyelitis .. .. .. .. .. .. .. .. .. .. .. .. .. • ... . . Pulmonary Tuber 208 .. 2 14 58 92 38 4 65 58 49 7 13 16 180 Other forms of Tuberculosis 75 3 14 39 8 8 2 1 22 17 15 4 8 9 19 Ophthalmia Neonatorum 10 10 .. .. .. .. .. .. 2 2 1 1 2 2 3 Anthrax .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Infantile Diarrhœa and Enteritis 5 4 1 .. .. .. .. .. 2 3 .. .. .. .. .. Acute Pneumonia 125 8 10 25 19 41 22 .. 58 15 25 3 15 9 .. Malaria 4 .. .. .. 1 3 .. .. 2 2 .. .. .. .. Dysentery .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Enceph. Lethargica .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Chickenpox 82 5 31 40 6 .. .. .. 17 6 42 8 9 .. .. Measles 28 9 18 1 .. .. .. .. 7 7 7 1 3 3 .. Totals 1685 62 301 699 222 258 81 12 416 375 413 113 154 164 1199 15 Table XIII. Deaths and Death Rates from Principal Infectious Diseases. Year Enteric Fever Small Pox Measles Scarlet Fever Whooping Cough Diphtheria Diarrhoea and Enteritis (under 2 years) Total No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate 1912 2 0.02 — — 28 0.26 6 0.05 24 0.22 11 0.10 28 0.26 99 0.91 1913 2 0.02 — — 50 0.45 3 0.03 43 0.39 20 0.18 90 0.81 208 1.87 1914 3 0.03 — — 50 0.46 9 0.08 9 0.08 25 0.23 88 0.81 184 1.69 1915 5 0.05 — — 49 0.44 9 0.08 61 0.55 10 0.09 94 0.85 228 2.07 1916 1 0.01 — — 32 0.29 5 0.05 14 0.13 13 0.12 49 0.44 114 1.03 1917 — — — — 30 0.29 2 0.02 20 0.19 22 0.21 56 0.54 130 1.25 1918 2 0.02 — — 19 0.19 3 0.03 50 0.49 12 0.12 20 0.19 106 1.04 1919 2 0.01 — — 21 0.18 9 0.08 1 0.01 16 0.14 33 0.33 82 0.74 1920 1 0.01 — — 19 0.16 2 0.02 16 0.14 21 0.18 39 0.34 98 0.85 1921 2 0.02 — — 1 0.01 13 0.11 14 0.12 13 0.11 55 0.48 98 0.86 Average for 10 yoars 2 0.02 — — 30 0.27 6 0.05 25 0.23 16 0.15 55 0.50 135 1.23 1922 2 0.02 — — 59 0.52 11 0.10 35 0.31 39 0.34 11 1.10 157 1.38 16 17 SOME NOTES FROM THE 1921 CENSUS. The Census was to have been taken on the 24th April, 1921, but owing to the industrial situation at that time this could not be accomplished, and so it was taken on 19th June at a time when, on account of the abnormally fine weather, some holiday movement was in progress. Thus certain holiday resorts yielded a return obviously swollen by visitors, and correspondingly, a diminished census figure, below expectations, fell to the lot of the many centres from which holiday movers had departed. The population inflation of the known holiday resorts equalled the deflation of the many towns and cities from which egress had taken place. No sure and certain allocation of the inflated figures to the deflated returns of the cities could be made, still, the Registrar. General made certain corrections whereby a nearer approximate estimate to the true census could be ascertained. The Administrative County of London consists of the 28 Administrative Boroughs; the Census for the County and the City was 4,484,523. In 1801 the population of the same area was 959,310. In 1901 the highest figure was recorded, 4,536,267. The decrease in the last 10 years has been at the rate of 10 per 1,000, but if the Census had been taken on the 24th April, a small increase might have been recorded instead. The population for Greater London in 1921 was 7,480,201, the highest yet recorded. Greater London includes the City of London and Metropolitan Police Districts and includes towns like Waltham Holy Cross, Erith, Epsom, Uxbridge, in the north, east, south and west respectively. The Census has shown that in the last decennium the same change has taken place, viz., the City and inner boroughs have yielded up substantial portions of their population as a result of the continuing substitution of business premises, warehouses, etc., in place of dwellings; the Outer Ring areas showed complementary increases. Thirteen boroughs presented this decrease, the City 30 per cent., whilst Finsbury, Holborn, St. Marylebone, Westminster and Stepney gave decreases of 14 to 11 percent. Increases were shown in Woolwich 16 percent., Lewisham 8 per cent., Hammersmith 7 per cent., Wandsworth and Greenwich 5 per cent. The emigration or outward movement of people from London County is only three.fifths of the 1901.11 decade, provided that in estimating the figures, we omit the war deaths which occurred abroad, and which amounted roughly to about 66,000. Only Lewisham and Woolwich did not show an outward migration. The City and Holborn were the only two areas in which the deaths exceeded the births. 18 The density or number of persons per acre numbered 60 for the County, the worst being Southwark 163, Shoreditch 158, Bethnal Green 154, whilst in the South.West and South.East the density fell to.Wandsworth 36, Greenwich 26, Lewisham 25, Woolwich 17. Deptford's density was 12. The worst wards in the whole County were—St. George.in.the. East (North Ward of Stepney) with 258 per acre, St. John's Ward, .outhwark 249 and 233 in the Golborne Ward of Kensington. Certain wards in Finsbury, St. Marylebone, Shoreditch and Stepney exhibit densities of over 200 While the acreage density affects certain medical and social questions such as the control of infectious disease, provision of transport and distribution of food supplies, it does not necessarily supply any index to overcrowding from the housing point of view. This latter depends entirely upon the sufficiency or otherwise of housing accommodation, especially as demonstrated by the average rooms per person. While overcrowding can and does occur in areas with a dense population, it is possible to find the association of high density with a relatively good housing position, and of the converse association of overcrowding with low population density. With few exceptions, Poor Law and Registration areas are identical. Concerning Parliamentary constituencies, there are 61 in the County, returning 62 members. The average population and electorate respectively are 72,331 and 33,935. The City of London returns two members though the census population is only 13,709 or 6,855 per member ; whereas, in Holborn the population is 43,192 per member. The population exceeds 100,000 in fiveconstituencies, namely, Deptford, Greenwich, Islington (North), St. Marylebone and Shoreditch. For the County of London the electorate forms 93.4 per cent. of the male population and 79.9 per cent. of the female population in the age classes above 21 for males and above 30 for females. Most of the women on the Parliamentary Register are married women who derive their right to the franchise because of their husband's occupation of premises. Buildings, Dwellings, Rooms and Families. A new term has been introduced as the housing unit serving as the basis of the returns. This is called a " structurally separate dwelling " and it means any room or set of rooms having separate access either to a street or to a common landing or staircase accessible to visitors. Each flat in a block of flats is a separate unit. A private house which has not been structurally divided is a single unit, whether occupied by one family or 19 by several. But where a private house has been structually divided into separate portions within the meaning of the definition, each portion is regarded as a separate unit. It has been possible in this census to indicate the extent to which houses originally built for the occupation of single families have been structurally divided to provide separate and independent occupation for two or more families. The average size of private families (persons) in the London County has fallen from 4.15 in 1911 to 3.79 in 1921, a drop of 9 per cent. In 1921, 147,797 private families, comprising 262,363 persons were living in one room, that is, there were 1.78 persons per family, and each person had .56 of one room. Such London families numbered 13.2 per cent. of the whole. Twenty.three and one.half per cent. of all families had three rooms and in such houses each person had .78 of a room to himself. The Registrar.General gives an explanatory footnote which is timely—"The ratio of two or more persons per room was selected in the Census Reports for 1911 and earlier years as an appropriate comparative index figure for the purpose of measuring the prevalence and distribution of overcrowding conditions. Since, however, that ratio has been commented upon as though it had been propounded as an absolute standard or a definition of overcrowding, it may be well to observe that its use in the census statistics implies no judgment whatever as to what in fact constitutes overcrowding." The fall from 4.15 persons per family to 3.79 in the last ten years is due to the increase in the marriage rate in association with a heavily reduced birth.rate and an increased (allowing for war deaths) death.rate. The reduction in the size of families does not abate the demands of individual families for separate dwellings. Nearly two.thirds of the families occupy a portion only of a structurally separate dwelling each. The average unit of occupation (rooms) has decreased from 3.56 rooms per family in 1911 to 3.38 in 1921. It is only in families numbering one or two persons that an improvement has been recorded as regards density standards in homes, whilst a deterioration has taken place for all other sizes of family. Measured in terms of families per dwelling, housing pressure is greatest in St. Pancras where the average of families to each dwelling is 2.3, and in Islington 2.12, but in these boroughs the dwellings are larger and the families smaller than in the rest of the County. One lodger in a boarding house counts as one family. Tbe following table illustrates the housing of private families in 13 Metropolitan boroughs and the City. Table XIV. BOROUCGH. Percentage of structurally separate dwellings. Rooms per Dwelling 1921 Families per Dwelling 1921 Persons per Family Rooms per Person All private Families 1921 Increase or Decrease in Dwellings. Increase or Decrease in Private Families. Population living more than two persons per room. Structurally Undivided Private Houses. Maisonettes, Flats, Tenements Attached to Shops, Offices, Warehouses. 1921 1911 1921 1911 City 10 23 67 3.70 1.09 3.31 3.56 1.02 - 356 -590 689 1,648 Bethnal Green 59 29 12 4.28 1.51 4.14 4.48 0.68 + 272 - 97 31,692 41,152 Camberwell 81 10 9 6.06 1.60 3.93 4.33 0.96 4.1767 + 7691 33,321 34,174 Chelsea 51 39 10 6.29 1.52 3.46 3.75 1.17 + 946 + 801 7,859 8,832 Deptford 82 11 7 5.98 1.57 3.93 4.31 0.96 + 1122 + 3033 14,122 13,185 Greenwich 82 9 9 5.70 1.39 4.10 4.38 0.99 + 791 + 2450 13,008 10,828 Holborn 16 61 23 4.35 1.49 3.12 3.59 0.89 -1168 - 902 5,977 9,716 Islington 76 13 11 6.54 2.12 3.59 3.94 0.85 + 1117 + 9950 62,436 62,789 Kensington 52 33 15 7.09 1.55 3.68 4.17 1.23 + 3285 + 5526 26,456 26,681 Lewisham 82 11 7 6.21 1.27 3.90 4.21 1.24 + 2528 + 6822 8,026 6,036 Poplar 82 7 11 5.18 1.62 4.19 4.48 0.76 + 664 + 2385 33,104 32,240 St. Pancras 67 17 16 6.57 2.30 3.45 3.84 0.82 - 407 + 4343 43,687 51,214 Southwark 50 40 10 4.52 1.62 3.79 4.10 0.73 + 1750 + 2499 41,574 46,800 Woolwich 89 4 7 5.26 1.29 3.92 4.27 1.03 + 4672 + 7338 10,270 7,110 '20 21 In contrast to these high rates of family occupation is the City with its comparatively small dwellings occupied by 1.09 families each, Lewisham 1.27, Wandsworth 1.29. Woolwich 1.29, Deptford 1.57, Greenwich 1.39. As regards average size of family in the boroughs, the poorest eastern boroughs are the largest—Stepney 4.26 (persons per family), Poplar 4.19, Bethnal Green, 4.14, Greenwich 4.10, Bermondsey 4.08. Deptford stands eighth out of the 29, having 3.93 persons per family. The smallest number is in Holborn 3.12, City 3.31, Westminster 3.31, St. Marylebone 3.33. The reduction in size of families since 1911 varies in the boroughs from 6 to 14 per cent. The average density (rooms per person) for the County is .96. The east end boroughs are worst—Shoreditch .65 rooms per person, Bethnal Green .68, Stepney .69. Poplar .76. Deptford is eleventh worst out of the 29, having .96 rooms per person. The most fovourable densities are—Hampstead 1.41, Lewisham 1.24, Kensington 1.23, Westminster 1 .23. The only boroughs whose density was found worse in 1921 as compared with 1911 were Greenwich, Hamersmith and Stoke Newington. Marital Condition. With regard to the widowed, the position in respect of men has remained practically stationary, but the large increase of 25,922 was recorded in the case of women. Of this number 11,000 were in the age group 20.39 and are therefore directly associated with the war. Births. Male births preponderate, but owing to the heavier death. rate amongst males the numbers of the two sexes are equalled at about ten years of age, after which the excess of females becomes greater. Husbands were found to be generally older than their wives, the average difference being 2 to 3 years. Excess of Females over Males. The proportion of females to 1,000 males has risen from 1,127 in 1911 to 1,165 in 1921, the numerical excess of female, now being 341,365, an increase of 72,362 over the corresponding figure for 1911. Metropolitan Boroughs. Local Age and Condition Distributions. Much depends whether a borough is residential, commercial or industrial in character. The greatest preponderance of females is found in the west end boroughs, Kensington, Hampstead, St. Marylebone, Chelsea and Paddington. Kensington has the largest number, 1594 to 1,000 males. The proportion of children to local population is lowest in these areas also, consequently the average age is higher than in other 22 areas. Unmarried women are most numerous also in these West end boroughs, and the ratio of married and widowed to the total is high in the case of men. Westminster is much the same but the number of single men and women is greater than would be expected. Lewisham has an excess of females corresponding more nearly to the average excess for the whole County. In industrial areas the populations become younger, as in Battersea, Camber well, Deptford and Woolwich, where the female preponderance and average ages are lower than the County average, though for both males and females the proportion married or widowed are still rather above the County as a whole. The extreme group where the population is youngest, where the males are nearly but not quite as numerous as the females, where there is a high proportion of children, are the inner boroughs of Bermondsey, Bethnal Green, Finsbury, Poplar, Shoreditch, Southwark and Stepney. Coming between this last group and the Deptford, Woolwich group, is Greenwich. Occupations. There is a slight decline in the proportion occupied both for males and females, but unmarried females at work have increased in number. This decline among males is most marked under 16 years. There is practically no employment under 14 years, and that between 14 and 16 has fallen by 16 per cent. Men are starting work later and continuing it longer than 10 years ago. The last. mentioned probably spells increased vitality and lessened invalidity in later life. There is remarkably little evidence to show that old age pensions have lessened the proportion of men employed at ages over 70. More females are at work between 16 and 25. At the 1921 census employment on the part of women seemed more a matter of choice than of necessity as compared with 1911. Occupations in the London Boroughs. Males—Nearly all males of working age are upon the labour market and only about one.third of all females. Commerce and finance employ the largest proportion of workers, being in the County 102 per 1,000 of all males over 12 years. I his proportion varies from 179 per 1,000 in Hampstead to 52 in Bermondsey ; they are chiefly shopkeepers and their assistants. Proprietors and managers of dealing businesses. Not all shopkeepers, though generally so elsewhere, reach the exceptional proportion of 72 per 1,000 in Hampstead. Bermondsey with 18 and Poplar with 19 are lowest in the scale, where the smallest proportion of shop assistants are found. Fulham has the largest number of shop assistants probably mostly employed outside their borough of residence. Commercial travellers per 1,000 population are most numerous in Stoke 23 Newington 21, Lewisham 19, Wandsworth 16, Hampstead 15. Many prosperous business men, brokers, owners and managers of dealing businesses live in Hampstead. Metal workers include 72 per 1,000 of the County of London population, and these come second in the list of occupations of males; they are most numerous in the South-East area, amounting to 157 per 1,000 in Woolwich, 124 in Greenwich, 123 in Deptford. Poplar, 89, has the largest figure North of the Thames. This work is widespread, nearly all boroughs having* over 50 per 1,000 except Stepney 35 and the City 26. The chief occupation is that of fitter, more important in Woolwich than elsewhere, 29 per 1,000, while machine tool workers are also more numerous in Woolwich, 27. Third in the list of occupations for London County comes "Miscellaneous and undefined workers" numbering 71 per 1,000, mostly general labourers. The largest proportion of these undefined workers is found in Greenwich 120 per 1,000, Poplar 110, Woolwich 108, the metal-working boroughs, whilst the lowest are found in Hampstead 23, Stoke Newington and the City 1 7. Road transport comes fourth with 66 per 1,000, especially prominent in Finsbury 90, Shoreditch 88, Southwark 86. Horse drivers abound more than motor drivers in the poorer areas amounting to Shoreditch 50, Bethnal Green 48, Bermondsey 45, Finsbury 44, whilst motor drivers, presumably receiving higher wages, are found in Fulham 33, Paddington 33, St. Marylebone 33, Chelsea 32 and Kensington 31. In part, these numbers are accounted for by domestic chauffeurs. In the South.East boroughs, Woolwich, Greenwich, Deptford and Lewisham, both horse and motor drivers are much below the average. Next in order are clerks, 64 per 1,000 for the County. They are found mostly in Lewisham 132, Stoke Newington 107, Wandsworth 106, and least in Shoreditch 20, Bethnal Green 23, Stepney 24, Finsbury 31. Railway workers are most numerous near termini, and merchant seamen near the docks. Poplar 35, City 29, Stepney 23, Bermondsey 21. Dock labourers are commonest in Bermondsey 91, Poplar 59, Stepney 58, and bargemen similarly. As a centre for electrical apparatus making and fitting, Deptford with 20 follows after Greenwich 49, Woolwich 35, Eulhain 25 and Hammersmith 22. Bermondsey is the centre for makers of leather. The Registrar.General gives a very exhaustive table, too large to produce here, entitled Occupations of Males in the Administrative County of London and in the Metropolitan Boroughs. Proportions per thousand, aged 12 and upwards. Engaged in (l) Occupational Orders or Sub.Orders. (2) The most important single occupations or related groups of occupations comprised in (1). 24 From the Registrar.General's table I have selected and put together in the accompanying table the list of occupations for Deptford and the adjoining boroughs, Greenwich, Woolwich, Lewisham, Camberwell, and Bermondsey, in such a way that the reader can see at a glance the proportion of people per 1„000 engaged in the same industry in each of these five boroughs. Further, I have placed the occupations in a column in such a way that by reading down the list, from 1, 2, 3, onwards, one can learn the chief occupation of Deptford, the second, third and so on, thereby gaining exact information as to the relative proportions of the workers per 1,000 engaged in industry, etc. It is Deptford's story, in short, and is surely worthy of thoughtful attention. Table XV. Proportion per 1,000 of Occupations of Males of 12 years and upwards in Deptford, illustrating successively from 1, 2, 3 onwards the Borough's chief industries, and giving a comparison with the numbers similarly engaged in Greenwich, Woolwich, Lewisham, Camberwell and Bermondsey:— INDUSTRY. Number of 1.000 of Males occupied in Deptford Greenwich Woolwich Lewisham Camberwell Bermond sey. 1 Metal work (not including electro plate and precious metals 123 124 157 74 76 60 2 Unoccupied and Retired 119 147 118 142 137 116 3 Other & undefined work 113 141 126 52 69 124 4 Commercial, Finance & Insurance Occupations 86 61 60 133 105 52 5 Clerks and Draughtsmen Typists (not Civil Service or L.A.) 68 41 42 132 83 44 6 Water Transport workers 53 54 24 13 15 140 7 Road Transport workers 51 34 28 37 71 79 8 Workers in Wood 36 31 28 29 38 28 9 Railway workers 35 10 8 18 15 18 10 Builders, Bricklayers, Stone and Slate workers, Contractors 34 27 27 35 35 20 11 Other workers in Transport, &c. 33 23 25 36 51 45 12 Public Administration 30 34 58 50 32 19 13 Warehousemen, Storekeepers and Packers 25 14 22 21 35 44 14 Persons engaged in Personal Service 24 23 25 23 33 28 25 INDUSTRY. Numbers per 1,000 of Males occupied in Deptford. Greenwich, Woolwich. Lewisham. Camber. well. sey. 15 Electrical Apparatus Makers and Fitters 20 49 35 20 13 9 16 Printers, Bookbinders, Photographers 19 7 7 25 42 21 17 Painters and Decorators (not Pottery) 18 17 19 25 26 13 18 Professional Occupations (including clerical staff) 18 25 25 43 22 8 19 Makers of Foods 13 9 8 11 14 23 20 Stationary Engine, Dynamo and Motor Attndts, 12 19 14 5 7 12 21 Makers of Textile Goods and Articles of Dress 11 8 12 15 17 12 22 Workers in Chemical Processes, Makers of Paints, Oils, &c. 7 11 23 3 4 7 23 Workers in mixed or unundefined materials (not elsewhere enumerated) 7 11 3 6 6 7 24 Persons employed in Gas Water and Electricity undertakings (not elsewhere enumerated) 6 17 3 7 5 3 25 Defence 6 32 73 7 5 4 26 Persons employed in Entertainment an Sport 5 3 4 6 6 2 27 Furriers, Skinners, Tanners & Leather Dressers 4 1 1 2 6 38 28 Makers of Glass and Glassware 4 5 2 1 3 1 29 Makers of Leather and Leather Substitute Goods 3 2 4 2 4 6 30 Makers of Watches, Clocks and Scientific Instruments 3 5 3 4 3 1 31 Agricultural Occupations 3 6 8 13 4 1 32 Workers in other materials 2 4. 3 2 4 3 33 Upholsterers 2 1 1 2 2 0 34 Makers of Drinks 2 2 2 2 4 6 35 Makers of Stationery, Cardboard Boxes and other workers in Paper 1 0 0 1 2 2 36 Makers of Bricks, Potters and Earthenware 1 0 0 0 0* 0 37 Workers in precious metals and Electro Plate 1 0 1 2 2 1 38 Textile Workers 1 1 1 1 1 1 39 Workers in Treatment of Non-Metalliferous Zinc and Quarry Products 1 1 0 0 1 1 26 In the Registrar-General's table, Deptford has a nil return under occupations of Males for (l) Fishermen. (2) Mining and Quarrying Occupations. (3) Makers of Tobacco, Cigars, Cigarettes, Snufif. (4) Makers of Paper, Pulp, Straw and Cardboard. Of all the London Boroughs, only four have over 100 per 1,000 male workers engaged in Metal work, viz :—Woolwich 157, Greenwich 124, Deptford 123, Poplar 109. Including the City of London, only five boroughs have fewer Unoccupied and Retired, Deptford 119, Woolwich 118, Bermondsey 116, Hammersmith 115, Southwark 111, City of London 95. Table XVI. Important Single Occupations of Males in six boroughs in London. OCCUPATION Deptford Greenwich Woolwich Lewis ham Camber. well Bermondsey. 1 Labourers (General Labourers) 95 120 108 41 52 98 2 Dock Labourers 31 15 — — 9 91 3 Salesmen and Shop Assistants 27 20 21 37 35 18 4 Proprietors, Managing Directors, Managers of Wholesale or Retail Businesses 27 22 21 40 51 18 5 Warehousemen, Storekeepers and their Assistants 19 10 18 17 25 32 6 Retired (not Naval or Military) 17 19 25 26 24 12 7 Civil Service Officials and Clerks 16 19 42 34 20 6 8 Lorries, Waggons, Vans and Carts (horse drivers) 16 12 9 8 22 45 9 Erectors, Fitters, Tool Setters, Millwrights 15 19 29 10 11 - 10 Messengers 14 11 14 14 20 21 11 Mechanical Engineers, Engineers, etc. 13 15 15 12 - - 12 Carpenters 13 12 15 15 13 7 13 MotorCar, Omnibus, Van and. Lorry Drivers 10 8 7 12 19 11 14 Porters (not elsewhere enumerated) 8 7 4 6 15 15 15 Others unoccupied 101 126 93 116 110 103 27 Deptford also returns Locomotive Engine Drivers 12 per 1,000. Greenwich also returns Army Officers and Men 20, Naval Officers and Men 11, Slotters and Millers 12 per 1,000. Bermondsey also returns Curriers and Leather Dressers 15, Barge men 15 per 1,000. Lewisham also returns Gardeners 12, L. A. Officials and Clerks 10 per 1,000. Woolwich also returns Army Officers and Men 69, Slotters, Millers, etc. 27, Chemical Workers 21 per 1,000. Occupations of Females. Over 77 per cent. of all female workers in the London County are employed in five groups, given herewith, in the proportions per thousand—Personal service (mainly domestic) 357, Making of Clothing, etc., 145, Clerical Employment 125, Commerce and Finance 80, Professional Occupations (mainly teaching and sick nursing) 65. 28 Table XVII. (Occupational Orders.) Occupations of Females in six Boroughs per 1,000 occupied, aged 12 years and upwards. OCCUPATION. Deptford Greenwich Woolwich Lewisham Camberwell Bermond sey 1 Personal Service (indoor domestic servants, charwomen, laundry, waitresses) 252 344 282 330 287 201 2 Clerks and Draughtsmen (not Civil Service or L.A.), Typists 160 135 155 224 161 87 3 Makers of Textile Goods and Articles of Dress 125 81 116 89 143 146 4 Commercial, Finance & Insurance Occupations 102 86 116 111 88 54 5 Professional Occupations 71 94 102 103 58 23 6 Metal Workers (not Electro Plate or precious metals) 61 35 14 5 10 66 7 Warehousemen, Storekeepers and Packers 40 27 14 14 42 111 8 Makers of Foods, Drinks and Tobacco 33 21 12 13 25 82 9 Makers of, and Workers in paper, Printers, Bookbinders, Photographers 28 14 9 15 60 72 10 Other and Undefined Workers 26 23 11 6 25 41 11 Public Administration & Defence. 24 24 40 36 26 7 12 Transportand Communication 21 17 19 22 22 24 13 Workers in Wood and Furniture 9 | 6 3 2 8 8 14 Textile Workers 9 11 4 5 3 4 15 Skin and Leather Workers, Makers of Leather and Leather Substitute Goods 8 2 2 3 12 37 16 Electrical Apparatus Makers and Fitters 7 52 59 4 2 1 17 Chemical Processes 5 3 2 4 4 10 A small number are engaged in Entertainment and Sport, and "Other Materials." 29 Table XVIII. Occupations of Females. The most important single Occupations. OCCUPATION. Deptford Greenwich Woolwich Lewisham Camber. well Bermondsey 1 Domestic Servants (indoor) 130 236 177 240 135 74 2 Saleswomen and Shop Assistants 76 62 87 83 65 39 3 Sewers, Stitchers 45 21 36 18 58 63 4 Teachers 42 40 51 59 30 9 5 Charwomen 33 29 29 21 34 57 6 Packers, Labellers, Ticketers 33 24 11 10 36 99 7 Dress and Blousemakers 31 29 37 37 33 16 8 Makers of Food 28 16 — 12 20 76 9 Laundry 27 20 19 27 52 14 10 Press Workers, Stampers Drawers (metal) 25 - - - - 22 11 Printers, Bookbinders, Photographers 21 10 - 12 39 45 12 Civil Services Officers and Clerks 21 20 34 32 22 6 13 Sick Nurses 19 41 19 31 16 8 14 Waitresses 19 16 14 10 27 17 15 Proprietorsand Managers of Wholesale or Retail Businesses 17 20 23 21 17 11 16 Milliners 14 10 14 14 8 8 17 Barmaids 12 9 11 — 8 10 18 Tailoresses 11 8 18 7 17 17 19 Telephone Operators 9 - 11 12 8 - Deptford has Solderers and Braziers 8 per 1,000, and Tinsmiths 12. Bermondsey has Tinsmiths 17, Furriers, Leather Dressers 22, Solderers and Braziers 14, Sugar Confectionery Makers 13. Woolwich has Professional Students 22. Both in metal.working as a whole and for the chief single occupations included, that of pressworking, stamping and drawing, Bermondsey 66 and Deptford 61, far exceed all other boroughs in the County. Deptford returns a high proportion for both sexes. Tin box making is largely located in Deptford and Bermondsey. 30 Birthplace and Nationality. Ninety-two per cent. of the persons enumerated in the County were born in England, about 3 per cent. in the remainder of the British Isles, nearly 1 per cent. in the various dominions, colonies, etc., and rather more than 3 per cent. in foreign countries. The immigrants from Wales, Scotland and Ireland generally bear relation to one another in proportion to the respective populations of those countries, such difference as there is being slightly in favour of Wales, whose contribution is rather higher, and against Scotland, where it is lower than the others, Ireland occcupying a position between the other two. What then is the reason for the cheerful comments made by the knights of the ink.pot in Fleet Street, who love to comment upon the breadth of the highway leading from Scotland to England ? Possibly it arises from the noise made by some of those who hail from the Clyde area, or perhaps there is something in the story of "the heads of departments." Infectious and other Diseases. 32 INFECTIOUS AND OTHER DISEASES. Under the provisions of the Public Health (London) Act, 1891, and the Tuberculosis Regulations, 1635 cases of infectious diseases were notified, as compared with 1,873 in 1921. In the Table will be found a list of cases notified and their distribution in the several Wards. To the seven principal epidemic diseases, viz:- Sinall-pox, Measles, Scarlet Fever, Diphtheria, Whooping Cough, Enteric Fever and Infantile Diarrhoea, 157 deaths were ascribed, and the death-rate was 1.38 per 1,000 as against 0.86 in the preceding year. A preceding table indicates the number of deaths and the death-rates from these diseases during the past ten years. There was a marked increase in the cases of Measles and Whooping Cough during 1922. Diphtheria also showed an increase. Cases of Diarrhoea were markedly fewer. Small-Pox. One case of Small-Pox was notified during the year, but the diagnosis was not confirmed. Scarlet Fever. 547 persons were notified as suffering from this disease during the year under report as compared with a total of 951 for the previous year. Included in this total are 14 patients who, after removal to hospital, were certified to be not suffering from the disease in question. There were 39 deaths as compared with 13, 2 and 9 in the three preceding years. Diphtheria. The total number of patients certified to be suffering from Diphtheria was 459 as compared with a total of 363 for the previous year. Of this number 13 were errors of diagnosis. There were 11 deaths as compared with 13, 21 and 16 for the three preceding years. Enteric Fever. Seven cases of Enteric Fever were notified, as compared with 9 in the previous year. There were two deaths. Acute Primary Pneumonia and Acute Influenzal Pneumonia. These diseases are compulsorily notifiable under the Public Health (Pneumonia, Malaria, Dysentery, etc., Regulations), 1918. 125 cases were notified during the year. 33 Puerperal Fever. Seven cases of Puerperal Fever were notified as compared with 11 in the previous year. There were 3 deaths. Ophthalmia Neonatorum. Ten cases were notified during the year. These were visited by the Health Visitors, and, where necessary, by a Ranyard Nurse, in accordance with the Council's scheme for the provision of nursing assistance. 3 cases were admitted to hospitals. From subsequent enquiries it has been ascertained that 8 patients recovered with no apparent impairment of vision. Two patients moved from the district and no information as to their present condition is available. Measles. Under the Deptford (Measles) Regulations, 1922, made by the Ministry of Health on the request of this Council, Measles is now a notifiable disease. These regulations came into operation on the 11th September, 1922. 28 cases were notified from that date to the end of the year under report, and were visited by your Health Visitors and arrangements were made by the Ranyard Nurses' Association for daily visits of a nurse to such cases as your Medical Officer of Health deemed advisable. Diarrhoea and Enteritis. Infantile Diarrhoea occurring in children two years of age and under is notifiable in this Borough by Order of the Council dated 27th July, 1920. During the year 1922, 5 such cases were notified. Diarrhœa and Enteritis caused 12 deaths during the year, and of this number, 11 were children under two years of age. Cerebro-Spinal Meningitis. Two patients were notified as suffering from this disease during the year. There was one death. Malaria. Four cases of Malaria were notified in the persons of ex-service men who had contracted the disease in the East. 34 Chicken Pox. By an Order made by this Council the notification section of the Public Health (London) Act, 1891, was made applicable to Chicken Pox for a period of three months from 23rd November. From the latter date to the end of the year under report, 82 cases were notified. Table XXI. Hospital Disposal of Notifiable Diseases during 1922. DISEASE Total Cases Notified Ca ses admitted to Hospital. Total Deaths. Diphtheria 459 452 39 Scarlet: Fever 547 530 11 Enteric Fever 7 6 2 (including Parataphoid) Small Pox 1 1 – (diagnosis) (incorrect) Puerperal Fever 7 6 3 Pneumonia 125 Nil 201 Measles 28 Nil 59 (as from) (11.9.22 ) Diarrhoea and Enteritis 5 Nil 12 Epidemic Cerebro-Spinal 2 2 1 Meningitis Chicken Pox 82 – (as from) 23.11.22) CAUSES OF SICKNESS. (Including information from General Practitioners.) From different parts of the Report it will be seen that more deaths occurred in 1922 from Measles than we have had since 1911. The 1922 figure was 59, compared with one death in 1921. 35 died from Whooping Cough compared with 14 in 1921. 39 died from Diphtheria compared with thirteen in 1921. Diarrhoea and Enteritis fell from 55 to 11, and Scarlet Fever from 13 to 11. Respiratory disease was greater. Elsewhere is explained the action taken to counteract and nurse these diseases. As regards Diphtheria, enquiry was made as to the procedure followed in the different Metropolitan Boroughs with respect to contacts. All contacts of school age now attend the Deptford Town Hall, and a proportion of these are swabbed. Similarly, the contacts of positive (bacteriological) cases are scrutinised and in certain 35 instances are swabbed. The subject of swabbing contacts is an extremely unsatisfactory one, as perfectly healthy people are known to harbour the causative germ in their throats and noses betimes. Tests for virulence or avirulence of a discovered bacillus take fourteen days, too long for practical purposes as a whole. I shall deal with this subject more fully next year. To obtain information from doctors practising in Deptford, I sent the following letter Dear Doctor, I am writing my Annual Report for 1922, on the Health of Deptford. The Ministry of Health have asked me to include any information which I have obtained from you in respect to any causes of sickness and invalidity during 1922. If anything particular came to your notice during 1922, I should be most grateful to you for a note on the subject, and should be happy to print the same in the Report along with other information from brother practitioners. This morning I had an interesting experience and it has led me to place the facts before you and ask your kind opinion on the treatment of chronic rheumatism. I was introduced to a lady who told me in the course of conversation that she used to suffer badly from rheumatism and that she still had twinges. A native of Lincolnshire, she said the disease was very common there, as also " hearts." As to treatment she said that the waters and mineral baths at Wood Hall Spa were excellent, but that the effect of the same was not fully appreciated until months after. The waters contained bromo-iodine and though such might be got in bottles, probably this would be dear. She dieted herself carefully,avoided starch foods (she could not remember when she had a potato last). A baker makes a special dry loaf for her, and this she consumes after toasting the same. As regards medicine, she has found that the salicylates made her ears ring and were not very useful for chronic rheumatism. Aspirin was valuable but depressing. Her main stand-by consists in taking large doses of sodium bicarbonate thrice weekly. It is of interest to note that she has a bit of a callosity on the inner aspect of the left foot at the metatarso-phalangeal articulation. Twinges occur here, but on paring the callosity and especially on making it bleed, relief is obtained. I wonder whether you could kmdly see your way to let me have a note of your views as to the treatment of chronic rheumatism. I would endeavour to write a paragraph (or short essay, depending on the extent of the replies 1 get) for the Annual Report, a copy of which, as issued, will be sent to you. I gratefully thank you in advance for your kind reply. Yours faithfully, Charles S. Thomson, Medical Officer of Health. 36 I am deeply grateful at the result of this letter. A number of replies have been received. If one subject be taken annually, very helpful information will be obtained by us all. I have given below the salient features of the replies received. Letter number 1. A frequent cause of Chronic Rheumatism is septic teeth. Case: a male, age 41, a compositor, worked all his life amongst newspapers. Strong and healthy. Teeth apparently good. For one or two years the patient had very severe cramp in left leg every night, coming on an hour after going to bed. Eight months' treatment of no avail. Could it be due to lead poisoning ? Sent patient to Guy's Hospital where teeth were cleaned and X-rayed. A septic tooth was found. This was extracted and within a week the cramp had left him. He has now been free of the pain for over a year. I find aspirin gives the best relief from pain in all forms of rheumatism, especially muscular. In lumbago, I find twenty-five grains of ammonium chloride, three times a day, acts like a charm. 2. So-called rheumatism may be due to many different causes, but if the case is of pure rheumatic origin, I find that aspirin, and secondly guaiacol carbonate give the best results. I am a firm beliver in Spa treatment if accompanied by strict dietary regimen. 3. After many years practice in this neighbourhood I believe that persistently wet weather is good for the general health ; it improves the general health of the community. The reason is that there is a constant washing of the atmosphere, roofs, drains, etc., causing amongst other things purification of the atmosphere. In addition, contrary to popular ideas, persistently wet weather decreases the tendency to rheumatic fever. On this account, we have not had a case in our triple practice since the wet weather began. With regard to chronic rheumatism, those bad forms which one sees in hospital and infirmary practice do not exist in middle class family practice in this neighbourhood. The form of chronic rheumatism which exists here usually affects both knee joints and the fingers, with occasionally the shoulder joint. Rarely are the other joints affected. These are usually helped by local applications, such as Scott's dressing. Persistent cases are nearly always benefited, and sometimes cured by three months' stay at one of the Spas, Droitwich being my favourite. I do not think that internal medication helps in any way. 4. The term chronic rheumatism is used to include rather vague complaints, hence one hesitates to dogmatise as to the treatment. 37 Excluding peri-articular arthritis and osteo-arthritis, there remains chronic articular rheumatism and the group comprising lumbago, torticollis, etc. In neither of these groups do I find much benefit from the administration of salicylates, but frequently give a course of potassic iodide and guaiacum, followed by an alkaline tonic. 5. Chronic rheumatism. I have had most success with the following line of treatment—Exclusion of red meat and acids from the diet. Colloidal sulphur and iodine taken alternately for a week at a time for a period of several months. Aspirin when the pain is severe. Inunction of methyl salicylate and Iodex into painful areas, and occasionally the use of the hot sand bath or the use of Antiphlogistin. 6. Chronic rheumatism. Constitutional. Remove any possible source of infection that can be found, e.g., pyorrhoea, septic tonsils, chronic appendix. Cut down intake of sodium chloride and carbohydrates. Promote healthy action of skin by rubbing, or if possible massage and Turkish baths. Local (l) For relief of pain. Iodine ointment with 10 per cent, methyl salicylate. Hot fomentations. Hot sand in bag wrapped round the joint. Radiant heat bath if possible. (2) To reduce swelling, Scott's dressing and strapping. Drugs. (a) Aspirin in mixture, not tablets. (b) Sodium salicylate with twice the quantity of sodium bicarbonate in each dose. Vaccines (stock). Have had little experience and no success. 7. I have never found any appreciable influence exercised by the use of sodium salicylate in chronic rheumatism. It frequently led to ear-ringing, occasionally deafness and also digestive disturbances. Aspirin is useful but depressing and is unsuitable for prolonged use. Undoubtedly sodium bicarbonate in large doses is useful in many cases. I have found that a combination of Salol and large doses of sodium bicarbonate is very useful. Certain cases seem to be due to some intestinal intoxication. I have found Salol and Yadil both act well, and this I put down simply to their intestinal antiseptic action. Curiously, sodium salicylate did not appear to me to have the same effect. One case did well with guaiacol carbonate, and one interesting case of a very chronic description and a " heart," which defied all other treatments, began to improve quickly with a vaccine prepared after bacterial investigation of the urine. Another similar case with chronic rheumatism and frequent and marked urticarial attacks did well with a somewhat similar vaccine, combined with administration of lactates. Another case with a chronic 38 history improved with urotropin. This leads one to wonder whether there is not a class of case due to pure " bacilluria," if I may use the expression. No gonococci or gonococcal history existed in any of these cases. A friend of my own derived much benefit from iodine ionization. I recently met a gentleman from Woodhall Spa. He confirms what you say about the prevalence of chronic rheumatism in Lincolnshire and the benefit derived at Woodhall. 8. The principal causes of ill-health in Deptford during 1922, were, to the best of my recollection, Measles and Whooping Cough in the earlier part of the year. What is chronic rheumatism precisely ? Chronic arthritis when the joints are disorganised, appears at any rate amongst the poorer classes to be little susceptible to treatment. In early cases 1 have sometimes seen great improvement and even cure in cases due to infection, by removal of the sources of infection, e.g., septic teeth, and the persevering use of Scott's ointment, strapping of the joint and the internal administration of guaiacum. 9. In Deptford, I have not noticed anything which could be mentioned in your Report, but as Senior Physician to the Eastern Dispensary and as Medical Superintendent to the East End Mission I have found large numbers of cases of chronic rheumatism, not only greatly improved bui in many instances quite cured by the following methods:—(a) Two hot baths a week. (6) Massage the affected part with hot soap suds every night, (c) Make a solution of Epsom salts, 3 ozs. in a quart of water. Dip flannel bandages in the solution and foment the parts for a few minutes. Bandage up the parts with the warm wet bandages. Protect the body from being wet. Keep the bandages on all night. In the morning use only the soap massage. Keep the parts wrapped in dry flannel. Drugs. 1 find the following very beneficial: Equal parts of sodium salicylate and potassic iodid mixtures. Add white mixture if there is constipation. In three weeks I have seen wonderful results, but if the case is of old standing, six or eight weeks elapse before improvement is noticed. 10. Chronic rheumatism is elusive, both in its nomenclature and essence, and I scarcely know exactly to what condition you refer. If you exclude articidar rheumatism, e.g., later stages of acute rheumatism, localised muscular rheumatism, stiff neck, pleurodynia, lumbago, etc., peri-neuritis (sciatica), fibrositis and contraction of fascia, rheumatoid arthritis and osteo-arthritis, what have you left except those subjective, shooting, transient pains often complained of, and I suppose 89 real enough, and popularly called rheumatism ? Salicylates are not of much use in treatment. It is I suppose a sort of disseminated muscular rheumatism without physical signs, and is quite common. Some of my panel patients find it quite useful. 1 treat with occasional purgation with sodium sulphate, attention to pyorrhoea and warm clothing. COMMENT. It is clear from these replies from my brother medical men in practice (and one was written from a sick bed), that it would benefit the nation if these able men eould work in "teams," and to a certain extent in consultation centres. A focussing of intellect, experience and ability and a combination of talents, what could this fail to do for humanity ? One hears talk of a State Medical Service, and whosoever would discuss this must walk warily and come armed with knowledge. Hut a few years ago, within the ken of our senior practitioners, there were no clinics, no tuberculosis dispensaries, no welfare centres and many infectious diseases were treated at home. A man passed through the university and acted as a house surgeon. He bought a practice. Fever hospitals sprang up, clinics opened, maternity homes evolved and a new generation of semi-State medical officers came into being. The older doctors saw their living threatened, their sphere encroached upon and they became suspicious and afraid. The more recently qualified man has been educated contemporaneously with the clinics era : his purchased practice has been acquired with full knowledge. The National Insurance Act has helped him. What, then, of the future ? Whatever be in store, it is to be hoped that individuality will not be sidetracked, that ability and activity will not be discouraged. The time, however, has surely come when " team " work must prevail. It is overdue. Look at the K.A.M.C. work in the war. I am not suggesting this as a model but as a very useful guide. There were, say, forty doctors in a hospital. There were one or two experts in bacteriology and pathology, two experts in eye work, some two outstanding men in surgery and two in medicine, two dentists, an X-ray department, visiting consultants. Some thirty doctors formed the backbone, the first line of attack upon disease. This organised body of knowledge was good for the patient. Good though our peace-time service is, it would seem that the time is ripe for development, for " team " work and consultation centres. There is a something awanting. There should be an annual overhaul of every citizen ; he should not wait until he is ill. Look at the doctors' replies 40 on chronic rheumatism. How many people are suffering from rheumatism simply because there is no half-yearly dental inspection ? Look at the suggestion they make that rheumatism is more especially a poor man's disease. We need more research. Is the poor man rheumatic because he is underfed and wrongly fed, or because his nervous system is deranged with worry, the lack of sunshine, good housing and an annual holiday ? We read that some cases of rheumatism could be cured with a vaccine. Is the cost of a vaccine within the reach of the conductor of that tramway car passing my window ? We need a broader basis, greater facilities for all, team work and consultation centres. We need convalescent homes and holiday centres. In short, we need more preventive medicine for the benefit of the public health. Summary of Nursing Arrangements, Hospitals and other Institutions Available for the District. Professional Nursing in the Home.—General, (l) There is one nursing home in the Borough, situated in Tressillian Road, Hilly Fields, Brockley, to which surgical and medical cases are sent by medical practitioners. On emergency, a maternity case can be taken to this home, but surgical and medical cases form the greater bulk of those admitted. Nurses can be obtained from this home to visit at the patients' own houses. No definite statement can be made, but as Deptford is an industrial area chiefly, it is likely that very few surgical and not many serious medical cases are treated in the patients' own homes. (2) The St. John the Divine Nursing Association, situated in Watson Street, New Cross Road, is recognised as a power for good. The staff consists of a sister-in-charge, two general trained nurses and two certified C.M.B's. All live in. Their services are obtained through doctors, clergymen and private persons. The staff covers a wide field in its operations and touches upon a portion of Greenwich at Creek Road and Princes Street. Practically the whole of Deptford is covered excepting St. John's and Brockley. This Association is honoured by all and simply cannot be dispensed with. (3) St. John's and the Congregational Church in Lewisham High Road enjoy the services of a nurse who resides in Upper Brockley Road. No midwifery is undertaken. A. Hendry. Photo. New Cross. Mrs. B. and her fourteenth baby, Nora Veronica, age 1 1 months. Weight 20 lbs. 4 ozs. Weaned 2 months ago. 41 (4) The Deptford Mission, too, have a nurse, whose sphere of work is probably chiefly east of High Street; the harder the district the greater the honour. (5) Two nurses are attached to St. James' Church, their headquarters being in Pagnell Street. Hospitals. (l) The Albury Street Sick Babies' Home is situated in Albury Street, off High Street. In 1922 the 8 cots were increased to 16. These are intended chiefly for infants, but a few children up to 5 years of age are admitted. The Deptford Borough Council has increased its subscription from £200 to ,£"400 in 1922, in view of the fact that the Conncil now has 8 cots at call in place of four as formerly. Cases are sent in by the Maternity and Child Welfare Medical Officer and the Medical Officer of Health direct from the Infant Welfare Centres, or following upon information brought to us by the Health Visitors. We send in cases of pneumonia, bronchitis, marasmus, debility, the intractable dyspepsias, etc. Infectious diseases are not admitted. This Babies' Home is a God-send without a doubt, situated as it is in the heart of our East Ward, in which ward our Infant Mortality-rate is 112, the highest in the Borough. The East Ward contains many who are living grey lives indeed. In his " Children of the Dead End," Patrick Macgill told us of the lives of the navvies at Kinlochleven, a sordid story of hard, physical toil, of drink, gambling and fighting, of men who, some of them, knew little or nothing of God. I am not suggesting that these conditions are comparable with our Giffen Street area, but there is an echo. East of High Street we have hawkers, men who live off the barrow, who sell wood, roast chestnuts, anything and everything. I have no room here to enlarge upon the lives of our friends who throng to the Princess Louise Infant Centre on Thursday afternoons. Miss Margaret McMillan touches upon the subject in her grand book on The Open Air Nursery School. There is a network of agencies, of different religious bodies, and the workers are by no means few, but how can you expect to raise folks living under conditions of overcrowding and in cheerless surroundings. Unemployment, poverty and despair knock the heart out of many. The " dole " and the Guardians help to save the situation. From such homes, and others, we send in babies. A mother comes to the Infant Welfare Centre and brings in her child to me. For three days he has been " hangy " and he won't take his 42 milk. There is a greyness, tinged with blue, on his face; the respirations are hurried, he pants, and the alae nasi move out and in. There is dullness on percussion here and there at the back of the lungs— broncho-pneumonia. A letter is written to the Matron at the Babies' Home and away the child goes. Should our cots be full, Mr. Cornish, Clerk to the Guardians, and Dr. Wiggins, of the Greenwich and Deptford Hospital, stand by us. In 1922, the Day Nursery building, run in conjunction with the Babies' Sick Home, was given over to be used as a home for the staff at the Sick Home. This was necessary, as the extension of the Sick Home encroached upon the nurses' rooms. A room was kept to be used as a day nursery, but seemingly the number of applicants has gone down. 1 trust that the Day Nursery will be resuscitated and that the necessary financial backing will be forthcoming to help the Directors on the Sick Home Committee who have done so admirably and so much for the Borough. Where a husband was out of work, it was no uncommon thing for the mother to do a day's charing and leave the baby at the Day Nursery. Has employment improved to such an extent that the need for the Day Nursery has disappeared ? No. Perhaps more toddlers are now attending the Rachael McMillan Memorial Open Air Day Nursery School, so diminishing the need for the Day Nursery. This subject needs a little more thought. (2) Many people attend the general hospitals. Of these, the Miller Hospital, situated in Greenwich, is a great boon to our people. It is equipped and prepared to treat any condition at any time. Some go to Guy's, King's College Hospital, St. Thomas's, the Ophthalmic and Sick Children's Hospitals and St. John's Hospital, Lewisham. The Greenwich and Deptford Hospital receives many of our sick poor including some suffering from tuberculosis. The Clerk to the Guardians is one of the friends of the public health in Deptford. His unfailing courtesy and sympathy stamp him as a true friend to the sick poor. Individual Guardians, too, such as the Mayoress, Mrs. Councillor Tiffen and Mrs. Drapper, J.P., Chairman of the Health Committee, have only to be appealed to to render yeoman service. Not every mother can find fifteen shillings a week to pay for a change at some seaside home. The Guardians have repeatedly sent away some overwrought mothers, threatened with tuberculosis, to a convalescent home, what time the children are well cared for at the Guardians' Home, Sidcup. 43 I labour this matter of the Greenwich and Deptford Guardians; as 1 have found them, they are one of the most humane bodies I have met. Infectious Diseases, Nursing at Home,—Very few of the major infectious diseases are nursed at home. Of the so-called minor diseases, such as measles and whooping cough, a few measles cases are taken to the Metropolitan Asylums Managers' hospitals, but most are nursed at home. Measles became notifiable in Deptford in September, 1922. Cases are visited by the Health Visitors, and on their report the Medical Officer of Health engages the services of a Ranyard nurse who is paid by the Borough Council. We learn of whooping cough cases through intimations from head teachers. The Health Visitors visit such cases as their already extensive duties permit. Midwives.—These are under the supervision of the London County Council. There are some nineteen in the Borough, of whom five are at the Municipal Maternity Home. No subsidy is paid to midwives locally. Clinics and Treatment Centres {see Table).—The Infant Welfare Centres are held in halls let to us by different religions organisations. There are two exceptions, viz., the Goldsmiths' Centre, held in a classroom at the Goldsmiths' College, London University, Lewisham High Road, and at the Princess Louise Centre, Hales Street. Until 1922, the last-named Centre employed its own medical officer, but during that year the Medical Officer of Health was appointed to carry out the Thursday afternoon consultations. The Borough Council, which also supplies two Health Visitors on Thursday afternoons, gave a grant of £20 to the Deptford Fund to help this Centre. Excep tfor the staff as described, this Centre is the only voluntary one in the Borough. In the six Infant Welfare Centres there are voluntary workers whose admirable work is prized by the Council and officials. There are consulting rooms for the doctor at each Centre (except at Erlam Road, where a portion of the room is curtained off). At this Centre, consultation work is not easy owing to the noise. Further consideration of this point is necessary. Until 1922, one Ante-Natal Centre was held in the morning at the Napier Street Centre. A second session was opened on Wednesday forenoon in view of the increased numbers attending. At an early date a third session will have to be faced. Dr. Hill attends from 10 a.m. 44 until 1 or 1.30 p.m. In addition to the ante-natal examinations, any urgent cases from any of the Infant Welfare Centres are seen on Wednesday forenoon at this Centre, where test feeds, Truby King methods, etc., are carried out and explained respectively. People are now learning that it is little short of a crime to allow a woman to face her confinement without careful ante-natal examination and re-examination. At a discussion on this subject at the New Cross Medical Society, the general feeling in favour of ante-natal examination of expectant women was a strong one, but there was a little hesitation expressed, as it was felt that if medical men advised ante-natal shepherding, there might not be wanting those who would take some exception to this " innovation "; indeed, some might even say there was a pecuniary side to the suggestion. Grossly unfair, of course, but if people will flout their advisers they must blame themselves if their wives are carried off with eclampsia or some other complication. Our midwives are now making such examinations, and if some abnormal condition is found, they come with their patient to Dr. Hill at the Centre. The Tuberculosis Dispensary at Hilary House, 78 Amersham Vale, is the property of the Borough Council. No dental work is carried out in the case of patients suffering from tuberculosis. The Ministry of Health have refused to sanction this expenditure twice during the last two years. I regret this decision very much, especially as permission for this expenditure is allowed elsewhere. Dental work for nursing and expectant women is carried out by Mr. McGraw, surgeon dentist. An inspection clinic is held every second month, and a treatmeat clinic similarly. Urgent cases arising in the interim are sent to the Miller Hospital and Guy's Hospital. New Cross. Photo. A. Hendry. The Princess Louise Infant Welfare Centre, Hales Street. 45 Table XXII. clinics and treatment centres. Maternity & Child Welfare. Venereal Diseases. (l) infant Consultations. Miller Hospital, Greenwich, S.E. 10. Daily from 2 p.m. Male and Female, Daily, 8 a.m. to 8 p.m. Monday, Gosterwood Street St. John's Lewisham, Morden Hill, S.E. 13. Tuesday, Napier Street Wednesday, Erlam Road Male and Female, Daily. 9 a.m. to 10 p.m. Thursday, Goldsmiths' College Do. Princess Louise Institute, Hales Street Guy's Hospital, St. Thomas Street, S.E. 1. Friday, Besson Street Various hours, daily, except Saturday. (2) Ante Natal Clinic. From 10 a.m. to 1 p.m. King's College Hospital, Denmark Hill, S.E. 5. Tuesday, Napier Street Wednesday do. Various hours, daily, except Saturday. special infant consultations. Wednesday, Napier Street. 11 a.m. Dental Inspection. School Clinics. Alternate months at Tuberculosis Centre. Deptford School Treatment Centre Deptford Green Eye and Minor Ailments (Eye) Tuesday and Thursday, 2 p.m. Dental Treatment. Alternate months, Albury Street Clinic (Rachael McMillan). Do. Ear. Minor Ailments Friday. 2 p.m. Operations Monday, 2 p.m., at Cyril Henry Centre, Woolwich Do. Skin Ailments Wednesday, 2 p.m. Tuberculosis Dispensary. 20 Albury Street Teeth Monday, 9.30 a.m. and 1.30 p.m Tuesday, 1.30 p.m. Wednesday, 1.30 p.m. Thursday, 1.30 p.m. Friday, 9.30a.m., 1.30p.m. Gas, Tuesday, 9.30 a.m. Inspections, Wednesday and Thursday, 9.30 a.m. Monday, 9.30 a.m. to 1 p.m. Men Tuesday, do. Women (Monday, 2 p.m. to 3 p.m., Children not at School) Tuesday, 6.30 p.m.-7.30 p.m., Men at work. Day Nursery. Albury Street (Closed at present) Wednesday, 9.30 a.m. onwards, Secretary's Consultations. Thursday, 9.30 a.m.-l p.m., Men Friday, 9.30 a.m.-l p.m., Women. Day Nursery School. (Open Air) Friday, 6.30 p.m. to 7.30 p.m., Women at work. The " Rachael McMillan " Memorial School. 46 Other Institutions. The Charity Organisation Society, 11 Amersham Road, puts in a hard year's work, which can only be appreciated by a perusal of the Annual Report. Admirably administered and executed with precision, the work of this Society bears the impress of the character and personality of Miss Marchant, ably supported by Miss Malin, the Secretary. The Red Cross has come to the aid of many in the Borough. It is not possible to do justice by simply quoting isolated cases ; the Annual Report must be studied. The Invalid Children's Aid Association helps, supervises and, where possible, cures seriously invalided and crippled children of the poor by obtaining for them the best medical treatment and giving them the means of obtaining a livelihood in the future. Miss Carruthers, the local Secretary, has helped us immensely by sending away children to convalescent homes, etc. Hostels.—During 1922, two hostels were opened in the Borough, one for women in Amersham Vale, and one for men, the latter under the auspices of the Deptford Central Mission. Hospitals Provided or Subsidised by the Local Authority in this District. (1) Tuberculosis. Cases put forward from our Tuberculosis Dispensary are sent by the County Council to various sanatoria, hospitals, etc. The Greenwich Board of Guardians send cases away also. (2) Maternity. The Municipal Maternity home is discussed elsewhere. (3) Children. The Albury Street Sick Babies' Home locally, and hospitals such as Vincent Square, Evelina and Great Ormond Street. (4) Fever. Metropolitan Asylums Board's Infectious Diseases Hospitals. Institutional Provision for Married Mothers, Illegitimate Infants and Homelp:ss Children in the District. Rest homes by the seaside, such as All Saints' Church, Margaret Street, provides, are taken advantage of by those married mothers who can pay a reasonably small fee. The Guardians similarly, send away cases. 47 Ambulance Facitities. (a) Infectious Cases.—Ambulance service is available for infectious cases at any hour of the day or night upon application to the Metropolitan Asylums Board, either at the Head Office, by telephone, or at any of the ambulance stations attached to the hospitals. The one situate in this Borough is in Old Kent Road, adjoining White Post Lane. (b) Non-Infections Cases. The ambulance service of the M.A.B. is also available for the conveyance of patients who are not suffering from infectious diseases, application being made in the usual manner. For such cases a charge of 10s. is made. The L.C.C. ambulances are available for use in street accidents, as also are the police ambulances. The L.C.C. Stations are as follows:— North End Road, Fulham. Buckner Road, Brixton. Herbrand Street, Russell Square. St. George's Market, London Rd Montclare St., Bethnal Green. Southwark, S.E. High Road, Lee. Woolmore Street, Poplar. For the conveyance of non infectious patients who are unable to pay the fees charged by the M.A.B., the Council made arrangement with the Greenwich Guardians for the use of their ambulance. The British Red Cross Society also have ambulances, stationed at St. John's Gate, Clerkenwell. A charge is usually made for their use, but in necessitous cases no charge is made. The London Ambulance Service is also available for the conveyance of expectant mothers for whom urgent necessity arises during the night, between the hours of 11 p.m. and 8 a.m. Application is made by telephone, and all patients booking at the Maternity Home are given a card of printed instructions with regard to these facilities. Laboratory Work at Seaman's Hospital, Greenwich. Material. Total Specimens examined. Number Positive. Number Negative. Swabs for Diphtheria 790 147 643 Blood for Enteric Fever 7 1 6 Faeces for Enteric Fever 1 – 1 Total 798 148 650 In addition to the above, 780 specimens of sputa were examined at the Council's Tuberculosis Dispensary, of which 133 were " positive " 48 and 647 were " negative." Diphtheria antitoxin is kept available at the Town Hall for practitioners requiring it in an emergency. Where the patient can pay for it, cost price is charged. In London, there is not the same great need for anti-sera at the Public Health Department as in the provinces, simply because when a practitioner sees a diphtheria case in a house he rings up the telephone and the case is removed to hospital rapidly, where the necessary serum is given. By-laws and Regulations of Borough Council 1. For the prevention of any nuisances arising from any snow, ice, salt, dust, ashes, rubbish, offal, carrion, fish or filth or other matter or thing in any street. 2. For preventing nuisances arising from any offensive matter running out of any manufactory, brewery, slaughterhouse, knacker's yard, butcher's shop or fishmonger's shop or dunghill into an v uncovered place, whether or not surrounded by a fence or wall. 3. For the prevention of the keeping of animals on any premises in such place or manner as to be a nuisance or injurious or dangerous to health. 4. As to the paving of yards and open spaces in connection with a dwelling house. 5. For securing the cleanliness and freedom from pollution of tanks, cisterns and other receptacles used for storing water used or likely to be used by man for drinking or domestic purposes, or for manufacturing drink for the use of man. 6. With respect to the keeping of waterclosets supplied with sufficient water for their effective action. 7. With respect to houses let in lodgings or occupied by members of more than one family. 8. With respect to the decent conduct of persons using the Public Lavatories and Sanitary Conveniences provided and maintained by the Council. By-Laws and Regulations made by the L.C.C. 1. Drainage by-laws. 2. Deposit of drainage plans. 3. Closing and filling up of cesspools and privies. 4. Removal and disposal of house and other refuse. 5. Removal of faecal and offensive matter by road. 6. Waterclosets, earthclosets and privies. 7. Ashpits. 8. Cesspools. 9. Receptacles for dung. 10. Conveyances of carcases of dead horses through streets. 11. Regulations as to Dairies, Cowsheds and Milkshops. A. Hendry. Photo. New Cross. A Breast Fed Baby. P.P. age 6 months. 20 lbs. 2½ ounces. 49 The Public Milk Supply and its Relationship to Science. Only a few years ago the farmer produced milk somehow and almost anyhow, and milk-borne disease claimed its place in the nation's bills of mortality and disability. To-day, although matters are far from perfect, there is just cause for believing that we are entitled to refer to the science of milk production. It is only by the education of the public that we will be able to procure the ideal milk supply. When the public know they will then demand, and the farmer who holds to old-fashioned methods must either sink or respond to the public's appeal. Come with me and let us con over some of those steps which prove that there is an awakening conscience. Those who criticise and jibe at the long years which have passed with apparently little improvement, must remember that no law can compel a farmer to produce milk, hence we find that in our latest Milk Act of 1922, Sir Alfred Mond himself said that it was a compromise Act, that if we made the conditions too onerous we would only get a smaller supply of milk and the position would be worse. He said that agriculture was much depressed, that the dairy industry was going through a crisis, and that landlords could not spend money in remodelling buildings. His Milk Act is calculated to leaven the whole, to teach the public that there is a good and a bad, and to make the consumer rise up and demand a better article. Already in Deptford we have seen, since January, 1923, firms and premises licensed to sell Certified Milk, as well as the usual doubtful fluid simply called Milk. What steps are being taken to produce a milk of blameless quality, of high chemical composition and of a satisfactory bacteriological standard ? You have all heard the names of the different breeds of cows. We have the Dexier, the Ayrshire and Jersey cattle, the Friesen, Kerry, Shorthorn, Guernsey, Red Poll and so on. The choice of a satisfactory breed, if you are starting a farm, is all important. It has been proved by Mackintosh, as a result of study spread over several years, of the data obtained at milking trials at the British Dairy Farmers' Show and at the Royal Agriculture Show, that it is possible to name those breeds which give :— (a) The heaviest yield of milk, (b) The best chemical composition, and to give farmers figures which help with regard to the cost of production. 50 The heaviest yields of milk are given by the Dexter, Ayrshire and Jersey animals. Chemical composition really means fat percentage, as all the other constituents, such as milk sugar, protein ash and water are classed as solids, not fat. The highest percentage of fat is given by the Jersey, Dexter and Guernsey animals The percentage of total solids is the best measure of the cheese making potentialities of the milk, and the best animals for this purpose are the Dexter, Jersey and Ayrshire cattle. Coming to cost of production, we realise that milk production is a business, it must be made to pay. The cost of milk production is dependent upon: (l) the cost of cows' food; (2) the cost of labour and the depreciation of animals through disease, such as tuberculosis. As to the Cost of Food, a cow's maintenance ration should be considered in relation to its live weight. So much of that ration is required for the cow's maintenance and so much for the production of the cow's milk. The outdoor cow needs more food than the indoor one, but the housed cow is not so healthy, and so the depreciation bill goes up. As to the Cost of Labour, The breed which is kept out of doors day and night, summer and winter, costs less in labour than the breed which is housed from October to May. Breeds kept in cold an exposed districts needing winter housing, cost more in labour than those kept in warmer and more sheltered districts. Depreciation depends on the cost of maintaining a herd at its normal size, replacing cows which have to be sold, or losses by disease and death. The scientific farmer is now able to define the actual cost of producing a gallon of milk. In the war years a Travelling Commission found that the cost of feeding cows formed 72 per cent. of the total cost of milk production in the winter, and 53 percent, of the total cost during the summer. The cow's ration is now calculated on scientific lines. This subject has been dealt with fully by Mr. Garrad, the Agricultural Organiser for Kent. The man who knows a cow simply as an animal which produces milk will be surprised to learn that in winter time she eats some 70 lbs. of food daily, made up of roots, hay, straw, wet grains, cakes and meals. Every county should have its Agricultunal Organiser. As an example of their value, take the case of Mr. Garrad, the Kent Organiser, He collected information from a number of farms through the milk recorders of the Kent Milk Recording Society, and he was at once struck with the enormous variations in the quantities of food given to the cows on the various farms. He found that the cost of food per cow per day and the cost of food per gallon of milk was at least three times as great on some farms as on others. 51 Farmers now write to Mr. Garrad giving him their returns, and he replies pointing out to this one that he is giving his animals too much food, and to another that he should alter the proportion of the food constituents, and so on. Now I have shown to you that the choice of a breed has been worked out on scientific lines, and the feeding is no longer conducted on haphazard lines by the modern farmer. He has his journals, his Conferences, his Shows, and his Ministry of Agriculture, and there is no excuse for conservatism any longer in this all-important industry. The production of clean milk fortunately has seized the imagination of numerous farmers, more especially as the cost entailed has not proved so great, and as the public has begun to show its appreciation : in short, keeping the business aspects before him, the producer is finding his market, inasmuch as the plain man has learned that he wants and must have clean milk. Clean milk is raw milk from a healthy cow produced in a hygienic way without contamination, sweet and safe. Clean milk does not sour in a few hours, but will keep for, say, three days. Nobody wants boiled stale milk, and yet we must still insist that if baby is fed on cow's milk the milk should be boiled and rapidly cooled. We desire sweet, palatable milk, but pasteurising is still advisable. We have not yet reached the goal of our desire, an educated and enthusiastic farm service and a public clamouring for the best. Still, things are improving. Three factors spoil milk:—(l) External contamination. (2) High temperature. (3) Age. Bacteria grow under such conditions and these sour and rot the milk. These germs may be disease-bearing or may cause souring. Dirt of course is to blame. A bacterial count, therefore, is a useful guide as to the purity of milk. To remove contamination, to avoid high temperature and to prevent age, we must concentrate on clean production, clean methods, reduction of temperature and speed in delivery. Dr. Orr told us in 1908 that 41 per cent. of the contamination was due to the producer's methods, and 58 per cent. was shared equally between the time in transit, the distributor and the home. To obviate these defects, the producer must have intelligent and interested labour and good raw material in the shape of strong healthy cows. In 1918, the United States Department of Agriculture said the following were the three main factors in clean milk production, as regards equipment (l) The sterilisation of utensils. (2) Clean cows, especially clean udd ers. (3) The use of covered or small-topped milking pails. 52 In this way a low bacterial count would be assured. Thorough cooling, not higher than 45° F., would then prevent further bacterial growth. Note how much we are in the hands of the worker. Labour must not be slack. A good head cowman is worth a good salary. The farmer must educate his hands and maintain their interest. He must show the workers the results of their work, both good and bad, he must show them reports of other farmers and rouse a spirit of competition. A bonus on a sliding scale should be paid the workers, depending on the bacterial count. Labour, then, is the most important point in the production of a clean milk supply. Equipment comes next. The dairy needs greater attention than the cowshed, because proper sterilisation has more effect than cowshed practice on the sweetness and keeping quality of the milk. Dairies and cowsheds alike need a good light by day and night. Dirt must be tackled. Paraffin pressure lamps will do for lighting. By day, windows and whitewash are needed for light as well as for disinfecting purposes. In the dairy, whilst smooth walls and floors are desirable, there should be hot and cold water, boiling water (or better still, steam) for sterilising the utensils, and cold water for cooling the milk. In addition to water and steam, we need steaming blocks or sterilising tanks, a cooler, brushes, soda and soap. Churns should be carefully chosen and should not hold more than ten gallons. Straining should be done in the dairy and straining cloths must be boiled thoroughly after every milking. The best strainer is a cotton wool pad used once then thrown away. Cowshed equipment includes dandy brushes and combs for grooming the cows, and ordinary barbers' clippers for the udders and the tail. Wash pails are needed, and both rough and fine cloths for wiping the cows. Covered milk pails keep out 40 per cent of the dirt. An ample supply of water is essential and is more important than reconstruction of mangers, standings and gutters, useful though these latter are. The health of his cattle is the farmer's prime care, especially freedom from chills or blows which cause inflamed udders. Inflamed udders lead to milk swarming with bacteria. The Medical Research Council has appointed a Tuberculin Committee, with which the Ministry of Health is co-operating, in order to investigate the meaning of the results obtained by this test. Tuberculosis works great havoc every year amongst cattle, and tuberculosis in cattle is of the greatest economic importance to 53 tunal interests, apart from the serious question of tuberculosis in milk and its effect on the human race. Now we come to the actual application of these principles I have referred to as necessary for the production of a pure milk supply. Dung must be removed before milking. The cows are groomed with a wet brush and curry comb. Dry grooming makes dust. Wash the udders with a rough cloth, then wipe them with a soft cloth wrung out in clean cold water. Keep the hair on the udders clipped short. Having cleaned the cows the milkers wash their hands, repeating this operation if necessary during the milking. Milk dry-handed with covered pails, after rejecting the first few squirts from each teat, as they contain most of the bacteria. The cows' milk is removed to the dairy at once and is strained, cooled and run immediately into bottles and churns. The collecting tank must be large so that the milk from a number of cows gets well mixed: otherwise variations in quality will occur. The cooling need not be as low as 45° F. if the milk is clean. With milking finished, the utensils must be promptly rinsed with cold water and then washed with warm water and soda, again rinsed and sterilised with steam or boiling water. The cleaning of all utensils must be carried out both night and morning, special attention being given to the straining cloth. Everything must be protected from subsequent contamination. It is the labour and not the equipment which costs money. In estimating the cost of labour alone, Mr. Lejeune took the labour figures for 11 months for three farms run on exactly similar lines, except that one farm produced Grade A milk and the others ordinary milk of a good standard. All three farms had 70 to 80 cows and their yield was approximately the same. The figures showed that the labour cost per gallon at the Grade A farm was .9 of a penny more than the one farm and .7 of a penny per gallon more than the other. This was cowshed labour only and did not include work in the dairy on the Grade A farm, nor did it include bonuses on bacterial counts paid to the Grade A cowmen, whose wages were otherwise the same as on the other farms. The Clean Milk Movement is spreading. Clean milk competitions have been organised in several counties, and have helped to show farmers and their men what can be done. The small farmer is learning that the wealthy have not the monopoly of clean milk production. The new Ministry of Health grading regulations came into force in January, 1923, and these show that the principle is recognised of grading the milk itself rather than the place from which it comes. 54 The fixing of a definite bacterial standard for Grade A milk will help to establish confidence in it, once its significance is understood, and confidence is what is needed for the establishment of a sale and the expansion of the market. Certified milk will always be demanded bv those who want the best possible, and it serves as an education to others and shows what kind of standard can be obtained. Grade A milk shipped in bulk from the farm and bottled by the distributor, should meet the public demand for a reliable milk at a reasonable price. Much depends on the attitude of the distributing trade and on the ability of the dairy engineers to produce the necessary plant. Where the demand for clean milk exists farmers will be found to supply it. I am quite aware that many think it will be another 40 or 50 years before farmers as a whole will produce clean milk on the lines outlined, and that the public are barely interested in the subject. That is wrong. Let me recount to you the progress in Reading. The Berkshire farmers tested their herds with tuberculin. They co-operated with the National Institute for Research in Dairying at Reading. They followed clean milk production, and what happened ? Dealers would not buy it, and so the Institute opened a sale depot of their own. The people crowded to the depot to buy pure milk. The dealers saw which way the wind was blowing and now everybody in Reading is going to the five centres where Grade A milk from tuberculin tested cows is sold at a penny a quart above the ordinary price. Leicester City Council determined to buy pure milk for their hospitals and schools, and they are paying threepence per gallon more to get it. One would expect an enlightened body like the Metropolitan Asylums Board would buy Certified or Grade A milk for the Infectious Disease Hospitals. The ignorance of the farm labourer and the indifference of the public have much to answer for. Dr. Nash knew a man who had a herd of 120 cattle, producing milk which he supplied for many years to an institution which has a large business in London. He got this herd absolutely tubercle free and went to the directors of the institution and said: I can now guarantee every drop of milk as tubercle free," and the answer he got was, " That does not matter—What is the price ? " What surprises me personally is that we have surgeons operating on surgical tuberculosis cases in our London hospitals every day, and yet 1 have never heard of any of them demanding of the Board of Governors that Certified or Grade A milk only should be supplied to the hospitals. 55 The Ministry of Health, perhaps, will make a recommendation to that effect. If the Ministry circularised all local authorities to advise local hospitals and Institutions to use Certified and Grade A milk, a good step forward would be taken. The next point to be considered is variation in composition of Cow's Milk. Local Authorities take samples of milk for analysis, to see whether the fat is under 3 per cent., the minimum legal amount, and to see whether the non-fatty solids are under 8.5 per cent. the legal minimum limit for " milk." In Deptford, in 1922, we took 403 samples, and it was found that nine were adulterated. Five prosecutions led to fines and costs amounting to £15 9s. The Public Analyst's report shows the deficiency. It is not for the Borough Council to explain how this deficiency has arisen, but it is for the milkman when he is prosecuted. Sometimes the Council rests satisfied with a warning letter, providing that the discrepancy is a small one ; otherwise a summons is taken out. If the milkman can prove that he sold the milk as he received it under a written warranty, he is exempt from punishment. Now the milk roundsman, retailer or distributor often brings forward various excuses putting the blame of the deficiency on the cow. No Authority wishes to prosecute an innocent retailer, but the trouble is that this world contains some people who are not so very innocent after all. Let us then consider the variations in the composition of cows' milk, for in so doing we are considering the excuses sometimes put forward by the solicitor for the defence. We know that on the average milk contains roughly 1/8 (one-eighth) of its weight of " total solids " and seven-eighths water, the "total solids" consisting roughly of threetenths fat and seven-tenths non-fatty solids. Expressed in percentages the average milk consists of—water 87.4 per cent., fat 3.7 per cent., and non-fatty solids 8.9 per cent. Total solids 12.6 per cent. The yearly average composition of milk does not vary at all widely in different localities or in different years, but in any one year there is an appreciable variation in seasons as brought out by the monthly average. There is a low fat percentage in the summer months and this is due to some extent to the greater average volume of the milk from the cow at this period of the year. This fluctuation is only present in a minor extent so far as the non-fatty solids are concerned. 56 Now as regards daily variation in respect to percentages of fat and non-fatty solids, these are small and unimportant. But if we analyse morning and evening milk we find an astonishing figure. Dr. Crowther showed that morning milk was quite frequently below the legal limit in fat, and in the evening milk the fat was considerably above. The fat variation as between morning and evening milk is very large relatively. I shall deal with this important point more fully later. Let us examine the natural causes of variations. Take 1. Individuality. Admitting that the milk-yielding capacity of cows varies greatly, there is no doubt that some difference in the quality of the milk does take place, though it is a sweeping statement to make that heavy milk production must necessarily be accompanied by low quality. The effect of individuality on the composition of the mixed milk of the herd varies with the size of the herd and is to some extent controllable by careful selection of the cows for quality of milk. 2. Advance in Lactation. The quality of the milk yielded by the cow gradually improves as lactation advances, at any rate after the first month or two. If a herd of cows have calved at about the same time there will be differences in the composition of the mixed milk at different periods. 3. Age. Age is frequently blamed for poor quality of milk, but the decline in quality due to advancing age of the herd is very gradual, and over a range of ten years probably does not amount on an average to more than 0.2 or 6.3 per cent. of fat. These are the natural causes of variation. Turn now to the artificial causes. The most influential of these is the interval between milkings. If the intervals between successive milkings are approximately equal, the morning and evening milks are practically identical in quality. The longer interval is almost invariably the night one, and so the morning milk is relatively poor in fat, whilst the evening milk is correspondingly rich in this ingredient. The remedy is apparently simple, but its application is said to be beset with difficulties. The consumer wants his milk from the cow between 7 and 8 a.m., and in the afternoon between 4 and 5 p.m. This means an early afternoon milking, and so if the intervals between milking are to be equal, there must be milking in the small hours of the morning. The farmer has difficulty in securing efficient milkers who will carry out milking at such an early hour. A second artificial cause for variation is imperfect milking. As the milking proceeds, the quality improves. Hurried or incomplete milking leads to a milk of a lower quality. 57 Feeding, or the influence of food on the cow is given as a cause of variation in quality, The defendant in a prosecution case frequently blames the cows' food. It might be said that starvation is the only condition which will make an appreciable influence in the variation in quality. Some blame the giving of too much water to the cow, but it is probable this only takes effect when the amount of water given, high or low, reacts detrimentally upon the general welfare of the animal. Despite this, we hear of defences in which it has been alleged that fresh young greens in the spring, wet brewers' grains and mangolds have produced more milk but of lower quality. It would seem that there is room for further investigation into the causes of fluctuations in quality and for endeavours to remove them by more efficient organisation and handling. It has been suggested that milk should be sold on a butter fat percentage basis, but as to how this could be done no one seems to know. The administrative difficulties are well nigh impossible on the grounds that very frequently you could not get a regular and fixed percentage of butter fat. I have said nothing, or very little of the gentleman who, when taking round a cart of milk and being desirous of saving a quart of milk for a friend, stops by the wayside pump to replenish the churn. To-day, in Deptford, Certified milk is sold at 1s. per quart, but in Reading, Grade A milk is sold at 9d. Ordinary milk is sold at 6d. Perhaps most of the milk sold in the Borough may be said to be subjected to a certain amount of pasteurising, but no firm is legally entitled (not being licensed) to say that its milk is legally pasteurised. Pasteurising means that the milk is subjected to a temperature of 145° for not less than half-an-hour. If a firm takes out a licence to sell pasteurised milk, then that milk, when sampled for bacteriological purposes, must not contain more than a certain number of germs in a cubic centimetre (about 15 small drops). If a household cannot afford to buy Certified or Grade A milk (and only a few can) they should bring up the ordinary milk to the boiling point and cool it rapidly, then cover the milk jug with a plate and keep the jug standing in cold water. The purity of the milk supply is in the hands of the public. Meanwhile, it is the firm conviction of Medical Officers of Health that dried milk for infants and children up to five years of age has solved many difficulties and is a great boon. 58 Where dried milk is used, some orange juice should be given daily. Of course, infants under nine months should be fed "on the breast." Nothing can hope to rival breast milk. No mother should refrain from breast feeding except on medical advice. TUBERCULOSIS. "Specify the ratio of non-notified tuberculosis deaths to total tuberculosis deaths, and add a note as to the efficiency of notification of tuberculosis in the district, and the action taken, if any, including particulars of any proceedings taken in cases of wilful neglect or refusal to notify." (Note from Ministry of Health's circular). In 1922, twenty-five deaths occurred from cases of Pulmonary Tuberculosis not notified during life, and eighteen deaths from other Tuberculosis not notified. The deaths from Pulmonary Tuberculosis were 133 and from other Tuberculosis 31. The notifications of Pulmonary Tuberculosis were 208, and from other Tuberculosis 75. Practically one death in six of Pulmonary cases was not notified during life and more than half the other Tuberculosis cases. The attention of the Council was drawn to the failure of practitioners re notification to the Local Authority. It was pointed out that in 1921, forty-three deaths occurred of cases not notified during life. It was felt that it might be difficult to prove wilful neglect on the part of a medical practitioner who had failed to notify a case which had terminated fatally, inasmuch as he might in defence plead that he was not aware that the patient was suffering from the disease. It was agreed that representations should be made to the Ministry of Health to amend the Regulations by prescribing a penalty for failure to notify, as is the case of other infectious diseases under the Public Health (London) Act, 1891. The Ministry replied by referring the Council to paragraph 6 of circular 194, issued on the 4th April, 1921, and suggested that unless any recent action had been taken by the Borough Council to direct the attention of all medical practitioners practising in the borough to the importance of strict compliance with their obligations under Article V of the Public Health (Tuberculosis) Regulations, 1912, this should now be done. The Ministry pointed out that under the Public Health Act, 1896, penalties are recoverable for wilful neglect or refusal to carry out the 59 Tuberculosis Regulations. The Ministry finally suggested that proceedings might properly be taken with a reasonable likelihood of success where a practitioner certifies a death is due to tuberculosis, although he has failed to notify the case prior to death, especially if the Borough Council have previously taken the steps of informing the practitioners of their obligation to notify. It appears to the Minister that prosecution even in one or two cases of this kind might have a very salutary effect and probably do much to secure the object which the Borough Council have in view." The Council decided to draw the attention of practitioners to the provisions of paragraph 6 of the Circular 194 of the Ministry of Health, and to inform them that in accordance with the Ministry's view contained in that letter, the Council will regard any case where death is registered as due to tuberculosis, which was not notified to the Council before decease, as wilful neglect or refusal to conform to the Public Health (Tuberculosis) Regulations 1912, and that action may be taken in such cases for such neglect. No doubt a practitioner feels that if he notifies a case of Tuberculosis, this may give offence to the family concerned. At the same time what chance has a Local Authority in its efforts to stamp out Tuberculosis if the practitioner does not notify ? A Medical Officer of Health is placed in a difficult position with his brother practitioners. He can either let the matter slip which is, or ought to be, damaging to his self-respect and his sense of loyalty to his authority, or else he can do his duty and consequently find trouble with his fellows in practice. It must be apparent to the Ministry of Health that the notification of Tuberculosis is not what it ought to be. Would it not be possible for the Ministry to call for monthly returns from each authority of deaths from Tuberculosis not notified during life, and to take proceedings themselves ? 60 METROPOLITAN BOROUGH OF DEPTFORD. Public Health (Tuberculosis) Regulations, 1912 and Public Health (Tuberculosis) Regulations (No. 2), 1918. Summary of Notifications for the period from 1st January, 1922 to 30th December, 1922. Notifications on Form A. Notifications on Form B. Number of Notifications on Form C. Age Periods. * Total cations on Form A. Number of Primary Notifications. Total Notifications on Form B. Cases admitted to 0-1 1-5 5-10 10-15 15-20 20-25 25-35 35-45 45-55 55-65 65 and up Total Primary Notifications. Poor Law Institutions. Sanatoria. Under 5 5-10 10-15 Total Primary Notifications, Pulmonary— Males ... 1 5 1 9 18 35 21 17 10 2 119 146 ... ... ... ... ... 16 94 Females ... 1 4 4 11 20 24 12 7 4 2 89 110 ... ... ... ... ... 14 56 Non-Pulmonary Males 3 6 11 3 ... 6 3 4 ... ... 1 37 40 ... ... ... ... ... ... 11 Females 8 14 9 1 1 ... 1 1 1 ... 36 44 ... ... 2 2 2 ... 8 61 Table XXII. Metropolitan Borough of Deptford. Return of work carried out in connection with the Tuberculosis Dispensary for the year 1292. Number of Examined for the first time during the year. Found to be Under observation at the Dispensary on Dec. 31, pending diagnosis. Ceased attendance before completion of diagnosis, Suffering from Tuberculosis. Not suffering from Tuberculosic. Pulmonary. Non-Pulmonary. (a) All persons (including " Contacts ") Adults M 149 50 2 87 8 2 F 183 52 3 118 8 2 Children under 15 M 155 0 6 144 4 1 F 144 4 10 125 5 0 Total 631 106 21 474 25 5 b) " Contacts included in (a) Adults M 32 3 0 28 1 0 F 48 4 0 41 2 1 Children under 15 M 71 0 2 69 0 0 F 80 1 3 76 0 0 (c) Insured persons included in (a) M 122 37 1 76 6 2 F 67 24 0 40 2 1 1 Number of patients under treatment or supervision (excluding persons under observation or domiciliary treatment) on the 31st December 485 2 Total number of attend- ances of patients at the Dispensary during the year Insured 2137 Uninsured 2422 3 Number of persons placed during the year under observation at the Dispensary for the purpose of diagnosis 356 4 Number of cases in which the period of observation at the Dispensary exceeded two months 24 5 Number of insured patients under domiciliary treatment on Dec. 31st 43 6 Number of reports received from Insurance Practitioners in respect of insured patients under domiciliary treatment during the year 14 7 Number of persons referred to affiliated hospital for consultation 8 Number of consultations with medical practitioners at the homes of patients Insured 2 Uninsured 6 9 Number of other visits paid by Tuberculosis Officers to the homes of patients 427 10 Number of visits paid by Nurses or Health Visitors to the homes of patients for dispensary purposes 3343 11 Number of specimens of sputum examined in connection with the work of the Dispensary 780 62 form has been devised, and this is prepared monthly for the Public Health Committee. In last year's Report, the Dispensary work was described by Dr. Donnelly. It is proposed this year to discuss the duties of the Secretary and the work of the Tuberculosis Care Committee. Miss Baird, Health Visitor, was appointed the first Secretary to the Tuberculosis Care Committee. One cannot dissociate a statement as to her duties from the Committee's work ; the publication of these may be useful, as there are very few other stipendiary Secretaries in this country. Reports re cases in sanatorium or nospital are sent periodically to the Secretary, dealing with children ; Miss Baird submits them to the meetings of the Deptford Tuberculosis Care Committee. Sometimes circumstances arise which make it desirable that a report on an adult patient should be obtained for the Tuberculosis Care Committee. In such cases the information is obtained from the London County Council. Assessments. Where a patient is recommended for Sanatorium treatment, the Secretary visits the home and ascertains the financial circumstances. In certain cases no assessment is made. (a) Where in the case of an insured person who is the head of the family, and whose income is the main support, the family income would be sensibly reduced. (b) An ex-service man in respect of whom the Ministry of Pensions will defray the cost of treatment. In other cases the Tuberculosis Care Committee weigh the income and circumstances of each family carefully, then assess accordingly. Concerning children, the assessment made is about equivalent to the cost of maintaining the child at home, provided the circumstances appear to justify the same. Future Employment of Returned Cases. With unemployment rife amongst healthy men, one can understand what a difficult task it is for the Care Committee to find suitable occupations for those whose working capacity has been reduced by Tuberculosis. 63 Every case on returning from the Sanatorium is visited by the Secretary who ascertains his future plans as regards employment. In some cases the former employers have been approached as to reemployment of patients, whilst others have been referred to the Red Cross for assistance in commencing out-door work, such as crockery stalls ; still the employment of ex-patients is without doubt somewhat of a difficulty. In the case of women ex-patients, many are willing to become domestic servants, but many employers are unwilling to have exSanatoria patients in their homes. It has been suggested that positions for women who are able and suitable might be found in Sanatoria and Hospitals, and that two ex-patients possibly should do the work of one ward maid. The question of accommodation has been brought forward as a drawback, but it is hoped that something may yet be done in this direction. Where returned patients are dressmakers, they are advised to carry on their occupations in their own homes, provided plenty of fresh air is possible ; failing this, the Care Committee endeavour to place those patients in suitable posts, near home where possible. In co-operation with the Charity Organisation Society, ex-patients with limb deformities are trained for suitable employment, e.g., fine needlework. To Sum up the Secretary's Duties. She visits all cases before and after treatment in Sanatoria, and if necessary she visits the family during the patient's absence. She completes and forwards to the London County Council reports on environmental conditions. Home enquiry forms are submitted to the Care Committee for assessment of contributions and are then sent to the County Council. She collects and sends to the London County Council all contributions for Hospital or Sanatorium treatment. Should patient's circumstances alter, she reports this to the Care Committee so that an alteration may be made in the assessment for recommendation to the London County Council. She co-operates with charitable and other bodies with a view to assisting patients and their families pro re nata. She endeavours to find suitable occupations for patients, or for the patient's wife while he is in a Sanatorium, if circumstances render this course desirable. In cases where extra beds and bedding are required, she gets in touch with the Charity Organisation Society or the Red Cross. 64 She brings to the knowledge of the Care Committee all necessary facts relating to the patient or his family, and acts on its decision or suggestion. Need for a Fund. It is manifest that though the Guardians and the Charitable Societies do everything possible to assist in tiding patients and their families over economic difficulties, none the less one feels the need of a fund to aid certain cases. Thus, where a mother wishes to visit her child resident at a Sanatorium, part payment, at least, of the fare could be made. There are necessitous cases too which might be helped, and a little advertising for employment might be attempted, tentatively by way of a start. When a father is admitted to a Sanatorium, the Insurance Benefit which helps the wife and family, can be supplemented by assistance from the Guardians (or it may be that the Red Cross assist the family of an ex-soldier), but what of the family where it is the mother who has to go to the Sanatorium ? The family income remains the same, but the expenditure is much increased as the father has to pay for some help in the home. It is in such a case that a Fund would be a great help. Outfits for necessitous patients going into Hospital or Sanatorium are given by the Red Cross in the case of ex-service men, and in respect to others, by the Charity Organisation Society. The Deptford Tuberculosis Care Committee consists of twenty-two members. Six of these are Aldermen or Councillors (but one of the Councillors sits as a Guardian's representative, another represents the Soldiers and Sailois Families Association). Other representations are : Guardians (total 2); London Insurance Committee; District Nursing Association; Invalid Children's Aid Association; Lady Almoner, Miller Hospital; Panel Committee (doctor); Friendly Societies; Trade Unions; Local Charitable and Social Organisations (3); Medical Officer of Health; Tuberculosis Officer; Divisional Medical Officer; School Care Committee Organizer; War Pensions Committee. General Sanitary Administration. Work of Sanitary Inspectors. During the year the District Sanitary Inspectors made 25,522 visits in all to 5,684 premises. 1,836 systematic house-to-house inspections were made. Numerous sanitary improvements and repairs were effected, as shown in the following table:— 67 METROPOLITAN BOROUGH OF DEPTFORD. ANNUAL REPORT OF SANITARY INSPECTORS FOR THE YEAR 1922. Table No. XXIII. Number of District. 1 2 3 4 5 6 7 Totals Complaints Received 16 48 43 24 63 48 23 265 House-to-house Inspections. 324 380 361 292 65 168 246 1836 Total Premises Inspected 806 784 831 801 793 930 739 5684 Re-Inspections, Calls, Service of Notices, &c., &c. . 2760 3552 2737 2625 2725 2921 2518 19838 Inspections under notice from Contractors, per Bye-Laws 13 9 34 16 64 17 17 170 Number of Cases in which Proceedings have been taken 1 ... ... ... 2 3 ... 6 " Intimations " Served 513 363 536 498 373 507 462 3252 " Statutory Notices" Served 8 42 35 31 14 29 29 188 Notices served under Section 28 Housing, Town Planning, &c., 1919 2 ... ... ... 2 ... ... 4 Number of houses in which work was carried out by Sanitary Authority in default of owner ... ... ... ... ... ... ... ... Number of houses upon which closing orders became operative ... ... ... ... ... ... ... ... Water Closets— Old Closets abolished ... 2 ... ... ... ... ... 2 New Closets provided ... 2 ... ... 2 ... ... 4 in Workshops ... ... ... ... ... ... .. ... Basin and Trap provided 49 17 61 26 86 24 14 277 Water Supply provided 7 20 ... ... 1 ... ... 28 Water Supply Apparatus provided 79 6 31 ... 1 ... 23 140 Limewashed 60 6 45 42 ... 32 36 221 Walls Repaired 62 4 33 47 ... 12 24 182 Floors Repaired 9 ... 3 1 3 2 6 24 Doors provided or repaired 21 2 15 2 3 ... 2 45 Ventilated ... 4 ... ... ... ... ... 4 Seats provided or repaired 21 7 3 2 1 4 38 Basins Cleansed ... 11 2 3 1 ... 17 34 Roofs repaired ... ... ... .. ... ... ... ... Drains- Drains Re-constructed 10 13 10 3 21 39 7 103 Surface Drains provided 5 ... ... 2 7 .. ... 14 Cleansed and Amended 21 34 44 52 40 20 34 245 Gully Traps fixed 7 4 43 9 39 ... 4 106 Soil Pipes and Vent Pipes fixed or repaired 16 7 16 9 33 14 10 105 Chambers built and Interceptors provided 4 2 8 2 15 ... ... 31 Interceptors only fixed ... ... ... ... ... ... ... ... Ventilated (fresh-air inlets provided, &c.) 4 4 2 7 ... 1 ... 18 Covers provided to chambers ... ... ... ... ... ... ... ... Clearing Eyes ... ... 11 4 ... ... 2 17 68 ANNUAL REPORT OF SANITARY INSPECTORS FOR THE YEAR 1922—continued. Table—continued. Number of District. 1 2 3 4 5 6 7 Totals Sinks, Bath& Lavatory Wastes, and Rain Water Pipes- Disconnected from drains, trapped and ventilated 19 5 33 34 13 114 31 249 Cesspools— Abolished ... ... ... ... ... ... ... ... Dustbins— Provided 173 61 131 86 115 115 102 783 Repaired ... ... ... ... ... ... 1 1 Yards- Paved ... 11 ... 6 30 ... 2 49 Surface Repaired 156 ... 30 46 ... 60 38 330 Urinals— Cleansed ... 12 5 5 10 ... 2 34 Repaired or improved 8 ... 3 3 1 6 1 22 Scullery &Wash-house— Floors paved or repaired 49 4 30 10 ... ... 16 109 Forecourts- Paved 1 ... 4 3 ... ... . .. 8 Surface Repaired 7 ... 7 4 ... ... 5 23 Gutters and Rain Water Pipes Provided and Repaired 147 47 90 88 64 105 78 629 Water Supply— Store Cisterns provided ... ... ... ... ... ... ... ... ,, ,, Covers provided ... ... 2 ... 1 ... ... 3 ,, ,, Cleansed ... ... ... ... 1 . ... 1 ,, ,, abolished ... ... ... 1 ... 2 ... 3 Supply Reinstated 6 ... 5 3 3 4 5 26 Fittings Repaired 11 ... 50 53 38 25 8 185 New Houses Inspected for Certificates before Occupation ... ... 8 ... 60 ... ... 68 Potable Water provided from Service ... ... ... ... ... ... ... ... Cleansing and Repairs— Houses Cleansed and Limewashed 313 144 237 270 195 185 287 1631 Houses repaired and Ventilation improved 288 26 277 219 171 97 232 1310 House roofs repaired 75 123 149 95 79 74 83 678 Dung Receptacles— Abolished ... ... 1 ... ... ... ... 1 Provided ... ... 1 ... ... ... ... 1 69 ANNUAL REPORT OF SANITARY INSPECTORS FOR THE YEAR 1921— continued. Tab1e—continued. Number of District. 1 2 3 4 5 6 7 Totals. Overcrowding- Cases Abated 3 ... ... ... ... ... 3 6 Accumulations- Removed 8 2 10 1 4 5 6 3G Animals— Ceased keeping as a Nuisance ... ... ... ... ... 2 2 4 Smoke Nuisances— Cases Abated ... ... ... ... ... 1 3 4 Observations ... ... ... 10 ... 4 8 22 Rooms occupied in such a manner as to be a nuisance 3 ... ... ... 2 1 2 8 District No. 1.—Inspector Simpson (East Ward). District No 2.—Inspector Shelley (East Ward). District No. 3.—Inspector Kemp (S.W. and part N.W. Wards). District No. 4.—Inspector Hewett (North Ward). District No. 5. Inspector Ai.lam (S. and S.E. Wards). District No. 6.—Inspector Yates (part N. and N.W. Wards and throughout Borough) for rat work. District No. 7.—Inspector Mayo (part N.W. Ward). 70 HOUSE-TO-HOUSE INSPECTIONS. House-to-house inspections were made in the following streets during the year 1922 :— Inspector Simpson.—East Ward. Houses in which defects were found. Houses in which no defects were found. Total houses inspected. Amelia Terrace 8 — 8 Andom Terrace 6 — 6 Benmore Street 11 — 11 Bronze Street 5 — 5 Church Street 9 — 9 Copperas Street 6 — 6 Dugald Street 6 — 6 Edward Street 6 — 6 Frankham Street 12 — 12 Giffin Street 16 — 16 Hales Street 56 4 60 Hosier Street 49 5 54 Hamer 5 — 5 Knott Street 3 1 4 Addey Street 8 6 14 Leonidas Street 11 — 11 Norval Street 3 — 3 Reginald Place 15 2 17 Reginald Street 11 1 12 Reginald Road 48 11 59 Total 294 30 324 Inspector Shelley—East Ward. Amersham Vale 11 32 43 Angus Street 9 29 38 Achilles Street 29 13 42 Glenville Grove 6 18 24 Napier Street 19 26 45 Pagnell Street 23 53 76 Railway Grove 16 41 64 Snead Street 5 11 16 Vance Street 9 23 32 Total 127 253 380 71 Inspector Kemp—North-west and South-west Wards. Barlborough Street 27 17 44 Besson Street 19 19 38 Dennetts Grove 18 8 26 Dennetts Road 12 2 14 Dollings Place 6 2 8 Eckington Gardens 2 — 2 Evelyn Buildings 12 2 14 Gibbon Road 6 5 11 Kenwood Avenue 8 3 11 Lindo Street 3 2 5 Martha Place 13 — 13 Mason's Cottages 10 — 10 Pomeroy Street 42 14 56 Powers Place 9 — 9 Prospect Place 14 1 15 Somerville Road 12 13 25 Walsham Road 14 5 19 Wrigglesworth Street 20 21 41 Total 247 114 361 Inspector Hewett—North Ward. Abinger Road 1 — 1 Alverton Street 3 4 7 Chilton Street 6 8 14 Colwick Street 39 5 44 Dorking Road — 2 2 Hanlon Street 20 19 39 Hoopwick Street 8 17 25 Junction Road 36 2 38 Kempslade Street 5 7 12 Sarah Place 2 — 2 Sayes Street 13 4 17 Shere Road 1 — 1 Windmill Road 62 27 89 Yeoman Street 1 — 1 Total 197 95 292 Inspector Allam—South and South east Wards. Fishers Rents 10 1 11 Martins Buildings 6 1 7 Spring Street 8 3 11 Summer Street 12 2 14 Wilson Street 21 1 22 Total 57 8 65 72 Inspector Mayo—North-west Ward. Blockhouse Street 52 21 73 Fawcett Road 31 10 41 Hornshay Street 22 5 27 Reculver Road 19 5 24 Rudford Road 20 3 23 Sharratt Street 26 4 30 Silwood Street 23 3 26 White Post Lane 1 1 2 Total 194 52 246 Inspector Yates—North and North-west Wards. Alexandra Street 4 - 4 Chipley Street 39 3 42 Knoyle Street 46 5 51 Lee Terrace 16 1 17 Liardet Street 24 2 26 Manor Cottages 4 1 5 Midway Place 7 3 10 Oareboro' Road 5 - 5 Sanford Street 6 2 8 Total 151 17 168 Grand Total 1267 569 1836 HOUSING. In December, 1920, the first two houses of the Council's Housing Estate, Arica Road, were completed, and were opened by His Worship the Mayor. During the year 1921, 109 houses were completed, making a total of 111 occupied or ready for occupation at the end of that year. During the year under report the building operations were completed and comprise the following houses and flats:— concrete construction. Type A (non-parlour) 19 houses Type B (parlour) 36 „ brick construction. Type B (parlour) 131 „ Type A (non-parlour) 42 ,, Flats 18 „ Total 246 „ Factory and Workshops Act. 74 Table XXIV. METROPOLITAN BOROUGH OF DEPTFORD. PROCEEDING DURING 1922. PREMISES. NUMBER OF PLACES— Number of inspections Number of notices Number of proceedings On register at end of 1921 Added 1922 Removed 1922 On register at end of 1922 Milk premises 136 19 2 153 421 6 .. Cowsheds .. .. .. .. .. .. Slaughter-houses 2 .. .. 2 62 .. .. Other offensive trade premises 2 .. .. 2 39 .. .. Ice cream premises 78 40 4 114 264 22 .. Fried fish, etc., shops 43 1 .. 44 229 18 .. Restaurants 53 .. 1 52 102 8 .. Other food premises 16 9 .. 25 188 9 .. Table XXV. METROPOLITAN BOROUGH OF DEPTFORD. PUBLIC HEALTH DEPARTMENT. TABULATION OF REPORT AS REQUIRED BY S. 131 OF THE FACTORY AND WORKSHOP ACT, 1901. INSPECTION OF FACTORIES, WORKSHOPS, AND WORKPLACES, during 1922. CLASS OF WORK. Number of Places Number of Inspections. Number of Notices. Number of Prosecutions. On Register at end of 1921 Added 1922. Removed 1922. On Register at end of 1922. Under Factory Acts. Under Public Health Acts. Premises. Rooms Factories Factory Laundries 4 1 3 17 6 Factory Bakehouses 14 1 15 29 82 5 Other Factories 182 26 19 189 568 281 16 Workshops Workshop Laundries 5 5 18 11 Workshop Bakehouses 45 45 90 235 3 Other Workshops 99 14 6 107 193 145 4 Workplaces- Places where Food is prepared for Sale 121 1 1 121 228 519 34 Workplaces other than the above 56 8 1 63 83 67 Home-workers' Premises 289 71 31 329 339 213 1 Total 815 121 59 877 1565 1559 63 75 Table XXVI. METROPOLITAN BOROUGH OF DEPTFORD. This Table is by request of the Secretary of State. Annual Report of Medical Officer of Health for the year 1922. On the Administration of the Factory and Workshop Act, 1901 in connection with FACTORIES, WORKSHOPS, LAUNDRIES, WORKPLACES, AND HOMEWORK. 1.—INSPECTION. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (including Factory Laundries) 369 13 Workshops (including Workshop Laundries) 391 4 Workplaces (other than Outworkers' premises included in Part 3 of this Report) 586 34 Total 1346 51 2 —DEFECTS FOUND. PARTICULARS Number of Defects. Number of Prosecutions Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts. Want of Cleanliness 17 17 Want of Ventilation Overcrowding 1 1 Want of Drainage of Floors Other Nuisances 15 15 Sanitary Accommodation Insufficient 6 5 Unsuitable or defective 37 36 Not Separate for Sexes 2 2 Offences under the Factory and Workshop Act. Illegal Occupation of Underground Bakehouse (sec. 101) Breach of Special Sanitary Requirements for Bakehouses (ss. 97 to 100) Other Offences (excluding offences relating to outwork which are included in Part 3 of this Report) Total 78 76 76 Table—Continued. 3.—HOME WORK. NATURE OF WORK. OUTWORKERS LISTS, SECTION 107 OUTWORK IN UNWHOLESOME PREMISES. SECTION 108 OUTWORK IN INFECTED PREMISES, SECTIONS 109, 110 Lists received from Employers. Notices served on Occupiers as to keeping or sending lists. Prosecutions. Twice in the year. Once in the year. Instances. Notices served. Prosecutions. Instances. Orders made (S. 110). Prosecutions (Sections 109, 110) Lists. Outworkers. Lists. Outworkers. Failing to keep or permit inspection of lists. Failing to send lists. Contractors. Workmen. Contactors. Workmen. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Wearing apparel— Making, etc 61 6 294 1 9 63 16 Cleansing and Washing 1 1 Fur-pulling 1 2 Total 62 6 297 1 9 63 17 77 Table—continued. 4.—REGISTERED WORKSHOPS. Workshops on Register (s. 131) at the end of year. Number. Bakehouses 42 Dressmaking 16 Laundries 5 Millinery 14 Tailoring 15 Wheelwrights (Smiths, &c.) 13 Others 52 Total number of Workshops on Register 157 5.—OTHER MATTERS. Class. Number. Matters notified to H.M. Inspector of Factories— Failure to affix Abstract of the Factory and Workshop Act (s. 133) 20 Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Act (s. 5) Notified by H.M. Inspector Reports (of action taken) sent to H.M. Inspector 12 12 Other — Underground Bakehouses (s. 101) :— Certificates granted during the year — In use at the end of the year 16 78 CANAL BOATS ACTS. Annual Report for the Year ended 31st December, 1922. To the Medical Officer of Health. Sir, I beg to report for the year ended December 31st, 1922, that for the purpose of Canal Boats inspection, I made 17 visits, on the following dates, viz. :— January 16th and 27th, February 13th, March 3rd and 29th, April 21st, May 2nd and 24th, June 26th, July 28th, August 9th, September 18th and 22nd, October 7th, November 3rd and 8th, and December 8th. Three boats were found and inspected during the year, as follows :— Boat "Victor," registered at Uxbridge, No. 470, on March 3rd. Satisfactory. Boat "Frays," registered at Uxbridge, No. 364, on May 2nd. Satisfactory. Infringements. The following matters were found requiring attention :— September 22nd. Boat "Woodcock," No. 692, registered at Chester. Fore cabin damp, boat leaking. Aft cabin occupied by a girl over 12 years of age in contravention of Register. Notice was served, and the defects have been certified as remedied. Children on Boats. One girl of school age was found on the boat "Woodcock," and the local Education Authority was notified. This Borough is not a Registration Authority. The arrangements made for the inspection of Canal Boats are: Periodical inspection by Sanitary Inspector duly appointed under the Canal Boats Acts, jointly with other duties as District Sanitary Inspector. I am, Sir, Your obedient Servant, F. Hewett, Canal Boat Inspector. January 4th, 1922. 79 UNSOUND FOOD. Inspector Simpson, acting on information received from a neighbouring borough, visited a shop in this borough and found deposited there 292 tins of condensed milk, which were unsound and unfit for the food of man. The articles were accordingly seized, condemned by a Justice, and destroyed. Legal proceedings were instituted and the defendant was fined £25 and £5 5s. costs. Inspector Shelley saw exposed for sale on a stall in Douglas Street 109 tins of jam which were unsound and unfit for the food of man. The jam was seized, condemned by a Justice aud destroyed. Legal proceedings were instituted and the defendant was fined £5 and £2 costs. During the year, the following quantities of food were brought to the notice of this Department, voluntarily by the owners, found to be unsound, and destroyed :— Apples 11 boxes Skate 20 stone Beef 7 lbs. Smoked codling 1 box Mackerel 1 box Tomatoes 120 lbs. & 3 boxes Potatoes 4 tons, 5 cwt. Turnip tops 2 bags Rabbits 69 Winkles 1 bag Sheep's plucks 6 FOREIGN MEAT REGULATIONS. The attention of this Department was drawn by H.M. Customs to 18 cwt. of cows' udders lying at a wharf in this Borough. These were found upon inspection ro be unfit for human consumption and, after formal notice to the owners, were destroyed. SALE OF FOOD AND DRUGS ACTS. 600 samples were purchased and submitted to the Public Analyst for analysis. Of this number, 15 or 2.5 % were adulterated. In 7 instances legal proceedings were taken, and fines and costs amounting to £19 12s. were inflicted. 80 Table XXVII. Proceedings Taken with regard to Samples Purchased during the year. Sample No. Article. Particulars of Adulteration or Infringement. Fine. Costs. Remarks. £ s. d. £ s. d. 13 A Butter 0 70 per cent. excess of water — — Vendor cautioned. 18 O „ 2.6 „ „ — — Vendor cautioned. 7 k Milk 91 per cent. abstraction of fat 2 0 0 — Or 28 days imprisonment. 1 SY „ 2 per cent. added water — — Vendor cautioned. 10 SY „ 12 per cent. abstraction of fat 2 0 0 2 2 0 — „ „ „ 1 0 0 — Servant of above. 34 k „ 6 per cent. abstraction of fat — 2 2 0 Summons dismissed on payment of costs 37 k „ 1 per cent. abstraction of fat — — Vendor cautioned. 13 SY „ 8 per cent. abstraction of fat 0 10 0 0 10 0 — 31 S Mustard 15 per cent. starchy farina — 2 2 0 Withdrawn on payment of costs. 36 H Vinegar 37 per cent. excessive water 1 0 0 1 1 0 — 56 H Butter 12 per cent. excess of water — — Vendor cautioned. 43 h Milk 5 per cent. added water — — Vendor cautioned. 51 S „ 2 per cent. added water — — Vendor cautioned. 44 t „ 5 per cent. abstraction of fat 3 3 0 2 2 0 — 76 O Butter 17 per cent. excess of water — — Vendor cautioned. SUMMARY. £ s. d. Fines 9 13 0 Costs 9 19 0 19 12 0 81 Table XXVIII. Legal Proceedings taken under Public Health Act and By-Laws. Premises. Offence. Fine. Costs. Remarks. £ s. d. £ s. d. 3 Dennetts Road w.c. pan fixed without notice — — Dismissed. Douglas Street (stall) Exposing for sale 109 tins of jam 5 0 0 2 0 0 40 & 44 Sandbourne Road Non-deposit of drainage plans 5 5 0 5 5 0 40 Sandbourne Road Premises in such a state as to be a nuisance 2 0 0 — And Order for necessary work to be carried out within 14 days 44 Sandbourne Road do. 2 0 0 — Do. 28 Briant Street Drainage works carried out without notice 0 10 0 — A. T. Kennedy Conveying offensive 3 0 0 — 297 New Cross Rd. matter during prohibited hours Do. do. 2 0 0 — F. Percy (servant to above) do. 1 0 0 — Do. do. 1 0 0 — 116 High Street Deposited for sale, 292 tins condensed milk 25 0 0 5 5 0 SUMMARY £ s. d Fines 46 15 0 Costs 12 10 0 £59 5 0 82 Table XXIX. Samples taken during 1922. Articles. Number Genuine. Number Adulterated . Total. Percentage of Adulteration. Baking Powder 1 • • 1 • • Brawn 1 • • 1 • • Butter 73 4 77 52 Cocoa 12 • • 12 • • Cocoanut, Desiccated 2 • • 2 • • Coffee 7 • • 7 • • Dripping 5 • • 5 • • Fish Paste 2 • • 2 • • Ground Ginger 2 • • 2 • • Jelly, Table 1 • • 1 • • Lard 9 • • 9 • • Milk 394 9 403 2.2 Meat Paste 2 • • 2 • • Meat, Potted 1 • • 1 • • Milk, Separated 1 • • 1 • • Milk, Skim 1 • • 1 • • Mustard 16 1 17 5.9 Pepper 15 • • 15 • • Sausage 3 • • 3 • • Sausage Meat 1 • • 1 • • Cream of Tartar 1 • • 1 • • Vinegar 31 1 32 3.1 Vinegar, Malt 1 • • 1 • • Informal Samples— Milk Powder 3 • • 3 • • Totals 585 15 600 25 83 The Shelter. The Public Health (London) Act, 1891, Section 60, Sub-Section 4, imposes on the Sanitary Authority the duty of making provision for the temporary housing of persons who are compelled to leave their dwellings for the purpose of enabling such dwellings to be disinfected by the Sanitary Authority. The accommodation provided consists of a detached building containing two separate and distinct tenements, each consisting of two bedrooms, kitchen, larder, bathroom, and w.c. The shelter was used during the year by the family of a patient notified as suffering from small-pox (wife and three children) while their home was undergoing thorough disinfecting and cleansing. Disinfection. The disinfection of infected clothing and bedding has been carried out at the Disinfecting Station, Watson Street, by means of two machines of the Washington-Lyons pattern with independent boilers. The number of rooms disinfected by the Council's staff during the year was 1,696. Disinfecting fluid is supplied gratis where required in cases of infectious disease. When necessary, the walls of the disinfected portion of the house have been stripped and the ceilings cleansed. 84 Table XXX. SHOWING THE NUMBER OF PREMISES, ROOMS AND BEDDING DISINFECTED DURING THE YEAR 1922. Date 1922 Premises. Rooms. Beds. Pillows. Bolsters. Mattresses. Sheets. Blankets. Odd articles Articles destroyed. January 169 190 92 226 80 46 118 190 396 1 bed, 4 palliasses, 2 sheets, 2 odd articles February 131 139 73 180 67 46 112 182 313 1 bed, 2 mattresses. M arch 132 146 66 139 56 27 100 132 258 April 97 117 45 103 47 22 60 93 136 1 bed, 1 mattress. May 145 193 65 115 36 15 70 69 107 2 mattresses. June 113 141 49 109 40 25 49 60 82 2 beds, 1 mattress, 2 palliasses. July 118 133 64 127 47 23 57 91 123 6 odd articles. August 82 103 43 89 29 16 46 47 99 I mattress, 1 sheet. September 100 113 68 132 44 20 64 92 189 2 beds, 1 mattress 2 pillows, 1 bolster, 2 sheets October 140 160 91 167 69 29 96 139 183 1 mattress, 17 odd articles November 122 142 90 178 61 36 95 174 236 December 110 119 57 126 46 20 67 109 128 Total 1459 1696 803 1691 622 325 934 1378 2250 Table XXXI. SHOWING NUMBER OF ROOMS DISINFECTED AFTER THE FOLLOWING DISEASES. 1922 Date Small Pox. Scarlet Fever. Diphtheria. Erysipelas. Puerperal Fever. Pulmonary Tuberculosis. Enteric Fever. Measles. Cancer. Influenza. Pneumonia. Scabies. Miscellaneous January • • 80 53 • • • • 30 • • • • 2 6 3 3 12 February • • 68 35 2 • • 14 • • 6 • • • • 5 • • 3 March • • 51 43 1 2 21 • • 6 1 • • 2 • • 7 April • • 35 20 • • • 33 • • 12 4 • • 1 • • 1 May • • 55 18 1 • • 27 1 11 1 • • • • • • • • I une • • 36 27 1 • • 33 6 3 1 • • 1 • • 3 July • • 39 33 1 1 35 • • 3 • • • • • • • • 4 August • • 36 18 • • 1 22 1 1 5 • • • • 2 • • September • • 40 31 2 1 21 2 1 1 • • • • 1 3 October .. • • 64 43 • • 1 35 • • • • 2 • • • • • • 8 November 4 59 46 3 • • 14 • • • • 2 • • • • • • 11 December • • 39 48 1 • • 23 • • 1 1 • • • • • • 1 Total 4 602 415 12 6 308 10 44 20 6 12 6 53 verminous premises. 106 premises consisting of 193 rooms were fumigated during the year. books. 290 Library books were fumigated during the year. 85 cleansing station. 2,082 articles of clothing, etc., were disinfected during the year. 1,837 children received baths. In 83 instances a second bath was required within a month, and in 7 instances, a third bath, making a total of 1927 baths given during the year. Factory and Workshop Acts (Infectious Diseases.) 4 bundles of paper bags, 50 gross of cardboard boxes, 18 new shirts, 36 camisoles, 40 pairs kid gloves, were disinfected and returned to the contractors. Total number of Premises disinfected 1459 ,, ,, Rooms ,, 1696 Beds ,, 803 Pillows ,, 1691 ,, ,, Bolsters ,, 622 ,, Mattresses ,, 325 Sheets ,, 934 ,, ,, Blankets ,, 1378 ,, ,, Odd Articles ,, 2250 Total articles 8803 Total number of Beds destroyed 7 ,, ,, Mattresses , 9 ,, ,, Palliasses ,, 6 ,, ,, Pillows ,, 2 ,, ,, Sheets ,, 5 ,, ,, Bolsters ,, 1 Odd Articles,, 27 Total 57 N.B.—The above Articles were destroyed at the request of the owners. Special Cases. Jan 2nd—Clifton Hill. Cancer. 1 mattress, 1 bolster, 1 blanket- disinfected. ,, 14th—Lewisham High Road. Cancer. 1 mattress, 1 bolster, 1 pillow— disinfected. Feb. 9th—Speedwell Street. Cancer. 1 bed, 1 mattress, 2 bolsters, 2 pillows, 2 sheets—disinfected. March 1st—Revelon Road. Cancer. 1 bed, 1 bolster, 3 pillows, 4 blankets— disinfected. April 27th—Rectory Buildings. Cancer. 1 mattress—disinfected. May 24th—Brocklehurst Street. Cancer. 1 bed, 1 mattress, 3 pillows, 1 bolster, 2 sheets—disinfected. June 28th—Childeric Road. Cancer. 1 bed, 1 bolster, 2 pillows—disinfected. July 26th—Snead Street. Cancer. 1 bed, 1 counterpane—disinfected. August 4th—Pomeroy Street. Cancer. 1 bed, 1 mattress, 1 bolster, 3 pillows —disinfected. ,, 8th—Crescent Way. Cancer. 1 bed, 1 mattress, 1 bolster, 2 pillows— disinfected. ,, 11th—Rolt Street. Cancer. 2 pillows, 2 odd articles—disinfected. ,, 11th—Rolt Street. Cancer. 1 mattress, 1 sheet—destroyed. 14th—Blllington Road. Cancer. 1 bed, 1 bolster, 7 pillows—disinfected. Sept. 8th—Bousfield Road. Cancer. 1 bed, 1 pillow—disinfected. ,, 11th—Amersham Vale. Cancer. 1 bed, 1 bolster, 4 pillows—disinfected. 18th—Avignon Road. Cancer, 1 bed, 1 bolster, 7 pillows—disinfected. Oct. 21st—Seldon Road. Cancer. 1 bed, 2 pillows, 1 bolster, 1 blanket, 1 mattress, 2 sheets, 6 odd articles—disinfected. ,, 26th—Seldon Road. Cancer. 1 mattress, 17 odd articles—destroyed. 26th—Brockley Road. Cancer. 1 bed, 2 pillows, 1 bolster, 3 blankets, 2 odd articles—disinfected. Nov. 1st—Breakspears Road. Cancer. 1 mattress, 1 bolster, 2 pillows— disinfected. 20th—Tyrwhitt Road. Cancer. 1 bed, 1 bolster, 4 pillows—disinfected. Dec. 21st—Erlanger Road. Cancer. 1 bed, 1 mattress, 1 bolster, 2 pillows, 3 blankets, 1 odd article—destroyed. 1 Army kit. 1 Navy kit. 1 taxi cab. 86 Mortuary Report for the year ended 31st December, 1922. Bodies Received, etc. Total. Male. Female. Inquests. Postmortems. Under 1 year of age. Unknown. Deposited to await burial only. Infectious. 125 75 50 124 74 15 3 l 1 Sixteen bodies were detained after inquests to await burial owing to lack of accommodation at the homes, and three owing to advanced decomposition. One body (infectious) was deposited to await burial after inquest. Boroughs of which deceased persons were residents. Deptford 70 Brixton 1 Greenwich 22 Southwark 2 Lewisham 11 Sydenham 1 Camberwell 1 Bermondsey 4 Plumstead 1 Rotherhithe 7 Foots Cray 1 Woolwich 2 Eltham 1 Holloway 1 Summary of Visits paid by Health Visitors. Ward (approximate) E. N. N.W. S. S.E. S.W. Total. Miss Baird (Jan. 1st to Aug. 31st) Visits 822 .. .. .. .. .. 822 Revisits 1124 .. .. .. .. .. 1124 Total 1946 .. .. .. .. .. 1946 Miss Clubbe Visits .. .. .. .. .. 754 754 Revisits .. .. .. .. .. 2485 2485 Total .. .. .. .. .. 3239 3239 Miss Holland Visits .. .. .. 372 479 .. 851 Revisits .. .. .. 616 1260 .. 1876 Total .. .. .. 988 1739 .. 2727 Miss Piper Visits .. 927 .. .. .. .. 927 Revisits .. 2020 .. .. .. .. 2020 Total .. 2947 .. .. .. .. 2947 Miss Smart Visits 1165 .. .. .. .. .. 1165 Revisits 1384 .. .. .. .. .. 1384 Total 2549 .. .. .. .. .. 2549 Miss Stowell Visits .. .. 1066 .. .. .. 1066 Revisits .. .. 2705 .. .. .. 2705 Total .. .. 3771 .. .. .. 3771 Total Visits 1987 927 1066 372 479 754 5585 Revisits 2508 2020 2705 616 1260 2485 11594 Total 4495 2947 3771 988 1739 3239 17179 87 SUMMARY OF WORK OF HEALTH VISITORS. The work done by the health visitors is summarised in the following Table:- 1st visits Re-visits Total Births 2381 9627 12008 Still Births 49 2 51 Infant Deaths 226 — 226 Expectant Mothers 320 273 593 Ophthalmia Neonatorum 14 10 24 Measles 1271 731 2002 Infantile Diarrhœa 1 — 1 Scabies in children 7 4 11 Verminous Children 11 12 23 Puerperal Fever 5 2 7 Tuberculosis 29 2 31 Pneumonia 6 5 11 Miscellaneous 582 8 590 Unsuccessful visits 527 802 1329 Scarlet Fever recoveries 140 112 252 Diphtheria „ 6 2 8 Whooping cough 10 2 12 Totals 5,585 11,594 17,179 Births Notified, Year 1922. Ward. Births Notified, Alive. Dead. By whom Notified. Total. Male. Female. Parent. Doctor. Midwife Other Person. East 590 311 279 578 12 55 87 438 10 North 614 309 305 602 12 130 163 313 8 North-west 468 222 246 459 9 107 127 225 9 South 349 185 164 344 5 92 96 149 12 South-east 260 146 114 253 7 77 86 92 5 South-west 285 144 141 277 8 119 60 100 6 2566 1317 1249 2513 53 580 619 1317 50 Milk supplied to Necessitous Mother's and Children. During the year 2,317 applications were received and were dealt with as follows:— Granted free 1815 „ at half-price 471 Refused 26 Grants at hall-price refused by applicant 5 2,317 88 Dried Milk, Virol, &c. During the year the following amounts of dried milk, Virol, &c., were distributed, mostly at cost price, to the mothers attending the Infant Welfare Centres:— Total Glaxo 3891 1 lb. packets Cow and Gate 2330 „ Cow and Gate, half cream 152 „ Lactogal 292 tins Virol 56 28 lb. tins Ambrosia 822 1 lb. packets Lacta 319 „ „ Dinner Tickets. During the year 64 tickets were granted to necessitous expectant mothers for dinners at the Albany Institute (Deptford Fund). Maternity Home. Particulars of cases admitted during the year 1922:— Cases admitted, 129. Average stay, Two weeks. Cases delivered by mdwives, 120. „ „ „ doctors, 8. Cases in which medical advice sought, 11. (a) Ante-natal, 1 (ante-partum haemorrhage). (b) During labour, 8 (Prolonged labour). (c) After labour 1 (post-partum haemorrhage). (d) For infant 1 (asphyxia). Cases notified as puerperal sepsis, Nil. Temperature rose above 100.4 for 24 hours with rise in pulse, 6. Notified as Ophthalmia Neonatorum, Nil. Inflammation (eyes), Nil. Not entirely breast-fed, 2 (insufficient breast milk). Maternal deaths, Nil. Foetal deaths, 1 stillborn, after prolonged labour and forceps delivery. 2 within 10 days of birth:— (a) Premature (at 28 weeks). (b) Partial obstruction of intestine by bands. 89 NAPIER STREET CLINIC. 1922. No. of times Clinic opened. New Cases. Total New Cases. Total Old Cases. Total New and Old Cases. Consultations with Doctor. Breast Fed. Mixed. Hand. Ages 1—5. January 5 1 1 7 1 13 147 160 98 February 4 10 1 3 3 17 161 178 119 March 4 16 2 2 3 23 148 171 102 April 3 8 1 1 2 12 99 111 66 May 4 18 .. 4 6 28 214 242 131 June 3 13 .. .. 2 15 155 170 79 July 4 11 3 .. 2 16 191 207 77 August 4 8 3 1 4 16 211 227 114 September 4 9 1 3 4 17 185 202 98 October 4 15 1 2 3 21 215 236 106 November 4 11 5 .. 8 24 179 203 98 December 3 12 .. 1 8 21 179 200 88 Total 46 135 18 24 46 223 2084 2307 1176 ERLAM ROAD CLINIC. 1922 No. of times Clinic opened. New Cases. Total New Cases. Total Old Cases Total New and Old Cases. Consultations with Doctor. Breast Fed. Mixed- Hand. Ages 1—5 January 4 6 2 2 2 12 180 192 95 February 4 7 2 1 4 14 207 221 100 March 5 9 1 .. 3 13 213 226 126 April 3 7 1 2 .. 10 113 123 65 May 5 12 1 2 5 20 211 231 118 June 4 10 1 1 .. 12 184 196 84 July 4 6 .. 1 3 10 182 192 61 August 5 8 3 4 1 16 265 281 101 September 4 12 2 3 1 18 221 239 93 October 3 7 1 1 5 14 185 199 96 November 5 6 2 2 4 14 265 279 126 December 3 2 1 .. 1 4 138 142 74 Total 49 92 17 19 29 157 2364 2521 1139 90 GOLDSMITHS' COLLEGE CLINIC. 1922 No. of times Clinic opened. New Cases. Total New Cases. Total Old Cases. Total New and Old Cases. Consultations with Doctor. Breast Fed. Mixed. Hand. Ages 1-5. January 4 16 5 3 1 25 289 314 109 February 4 10 2 2 2 16 331 347 112 March 5 23 2 6 5 36 438 474 154 April 3 14 1 1 1 17 229 246 93 May 4 21 .. 5 .. 26 274 300 109 June 5 20 4 2 4 30 372 402 133 July 4 18 4 8 4 34 316 350 105 August 5 27 2 6 4 39 439 478 152 September 4 21 3 4 4 32 385 417 124 October 3 13 1 1 3 18 298 316 99 November 5 14 2 6 3 25 407 432 154 December 3 7 2 2 2 13 237 250 96 Total 49 204 28 46 33 311 4015 4326 1440 BESSON STREET CLINIC. 1922. No. of times Clinic opened. New Cases. Total New Cases. Total Old Cases. Total New and Old Cases. Consultations with Doctor. Breast Fed. Mixed. Hand. Ages 1—5. January 4 13 1 5 2 21 275 296 120 February 4 8 1 4 3 16 278 294 121 March 5 20 3 2 5 30 362 392 167 April 3 14 2 5 1 22 191 213 111 May 4 10 3 3 2 18 278 296 134 June 5 12 1 3 1 17 293 310 126 July 4 10 4 .. 2 16 249 265 96 August 4 15 2 7 1 25 276 301 113 September 5 18 2 4 1 25 428 453 163 October 3 5 2 .. 4 11 201 212 75 November 4 9 1 2 8 20 283 303 130 December 4 8 2 1 1 12 231 243 111 Total 40 142 24 36 31 233 3345 3578 1467 91 GOSTERWOOD STREET CLINIC. 1922. No. of times Clinic opened. New Cases. Total New Cases. Total Old Cases. Total New and Old Cases. Consultations with Doctor. Breast Fed. Mixed. Hand. Ages 1—5. January 5 17 3 5 2 27 334 361 171 February 4 9 1 4 3 17 264 281 108 March 4 13 1 2 5 21 259 280 112 April 4 10 .. 1 2 13 119 132 50 May 5 25 3 4 4 36 283 319 117 June 4 10 2 5 3 20 163 183 65 July 5 14 4 4 2 24 323 347 107 August 3 14 .. 2 3 19 204 223 91 September 4 22 1 1 3 27 276 303 118 October 4 17 3 3 7 30 295 325 125 November 4 7 .. 4 6 17 260 277 113 December 3 7 3 2 1 13 221 234 88 Total 49 165 21 37 41 264 3001 3265 1265 HALES STREET CLINIC. 1922. No. of times Clinic opened. New Cases. Total New Cases. Total Old Cases. Total New and Old Cases. Consultations with Doctor. Breast Fed. Mixed. Hand. Ages 1-5. January 4 12 3 2 17 17 181 198 71 February 4 20 1 11 32 32 257 289 105 March 5 12 1 2 15 45 284 299 76 April 3 13 .. 1 14 14 161 175 57 May 4 13 1 .. 14 14 187 201 70 June 5 14 .. 1 15 15 225 240 77 July 4 10 4 .. 14 14 185 199 63 August 5 20 3 3 26 26 271 297 164 September 4 18 .. 2 21 21 210 231 153 October 3 11 2 6 22 24 178 202 120 November 5 14 .. 5 30 30 316 346 189 December 3 9 .. 2 14 14 226 240 127 Total 49 166 15 35 234 236 2681 2917 1272 92 Dr. S. Eleanor Hill's Report on Maternity and Child Welfare. 1. The Infant Welfare Centres. It is desirable that the public should be reminded, from time to time, of the purpose and scope of Infant Welfare Centres, of which there are six in Deptford. At these, babies and children under five years of age are weighed and examined in order that their progress may be noted, and any defect or disease may be discovered as early as possible. The Health Visitor keeps a record of the baby's weights and also of any notes made by the doctor as to the child's condition. The mother also keeps a card with the dates of baby's attendances and weights, and on this card the Health Visitor writes down detailed instructions as to the feeding and any other advice given by the doctor. The aim steadily kept in view is to prevent disease by educating the mother as to the best method of feeding, clothing and managing her infant, and by giving her advice as to air, exercise and the general hygiene of the home. Special attention is paid to detecting the early signs of disease, and the mother is directed to get immediate treatment for any condition requiring it, while she is warned against the injurious practice of giving medicines unnecessarily or without medical advice. Treatment of children who are ill cannot be properly undertaken at the centres, (a) because they are not equipped for this purpose, (b) because it is undesirable to crowd sick babies into a room with a number of healthy ones, (c) because a child who is ill requires to be seen by a doctor more frequently than once a week, and (d) because there is ample provision for such treatment elsewhere, and mothers are encouraged to seek it through the usual channels, viz., the family doctor, the neighbouring hospitals, or the parish doctor, as the case may be. Much help is, however, given to harassed mothers by telling them whether treatment is really necessary, and by advising them, in hospital cases, where and when to go, and how to get there, a letter being sent with the patient, in special cases, by the medical officer, giving the medical history and any important symptoms observed. Among the poorer families, where a doctor's fee is out of the question and the expense and loss of time involved in going to hospital make it difficult for the mother to obtain treatment, a few simple remedies are applied for minor ailments, but the use of these is strictly limited. In cases where the family income is small and extra nourishment is needed, some help is given by the sale of dried milk, cod liver oil emulsion, etc., at the wholesale price, and in necessitous cases grants of milk are allowed according to the scale approved by the Ministry of Health. In 93 the earlier part of the year free milk was given in many cases by the Guardians, in addition to the ordinary relief, but it was found that the rules under which these grants could be made differed somewhat from the rules applying to grants under the Maternity and Child Welfare scheme, and therefore this very useful form of co-operation fell through. Allowances of free milk or milk at half-price are now made to all families whose income is below the scale, and who are eligible for it, whether such income be derived partly from parish relief or no. 2. Staff. Arrangements were made in June that the Hales Street Centre should be placed under the personal supervision of the Medical Officer of Health, the other five being in charge of the Maternity and Child Welfare Medical Officer. In each centre the work is done primarily by the Health Visitor in whose ward the centre is situated, and she is assisted by one, and in some cases two, Health Visitors, and also by voluntary lady workers, whose help is a most valuable asset. Tea is provided for the mothers at 1d. per cup; and lectures or short talks are sometimes given to them while waiting, usually by the Medical Officer of Health. An atmosphere of cheerfulness prevails, and everything is done to encourage, especially those to whom the struggle for baby's health is the hardest. 3. Frequency of Attendances. In the earlier months of life babies are weighed every week; but if they have been found at the first examination to be quite healthy and are making steady progress, they are not sent in again to see the doctor until the period of teething or weaning. Children who lose, or fail to gain, or appear to be unsatisfactory in any way, are medically examined as frequently as may be necessary, and the mother is advised according to the findings of the doctor. As the child gets older, fortnightly or monthly attendances are the rule, and after 18 months, attendance is not encouraged more than once in three months. The frequency of attendances has to be limited to a certain extent by the amount of accommodation and the time of the staff, as overcrowding in the centres and too hurried consultations do more harm than good. 4. The Treatment Centre held on Wednesdays at 10 a.m. has been renamed the "Special Clinic," being in fact a centre where infants can be seen by special appointment. The type of cases attending are:— (a) Those which require extra time for more thorough examination by the doctor, or in order that letters may be written, forms filled in, etc., referring patients to family doctors, hospitals, convalescent homes, etc. 94 (b) Those which it is desirable to keep apart from other children. (c) Babies requiring to have test feeds, treatment for certain minor ailments, etc. (d) Those whose mothers are unable for some good reason to attend their own centre at the usual time. The numbers attending this centre are low, but the work done is important. Unfortunately, Wednesday morning has now to be partly devoted to the second ante-natal clinic, and consequently the work of the Special Clinic is somewhat curtailed. Instruction is given to mothers whose children require simple massage and exercises; but patients requiring more skilled massage and electrical treatment are referred to the Miller Hospital. Unfortunately, only a proportion of the cases so referred ever reach the massage department of the hospital, but those who do, always receive great benefit. Failure is usually due to disinclination on the part of the mother to attend, and such cases need energetic following up on the part of the Health Visitors. 5. Dental Clinic. Dental inspections were formerly held at intervals of about three months. It was found advisable to arrange for a regular date, and dental inspections are now held on the third Tuesday of every alternate month. Until this year, children only were given treatment, but as it is most important to the welfare of their infants that expectant and nursing mothers should have sound teeth, it was decided in the autumn to make some provision for mothers also, in special cases. A dental chair having been formerly provided at the Tuberculosis Dispensary, where sanction for its use has not been granted, the Public Health Committee decided to lend this chair to the children's dental clinic in Albury street in order that mothers might have dental treatment when required. The sum to be spent on this item and the children's dental clinic together is limited to £50 per ann. Patients requiring extractions only are referred as a rule to the Miller Hospital. All dental patients who can afford to do so are advised to consult their own dentist; but it is unusal for the mother of a family to find the means of doing this. 6. The Ante-natal Clinic. Expectant mothers attend at the Napier Street Mission Hall on Tuesdays, at 9.30 a.m, for medical examination and advice. The attendances having increased so much that the morning's work could not be finished before 2 p.m., it was found necessary to have a second session on Wednesdays. Patients 95 seeking admission to the Council's Maternity Home are examined here before booking, and only those cases which will probably be normal are accepted. They subsequently attend for a routine examination at intervals as may be considered necessary by the doctor. Detailed instructions are given as to diet, clothing, and the hygiene of pregnancy, patterns of baby clothing being supplied by the Health Visitor, who gives short talks to the mothers who are waiting their turn to see the doctor. Besides those intending to enter the Maternity Home, many expectant mothers attend this clinic, the patients being: (a) Those who have made no arrangements and who ask advice as to the best course to follow in their special circumstances. (b) Those intending to enter the Deptford and Greenwich Hospital. As there is no out-patient department to the hospital, ante-natal supervision is given to these mothers at the clinic. Patients requiring medical or surgical treatment are promptly admitted to the hospital whenever necessary. (c) Those who have booked with midwives. If the patient brings a letter or card from the midwife, a written reply is always sent by the doctor, stating the nature of any abnormality found and advising the midwife how to deal with the matter. Midwives occasionally come with their patients. (d) Patients who have booked with a doctor very rarely attend the clinic (about 5 per cent. of our total); but if they do they are told that their own doctor is the person to whom they should go for advice. As a rule such patients state that they have never been examined and they wish to know whether everything is satisfactory. In such circumstances they are examined once only at the Ante-natal Clinic, and if any abnormality is found they are urged to go at once to their doctor. They are given the usual instruction by the Health Visitor as to baby clothing, etc. A register is kept of patients who have attended the Ante-natal Clinic and a note is made of the dates on which they are advised to come again. If they fail to attend, the Health Visitor calls at the home to enquire whether anything is wrong, and takes the opportunity of giving advice where it is needed. 7. The work of the Health Visitors. The duties of a Health Visitor are more numerous and much more arduous than is generally supposed. They include ante-natal visiting; visiting of infants under the Notification of Births Act; re-visiting at intervals of all children up to five years of age: reporting sanitary defects; following up of special cases seen at the Infant Welfare Centres; following up of 96 notified cases of certain infectious diseases (measles, whooping cough, patients discharged from hospital after scarlet fever, and also cases of puerperal fever and ophthalmia neonatorum), and in addition each Health Visitor attends at the Infant Welfare Centres on three afternoons a week and at the Ante-natal Clinic on one morning in three weeks. The need for an additional Health Visitor has long been discussed, and upon the appointment of Miss White to succeed Miss Baird in the East Ward, when the latter took up the Tuberculosis work, a new arrangement of the Health Visitors' districts was made. The object of this reorganisation of the work was to economise distances, by making the areas worked by Miss Piper and Miss Stowell more compact, also to equalize the number of births in the six areas, whose boundaries do not now correspond exactly to the boundaries of the municipal wards. The main argument in favour of this plan was that it cost nothing, and it has been to a certain extent successful; but it does not obviate the fact that each Health Visitor has more work than can be done thoroughly by one person. (The Council has kindly recognised this and appointed a parttime Health Visitor to the Staff.—M.O.H.) 8. The Maternity Home. At the end of the first complete year of its existence, the Municipal Maternity Home is acclaimed as a great success by dozens of small, and as yet inarticulate, voices. Many indeed have been the expressions of appreciation and gratitude from mothers whose "time of trouble" has been more "like a holiday." But the supreme vindication of this municipal undertaking is "out of the mouths of babes and sucklings." It is a recognised fact, at the Infant Welfare Centres, that there is something distinctive about the "Home" babies. They are singularly free from all the troubles that afflict the new baby of an inexperienced mother. The secret lies in the way they are managed from the beginning. The Home itself should be, and is, a great educational force; but not only so, the "Home" mother is ready to learn more herself, and teach others all that will make for baby's health and well-being. There were three changes in the Staff, in the earlier part of the year, the three staff nurses in turn resigning, owing to marriage, home ties, etc., and for a few weeks it was necessary to get in temporary help. As the Home does not train pupil midwives there is more difficulty in getting fully qualified nurses who are willing to undertake all the work, quite apart from the fact that more has to be paid in salaries to qualified 97 nurses. It is however an additional advantage to the patients that we have now three very suitable fully trained nurses, as well as the Matron and Sister. To meet the possibility of any serious emergency arising in the Home, it was felt necessary to appoint a consultant who might be called in, in a case of extreme danger or difficulty, or where any abdominal operation was required. Although such a possibility is generally guarded against by having all patients examined at the Antenatal Clinic, it is not possible to prevent accidental complications. Arrangements for having as consultant a member of the visiting staff of the King's College Hospital were still under discussion when the year ended. Dr. Hills' very clear Report does not require much amplification, still a few notes may be added to complete the tale. Sewing Class. Our one outstanding need is a mending, knitting and sewing class for mothers, such as 1 saw at the Jewish Maternity Home, Whitechapel and at Ampthill Square. At Whitechapel a paid teacher conducts these classes on Monday and Wednesday from 2 to 4.30 p.m. Primiparæ are required to attend, and if the "young expectant" fails to come a friendly visit is made to the home to encourage her. Primiparae attend during the last five months of pregnancy and receive sixteen lectures or demonstrations in knitting and sewing. Material is bought wholesale and is sold at cost price. The expectant mother does not commence making baby's clothes until she has shown proficiency at knitting and sewing. Some twenty-three attend this class at a time. The mothers make knitted vests, long sleeves, open double-breasted front; long flannel double-breasted robes and night-gowns and knitted belts: flannel jackets. Patterns for short clothes are given to the mothers to take home after they leave the Maternity Home. At the St. Pancras School for Mothers, 1 Ampthill Square, I learned that in connection with the needlework and knitting class, flannel and wincey are bought in bulk and sold to the mothers at cost price. The Superintendent keeps an account for each mother and collects the money each week. The teacher is paid five shillings for each class. The mothers look on at first and see a garment cut. The mother cuts her own garment for baby while the Superintendent watches. General knitting and sewing are taught. 98 At 1 Pimlico Road, one of the City of Westminster's Centres, I learned that an experienced seamstress is paid £50 a year by the Borough Council to teach at two weekly sessions. Saxony flannel, Madaplin cotton and wincey are used. Garments are made for the expected baby and for children up to school age. They are not taken away until paid for. Old garments are undone, washed and "made up" into new. A voluntary worker keeps the toddlers in a room with toys whilst their mothers attend the class. These are points picked up at some of the sewing classes I visited in 1922, and the information gleaned will no doubt be helpful. Lectures for Fathers. This is a genuine proposition and further consideration was adjourned until a suitable place could be obtained to give the "talks." Everybody knows that some fathers "push" the dose of dried milk given to their babies. Suggested subjects are: "The father's responsibility in over-feeding infants," "The Injury of late hours to babies and young children," "The wife's health, a man's consideration." Home Helps. This should be kept in view. A Home Help is a woman employed during the lying-in period, to look after the home, wash and feed the children, mend clothing and make the husband's dinner. She must not nurse the case nor deliver the woman. She is paid four shillings a day and food. Not every lying-in woman has a mother or friend to stand by and do the housework. At the Jewish Maternity Home, untrained women, kept under the midwives' observation, are attached to the Home. They are paid thirty shilling a week while at a case and are given a day or two's pay when the case is finished. No pay is given while waiting on a case, but the twenty home helps are usually kept busy. Their pay is partly found by the patients who pay into a provident fund shortly after becoming expectant. Even after the confinement is over the young mother continues to pay into the club for future similar eventualities. If the case is destitute the Jewish Board of Guardians pay the whole fee to the Home Helps. A voluntary worker runs the Providential Fund. Contributions are paid to the clerk at the office of the Maternity Home. Voluntary subscriptions are also collected towards the cost of Home Helps. Health Week. The second annual Health Week was held from October 2nd till October 6th, both dates inclusive, from 2.30 to 8.30 p.m., at the Baths. The total cost was approximately £22. The clergy 99 were asked to make reference to Health Week on Sunday, October 1st, and the Medical Officer appeared in two pulpits. Advertisements were inserted in the press. Demonstrations were made each afternoon by the Health Visitors at different stalls. Other stalls were:—The Maternity Home; The Sanitary Inspectors; The Tuberculosis Dispensary; Ambrosia; Virol; The Royal Arsenal Co-operative Society (Milk); Sapon Soap Company. Afternoon addresses were given by Dr. Hill and the Medical Officer of Health. Evening lectures were given from 6.45 to 7.30 by Dr. Harbison, the Tuberculosis Officer; Mr. Magraw, Surgeon Dentist; Dr. Octavia Lewin, on the Care of the Throat and Nose; Miss Liddiard, Matron, Truby King Hospital: Miss Norah March, of Carnegie House. A film on "The Gift of Life" was exhibited by the N.C.C.V.D., who provided a lecturer and gave a very instructive exhibition at their stall. Miss Halford lent charts and diagrams from Carnegie House A competition was held for prizes for the best home-made cots, play-pens, etc. The London County Council sent classes of older girls with teachers in charge to attend the afternoon addresses, the consent of the Board of Education having been obtained. Tea and cake were provided for one penny, the caretaker of the Napier Street Centre taking charge. The Health Visitors obtained the crockery. During this week the ordinary clinics were conducted by Dr. Hill at the Exhibition at 2 p.m. instead of at the usual centres. The Deptford Fund kindly provided Girl Guides from 5 to 8.30 p.m. to keep any noisy children in order. From first to last the Exhibition went with a swing and was very well attended by the general public. The Mayor and Mayoress, Alderman and Mrs. Green, Mr. Councillor and Mrs. Tiffen, Councillor the Rev. Father Mahoney, Councillor Mrs. B. M. Drapper, J.P. and Councillor Mrs. White took the Chair at meetings, and with others, judged the competitions. Members of Parliament and of the County Council came and went, and to wind up, an Inspector from the Board of Education came to see that the addresses to school girls were given at 3 p.m. as promised. This Exhibition must be an annual event. I have given the details somewhat fully, as apart from the general interest, they may assist those who are contemplating a similar venture. Foster Children and Inspection of Lying-in Homes. In March, 1921, the London County Council experimented by authorising the Greenwich Borough Council to exercise the powers of Infant Life 100 Protection Visitors under Part I of the Children's Act, and delegated to the Greenwich Borough Council the powers of the County Council re inspection of lying-in homes in the Borough for one year. The experiment was a happy one and has been continued in Greenwich. The County Council sounded the other boroughs on the subject and the Deptford Council replied that it was desirable that the County Council's powers on these two subjects should be transferred to the Metropolitan Borough Councils. The Municipal Maternity Home, 52 Wickham Road, was opened in July, 1921, the first bed being occupied on 14th July. The numbers admitted per month since, are as follows: 1921, July 2, August 2, September 4, October 7, November 12, December 8. 1922, January 13, February 13, March 9, April 8, May 9, June 5, July 11, August 14, September 9, October 8, November 15, December 15. 1923, January 13, February 13, March 9, April 13, May 20. At the time of writing, the Home is booked practically full for June and July, whilst many names are already down for August and September. Table showing Attendances at the Ante-natal Centre and Special Clinic for Babies During 1922. Ante-natal Examinations. Period. Number. Babies' Special Clinic. Number. December 30 to January 12 (2 sessions) 26 6 January 13 to January 26 „ 36 9 January 27 to February 9 „ 28 12 February 10 to February 23 „ 26 10 February 24 to March 9 „ 27 8 March 10 to March 23 „ 28 19 March 24 to April 3 (3 „ ) 30 22 April 21 to May 4 (2 „ ) 28 6 May 5 to May 18 „ 22 14 May 19 to June 16 (3 „ ) 60 50 June 16 to June 29 (2 „ ) 32 22 June 30 to July 13 „ 44 12 July 14 to August 24 (5 „ ) 94 83 August 25 to September 7 (2 „ ) 42 21 September 8 to September 22 „ 45 21 September 23 to October 5 „ 50 22 October 6 to November 27 (7 „ ) 206 37 November 28 to December 11 (4 „ ) 64 18 101 It is generally held that a Maternity and Child Welfare Officer cannot do more than twelve cases at one session. It would appear therefore that we must face the question of a third session each week, and yet it seems only yesterday that we opened our Ante-natal Centre tentatively, wondering whether anything was going to happen ! The success of the Ante-natal Centre is assured; similarly, the Municipal Maternity Home, by another year, may be two small for the Borough's needs. If we cannot get houses for heroes, we must at least provide spacious and comfortable maternity homes for heroes' wives. From our Ante-natal centre many expectant women have been sent to our dental clinic for treatment. In emergencies, we have sent twelve to the Miller Hospital dental department. Four cases presenting antenatal complications were sent to Guy's Hospital, and one suspected V.D. case was sent to St. John's, Lewisham. Notification of Still Births. This has been very unsatisfactory ; such are not registered at the Registrar's. Particulars of each case are now obtained through the Borough Accountant's office, as the father has to arrange through the same as regards burial. Notification of Pregnancy. This was mentioned to the Maternity and Child Welfare Committee. If the neo-natal mortality is to be reduced (the deaths occurring before birth and for one month after) a visit during early pregnancy should be made to the Ante-natal Centre. In Huddersfield some 35 per cent. of pregnancies are notified. The expectant mother's consent is required, and notification must be sent to the Medical Officer of Health within seven days of the engagement or no fee is paid. THE PUBLIC HEALTH YEAR, 1922. A few notes on some of the subjects which came up for consideration during 1922, are desirable. The Public Health Committee meet once a fortnight and at each meeting a full record is presented dealing with the work of the department, statistics, etc. I have presented many reports, including:— Vaccine Therapy. Unsound Food destroyed in London in 1921, The Tuberculosis Scheme for the year 1923-4. Dental Treatment for non-insured Tuberculosis patients. Case of alleged Food poisoning. 102 Case of alleged Small-pox. The Tuberculosis (Dispensary) Service. "Following-up " in Tuberculosis. Circulars 304, 307, 149, 30 T, 194, 257. Administration and Practice at the Dispensary. The Present Health and Position of each Tuberculous Ex-service man in Deptford. The Tuberculosis Dispensary and Ameliorative Agencies. Cancer. Conference on Venereal Disease at the Guildhall. Food Preservatives—Boric Acid and Cream. Food Poisoning and Food Infections. The River Ravensbourne. The Milk and Dairies (Amendment) Act, 1922. Health Week. Diphtheria Anti-toxin. Conference at Islington on Unsound Food. The Guildhall Conference on Venereal Disease. It is estimated that fully 40 per cent, of the patients enrolled at the V.D. Clinics do not return for the full course of treatment, but leave off once their immediate sufferings are ameliorated or abated ; they are therefore still infectious. To a certain extent, therefore, money is wasted in that the Clinics are not able to function fully owing to the modesty of their patients. At one London clinic there were 3,834 new cases in 1921, and 1,514 did not complete their course of treatment. Syphilis is the third most destructive disease. The patients in lunatic asylums suffering directly or indirectly from the results of this disease cost nearly one-third of a million pounds annually. There are 200,000 fresh cases of the disease every year. It is imperative that this disease should become compulsorily notifiable. In Western Australia the disease is notifiable, but the names and addresses are not given. The identity is disclosed only if the patient ceases treatment before the infectious stage is passed. Court proceedings are taken in camera and it is unlawful to report proceedings in any newspaper. The Deptford Borough Council resolved that the Ministry of Health, the London County Council and the other Borough Councils should be asked to favour the proposal that compulsory notification should be established, as in Western Australia, name, address and identity not to be disclosed, unless treatment should be broken off before the infectious 103 stage was passed. The County Council replied that they were awaiting the issue of the report of the Special Committee recently set up to investigate the whole matter. The majority of the Metropolitan Boroughs replied in favour of the proposal. There the matter at present stands. Food Preservatives. Boric Acid and Cream. This subject is in a most unsatisfactory state. A radical enquiry into the whole question is long overdue. In 1901, the Departmental Committee said that .25 per cent (17.5 grs. to the lb.) should be the maximum amount of boric acid used in cream as a preservative. Borough Councils asked the Local Government Board to give effect to the Departmental Committee's suggestion, but this was not done. In 1909, the Kensington Borough Council notified cream vendors that they would prosecute anyone selling cream containing boric acid without disclosing its presence, and further, even though its presence was declared, a prosecution would follow if more than .25 per cent. (17.5 grs. per lb.) were found in cream. In 1912, the Local Government Board issued the Milk and Cream Regulations, and in 1917 amended the same, no preservatives to be added to cream except boric acid and not more than 28 grs. per lb. (.4 per cent.). Labels to be used, "Not suitable for infants or invalids." Kensington adhered to their 17.5 grs. standard and notified traders again to that effect. Wholesalers, however, sometimes added 28 grs., and Kensington retailers had difficulty in finding less. The Kensington Borough Council felt that no cream preservative was necessary if quick transit and clean methods were used. The Local Government Board stated in 1917 that their Order was an Interim one, and that a small expert Committee would be appointed after the war. As this had not been done, the Kensington Borough Council besought the other Metropolitan Boroughs in 1922, to help Kensington in asking the Ministry of Health to institute the enquiry promised by the President of the Local Government Board in 1917, concerning the use of boric acid in cream, so that matters would be made fair to the trader, consistent with the provisions of the Food and Drugs Acts, and would protect the health of the people. The Deptford Council addressed the Minister of Health, asking that the enquiry promised in 1917 should be instituted forthwith. A reply came to the effect that a Committee of enquiry had been appointed in 1917, and that no useful purpose would now be served by the appointment of a Committee for the investigation of the question of preservatives in cream. 104 Later in 1922, Bermondsey Council suggested that pressure should be brought to bear on the Ministry, urging that a new Committee should be appointed to bring the recommendations up to date, and that the Ministry should initiate legislation. Deptford again gave its support. I understand that a fresh enquiry is to take place. It is desirable that something in the nature of a standard should be made with respect to preservatives in foods. The present position is vexatious, as it has happened that a conviction has been obtained in one part of London for selling one pound of tinned green peas containing 1.3 grs. copper sulphate (added to give the peas a fresh green appearance) and yet in another part of the Metropolis a prosecution for selling a tin of peas containing approximately 3 grains of copper sulphate per pound of peas was dismissed. Meanwhile, the Deptford Borough Council has decided to issue warning notices in the press and trade journals to the effect that in future any vendor selling tinned foodstuffs containing metals or their salts (such as copper sulphate in tinned peas) will be prosecuted. Small-pox and Chicken-pox. In view of the presence of Smallpox. in London it was decided that Chicken-pox should be made notifiable for the three months ending February 17th, 1923. During this period numerous notifications were received, and I visited approximately 50 per cent. of the cases; a happy working arrangement to this end had been made previously with the general practitioners. In five doubtful cases I was called in consultation. One case of Small-pox was notified in November, but the diagnosis was not upheld at the Metropolitan Asylums Board's South Wharf; meantime, every contact had been vaccinated, and the family had been removed to the Temporary Shelter in Watson Street. An exhaustive enquiry into everybody's movements had taken place. The scare led to a fair amount of vaccination in the Borough. Measles. As from 11th September, 1922, Measles was made notifiable in the Borough for five years. Alleged Food Poisoning. A case was reported, and with the Coroner's consent I attended the post mortem, when ruptured gastric ulcers were disclosed. Preparations had been made to send foodstuffs and portions of the organs to Mr. Bruce White's laboratory at Bristol, where such investigations are made by agreement with the Ministry of Health. 105 Influenza and Cinemas. In 1912, Local Government Board Regulations made a thirty minutes' interval compulsory, but these were withdrawn in May, 1919. The Council asked the Ministry of Health and the County Council, in February, 1920, to take more stringent precautions to prevent infection in places of amusement, especially as regards disinfection and ventilation between performances. The Ministry advised that Local Authorities should use steady pressure in conjunction with the local licensing authority. In January, 1922, the Borough Council wrote again to the Ministry and County Council asking that the matter be considered again, making it compulsory to have an interval of half-an-hour between performances. The Ministry felt that attention to the general system of ventilation would be more effective than the proposed interval. I visited two cinemas, and drew the attention of one manager to the abominable ventilation. The manager explained that one of the fans had broken down and that arrangements had been made to put it in order. Ice Cream. The London County Council (General Powers) Act, 1902, Part 8, came into operation on November 1st, 1902. This calls upon merchants or dealers in ice creams not to make this commodity or store it in any cellar, shed or room in which there is any inlet or opening to a drain or which is used as a living room or sleeping room. The commodity must not be exposed to infection or contamination by any act or default. The merchant or dealer must give notice forthwith to the Medical Officer of Health of any outbreak of infectious disease amongst employees living in or about the premises, etc. Itinerant vendors must have on their barrows the name and address of the person from whom he obtains such commodity, or his own name and address if he is the manufacturer himself. In September, 1921, the Borough Council asked the County Council to register retailers and wholesalers of ice cream, as Regulations could not be enforced if the Local Authority did not know the extent to which ice cream was manufactured or sold within their area, and that only by means of compulsory registration could this be done. Further, a reasonable standard of cleanliness could be enforced before registering premises. There are 93 ice cream makers in Deptford, but vendors can stroll in from any outside area. It is extremely desirable that the Borough Council should press this matter with the County Council. No man should be allowed to sell ice cream unless the premises are registered. The Inspector should 106 call in the Medical Officer of Health when visiting applicants seeking registration, where he has the slightest doubt as to the suitability of the premises or the habits or personal cleanliness of the would-be manufacturer or retailer. The use of glasses for the retail of small quantities should be strictly forbidden, and wafers only should be allowed. This pernicious practice must cease. Rats. The Ministry of Health was approached with a view to having disused drains sealed off, and they agreed to consider the point when any legislation concerning rat destruction was proposed. The County Council said that legislation would be promoted, placing upon owners or occupiers of property an obligation to notify the Local Authority on ceasing to use any drains or similar sanitary fitting, and making it an offence to cease to use any such drain or sanitary fitting without efficient sealing off. Public House Urinals. These were found to be good structurally, though some retarring and cleansing were necessary. A circular was sent out to the publicans. Enteric (Typhoid) Fever. A girl died from peritonitis following upon an obscure illness. At the post mortem, typhoid ulcers were found in the intestine. Twelve months before, the father had suffered from gastro-enteritis. Pathological tests failed to disclose a connecting link. Ophthalmia Neonatorum. The Ministry was approached with a view to medical men and midwives using antiseptics for the eyes of each newly-born baby. By-laws as to Houses let in Lodgings. Draft by-laws were made by the County Council with respect to houses intended or used for occupation by the working classes and let in lodgings or occupied by members of more than one family. The Borough Council felt that the by-laws were objectionable and could not be worked. The defininition would include many thousands of houses in the Borough, and their registration as lodging houses would involve increased staff of inspectors, and a considerable increase in the number of visits and inspections. River Ravensbourne. This river separates Deptford and Greenwich close to the Broadway. It was stated that papers tended to collect at both sides of the river and that there was some suggestion of a nuisance. Some time ago the Council built a concrete retaining wall to narrow the river and deepen the centre, thereby increasing the force of the current. 107 No nuisance was found to exist in 1922, but some papers were noticed on both sides. Messrs. J. H. Robinson were asked whether they would be good enough to open their lock-gates at judicious intervals and at suitable states of the tide. The Greenwich Council agreed to co-operate with Deptford if any material change occurred in the state of the river. Circular, Milk Prosecutions. This circular stated that it was extremely undesirable that a prosecution should be based (as a result of a milk analysis) upon the results of an isolated test, therefore prosecutions should be instituted only where a series of tests have shown repeated default. The Council took exception to this circular, and asked the Ministry to withdraw it. The general reception given to this circular was such that the Ministry eventually withdrew it. Milk and Dairies (Amendment) Act, 1922. Whilst this was still a Bill, the Member of Parliament was asked to support an amendment urging the abolition of the statutory defence of Warranty. The warranty is still in existence and it is a curse to every person anxious that the public should receive milk which is of the nature, substance and quality demanded. The Milk and Dairies (Amendment) Act, 1922 is chiefly an educational measure. People are learning that milk is graded into "Certified" milk, "Grade A" and "Pasteurised." Once the difference between these and ordinary milk is realised, the demand for the better qualities will doubtless increase. The Act forbids the addition of colouring matter or water, or any dried or condensed milk, or any fluid reconstituted therefrom, or any skimmed milk or separated milk to milk intended for sale. It is forbidden to sell the milk of a cow suffering from tuberculosis of the udder. If the dairy farmer could have ascertained the existence of the same by the exercise of ordinary care he shall be held guilty. Provisions are made in the Act for the obtaining of the necessary licences. Housing. Barely a week passes without an application at the Town Hall for a house. There are, of course, none to be had. The Council have built where land was available (see last year's Report). In the Baildon Street area there are some houses, the leases of which terminate in a few years. It is one region in which a Housing scheme might be carried out. Behind Speedwell Street there is some vacant land, not much it is true, but sufficient to commence building. The operation could be extended by degrees in this locality as room is made by pulling down old property. 108 Section 28 of the 1919 Housing Act has been found to have limitations in the light of certain Court cases. If a Council proceeds to do the work of repairing houses in default of the owner, there is a risk that difficulty may arise before the money can be collected. In Deptford, therefore, the use of Section 28 will be restricted. Tuberculosis. In January, I wrote a Report on the Tuberculosis Service. The scheme was built on the thirteen paragraphs in Circular 149, issued by the Ministry of Health on 23rd December, 1920. The Tuberculosis Officer visits patients' homes at least once to supervise the nurse's work and familiarise himself with the patient's surroundings. The Tuberculosis Officer holds eight Dispensary sessions per week; he has a certain amount of clerical work to do, and holds consultations over cases. Treatment is limited to Tuberculin "and those unable to obtain other adequate medical attendance." Education as to the hygienic mode of life is given. Children of school age suffering from adenoids, defective teeth and enlarged tonsils are referred to the school clinic. In March, I gave a Report to the Public Health Committee on "Following Up." Later a Report was given on the Administration and Practice at the Dispensary. This dealt with (1) Notification: (2) Disinfection; (3) Visiting by the Tuberculosis Officer. I visited the homes of every case attending the Dispensary, namely, 101 people. (4) Contacts; (5) Lapsed cases; (6) Diagnosis pending cases. The Committee agreed to the keeping of certain new registers:— (a) The contacts of each case were to be put down in a book and ticked off as examined. Revisits to be paid in 14 days where contacts had failed to attend. (b) A Register with the name and address of each new case, with the date on which the patient is due to return. To be visited if one month overdue. It was decided to re-cast the form on which the monthly statistical report was made up. The following is a copy:— Jan. 1st Month to end of period of under report. 1. Persons, other than "Contacts" examined for the first time at or in connection with the Dispensary— (a) Found to be suffering from Pulmonary Tuberculosis (b) Found to be suffering from other Tuberculosis (c) Found to be Non-Tuberculous (d) Diagnosis pending 109 2. "Contacts" examined at or in connection with the Dispensary— (a) Found to be suffering from Pulmonary Tuberculosis (b) Found to be suffering from other Tuberculosis (c) Found to be Non-Tuberculous (d) Diagnosis pending 3. Total attendances at Dispensary including above 4. Attendances at which systematic examinations and records were made 5. Visits to homes by Medical Officer 6. Visits to homes by Tuberculosis Nurse 7. Consultations with Medical Practitioners at homes 8. Specimens of Sputa examined— (a) Positive (b) Negative Under Nos. 1 (d) and 2 (d), the number who are still under observation for final diagnosis is—, and of these—have been so for more than two months. After visiting the homes myself of each ex-service man suffering from tuberculosis, I drew up a report on the present health and position of each man (the total came to 132) for the Public Health Committee. Every case had received treatment, some more than once, in hospital and sanatorium. Various reports on Circulars were written, including Nos. 149, 30 T, 194, 257. THE PREVENTION OF HEART DISEASE. "The time has come when it it our duty to make some new effort to protect the children from the dangers of heart disease." These words occurred in a letter written to me by Dr. F. J. Poynton, F.R.C.P,, Physician to the University College Hospital and the Hospital for Sick Children, Great Ormond Street. A few weeks ago Dr. Poynton delivered a clinical lecture to the students at Great Ormond Street Hospital, and the lecture has attracted widespread attention. It is desirable that the public should be acquainted with the facts, and this can be furthered if they are broadcasted in a Medical Officer's Annual Report. The following is a summary of Dr. Poynton's excellent lecture:— 110 The Gravity of Rheumatic Heart Disease. Heart disease caused by rheumatism is very frequent and very constant in its occurrence, particularly in London. The major part of the heart disease we meet with in children arises from infection, and it is the infection in particular which causes rheumatism that leads to serious damage to the heart valves, to the heart bag, or to the muscular heart walls in so many young children. Is it not possible to take preventive measures ? Look for a moment at The Gravity of Rheumatic Heart Disease. Acute rheumatism is a disease of children of the "hospital class," and not to any extent of children living in better circumstances. In the year 1919-20 a bad outbreak occurred, and 172 cases were admitted to Great Ormond Street Hospital, the average stay in hospital being 60 days, whereas, as a rule, the average stay in hospital for a medical case is 28 days, and the cost of each case is £2 9s. per week. In maintenance, this outbreak of 172 cases cost the hospital £4,589. But what of the damage to the children arising from the disease? 66 per cent. of these children had signs of organic disease of the heart, 22 cases died and 38 became complete invalids. Twelve is the age limit for admission to Great Ormond Street, and of the 172 cases mentioned above, some were two years of age, whilst 30 first-attacks occurred at seven years of age. As soon as the school age is reached a steady increase in the incidence occurs. Cardinal Pathological Facts. If the infection, the poison, attacks the muscles and nerves of the heart, these cannot be replaced if destroyed; it is only if the damage is slight or partial that complete recovery can be looked for. When the poison attacks the heart's framework, that is, the fibrous tissue (not the muscle) found in the valves and heart bag, then this fibrous tissue is replaced by scar tissue which may thicken and contract if the irritation be prolonged. The chief cause for a heart breakdown in a child is active infection. If the pericardium (the heart bag) becomes the seat of a chronic rheumatic infection, it becomes thickened and densely adherent to the heart and possibly to the surrounding tissues. Serious then is the condition, the outlook, when the poison of rheumatism affects the muscle and fibrous tissue alike, of a child's heart. How can the heart, the mechanical pump, work when the valves are scarred? 111 Diphtheria. This is a disease which can kill the heart muscle and nerves, but it does not produce scarring. Diphtheria is notifiable and is under supervision. We know that from about the third to the fifth weeks of attacks of diphtheria, troublesome heart symptoms may become manifest. But in diphtheria the heart condition is well supervised ; it is anticipated, whereas the rheumatic heart of the child may work havoc before medical aid is sought. Heart disease from tuberculosis is uncommon, but in the case of heart disease from scarlet fever, this is an event which, where it occurs, tends to arise after the child has left the hospital, and so supervision of scarlet fever "recoveries" (as is done in Deptford) is imperative. Rheumatic Heart Disease. Acute rheumatism is not notifiable and perhaps should not yet be made notifiable, as some doctors doubt whether the disease is infective and so they dispute its cause. Others again believe (including Dr. Poynton) that it is a definite infection and a definite disease. Prevention can often be only Partial. When sufferers from acute rheumatism come under the doctor's care, the damage, frequently, has already been done; thus one can but strive to stave off further attacks. There is a limitation at present to our control over rheumatic heart disease, notwithstanding the value of the salicylates in treatment. But there is a someth0ing wanting in the general management of rheumatic children. If this can be defined and applied, much severe heart disease will be prevented, and many lives will be made more useful to the State and happier to the patients. Defects in the Management of Heart Disease in Infants. 1. Imperfections in Medical Education. Greater opportunities are required for students to see cases of acute rheumatic conditions in the child. It is one thing to see the closing chapter of heart disease in the adult, but the dawn of heart disease in the child is that which the student requires to familiarise himself with. 2. Public Ignorance. Propaganda and instruction are necessary, because the public do not appreciate the gravity of heart disease in childhood. The disease may commence insidiously, no pain, perhaps, nothing to alarm or strike the warning note. A serious organic change 112 may occur with no striking symptoms to account for it. Parents, seeing their children lying in bed without pain or distress, are shocked when they are told that convalescence must be slow and carefully supervised. But once the parents are told that the disease is due to a microbe which causes poisoning and that the poisoning softens the heart muscle, they are more likely to appreciate the necessary care ; and again, they are impressed when emphasis is laid upon the fact that the entire future of the child depends upon the heart muscle becoming once more firm and strong. It is necessary therefore to get at the public somehow and warn them. The object is not to wait until some child in the family has been stricken down, but instead to give everyone the information now. The following should be known to everyone:— 1. Rheumatism is caused by infection by a microbe and is a frequent disease in large cities. 2. In children, rheumatism often attacks the heart, and is the most frequent cause of organic heart disease. 3. Pains in the muscles and joints in children should receive attention, as possible warnings of rheumatism. 4. Sore throats are often associated with acute rheumatism. 5. Rheumatic heart disease is often painless and requires a doctor's examination for its detection. Shortage of breath and pain over the heart require immediate attention. 6. The heart, when injured by rheumatism, recovers slowly from the poisoning, and one of the greatest dangers to the child's future is for it to resume an ordinary life before the heart is firm. 7. Chorea, or St. Vitus's dance, is rheumatism attacking the brain, and its chief danger is the tendency of the heart to be injured by the rheumatism at the same time. 8. Great nervousness, dreaming of school work, alteration in disposition and slight twitchings are often seen before the Chorea has become definite, and are warnings. 9. Rheumatism often recurs, especially in the Spring and Autumn. 10. An occupation in life for a child with heart disease requires careful choice. Chorea and School Teachers. In London there is a considerable amount of chorea during school age. Chorea is rheumatism of the brain, and it is probable that this frequency is in part due to overstrain and lowering of the resistance of the nervous system to infection. Hence, if we find a school child 113 flagging in health and becoming irritable and unequal to school life, still more if we find warnings of chorea, we must advise a term away from school and advocate mental and physical rest. Chorea is certainly rare among those school children whose parents can afford to take them away from school and give them mental and physical rest for a term. Possible Steps for the Prevention of Chorea. 1. The education of parents as already indicated. 2. Simple lectures on rheumatism to parents and school teachers. 3. An investigation by school medical officers into the frequency of chorea in school children and into their histories just before their actual breakdowns. The facts which would be ascertained would cause parents to attend to ill-health more promptly. Already the school medical officers have done splendid work and have picked out many cases and sent them for treatment. May it not be that having regard for the sensitiveness of rheumatic children, some modification of the educational machinery for such children may be promoted where non-existent? The Weak Point in Hospital Treatment. To-day, when a child has been nursed through an attack of acute rheumatism in hospital, we have to send the child direct to its own home, often situated in an unhealthy overcrowded street. Instead of this there ought to be an auxiliary hospital near London to which convalescent children could be sent so as to get the much needed rest and graduated exercises required in this ailment, in addition to fresh air, sunshine and good food. In course of time the patient would be able to return home with a heart strengthened to the level of carrying on an ordinary life; if that is unattainable, then the child's limitations must be made clear to the parents. Look therefore for that country auxiliary hospital with its level paths and gradients of different degrees, with its massage and, yes, for its arrangements for the general education of the patients, who are gradually mending back to the work-a-day level of health. Think of the great value of such an institution acting as the handmaiden of, say, Great Ormond Street Hospital. Suitable Employment for Cardiac Cases. Why is it that there is a greater organisation in America for the care of "heart" cases of all ages and so little in our own country, comparatively? Realising that so many of our lads and girls approaching school age have hearts of different degrees of weakness 114 resulting from attacks of acute rheumatism, leading to different grades of invalidity, surely it is incumbent upon us to help and guide the parents of such children by providing information so that children will not be sent to the wrong occupation? For example, a boy with "rheumatic heart" should not be made a coal heaver or a furniture remover. Think of the suffering and the loss of life and loss to the State from such mistakes. Lists of suitable occupations should be provided to the parents of such cases. A Central Office. There is an organisation required, a central bureau or office, an intelligence staff, small, but competent, which could keep in active touch with hospitals in the city and convalescent homes in the country, with parents in the houses and their sick or recovered children, which could supervise and direct propaganda and syllabuses of popular lectures. Treatment of Local Foci of Disease. Sometimes a local focus or infection in the body has led to the rheumatic heart disease in children. For example, acute tonsilitis has undoubtedly been the starting point of many a rheumatic heart. In children it is wise, therefore, to remove enlarged tonsils if these are diseased. Unhealthy tonsils in rheumatic children should be removed as there is a risk of rheumatic heart disease if they are retained. Summary of Argument. To sum up the steps which would be of service; these are:— 1. Improvement in medical instruction. 2, Education of the public, particularly parents and school teachers, by propaganda and lectures. 3. Further investigation into the incidence of chorea in London. 4. Auxiliary country hospitals with a special department for cardiac children. 5. A schedule of suitable occupations for cardiac children. 6. A central bureau for purposes of organisation. In the far future an institution for research into and the study of rheumatism. 7. Discreet treatment of local foci. 115 Expectations from Prevention, It is sad to think that at present the policy is one of " Drift." Hitherto we have treated the acute rheumatic heart, and we have patched up the chronic heart that is so often the result of rheumatism. We have treated the actual heart condition when we have met with it in the wards or in private practice. We must now face the preventive side with vigour. We must hark back upon the causes, we must control the active element of the disease, the germ, the poison, and destroy the conditions which make its growth and propagation possible. Prevention has not been given the attention it deserves. Dr. Poynton's lecture calls upon the hygienist to play an active role. Such apparently simple matters as the care of the teeth, the proper clothing and footgear of children, the house, wind and weather tight, should play their part as factors in the campaign against rheumatism. A heavy responsibility rests upon all local authorities through their Maternity and Child Welfare and School Medical Inspection Centres, to educate parents on these matters. Research is called for. Dr. Poynton says it is a disease of the "hospital class" of children rather than the better circumstanced. Good housing, more space, more and better food and clothing, more education, these are required, though not everything. It is desirable that all cases of rheumatic fever (but not simply rheumatism) should be made notifiable, so that complete records could be made of the whole history, circumstances, etc., by the Medical Officer of Health. Through the Ministry of Health, such records, together with those of the research laboratory, and clinical workers, should be pieced together. Rheumatic fever is ignored because its damaging results are not immediate and clamant, and öbecause, apparently th evirus is of low degree of infectivity. There is room for a Departmental Committee to enquire. SOME REFLECTIONS ON CANCER. Preface by Sir Thomas Oliver, M.D., F.R.C.P., etc., Professor of Medicine, University of Durham; Consulting I'hysician, Royal Infirmary, Newcastle-on-Tyne. Author of " Industrial Diseases," etc. The ravages of cancer have certainly brought home to the public the urgent necessity for a careful enquiry into the cause or causes of the disease. Before we can treat disease we must know something of its causation. That repeated irritation is capable of inducing the 116 malady is now, I think, generally admitted. Dr. Thomson has alluded to cancer of the lip in persons who have been in the habit of smoking a short and dirty clay pipe in support of this contention. In the case of primary malignant disease of the gall bladder, where the liver for the time being has escaped, gall stones are present in probably 90 per cent. of the cases. This is not only true of man, but also of the lower animals. I have seen the association of the two in horses. There was on the part of many members of the medical profession, years ago, the tendency to discount the association of injury and cancer, but the opinion is growing that in many instances there is a causal relation between the two events. That chimney sweeps cancer is a consequence of the irritating action of the soot is now widely accepted, and in addition to the mode of cellular in vasion mentioned by Dr. Thomson, there is also the probability that the presence of arsenic in the soot is not without a harmful influence. The malady is occasionally met with in the hands of gardeners who are in the habit of sprinkling soot upon the soil around plants. Dr. Thomson, in support of the irritation as causative of cancer, has drawn attention to the presence of malignant disease in the alimentary canal, and there is certainly a sufficiently large number of cases to support the view that cancer has developed on the site of an old or of an unhealed ulcer. Fortunately, the occurrence is less frequent than might be expected. That the disease may be due to a germ is more than likely. The parasitic theory has many adherents, but although microscopic bodies have been described and photographed, no one and definite object has yet been found in all cases. Much light will be thrown on this subject by further research and by the study of the growth of embryonic and other tissues apart from the living body. It is an interesting fact that of all the various kinds of tissue which can thus be grown, watched and experimented upon in the laboratory, one of the most rapidly-growing tissues is that taken from a cancerous tumour. As regards the infeotivity of cancer, I have cases where there was a strong suggestion of such having taken place. I discussed the subject with Sir William Macewen, who was convinced of the probability of cancer of the rectum having been conveyed by an enema tube which had previously been used by a patient suffering from the disease and who had apparently, by this means, passed it on to other persons. It is gruesome to think that there is the possibility of cancer germs lurking in houses. Without going into details I will simply give a few 117 facts taken from a paper published by Besson in the Annates D'Hygiene Publique, January, 1923, who states that in Paris, between August, 1906 and 31st December, 1914, there had occurred 24,957 deaths from cancer. In 3,175 houses there had occurred 2 deaths; in 708, 3 deaths; in 181, 4 deaths; in 48, 5 deaths; in 13, 6 deaths; in 2, 7 deaths; and in 1, 8 deaths. Besson discusses the question of chance and coincidence, and he closes with the words: "There is therefore confirmation of the opinion, widely admitted, as to the contagiousness of cancer." Dr. Thomson has written a suggestive paper. He has dealt with a Public Health question in an exhaustive manner commensurate with the limits of his article. Some Reflections on Cancer. By The Medical Officer of Health. The public mind is disturbed by the threat of cancer. The incidence of cancer, we are told, is becoming greater. A scrutiny of the number of deaths from cancer occurring during the last ten years in Deptford affords no grounds for believing that the disease is increasing locally. True, the deaths have increased from 121 to 146 in ten years, but this is countered by the relative increase in the age of the population, and by greater precision in diagnosis, arising out of the general advance in laboratory facilities. The practitioner turns to his Borough Council's or private laboratory every day: we speak justifiably of the science of medicine. The flash of the surgeon's blade has long since hypnotised the public imagination, but the steady advance of clinical and pathological methods has raised the physician to his rightful place in public esteem. It is not the surgeon who has bolted the door against smallpox, typhus and enteric fever; he has played no part in the evolution of our Factory Acts, in industrial conditions, lead poisoning, fatigue, and so on. We look then to the physician to bring to the light of day the parasite, the germ, which causes cancer. It is meet that the public should receive some information as to the viewpoint of some eminent physician on the subject of cancer. Accordingly I have ventured to approach Sir Thomas Oliver, M.D., F.R.C.P., of Newcastle, who, despite a busy life as a Professor of Medicine and Consulting Physician, has won for himself, alike by the pen and the spoken word, a position of great eminence in the public health world. 118 I have submitted to him, with some trepidation, the views expressed herewith, and have asked simply whether he could spare a little time to favour the Borough Council, the citizens of Deptford, and the circle of readers beyond, with a few notes on his views upon cancer. Professor Dreyer has brought hope where no hope was into the tuberculosis fold. The ring is tightening around tuberculosis, and high are the hopes, and undaunted the courage with which we of the preventitive brigade, look to the day when cancer will be arraigned at the bar of medical science, and the evidence as to the causative agent be conclusively proved. One of the most attractive books, and most convincing, for the reader, either medical or non-medical, on cancer, is that written by Dr. A. T, Brand, of Driffield, Yorkshire (publishers, John Bale, Sons and Danielsson, Ltd.). He believes in the infectivity of cancer, that it is caused by infection from without, A number of vague causes have been put forward, such as overindulgence in tea, the consumption of too much sugar, whilst tomatoes, salt and flesh eating have each been blamed. Hindoos, however, eat but little flesh and they too are subject to cancer. Cancer was known before the days of tea and sugar. Rollo Russell suggests that cancer is due to food and drink taken at high temperature and to the free use of wine, beer, spirits, flesh, coffee, tea and tobacco. But do many people take their food and drink at a temperature which is unpleasant to themselves ? We are on safe ground in saying that cancer follows upon prolonged irritation. Pott first described chimney sweep's cancer in 1775. Here the creases in the skin are habitually filled with carbon particles and then pass between and into the cells causing cell multiplication, leading to cancer. X-ray workers, after some years, have developed cancer through the irritation of the rays. Bloch, Driefuss and others have produced cancer in mice through the irritation of coal tar. The irritation produced through constantly smoking a clay pipe has led to or has made possible cancer of the lip. The continued presence of ragged teeth in the mouth have caused cancer. Is cancer of the gall bladder caused by irritation of gall stones? Prolonged irritation then is the forerunner of cancer. Cancer of the stomach has followed upon ulceration, upon chronic dyspepsia. Lactation leads to fissured nipples, hence, sometimes, cancer of the breast. 119 The commonest site for cancer is the alimentary canal. Is cancer induced through irritation caused by some irritant or infective agent taken in the dietary? The female reproductive organs are frequently affected. The os uteri is fissured after frequent deliveries. Irritation then, or injury, is a prime factor in our considerations. Cohnheim believed that malignant tumours were due to awakened growth of embryonic rudiments. In the process of development, some embryonic portion of tissue fails to grow, but later in life becomes active and forms a malignant tumour. Thiersch maintained that the downward growth of superficial cells and upward growth of bloodvessels led to interlocking and so to the formation of cancer. Creighton attributed the formation of cancers to wrong action of the superficial cells, with long-standing catarrhs, repeated congestions, etc. The Theory of Infection. Can cancer be due to a parasite, a micro-organism? I believe the answer to be in the affirmative. The evidence in favour is circumstantial. It is as well to face the criticisms. In his book, "Theories and Problems of Cancer," 1923, Dr. C. E. Walker, of Liverpool University, disposes of the parasite theory to his own satisfaction:— "The parasitic theory was most popular in theeirly nineties, but since then its adherents have diminished in numbers with ever-increasing rapidity. Very many "discoverers" of the cancer parasite have not had the necessary knowledge and skill to conduct the investigations. The motley throng which has in the past claimed the discovery of the parasite of cancer consists mostly of the ignorant, but includes some very competent men," Dr. Walker quotes Dr. James Ewing as saying that "the cancer parasite is the cancer cell." Yes, but what causes the cancer cell, what is the vis a tergo? The answer is a germ. Abuse from any inicroscopist will not prevent many from adhering tenaciously to the germ theory. Cancer must be due to a cause from without, inasmuch as the cause of nearly every disease arises outside of the body. Once cancer has gained a footing it spreads locally, infecting its immediate environment; it is disseminated metatastically by the blood current and lymph streams, the latter infecting glands en route. A local diseas to begin with, cancer eventually becomes constitutional, one of the proofs being 120 the gradual establishment of cachexia, i.e., an appearance of characteristic pallor and exhaustion resulting from saturation of the system with the toxins of the microbe causing the disease. The sites in which cancer usually appears are easily assailable by infective germs. Fiftyfive per cent. are in the alimentary canal and probably result from the ingestion of the infection. Long continued irritation leads to a breech in continuity of tissue, thereby admitting the parasite. In the middle aged and the old, where the tissues are undergoing degeneration and the resisting powers are reduced, the infection more readily gains a footing. The cancer cell or a germ—which? If a cancer cell is the cause of cancer, then how came it to be there? That is what we think of when we look upon a cancerous tumour. We must go further back than the cancer cell. Some other reflections seem to strengthen the germ theory. Dr. Brand has marshalled these very convincingly to my mind, in his book. Take auto inocculation. Ebert has collected 23 cases of contact cancer, such as hp to lip, tongue to gum, etc., and mentions the case of a woman who inoculated the cornea of her eye from a cancer on the back of her hand. There are many cases of cancer a deux on record, the most significant in support of the germ theory being those described by Tross and Guelliott. Dr. Brand's case will appeal to the Deptford Borough Council as, with other cases mentioned below, this will raise the question of notification, enquiry and disinfection. A woman developed cancer of the breast and was nursed faithfully until her death by a healthy woman, aged 46. The latter developed cancer of the stomach and died from it within twelve months of the death of the woman she had nursed. "This nurse was practically in constant attendance upon the case of mammary cancer and, not being a particularly clean person, it is more than probable that she had eaten her food with hands unwashed after dressing the ulcerated sore or handling the soiled dressings." Accidental Inoculation. A London Hospital surgeon developed cancer of the tongue after having accidentally got into his mouth some of the discharge from a cancerous breast. There are other cases. Experimental Inoculation. Cancer has been successfully inoculated experimentally, chiefly however in the lower animals. 121 Cancer Districts, Houses and Rooms. I am convinced from my own experience that this part of Dr. Brand's book, associated with a consideration of heredity, is so striking that Public Health Authorities cannot afford to leave matters where they are. True, in Deptford we have not been idle. We have received the kind assistance of the Kentish Mercury and the South Eastern Herald in our cancer propaganda work, and in many public health matters, and we have printed and circularised bills (see below) warning the public of the signs and symptoms of cancer. Now this particular reference to cancer houses, districts, etc., will interest all, as every family has talked about such and such a house as being a cancer house, etc. What are the facts? We speak of "cancer fields." The highest death-rate from cancer occurs in low-lying districts, those liable to seasonable floodings and characterised by alluvium and sub-soils of the various clays. Cancer is least prevalent in elevated districts where there is a good fall for drainage, freedom from floods and characterised by porous sub-soil and the oldest paleolithic rocks, especially the limestones. Cancer is most rampant where sewage is most difficult to be got rid of, and where it is most likely to be deposited and remain after floodings or high tides, on a non-porous soil. As a result there is a prolific growth of micro-organisms with probable contamination of shallow surface wells. Certain houses in such districts present cases of cancer. Three women, unrelated, successively occupied a room near London. Each had lived in other rooms in the same house. Within a year of occupying this room, they developed cancer, and died. The room was disinfected and the bedding burnt. No further case occurred in the house. Dr. Scott related in the British Medical Journal that J. K., aged 50, died of cancer of the liver. J. L., aged 54, succeeded him and died two years after from cancer of the bladder. A. L., aged 60, was then appointed and died in 18 months from cancer of the stomach. These three men all inhabited the same room in turn and slept in the same bed, which was a walled-in one. They were all strong and well when they came to live in this room. They were not related and they had no history of heredity. Many other cases could be quoted. The following is from Dr. Behla:— "The town of Luckau, in Bavaria, consists of a central main portion with 3,000 inhabitants, flanked on the east and west respectively by 122 subdivisions of the city called Kalau and Sando, each with a population of 1,000, making 5,000 in all. In 22i years (1875-1898) no case of cancer occurred in the western suburb, Sando ; cases were not infrequent in the central main town, and 73 deaths from cancer, out of a total of 663 deaths from all causes, occurred in the eastern suburb, Kalau. Cancer, therefore, caused one death out of nine in Kalau, one out of 25, or 30 in the entire town, whereas no cases occurred in Sando. During the 22½ years the number of inhabitants and their habits of life remained the same. The population is agricultural and lives on the products of its own gardens and fields. The dwellings are similar in size. The soil of Kalau and the central town is flat, low and moist ; that of Sando, elevated, sandy and dry. A stream or ditch closely encircles the central town and Kalau. Cancer followed the course of this ditch. In Kalau all the gardens were watered by it. Of the 127 houses in Kalau, 56 were cancer houses; 45 had a single case, 10 two cases and 1 four cases." Bella attributed this unequal distribution of cancer to the location of the ditch. In the cancer suburb, all the gardens were watered from it, and the people were in the habit of rinsing vegetables in water from it which was stagnant and foul. Behla believed the vegetables were infected from the water of the ditch, and the people by the vegetables, large quantities of the latter being eaten raw. Behla considered that a parasite must be the cause of this irregular distribution of cancer. Again, in his work, "Cancer Clinically Considered," Sir John Bland Sutton says:—"The frequency with which cancer attacks the large intestine is in favour of those who believe that cancer is due to a microparasite, probably something which is taken in with uncooked food or with water. Indeed, I feel so strongly on this matter that for many years 1 have avoided eating all sorts of uncooked vegetables. Much as I enjoy salad with my chicken or my cheese, I do not touch it. ... " Cancer is more prone to arise in glandular organs which have been injured or are the seat of chronic disease, than in those that are healthy. Strong are the grounds for believing cancer is infectious, that is, transmissible from one individual to another, directly or indirectly, by the agency of a specific micro-organism, either a bacterium or a protozoon. Dr. Gaylord showed that rats developed the disease after occupation of cages previously occupied by other rats suffering from cancer. When the infected cages were thoroughly disinfected no further infection occurred. 123 Heredity. There is no evidence to show that transmission of the disease from parent to offspring itself has ever occurred. It may be that, as in the case of tuberculosis, the children of cancerous parents may acquire more or less vulnerability congenitally. If so transmitted, then why does it not show itself soon after birth ? The advocates of heredity cannot trace cancerous parentage in more than 50 per cent, of cases of this disease. The occurrence of cancer in several members of a family after the death of parents from that disease, is evidence of infection from an obvious source. Prevention of Cancer. 1. Notification. The microscopists have not found out the cause of cancer. Is it not time that, accepting the possibility that cancer is an infectious disease, of a low degree of infectivity, the disease should be made compulsorily notifiable ? What we require is careful enquiry into each case, the history, the house, the environment, sanitation, habits, family history, occupation, etc., etc. We are doing absolutely nothing in Deptford just now unless by disinfection, by consent, at death. The situation is absurd; we are folding our hands in pessimistic despair. Let the Borough Council approach the Ministry of Health and ask for powers to have the disease made compulsorily notifiable locally. The Ministry may reply that, as cancer has not been proved to be an infectious disease, therefore it cannot be made notifiable. Perhaps the Ministry might do this for Deptford, as an experiment, on condition that full records of the inquiries be supplied to them, the inquiry to be made on lines approved by the Ministry. It would be somewhat discouraging if we did not receive a helpful reply. Notification would be more accurate as regards localities where the disease arises than the information which can be now obtained from statistics as to the places of death from cancer. 2. Disinfection. Until notification comes into being, it is desirable that we should circularise the medical profession locally that we shall be glad to have their kind influence in persuading the relatives of any who have died of cancer to have thorough disinfection of the house, bedding, clothing, etc., and to permit a few enquiries to be made by the Medical Officer of Health in person, on the lines indicated above, preferably as soon as the diagnosis is made. 124 3. Cancer Leaflets. Below will be found the leaflet in use locally. To this should be added that food should never be taken with unwashed hands, especially of course where a cancer patient is being nursed. Vegetables, if eaten raw, should be thoroughly cleansed, first by scrubbing. Dressings from patients should be burned and the dejecta treated with a strong disinfectant solution. Metropolitan Borough of Deptford. CANCER. Special Notice to the Public. The following leaflet is issued because so many persons die from Cancer whose lives could be saved if they acted upon the advice here offered. The importance of this subject to the public is shewn by the fact that of all deaths of persons over 40 years of age, one in NINE IS FROM CANCER. Issued by the Public Health Department, Deptford CANCER. It is vitally important that the following facts about Cancer should be known. It is now an established fact that of the number of persons who die each year from Cancer many could have been cured if they had applied fearlier for medical advice. On questioning patients as to why they do not apply to a doctor earlier, the reason almost invariably given is that, as the early symptoms were unaccompanied by pain, it was thought that nothing serious was the matter. In order, therefore, to call the attention of the public to the significance of certain symptoms and to the vital importance of acting promptly on the occurrence of these, it has been decided to make the following facts public. Practically the only cure for Cancer at present known is its early and complete removal. Its destruction by X Rays or Radium, though hopeful, is still in the experimental stage. Cancer, if removed early enough, has been proved conclusively to be a curable disease. If neglected, and not dealt with in its earliest stages, it is almost invariably fatal. The paramount importance of its early recognition and early removal is therefore evident. For this purpose the assistance both of the public and the medical profession is requisite; and a grave responsibility rests on both. It is only by their mutual co-operation that the ravages of this terrible disease can be lessened. The following information is of vital importance to the public. It is no exaggeration to say that, if acted upon, the result would be the saving annually of many lives which at present are sacrificed. 1. Cancer, in its early stage, may give rise to no pain or feeling of ill-health. 2. Nevertheless, in the commonest situations, the symptoms of Cancer in its early stage are generally manifest. 125 3. If any swelling occurs in the breast of a woman, especially after 40 years of age, a medical practitioner should at once be consulted. A large proportion of such swellings are Cancer. 4. If any bleeding, however trivial, occurs after the change of life it generally means Cancer, and Cancer which is then curable. If neglected till pain occurs, it means Cancer which is almost always incurable. 5. If any irregular bleeding occurs at the change of life it should always be submitted to a doctor's investigation. It is not the natural method of the onset of the change of life, and in a certain number of cases means commencing Cancer. 6. If any wart or sore occurs spontaneously on the lower lip of a man over 45 years of age it is almost certainly Cancer. If removed at once the cure is fairly certain; if neglected the result is inevitably fatal, 7. If any sore or swelling occurs in the tongue or inside of the mouth in a man over 45 years of age it should be submitted to medical inspection without a moment's delay. It may be necessary to decide by expert microscopal examination as to whether it is Cancer or not. A very large proportion of such sores and swellings occurring at this time of life are Cancer, and if neglected for only a few weeks the result is too often fatal. If removed at once the prospect of cure is good. 8. If any bleeding occurs from the bowels after 45 years of age (often supposed by the public to be "piles") it should be submitted to investigation at once. A large proportion of such cases are Cancer, which at this stage is curable. 9. When warts, moles, or other growths of the skin are exposed to a constant irritation they should be immediately removed. A large number of them, if neglected, terminate in Cancer. 10. Avoid irritation of the tongue and inside of the cheek by broken jagged teeth, and of the lower lip by clay pipes. Many of these and other local irritations, if neglected, terminate in Cancer. INSULIN AND THE TREATMENT OF DIABETES. By Geo. A. Allan, M.B., F.R.F.P.S. (Glasgow). Senior Assistant Professor of the Practice of Medicine, University of Glasgow, and Assistant Physician, Glasgow Western Infirmary. One of the very definite advances in medical treatment during the past year has been the discovery of Insulin by Dr. F. G. Banting, of Toronto, and its introduction to the profession as an aid in the treatment of diabetes. It has been accepted by most that diabetes is due to a defect in the secretion of the Islets of Langerhans in the pancreas, but its isolation has hitherto presented special difficulties which have been 126 overcome. The energy with which selected manufacturing chemists have tackled its production on a commercial scale from the pancreas of different animals has been most commendable, and Insulin is the name that has been given to this product. In this Country the manufacture and distribution of Insulin are undertaken by several firms under licence from the Medical Research Council, who holds the patent rights, and it is retailed at a uniform price of 25s. per 100 units. It is unfortunate that the press has exaggerated the claims of this discovery, and has proclaimed to the public " a cure for diabetes" and has thus raised unjustifiable hopes in the minds of the sufferers from diabetes, when it is more correctly an adjunct to dietetic treatment. Sugar is normally present in the blood, and the amount varies in health with the amount of carbohydrate in the diet, but it never rises above a definite level. In diabetes the patient cannot dispose of carbohydrate in the same way as in health: sugar accumulates in the blood above the normal level and as a result sugar passes in to the urine. Insulin has the power of dealing with carbohydrate, thus removing the excess from the blood, while allowing the patient to take a sufficient diet. The most serious complication of diabetes, namely, coma, is due to the presence of acid bodies in the blood due to defective combustion of carbohydrate. Insulin, in dealing with the carbohydrate, causes a disappearance of these acid bodies and so wards off this complication. If Insulin is given in doses too large in proportion to the diet taken, the blood sugar is reduced to a dangerous level, and certain nervous symptoms, coma and death might follow. It will thus be seen that Insulin should be given in dosage sufficient to keep the blood sugar within no rnal limits, and yet not so low as to produce Insulin symptoms. To do this efficiently blood-sugar estimations are necessary when dealing with true diabetes, keeping a trace of sugar in the urine will ensure that the dosage is not excessive. Certain persons, with normal blood sugar, pass sugar in the urine. As a rule there are no symptoms, and sugar is found on routine examination. To give Insulin to the case of Renal or Innocent Glycosuria would be dangerous. To diagnose this class with certainty, blood sugar estimation is necessary. Insulin is administered by hypodermic injection and 10 units (0.5 cc.) is considered as one dose. The exact dosage is determined by the severity of the case, the blood sugar, and must be regulated 127 according to the diet being given. It is usually given a quarter to halfan-hour before a meal. Symptoms of over-dosage may occur one to three hours later, and can usually be controlled by giving sugar by the mouth, or in severe cases, a solution of glucose into a vein. Insulin does not replace the dietetic treatment of the disease. It is an adjunct to it, and permits the giving of a more generous diet. It is an expensive drug. A single dose costs 2s. 6d., and three to six may be required each day in a moderately severe case. Its chief value at present is in the treatment of complications, in putting the patient in a safer state to undergo any necessary operation, in ameliorating more serious symptoms, and no doubt adding to the life and comfort of those afflicted with this disease. So far as is known it is not a cure. Whether in saving the pancreas from fatigue for a time it may allow that organ to completely recover its function in certain cases has still to be determined. INDEX. A PAGE Acres 7 Acute Primary Pneumonia 32 Acute Influenzal „ 32 After-care Committee (Tuberculosis) 64 „ ,, Secretary of 62-3 Agricultural Organiser 50 Albury Street Sick Babies' Home 41 Allan, Dr. George 1 Ambrosia 99 Ambulance facilities 47 „ L.C.C. (Centres for) 47 „ Red Cross 47 ,, Guardians 47 „ Metropolitan Asylums Board 47 Ampthill Square (Clinic) 97 Ante-Natal Examination 44 Ante-Natal Clinic 43,94 Ante-Natal ,, attendances 100 Antitoxin (Diphtheria) 48 Area and Population 7 Army Medical Service 39 Available Hospitals 40 B Baby's clothes 97 Besson Street Centre 90 Births 7 Birth-rate 7 Births, England and Wales 7 „ County Boroughs 7 „ Smaller Towns 7 „ London County 7 „ Ten years 8 „ Illegitimate 8 „ „ in Wards 8 „ ,, „ Occupation of Mothers 8 „ Notification of 8 ,, Table 87 ii. B—continued. PAGE Bland Sutton on Cancer 122 Boric Acid in Cream 10.3 Bye-laws of Borough Council 48 L.C.C. 48 • c Cancer 1,115-120 Cancer houses 121 ,, Disinfection for 85 Canal Boats Acts 78 Causes of Sickness 34 Census 7 „ 1921, Notes on 17-30 Cerebro-spinal Meningitis 33 Certifield Milk 54 Charity Organisation Society 46 Chicken-pox 34 Chorea 113 „ and School Teachers 112 Circular on Milk prosecutions 107 Clean Milk Movement 53 Cleansing Station 85 Clinics and Centres 43, 45, 89, 90, 91, 92, 93, 94 Coma 126 Comment on Doctors' replies 39-41 Committee, Public Health 3 ,, Maternity and Child Welfare 3 Composition of Tuberculosis Care Committee 64 Consultation Centres 39 Contacts (Diphtheria) 34-5 Cornish, Mr. 42 D Dairy equipment 52 Deaths 9 Death-rate 9 „ comparisons 9 „ during 10 years 9 D—continued. PAGE Deaths in Wards 9-10 ,, percentage in age groups 10 ,, cause of 13 „ ages at 13 ,, Infantile, causes 14 „ Infectious disease 16 Dental Clinic 94 „ Inspection 40 Deptford Mission 41 Diabetes and Insulin 126 Diarrhoea 33 Diphtheria 32-111 „ Contacts 34-5, 47 Dinner tickets 88 Disinfection 83-84 Dr. Harbison 99 Dr. Hill 43, 92-3, 96 Dr. Octavia Lewin 99 Dr. Poynton 109 Dr. Wiggins 42 Dried Milk 57-8, 88 Drugs Acts 79-82 E Enteric Fever 32, 106 „ (agglutination test) 47 Enteritis 11, 33 Erlam Road Clinic 89 F Factory and Workshop Act 74-5 Feeding of Cattle 57 Females, occupation of 27, 28, 29 Food Poisoning 104 „ Preservatives 103 ,, Unsound 79 Foreign Meat Regulations 79 Foster Children 99 iv. Q PAGE General Practitioners 35 Girl Guides 99 Goldsmith's College (London University) Centre 90 Gosterwood Street Centre 91 Glycosuria 126 Grade A Milk 54 Green Peas and Copper Sulphate 104 Guy's Hospital 42 H Hales Street (Princess Louise) Centre 91 Health Committee 3 Health Visitors, visits 86-7 ,, duties 95 „ and Measles 43 Health Week 98 Home Helps 98 ,, Nursing in Infectious Disease .43 Work 76 Hostels 46 Houses, New 72 Housing 2,107 House-to-house Inspections 70-72 Houses let in lodgings 106 I Ice Cream 105 Illegitimate Births 8 „ Births in Waids 8 „ Occupation of Mothers 8 ,, Infants and Homeless Children 46 Infant Mortality 10—11 „ „ rate 10 „ ,, in Wards 10 „ „ from Diarahoea and Enteritis 11 „ „ Comparative Tables 11 „ „ Table of causes 14 V. I—continued. PAGE Infant Welfare Centres 92 „ „ ,, • Erlam Road 89 „ ,, „ Goldsmith's College 90 „ „ ,, Gosterwood Street 91 ,, ,, „ Hales Street 91 „ „ „ Napier Street 89 „ „ ,, Besson Street 89 Infectious Diseases (Hospital disposal) 34 „ „ and Home Nursing 43 „ „ Notifications 15 „ ,, Table of deaths and rates 16 „ „ 32 Influenza and Cinemas 105 Influenzal Pneumonia 32 Institutional Provision for Married Mothers 46 Insulin and Diabetes 125-127 Invalid Children's Aid Association 46 Isolation Shelter 83 J Jewish Maternity Home 97 K Kent Milk Recording Society 50 L Laboratory Work at the Seamen's Hospital 47 Lectures for Fathers 98 Liddiard, Miss 99 Luckau 122 Lying-in-Homes 99 M Macewen, Sir William 116 Magraw, Mr. E. (Surgeon-Dentist) 44 Malaria 33 Males, Occupations of 24-25 „ „ (Comparisons) 26 March, Miss Norah ... 99 vi. M—continued. PAGE Marriages 8, 9 Marriage Rate 8 Maternity and Child Welfare Committee 3 Maternity Home 46, 88, 96, 100 ,, „ Consultant 97 „ „ Stall 99 McMillan, Miss Margaret 41 Measles 33, 34, 38, 104 „ Regulations 19,22,23 Medical Service, State 39 Medical Society, New Cross 44 Metropolitan Asylum Board Hospital 46 Midwives 43 Miller Hospital 42 Milk Act, 1922 49 „ Composition (variations in) 55-56 „ Pasteurised 57 ,, Prosecutions 55 „ Supply 49,58 ,, ,, to Nursing Mothers, etc. 87 Ministry of Health, Notification of Tuberculosis 58, 59 Mortality of Infants for 10 years 11 „ „ from Diarrhoea 11 „ ,, Table of causes 14 ,, „ in Wards 10 Mortuary Report 86 Municipal Maternity Home 46, 88, 96, 100 N New Cross Medico-Chirurgical Society 44 New Houses 72 Notification of Pregnancy 101 „ Still-births 101 Nursing Arrangements 40 „ ,, in the Home 40 o Occupations of Females 27, 29 ,, „ Comparisons 28 „ „ of Males 24, 25 „ ,, Comparisons 26 vii. O—continued. PAGE Oliver, Sir Thomas 1,115 Open Air Nursery School 41 Ophthalmia Neonatorum 33, 106 P Pasteurised Milk 57 Pimlico Road 98 Population 7 Population in Wards 7 Ponyton, Dr. 1, 115 Prevention of Heart Disease 109 Primiparae 97 Private Nursing Home 40 Professional Nursing in the Home 40 Public Health Committee 3 Public Health Year 101 Public House Urinals 106 Public Milk Supply 49,58 Puerperal Fever 33 Purkis, Mr. A. (Town Clerk) 3 R Ranyard Nurses 33, 43 Rats 106 Red Cross Society 46 Registered Workshops 77 Registrar.-General 7 Research. 40 Rheumatic Heart Disease 110 Rheumatism 35, 38 River Ravensbourue 106 s St. James Church 41 St. John the Divine Nursing Sisters 40 Sanitary Inspectors'work 67,68,69 ,, ,, Stall at Exhibition 99 Scarlet Fever 32 Section 28 Housing Act, 1919 108 Sewing Class 97 viii. S—continued. PAGE Shelter 83 Small-pox and Chicken-pox 2,32,104 Sputum tests 47 Stalls, Maternity Home 99 ,, Royal Arsenal Co-operative Society 99 „ Sapon Soap Co. 99 „ Tuberculosis Dispensary 99 „ Virol 99 State Medical Service 39 Statistics 4 Superintendent Registrar 8 T Team Work 39 Treatment of Chronic Rheumatism 35, 36, 37, 38 Truby King—Methods 44 Tuberculosis—After Care Committee 52, 62, 63 „ Dispensary 44, 45, 61 ,, General 58, 59, 108, 109 ,, In Cattle 52 „ Notification Table 60 ,, Unnotified, deaths from 58 V Vaccination 2 Vaccine Therapy 101 V. D. Conference at Guildhall 102 Virol 88 Vital Statistics 4,12 w Whooping Cough Deaths 34 Wincey 97 Woodhall Spa 35