dept 19 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. (Grccce). Fellow of the Royal Institute of Public Health. Fellow and Member of the Council of the Institute of Hygiene. Member of the Royal Sanitary Institute. Member Executive Committee National Baby Week Council. Examiner in Hygiene, University of London (Goldsmiths' College). Medical Officer of Health. 1 925 deptford: Gaylard & Son, 446 New Cross Road, S.E. 14, Public Health Committee. Magor. Alderman F. TREW, J.P. Chairman. Alderman W. TAYLOR. Vicre=Chairman. Councillor W. H. GREEN, J.P. Alderman Mrs. G. E. Green Councillor Mrs. A. A. Cheason Councillor Mrs. B. M. Drapper, J.P. Councillor J. G. Hicks Councillor A. G. Howard Councillor Mrs. G. Tiffen Councillor Miss K. P. Warcup Councillor Mrs. L. E. White Councillor E. C. Wood Maternity and Child Welfare Committee. Chairman. Alderman Mrs. G. E. Green Vice-Chairman. Councillor Mrs. M. Herlihy Alderman W. H. Green, J.P. Alderman W. Taylor Councillor A. J. Boyd Councillor Mrs. A. A. Cheason Councillor Mrs. B. M. Drapper, J.P. Councillor W. H. Green, J.P. Councillor J. G. Hicks Councillor Mrs. G. Tiflfen Councillor Miss K. P. Warcup Councillor Mrs. L. E. White Staff of the Public Health Department. Medical Officer of Health and Administrative Tuberculosis Officer. Charles. S. Thomson, m.d., ch. b. (University of Glasgow), b.hy. and d.p.h. (Durham), o.m.m. (Greece.) Assistant Medical Officer of Health and Tuberculosis Officer. N. M. Donnelly, m. b., d.p.h. Second Assistant Medical 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. A. G. W. Pettitt, H. E. Green, G. A. Langley. 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). Harry Allam, ,, ,, ,, ,, ,, si 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. (L'ndon). Health Visitors. Miss E. Clbbbe, Certs. General Training; c m.b. and Health Visitor (r.s.i.) ,, E. Holland ,, ,, ,, c.m.b. and Health Visitor (r.s.i.) San. Insp. (r.s.i.) ,, E. E. Reynolds ,, ,, „ c.m.b. „ M. F. Robus ,, ,, ,, 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. *A/>foititetl as Sanitary Inspector and Health Visitor. Mrnicipal Maternity Home. 52 Wickliam 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: L. VOYSEY, ,, ,, ,, A. Chattehs, ,. ,, ,, M. Baxendale, ,, ,, „ Tuberculosis Dispensary. Hilary I louse, 78 Amersliam Vale, S.E. 14. Tuberculosis Officer—N. M. Donnelly, m.b., d.p.h., Secretary, Tuberculosis Care Committee. Miss B. Lewellin. Tubctculosis Nurse.-—Miss E. M. Porteous. Miss A. M. Roy. Diifcnser—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 Disiufector—T. Lyons. J. Crisp, F. Smith. J. Lloyd. General Assistant. E. H. Evans Alderman WALTER TAYLOR, Chairman of the Health Committee. Metropolitan Borough of Deptford. Public Health Department, Town Hall, New Cross Road, S E. 14 July, 1926. To His Worship the Mayor, Aldermen and Councillors of the Metropolitan Borough of Deptford. Mr. Mayor, Ladies and Gentlemen, I have the honour to present to you my fifth Annual Report on the health and sanitary circumstances of the Borough for the year 1925. This report is a Survey report, prepared in accordance with the instructions of the Ministry of Health as set forth in Circular No. 648, dated December 10th, 1925. In this Survey Report the Ministry request Medical Officers of Health to deal comprehensively with :— (a) The measure of progress made in the area during the preceding five years in the improvement of the public health. (b) The extent and the character of the changes made during that period in the public health services of the area. (c) Any further action of importance in the organisation or development of public health services contemplated by Local Authorities or considered desirable by the Medical Officer of Health. Briefly, it may be said that the five years in question have seen the establishment of the following " measures of progress " and " changes in the public health services of the area." 1. A Municipal Maternity Home, with 12 beds, has been opened. In 1925 the Home was used to the extent of 80 per cent, of its total capacity. 2. Ante-Natal work was established at the Napier Street Centre. From one session per week the work has grown to three sessions. A fourth session has now become imperative. 2 3. The Hales Street (Voluntary) Infants' Welfare Centre is now conducted by your Medical Officer of Health. 4. A most successful Health Week (including Baby Week) is now held, attended annually by thousands of people. 5. Although the provisions of the Public Health Act, 1925, do not apply to London, and we are therefore precluded from spending money on Public Health Propaganda, a series of eight lectures on health subjects was given in the Town Hall, by your medical officers, on alternate Wednesday evenings to appreciative audiences. Now, prevention is cheaper than cure, and as I have always maintained that progress in public health depends first and foremost on an enlightened public opinion on health matters, it has been my aim to push the educational side of our work to great lengths. The public press has been freely used, and many a winter afternoon or evening has been given up to expounding the principles of health to public and private groups and associations in the Borough. Quiet and effective educational work has been carried out by the Health Visitors and Sanitary Inspectors in their day-to-day visitations. Much use has been made of leaflets and booklets giving advice as to cancer, measles, whooping cough, diphtheria, flies and summer diarrhoea, as well as those on the rearing of infants and the care of the expectant mother. 6. The work at the Tuberculosis Clinic has been reorganised, and the good work of the Tuberculosis Care Committee can be visualised by a perusal of the special report on the Secretary's experiences, embodied herein. 7. The growth of the Ante-Natal, Tuberculosis, and Ultra-Violet ray activities has involved the consideration of plans for a new building, but this latter will be dealt with in my report of next year. 8. In the Autumn of 1925, I wrote a lengthy report for the Public Health and also the Baths and Washhouses Committee, advocating the necessity for the provision of a continuous flow of clean water in the swimming baths so as to remove impurities and to bring matters up-to-date in this connection. The Council decided to instal Bell Bros, filtration and aeration plant and accessories at the Laurie Grove Baths. 9. Following a Representation made in 1925, under Section 4 of the 1890 Public Health Act, concerning the Watergate Street area, 3 comprising many houses, a Public Enquiry was held, presided over by a representative of the Ministry of Health. I understand that the plans of the County Council are well in hand and that this area will soon be demolished. And now we have to consider (c) "any further action of importance contemplated by the Local Authority or considered desirable by the Medical Officer of Health." Yes, there is one serious matter requiring attention—the demolition of some 3,000 houses, principally in the East End, and the provision of say 2,000 houses apart altogether from the provision which would be required for those displaced as above. It is no use blinking at the facts, we are suffering badly from overcrowding. Families are living crowded together in conditions of discomfort. Others families again are living two and three families in one house. Where privacy is awanting, happiness must be at a discount. Deptford's problem is a housing one. In the course of the report I have given instances of overcrowding that would melt the heart of an optimist. All this overcrowding adds to our labours in the fight against disease. Diphtheria, for example, gives trouble: I examined over 1,000 contacts during the past year. Ample instructions, throat swabs and following up have helped, but any observer can see that it is not in the comfortably housed portion of the borough that our cases occur. It is true, as I have pointed out to the Public Health Committee, that if we followed the example of Edinburgh, Aberdeen and Newport, where the Shick test is now in operation, we could cut down the incidence of diphtheria. I must emphasise that it is only in this way, as things are at present, we can hope to limit the number of cases. At present, in co-operation with the County Council, we are sending "carriers" to a special clinic at Guy's Hospital, where it may be that oro-nasal work may help to dislodge the pertinacious virulent germ from the crypts of the throat and nose. The constant kindness which I have received from your Council makes me hesitate before mentioning one further point, but it is evident that this should be mentioned under section (c). If and when financial circumstances permit, perhaps it might be possible to give a little consideration to the size of my clerical staff compared with the staffs in the Health departments of other metropolitan boroughs. I feel sure that action taken as a result of such comparison would add to the efficiency of your Health department. 4 During the year 1925, official circulars were issued dealing with the following matters:— Food and Drugs. 12.6.25. No. 604. Re Public Health (Meat) Regulations, 1924. 8.25. No. 616. Tuberculosis Order of 1925 (No. 2), Meat Inspection. 4.8.25. No. 755. Public Health (Preservatives in Food) Regulations, 1925. 11.8.25. No. 606. Ditto ditto Tuberculosis. 7.8.25. No. 615. Public Health (Prevention of Tuberculosis) Regulations, 1925. 9.25. No. 37/T. Tuberculosis (England). Maternity and Child Welfare. 2.25. No. 101 (M. & C. W.). Training of Health Visitors. 9.2.25. No. 557. Training of Health Visitors. Housing. 29.6.25. No. 608. Re Housing Act, 1925. 1.9.25. No. 866. Housing Consolidated Regulations, 1925. Infectious Diseases. 5.25. No. 103 (Med.). Pemphigus Neonatorum. Reference to the Meat Regulations in particular will be found in the Report. I wish to extend my grateful thanks to all my colleagues who have responded so loyally and willingly to the calls made upon them, and to express my gratitude to my colleagues in other departments for much kindness. The pleasure which our work has been to us all is due in great measure to the kindness and support of the Council, particularly to the members of the Public Health and Maternity and Child Welfare Committees. I conclude my introductory letter with a brief resume of the more important rates for the five years under consideration. 1921 1922 1923 1924 1925 General Death Rate „.. 12.2 13.8 11.1 12.0 12.1 Infant Mortality Rate 88 74 59 76 63 Birth Rate 23.5 23.1 21.1 20.6 18.8 Cancer Death Rate 1.3 1.3 1.2 1.3 1.4 Tuberculosis Death Rate (Respiratory and other T.B.) 1.4 1.4 1.0 1.1 Your Obedient Servant, Charles S. Thomson. 5 Nummary of Vital and Mortality Statistics. Area 1925. 1924. 1,564 acres 1,564 acres Population— Census 1911 109,496 109,496 Census 1921 112,534 112,534 Estimated to middle of year 115,900 115,200 *Number of inhabited dwellings (Census 1921) 18,122 18,122 Number of families or separate occupiers (1921) 28,007 28,007 Average number of persons per dwelling 6.4 6.4 Density 74 per acre 74 per acre Length of Public Streets 53 miles approx. 53miles approx. Rateable Value £647,507 £647,431 1d. Rate produces (approximately) £2,632 £2,624 Cost of administration of Public Health Department £4,242 £4,246 Marriages 936 848 Marriage Rate 8.1 7.4 Births 2,175 2,376 Birth Rate 188 20.6 Birth Rate, average for the last 10 years 22.9 23.7 Deaths 1,399 1,379 Death Rate 12.1 12.0 Death Rate, average for the last 10 years 14.1 14.4 Infantile Mortality (total) 63 per 1,000 births 7 6 per 1,000 births Infantile Mortality of illegitimate babies 98 per 1,000 births 172 per 1,000 births Infantile Mortality, average for the last 10 years 88 per 1,000 births 90 per 1,000 births Zymotic Death Rate 0.7 0.7 Deaths from Measles (all ages) 31 34 Deaths from Whooping Cough (all ages) 17 15 Deaths from Diarrhœa and Enteritis (under 2 years of age) 12 16 *Structurally separate dwellings occupied by private families, i.e., houses and self contained flats. A DEPTFORD BAIRN. Joan Means, 6 weeks, 12 lbs. 8 ozs. Breast fed. Area and Population. Births and Deaths. 9 Area and Population. Acres. Estimated Population. 1,564 115,900 The population of Deptford to the middle of 1925 has been estimated by the Registrar-General as 115,900. 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 21,965 South 13,453 North 24,658 South-East 13,485 North-West 24,805 South-West 17,534 As the Borough has an area of 1,564 acres, the density of the population on this estimate is 74 persons per acre approximately. Births. Births. Birth rate per 1,000. 2175 18.8 The total number of births registered in the Borough was 2,017, and of these 106 were transferred to other districts, as the permanent addresses of the parents were outside this Borough. Similarly, 264 births occurring outside of the Borough, in maternity hospitals, were transferred to Deptford, making a total of 2,175 births in all belonging to Deptford. Of these, 1,112 were males and 1,063 were females. This figure gives a birth-rate of 18.8 per 1,000 of the estimated population, as compared with 20.6 for the year 1924. The birth-rate for England and Wales for 1925 was 18.3. „ „ the 105 County Boroughs and Great Towns was 18.8 „ „ the 158 Smaller Towns was 18.3 „ „ the County of London was 18.0 The rate for Deptford was therefore 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. 10 Table 1. Year. Births. Estimated population. No. Rate per 1000. 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 1922 114,100 2631 23.1 1923 114,900 2428 211 1924 115,200 2376 20.6 Average for 10 years 113,964 2610 22.9 1925 115,900 i 2175 18.8 Illegitimate Births. The illegitimate births numbered 61 or 2-8 per cent, of the total births. These occurred in the several wards as follows :— East ... ... 21 South ... ... 7 North ... ... 9 South-East ... 12 North-West ... 7 South-West ... 5 As far as can be ascertained, the occupations of the mothers in these cases were:—Domestic servants 7; Factory hands 10; Barmaids 5: Shop assistants 6; Typists 3. 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 2,047 births. Omitting still births, which numbered 40, this gives a percentage of births notified to those registered of 92. Midwives notified 1,284 ; doctors 500; parents 241 ; other persons 22. Marriages. Marriages. Marriage Rate 936 8-1 The Superintendent Registrar has kindly furnished me with the particulars. There were 936 marriages in the Borough during 1925 as compared with 848 in the previous year. The marriage rate was equal to 8-1 per 1,000 of the population as compared with 7*4 for the year 1924. 11 The marriages were celebrated in the following places :— 601 in Churches of England. 88 in other Places of Worship. 247 in the Superintendent Registrar's Office. 936 Total Deaths- Deaths, Death Rate. 1,399 12.1 The deaths registered in Deptford numbered 818 equalling a deathrate of 7.1 ompared with 915 and a death-rate of 7.9 for the preceding year. Of this number, 142 were non-parishioners. The deaths of Deptford residents occurring outside the Borough in public institutions were 723, making a total of 1,399 deaths belonging to this Borough. Of these 756 were males and 643 were females. The death rate was 12., compared with 12. in 1924. The death-rate for England and Wales was 12.2 „ „ for the 105 County Boroughs and Great owns was 12.2 „ „ for the 157 Smaller Towns was 11.2 „ „ for the County of London was 11 • 7. 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. 1915 110,299 1962 17.8 1916 110,299 1666 15.1 1917 *T03,527 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 1922 114,100 1574 13 8 1923 114,900 1272 11.1 1924 115,200 1379 12.0 Average for 10 years 111,070 1560 14.1 1925 115,900 1399 12.1 * 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 :— 12 Table III. Ward. Males. Deaths. Total. Death Hate per 1,000. Females. Children under 1 year East Ward 179 141 47 320 15.6 NorthWard 157 137 39 294 11.9 North-West Ward 127 115 25 242 9.8 South Ward 70 81 3 151 11.2 South-East- Ward 126 71 9 197 14.6 South-West Ward 97 98 14 195 11.1 The proportion which the mortality at various ages bears to the total number of deaths during 1925 and the previous year is as follows :— Table IV. 1924 1925 Under 1 year 13.1 per cent. 9.8 per cent. 1 to 2 years 4.4 2.9 2 to 5 „ 3.4 3.9 5 to 15 „ 3.1 3.5 15 to 25 ,, 4.1 4.1 25 to 45 „ 12.8 10.0 45 to 65 ,, 24.0 28.0 65 years and upwards 35.1 37.8 Infantile Mortality. Infant Deaths Infantile Mortality Rate. 137 63 137 Infants died before attaining the age of one year, i.e., 63 per 1,000 of the births registered. Of this number 6 were illegitimate, representing an illegitimate infant mortality rate of 98 per 1,000. The mortality amongst infants in the various wards is shown in the Fnllnwinc table!— Table V. Ward. Births Registered Deaths under 1 year of age. Infantile mortality per 1000 Births. East ... 548 47 86 North... 483 39 81 North-West ... 386 25 65 South... 290 3 10 South-East 240 9 38 South-West ... 228 14 61 13 Table VI. RATE PER 1000 BIRTHS. Diarrhoea and Enteritis under two years. Total deaths under one year. England and Wales 8.4 75 105 Great Towns 10.8 79 157 Smaller Towns 7.6 74 County of London 10.6 67 Deptford 5.5 63 Table VII. TABLE SHOWING THE NUMBER OF BIRTHS AND DEATHS IN THE BOROUGH DURING THE YEAR 1925. Births Deaths 2175 1399 Excess of Births over Deaths 776 Comparative table of infantile deaths from Diarrhoea and Enteritis Table VIII. INFANTILE MORTALITY RATE FOR THE PAST TEN YEARS. Year. Deaths under 1 year. Infantile Mortality Rate. 1915 391 132 1916 258 88 1917 239 102 1918 205 97 1919 207 85 1920 259 79 1921 234 88 1922 195 74 1923 143 59 1924 180 76 Average for 10 years 231 88 1925 137 63 Table No. IX. METROPOLITAN BOROUGH OF DEPTFORD. VITAL STATISTICS OF WHOLE DISTRICT DURING 1925 AND PREVIOUS YEARS. Year. Population estimated to Middle of each year. Births. Total Deaths Begistered in the District. Transferable Deaths Nett Deaths belonging to the District. Uncorrected Number. Nett. Under 1 year of Age. At all Ages. Number. Bate. of Nonresidents registered in the District of Residents not registered in the District. Number. Rate per 1,000 Nett Births. Number. Bate. Number. Kate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1915 110,299 2,891 2,955 268 1,406 12.7 144 700 391 132 1,962 17.8 1916 110,299 2,838 2,918 265 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 2,093 183 1.361 13.3 230 696 205 97 1 827 17.9 1919 111,205 2,396 2,426 205 1,051 9.5 202 620 207 85 1,469 13.0 1920 115,636 3,191 3,276 28.3 1,003 8.7 207 612 259 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 1923 114,900 2,286 2,428 21.1 822 7.2 161 611 143 59 1,272 1.11 1924 115,200 2,177 2,376 20. 6 915 7.9 209 673 180 76 1,379 12. 0 1929 115,900 2,017 2,175 18.8 818 7.1 142 723 137 63 1,399 12.1 Area of District in acres (land and inland 1,564. water). Total population at all ages 112,534, Total families or separate occupiers, 28,007. At census 1921 14 15 Table No. X. METROPOLITAN BOROUGH OF DEPTFORD. Causes of, and Ages at, Death during the Year 1925. Nett Deaths at the subjoined Ages of " Residents" whether occurri rig within or without the District. CAUSES OF DEATH. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under25 years. 25 and under 45 years. ' 45 and under 65 years. 65 and under 75 years, | 75 and upwards. 1 2 3 4 5 6 7 8 9 10 11 All causes 1399 137 40 54 49 57 341 392 280 249 .. .. .. .. .. .. .. .. .. .. Small Pox .. .. .. .. .. .. .. .. .. .. Measles 31 8 12 10 1 .. .. .. .. .. Scarlet Fever 3 1 .. 1 1 .. .. .. .. .. Whooping Cough 17 8 3 5 1 .. .. .. .. .. Diphtheria and Croup 23 .. 1 9 13 .. .. .. .. .. Influenza 34 2 — .. 1 2 1 8 9 11 Encephalitis Lethargica 5 1 .. .. 1 .. .. .. .. .. Meningococcal meningitis 1 .. .. .. .. .. .. .. .. .. Tuberculosis of respiratory system 104 .. 1 1 3 20 44 30 4 1 Other Tuberculous Diseases 20 3 2 4 3 2 3 2 .. .. Cancer, malignant disease 164 .. .. 1 .. .. 17 82 37 27 Rheumatic Fever 4 .. .. 1 1 1 .. .. 1 .. Diabetes 12 .. .. .. .. .. 2 2 6 .. Cerebral Haemorrhage, &c. 55 .. .. .. .. .. .. .. .. .. Heart Disease 176 .. .. 1 4 7 12 69 45 38 Arteriosclerosis 36 .. .. .. .. 1 6 19 10 Bronchitis 123 7 3 1 1 .. .. .. .. .. Pneumonia (all forms) 114 20 12 8 4 3 7 29 .. .. Other Respiratory Diseases 15 2 1 .. .. .. .. .. .. .. Ulcer of Stomach or Duodenum 17 .. .. .. .. .. 3 10 1 2 Diarrhoea, &c. 17 11 1 .. .. .. .. 3 2 .. Appendicitis and Typhlitis 7 .. .. .. 3 .. .. .. .. .. Cirrhosis of Liver 7 .. .. .. .. .. .. .. .. .. Acute and chronic Nephritis 33 .. .. 1 1 1 4 15 7 4 Puerperal Sepsis 7 .. .. .. .. .. .. .. .. .. Other accidents and diseases of Pregnancy and Parturition 2 .. .. .. .. .. 2 .. .. .. Congenital Debility and Malformation, including Premature Birth 51 51 .. .. .. .. .. .. .. .. Suicides 17 .. .. .. .. .. .. .. .. .. Other deaths from violence 56 3 l .. 8 8 .. .. .. .. Other defined diseases 247 20 3 10 3 7 16 59 45 .84 Diseases ill-defined or unknown 1 .. 1 .. .. .. .. 1 .. .. 16 Table No. XI. METROPOLITAN BOROUGH OF DEPTFORD. Infantile Mortality, 1925. 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 under12 months. Total Deaths under 1 year. All Causes 55 8 7 5 75 29 16 26 34 180 Small Pox .. .. .. .. .. .. .. .. .. .. Chicken Pox .. .. .. .. .. .. .. .. .. .. Measles .. .. .. .. .. .. 1 2 5 8 Scarlet Fever .. .. .. .. .. .. .. 1 .. 1 Whooping Cough .. .. .. .. .. 1 2 2 3 8 Diphtheria and Croup .. .. .. .. .. .. .. .. .. .. Influenza .. .. .. .. .. .. .. .. .. .. Erysipelas .. .. .. .. .. .. .. .. .. .. Tuberculous Meningitis .. .. .. .. .. .. .. .. .. .. Abdominal Tuberculosis .. .. .. .. .. .. .. .. 1 1 Other Tuberculous .. .. .. .. .. .. .. .. .. .. Diseases .. .. .. .. .. 1 1 .. .. 2 Meningitis (not tuberculous) .. .. .. .. .. 1 .. 1 .. 2 Convulsions 1 .. .. .. 1 2 1 .. .. 4 Laryngitis .. .. .. .. .. .. .. .. .. .. Bronchitis .. .. .. .. .. 2 3 1 1 7 Pneumonia (all forms) 1 1 .. 1 3 2 4 16 15 20 Diarrœha .. .. .. .. .. .. 2 .. .. 2 Enteritis .. .. .. .. .. 4 4 1 .. 9 Gastritis .. .. .. .. .. .. .. .. .. .. Syphilis .. .. .. .. .. .. .. .. .. .. Rickets .. .. .. .. .. .. .. .. .. .. Suffocation, overlaying 2 .. .. .. 2 .. .. .. .. 2 Injury at Birth 3 .. .. .. 3 .. .. .. .. 3 Atelectasis .. 1 .. . . 1 .. .. .. .. 1 Congenital Malformations 2 2 2 1 7 1 2 .. .. 10 Premature Birth 21 2 4 .. 27 .. .. .. .. 27 Atrophy, Debility, and Marasmus 2 1 3 1 7 4 1 1 1 14 Other Causes 2 .. .. . . 3 4 2 2 2 13 Influenza .. .. .. .. .. .. 1 1 .. 2 Encephalitis Lethargica .. .. .. .. .. .. .. 1 .. 1 34 7 10 3 54 22 24 19 18 137 Table No. XII. METROPOLITAN BOROUGH OF DEPTFORD. CASES OFINFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1925. Number of cases notified. Total cases notified in each Ward. Total Cases Removed to Hospital. Notifiable Disease 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 IS 15 to 25 25 to 45 45 to 65 ! 65 and | upwards Small-pox .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Cholera .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Diphtheria including .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Membranous Croup 610 7 170 350 52 30 l .. 106 113 206 24 57 104 606 Erysipelas 65 1 6 9 8 19 16 .. 31 7 14 2 6 5 19 Scarlet fever 310 6 106 159 33 5 1 .. 65 79 80 27 30 29 303 Typhus fever .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Enteric fever 4 .. .. 2 1 .. 1 .. .. 1 3 .. .. .. 4 Relapsing fever .. .. .. .. .. .. .. .. .. .. .. .. .. .. Continued fever .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Puerperal fever 17 .. .. .. 4 13 .. .. .. 8 7 1 1 15 Cerebro-Spinal Meningitis 3 .. 2 1 .. .. .. .. 1 .. 2 .. .. .. 3 Poliomyelitis 4 .. 3 1 .. .. .. .. .. . . 1 1 1 1 2 Pulmonary Tuberculosis 207 1 2 15 54 87 44 .. 47 33 50 12 28 37 263 Other Tuberculosis 71 3 25 24 9 7 3 .. 30 7 12 7 6 9 41 Ophthalmia Neonatorum 20 20 .. .. .. .. .. .. 6 3 5 2 2 2 10 Anthrax .. .. .. ... .. .. .. .. .. .. .. .. .. .. . , Infantile Diarrhœa and Enteritis 48 23 25 .. .. .. .. .. 29 3 7 6 3 6 Acute Pneumonia 153 7 49 14 11 42 26 .. 41 16 51 7 20 19 16 Malaria 5 .. .. .. 1 4 .. .. 1 .. 3 1 .. .. Dysentery .. .. .. .. .. .. .. .. .. .. •• .. .. . . .. Enceph. Lethargica 9 .. 2 2 2 2 1 .. 1 2 2 1 2 1 7 Measles 1207 56 585 556 6 4 .. .. 428 330 105 106 174 64 109 Totals 2733 124 975 1133 181 213 93 14 786 602 548 190 333 274 1404 17 Table Xill. Deaths and Death Rates from Principal Infectious Diseases. Hnteric Fever Small Pox Measles Scarlet Fever Whooping Cough Diphtheria Diarrme.4 and Enteritis (i.nder 2 years) Total Year No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate No. of Deaths Rate No. of Deaths Kate No. of Deaths Rate No. of Deaths Rate 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 1922 2 0.02 — — 59 0.52 11 0.10 35 0.31 39 0.34 11 0.10 157 1.38 1923 2 0.02 — - 8 0.07 2 0.02 12 0.10 33 0.29 18 0.16 75 0.65 1924 3 0.03 — - 34 0.30 2 0.02 15 0.13 15 0.13 16 0.14 85 0.74 Average for 10 years 2 0.02 — - 27 0.24 6 0.05 24 0.22 19 0.17 39 0.36 117 1.06 1925 — — — - 31 0.27 3 0.03 17 0.15 23 0.20 12 0.10 86 0.74 18 Infectious and other Diseases. 20 INFECTIOUS AND OTHER DISEASES. Under the provisions of the Public Health (London) Act, 1891, and the Tuberculosis Regulations, 2,733 cases of infectious diseases were notified, as compared with 2,597 in 1924. In a preceding Table will be found a list of cases notified and their distribution in the several Wards. To the seven principal epidemic diseases, viz.:— Small-pox, Measles, Scarlet Fever, Diphtheria, Whooping Cough, Enteric Fever and Infantile Diarrhœa, 86 deaths were ascribed, and the death-rate was 0.75 per 1,000 as against 0.74 in the preceding year. A preceding table indicates the number of deaths and the death-rates from these diseases during the past ten years. Small-Pox. No person was notified as suffering from Small-Pox during the year. Scarlet Fever. 310 persons were notified as suffering from this disease during the year under report as compared with a total of 291 for the previous year. Included in this total are 26 patients who, after removal to hospital, were certified to be not suffering from the disease in question; also 7 cases which occurred amongst the Staff of the South Eastern Hospital. There were 3 deaths as compared with 2, 2 and 11 in the three preceding years, giving a death rate of 0.03 per 1,000 population, as compared with 0.03 for England and Wales, and 0.02 for the County of London. Diphtheria. The total number of patients certified to be suffering from Diphtheria was 610 as compared with a total of 374 for the previous year. Of this number 44 were errors of diagnosis, and 12 were cases amongst the Staff of the South Eastern Hospital. There were 23 deaths as compared with 15, 33 and 39 for the three preceding years, giving a death-rate of 0.20 per 1,000 population as compared with 0.07 for England and Wales, and 0.11 for London. Enteric Fever. 4 cases of Enteric Fever were notified, as compared with 20 in the previous year. Two of the 4 were nurses in the South Eastern Hospital, and the other 2 were Paratyphoid cases. 21 Acute Primary Pneumonia and Acute Influenzal Pneumonia. These diseases are compulsorily notifiable under the Public Health (Pneumonia, Malaria, Dysentery, etc., Regulations), 1918. 153 cases were notified during the year, as against 144 in the previous year. Puerperal Fever. 17 cases of Puerperal Fever were notified as compared with 6 in the previous year. There were 7 deaths. Ophthalmia Neonatorum. 20 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. 10 cases were admitted to hospitals. From subsequent enquiries it has been ascertained that all patients recovered with no apparent impairment of vision, but 1 infant died from other causes. 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, and terminate on September 11th, 1927. 1,207 cases were notified during 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. Diarrhœa and Enteritis. Infantile Diarrhoea occurring in children of two years of age and under is notifiable in this Borough by Order of the Council dated 27th July, 1920. During the year 1925, 48 such cases were notified, and 6 of this number were admitted to Hospital. Diarrhœa and Enteritis caused 17 deaths during the year, and of this number, 12 were children under two years of age. Cerebro-Spinal Meningitis. 3 patients were notified as suffering from this disease during the year; after removal to hospital, two patients were certified not to be suffering from this disease. 22 Malaria. Five cases of Malaria were notified in the persons of ex-service men who had contracted the disease in the East. Encephalitis Lethargica. Nine cases were notified during the year ; one case was afterwards certified to be not suffering from this disease. Acute Anterior Poliomyelitis. Four patients were notified suffering from this disease. Table XIV. Hospital Disposal of Notifiable Diseases during 1925. DISEASE Total Cases Notified Cases admitted to Hospital, Total Deaths. Diphtheria 610 606 23 Scarlet Fever 310 303 3 Enteric Fever (including Paratyphoid) 4 4 - Puerperal Fever 17 15 7 Pneumonia 153 16 114 Measles 1,207 109 31 Diarrhœa and Enteritis (under 2 years of age) 48 6 12 Erysipelas 65 19 — Poliomyelitis 4 2 — Encephalitis Lethargica 9 7 5 Ophthalmia Neonatorum 20 10 — Prevalence of, and Control Over Infectious Diseases. The Table giving the incidence of notifiable diseases for the year 1925 will be found elsewhere in the report. This table gives the cases in accordance with the age groups requested by the Ministry of Health. The following Table gives the incidence of the infectious diseases over the last five years:— 23 List of Infectious Diseases for the Past Five Years. Disease. Notified in Admitted to Hospital. Total Deaths. 1921 1922 1923 1924 1925 1921 1922 1923 1924 1925 1921 1922 1923 1924 1925 Smallpox 0 *1 0 *1 0 0 1 0 1 0 0 0 0 0 0 Scarlet Fever 951 547 349 291 310 876 530 331 278 303 13 11 2 2 3 Diphtheria 363 459 417 374 610 357 452 409 371 606 13 39 33 15 23 Enteric Fever (including Paratyphoid 9 7 10 20 4 8 6 10 20 4 2 2 2 3 0 Puerperal Fever 11 7 7 6 17 11 6 7 5 15 4 3 2 3 7 Pneumonia 47 125 74 144 153 0 0 5 6 16 119 201 91 150 114 Erysipelas 58 75 57 79 65 0 0 9 20 19 0 0 0 0 0 Cerebro-Spinal Meningitis 3 2 0 *1 3 2 2 0 1 3 3 1 0 0 1 Poliomyelitis 4 0 3 2 4 4 0 3 2 2 3 0 0 0 0 Malaria 7 4 4 5 5 0 0 0 0 0 0 0 0 0 0 Dysentery 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 Measles 0 28 204 1282 1207 0 0 9 92 109 1 59 8 34 31 Encephalitis Lethargica 1 0 0 24 9 1 0 0 13 7 0 1 0 6 5 *Was not a true case. Measles became notified in September, 1922. This table shows clearly that cases of Pneumonia are not notified by practitioners as they should be. In every year the number of deaths has exceeded the number of notifications. In a previous part of the report will be found a record of the pathological work carried out for the Borough at the Seamen's Hospital. 24 Encephalitis Lethargica. It was in 1924 that further attention was arrested locally by this disease, no fewer than 24 cases occurring in that year. This number fell to 8 in 1925. In 1921, there was one case, but none occurred in 1922 and 1923. The disturbing factors in this disease are the high death rate and the serious damage which occurs in several of those who recover from the acute phase of the illness. Perhaps a short note on the cases notified in 1925 will serve to indicate the nature of the disease:— 1. L.M., male, age 31. Symptoms, pain over eye and spine. Mentally composed, delirious, then became unconscious. Had been sleepless for many weeks at outset. Six months afterwards we found that his intelligence had recovered and he slept well. He was slow in speech, complained that his nerves were bad and had no confidence in himself. 2. E.T., female, age 9. Had a history of Meningitis in 1923. Child was noticeably sleepy in September, was admitted to the Miller Hospital in October, and the House Physician wrote: "She smiled in a queer way, and was always breathing deeply. She would half close her eyes, open her mouth wide and would not answer if spoken to." Improved, and left hospital in October. In December, condition was much as on admission to Hospital. 3. J.B., male, age l½. Became ill in September with severe vomiting. He became comatose, whilst his breathing became quick; there was squints and retraction of head. In November, he was weakly and looked ill, was irritable, but slept well at night. In February 1926, was less irritable, muscles firm and looked well. 4. B.M.T., female, age 47. Suffered from "nerves," became sleepy, saw double, had headaches and aphasia. 5. G.P., male, age 37. Suffered from pains in the legs and complained of loss of power in the limbs. 6. H.J.L., male, age 22. Complained of headaches and dizziness, sleepiness and double vision. He had a fixed expression and the eyeball shook laterally. There had been a history of pneumonia six months previously. Patient was admitted to hospital. Just a series of convulsions and died. 7. W.F., male, age 3. Had been knocked down by a bicycle. He became sleepless, bad tempered and suffered from headache. Delirium, fever and slight convulsions ensued. 25 These brief notes are sufficient to show that we are dealing with a distinctive infection, affecting the nervous system, and leading in a number of cases to death, and in some others to a degeneration in the nervous system and in character. Arrangements have been made whereby the Metropolitan Asylums Board will admit a number of cases for after-treatment. It is indeed fortunate that the number of cases has fallen. The disease is probably the aftermath of Influenza. Diphtheria. The notifications for the five years were:— 1921 363 1922 459 1923 417 1924 374 1925 610 The incidence of this disease in 1925 was severer than for several years past. It was noticeable that Diphtheria affected the Thames side in London during 1925. The whole situation with regard to this disease is extremely unsatisfactory. Over two years ago I began examining, as far as I could, the contacts of each case as these cases were notified to me. Swabbing was carried out thoroughly for one quarter with no appreciable result. Contacts have been examined, mainly at 10 a.m., at the Town Hall, but where the disease has tended to persist, the homes have been visited. During the winter of 1925, a daily visit was paid by me to the same contacts of all cases which had occurred for 21 days in the Canterbury and Hatcham Wards. This was a heavy undertaking when the numbers which occurred in the Reculver Road, Pomeroy Street and Besson Street sectors are remembered. The value of contact examination can be appreciated when it is noted that of the 610 occurring during the year no fewer than 32 were detected and notified by your Medical Officer. Despite all this following up, the disease continued to flourish. In all cases where a case occurred in a family, throat antiseptics were freely given. I really wonder whether they are of any use. Obviously the tenacity of the disease was due to the occurrence of "carriers." Now this report on Diphtheria is written in simple language in the hope that, following my two special reports to the Health Committee, permission may be given to your Medical Officers to carry out the only possible means there are of cutting down and possibly 26 eventually minimising the disease. I refer to the Schick test. Below I explain this test once again. May it be that this long drawn out anxiety—the hopeless attempt to prevent Diphtheria—will be alleviated by the grant of permission to perform the test described. The causes of Diphtheria as I found them this winter are:— overcrowding; lack of cleanliness; carriers; lack of food. Diphtheria is caused by a germ which is actually sometimes present in the persons throat and nose without causing any harm; in such a state the germ is avirulent—more or less harmless. Something then happens to induce the germ to become virulent. The individual's resistance it may be becomes lowered. Mentally depressed through want of work, herded together with others in the family, poorly fed, sometimes dirty in personal habits, it is easy to see how propinquity leads to interchange of germs from throat to throat; the avirulent germ is stirred up to activity by some germ so transmitted and the soil (throat and health generally) being weak, the now virulent germ proceeds to form membrane. The patient is sent off to hospital and contacts are examined and given antiseptics. Now the difficulty with regard to throat swabbing is this: if one swabbed a contact's throat on Monday, the result might be negative. Swabbed again the next day the result might be positive. Again swabbed on Wednesday the result is negative again. It simply comes to this, that swabbing is of limited value, and the reason is that whereas one day the germ may be accessible, on the next it may be buried in some of the crypts and lacunae of the tonsils. Where we found the germ present, a positive swab, the case could not be sent to hospital unless there were signs that the child had membraneous, clinical diphtheria. It is true that I have sent cases into hospital when I felt that such a "positive" throat was the cause in a family of other cases, but the infectious disease hospitals have surely more to do than receive cases in which there is nothing to be seen in a throat. If a contact is found to have a positive swab and yet presents no clinical evidence of the disease, the only means of determining whether the case should be sent into hospital is by inoculating a guinea pig with an emulsified growth of the germ. If this proves the germ to be malignant, the case should be sent into hospital. With my experience of diphtheria in 1925 in my mind, I have no hesitation in saying that whereas there may be a fall in the incidence of the disease in this, that, or the other year, the Borough will continue to be scourged from time to time with this disease, which it is clearly 27 proven, unless it can be reduced to infinitesimal proportions by means of the Schick test. We keep on talking about the drains which we religiously test, and we think of the advance of sanitary science, but so far as diphtheria is concerned, we are not advancing, we are going back. We have at hand the means for cutting down the incidence of the disease, but there is a reluctance in adopting this saviour of the children, simply because it smacks too much of vaccination and smallpox. Why we do this I do not know; it is something which no "fellar " can understand. To explain the Schick test: One-tenth of a cubic centimetre of diluted diphtheria toxin is injected between the epidermis and dermis, and this is followed by a small wheal or milk-white elevation around the point of the needle. The reaction, of course, depends on the local irritant effect of the diphtheria toxin. If the blood of the subject tested contains no anti-toxin naturally, or in an insufficient amount for protection, a positive reaction will appear in from 24 to 48 hours. This reaction is characterised by a circumscribed area of redness and slight infiltration measuring from one-third to two-thirds of an inch in diameter; it generally persists for from seven to ten days, and on fading shows superficial scaling and a persistent brownish pigmentation. In order to distinguish the true reaction from false reaction which occurs in a small percentage of older children and adults, a control solution of diluted toxin heated to destroy specific activity is injected into the opposite forearm at the time that the Schick test is made. After three to five days, final readings are made as follows:— 1. Positive, if there is a definite well-pronounced red area on the test forearm and no redness or pigmentation on the control forearm. 2. Negative pseudo if there is a fading brownish or reddish-brown area of pigmentation not sharply circumscribed but equal in size and similar in appearance on the two forearms. 3. Positive combined (positive) if there is a typical positive reaction on the test forearm and a faded pseudo-like reaction on the control forearm. Individuals exhibiting positive or positive combined reactions should be immunised, either with diphtheria antitoxin or with toxinantitoxin mixture (Diphtheria Prophylactic) the choice of immunising agents depending on whether or not there has been recent exposure. Ninety per cent. of all susceptible children can be immunised by these injections. The protection thus afforded lasts for years and possibly for life. The following are the indications for the use of the method described. 28 1. For general prophylaxis against diphtheria in schools and communities, excluding immediate contacts. 2. For immunisation of individuals not immediately exposed to infection. 3. For immunisation of individuals exposed to diphtheria after anti-toxin has been administered. The administration of toxin-antitoxin should be delayed for at least two weeks after the serum injection. The above description, mainly after Parke, Davis & Co., gives the impression, perhaps, that the actual work is laborious; in actual practice this is not so. Diphtheria will never be got under in London until these steps are taken. In Deptford we supply diphtheria anti-toxin to any practitioner who applies at the Town Hall for it. The demand is small, as cases are usually sent at once into hospital. The following leaflet is given to each family in a house where a case has occurred:— Metropolitan Borough of Deptford. Important Notice concerning DIPHTHERIA. Diphtheria is a dangerous infectious disease caused by a germ which settles on the tonsils and throat forming a bluish-white film or membrane. The throat often becomes red, swollen and inflamed. From the throat, poisons pass into the body causing sometimes temporary paralysis of limbs or even death from heart failure. If a case of diphtheria is recognised in the first day or two of illness and hurriedly given serum (usually in hospital), then the patient generally does well; but if there is delay in calling in the family doctor and the case is not therefore given serum until the third or fourth day of illness, then it may be serious. Where one case occurs in a family, a second or third case frequently occurs in the same house within the next week or two or even later. It is most important therefore, when the first case occurs, that the throats of all others in the house (the contacts) should be examined either by the family doctor or by the Medical Officer of Health, Public Health Department, Deptford Town Hall, New Cross Road. (Contacts seeing the Medical Officer of Health should call at the Town Hall between 10 and 11 a.m.). No charge is made for 29 examinations at the Town Hall and antiseptic lozenges are also given there, after the examination, free of charge. Certificates to return to school or to work are also given without fee by the Medical Officer. Sometimes such contacts have the disease without knowing it. Therefore, do not delay in seeing the family doctor or the Medical Officer any morning (except Sunday) between 10 and 11 a.m., at the Town Hall. Sterilise by boiling all eating and drinking utensils such as cups and saucers, plates, tumblers, jugs, knives and spoons, and give the house a thorough cleaning after disinfection. All library books should be handed over to the disinfectors or brought to the Town Hall for disinfection. CHARLES S. THOMSON, Medical Officer of Health. Public Health Department, Deptford Town Hall, New Cross, S.E.14. The London County Council officers have helped us throughout the year by sending medical officers and nurses to examine contacts in the schools. Though valuable time and much trouble have been given and taken respectively alike by the Borough and County officers, I am satisfied as I have explained above that our methods are somewhat obsolete. Scarlet Fever. 1921 951 1922 547 1923 349 1924 291 1925 310 Relatively speaking, 1925 was a normal year for scarlet fever in the Borough. The mildness of the disease to-day increases the difficulty of the diagnosis. The question of the Milne treatment was raised, reported on and dropped. The line of advance in respect of scarlet fever lies in a different direction. It is now quite possible to diagnose scarlet fever with almost a hundred per cent. of accuracy. If a minute dose of diluted scarlet fever Streptococcus anti-toxin is injected into (not under) the skin, this, in a true case of scarlet fever, will produce a marked blanching effect, extending over an area of one or two centimetres in diameter. In a true case of scarlet fever the red rash is blotted out all round the point of injection of the anti-toxin in from six to twelve hours. Right throughout the disease this blanched area persists. 30 So far as I know this test is not in use by any practitioner in the Borough. It is a matter of prime importance and should he used in any case presenting difficulty in diagnosis. During 1925 your Medical Officer of Health made a number of personal enquiries in respect to scarlet fever. Nothing pointed to conveyance through milk; infection through contact was the outstanding factor. Enteric (Typhoid) Fever. The steady decline in this disease is one of the triumphs of public health. Very common only a matter of fifteen or twenty years ago, to-day there is difficulty in teaching the subject clinically to medical students owing to the paucity of cases. For the past five years the incidence in the Borough has been:— 1221 9 1922 7 1923 10 1924 20 1925 4 Unfortunately there is little tangible to report respecting the cases in 1925, as two of these occurred amongst nurses on the staff of the South Eastern Hospital. In respect to the third case which was not really Enteric but Paratyphoid B, there were indications that the patient, a boy of seven, had perhaps contracted the disease from infected fish consumed at a seaside resort. An exhaustive enquiry failed to disclose any other possible cause. The fourth case, in a boy also of seven years, was diagnosed by your Medical Officer, called into consultation. This also was a Paratyphoid B infection, and no proven cause could be ascertained. It is the cases which occurred in 1923 that I wish to deal with mainly as these gave satisfaction in that the cause was ascertained on a scientific and not a speculative basis. The 1924 cases therefore need not detain us in our scrutiny for long. Five of the twenty notified in 1924 were reported by the Medical Superintendents not to be Enteric Fever. Of the fifteen cases:— 1. Cause not discovered. 2. Suspected cause: shrimps purchased from hawker. 3. Possibly contracted from work in London. 4. Believed to be due to watercress from an itinerant vendor. 5. Infected, perhaps, while under treatment for diphtheria. 6. Possibly frcm fried fish from Billingsgate. 7. From ice cream consumed at the coast—uncertain. 8. Watercress suspected. 31 In all these and other cases full enquiries and firm steps were taken. 1923, On October 20th, 1 received a notification of enteric fever in a child, E.H., 6 years, living at P. Street. The child was removed to the South-Eastern Hospital. The last date on which he attended school was October 9th. He was taken ill on the 9th and the doctor was called in on the 10th, in view of his feverish condition. The nature of the illness became manifest on the 18th, the diagnosis being confirmed by a Widal test. I visited the house and made an appointment to meet all the members of the three families living there next day (Sunday). The three families were closely related, comprising thirteen people, living in seven rooms, of which four were bedrooms. Three brothers were the heads of the three families. Taking the patient's family first. This consisted of E.G.H., 35 years, who shares a bed with his son, the patient E.H. The father E.G.H. is an engine driver on the L. B. Railway, and has lived for five years at P. Street. His health history was good with no recollection of any transient febrile disorder such as might have been a mild typhoid attack. He said that the patient, his son, had had headaches, pains in the abdomen, sickness and vomiting. The father had had diarrhoea for one day himself. A sample of the father's faeces was taken for a bacteriological examination, but proved negative. The second family consisted of J.H.H. (brother of E.G.H. above), his wife, F.H., his sister, T.H., and five children, namely C.H., 13 years, T.A.H., female, 9 years, L.H., male, 8 years, E.H., female, 5 years, and B.H., female, 4 years. The health history of the family was as follows:—The father, J.H.H. had pleurisy and pneumonia in December, 1921, and was in bed 6 weeks. His physical signs were slow in clearing up and the family doctor sent him to the Tuberculosis Dispensary for co-operative observation. His chest cleared up and since then his health had been satisfactory. In the past, one has come across cases in which an attack of pneumonia has been a complication of a true typhoid infection, so it was felt advisable that samples of his dejecta should be examined lest he should be a typhoid carrier. Mrs. J.H.H. had a goitre for which she was receiving medical treatment. The sister, T.H. had suffered from anaemia and constipation. The child C.H., aged 13, though seemingly in perfect health, had diarrhoea on the 14th and 15th. His blood serum gave a negative Widal. The faeces were negative, no B. Typhosus being isolated. 32 T.A.H., female, age 9 years, had a headache on Sunday, 21st, which cleared off by next day. L.H., male, 8 years, had diarrhoea on the 19th and 20th. A Widal test was negative. E.H., male, 5 years, is usually loose, Widal, negative here. I have explained to the Committee before that a lapse of days has to take place before certain substances in the blood are formed—where infection with a typhoid bacillus has taken place—whereby a positive Widal, that is an agglutination can be secured. The health history of the third family was of the first importance, and this should be read carefully. J.T.H., the father left England on 1st March, 1912 and arrived in the Argentine on 23rd March. He worked as a locomotive fireman and driver at Tucamen, 700 miles inland from Buenos Ayres. There were numerous cases of enteric fever there and he contracted the disease and was ill during March, April and May, 1913. He left the Argentine in September, 1915 and enlisted in the Army in England on November, l0th, 1915, leaving for France in February, 1917. He was discharged from the Army in February, 1919, and returned to his home at 79 M.C. Road. His daughter, P.H., contracted enteric fever in 1920. His wife contracted the disease in August, 1923, dying in a few days, the provisional diagnosis being confirmed at a post mortem. It should be particularly noticed that this family moved on 20th September, 1923, to join the other two families at 18 P. Street. The arrival of this family at 18 P. Street and the illness of E.H. on 9th October gave rise to a suspicion that either J.T.H. or his daughter, P.H., or both, were carriers. Enquiry was made as to the sleeping arrangements and these were found to be—First bedroom: E.G.H. and son (the patient), aged 6 years slept in one bed. J.T.H. and son, J.H., 17 years, slept in a second bed. Second bedroom: Miss T.H. (aunt) and P.H., aged 19 years (daughter of J.T.H., who formerly had enteric fever), slept in one bed. Third bedroom: J.H.H. and wife F.H., and daughter, B.H., aged 4 years slept in one bed. Fourth bedroom. In one bed, C.H. (male, aged 13 years), and L.H. (male, aged 8 years). In second bed, T.A.H. (female, aged 9 years) and E.H. (female, aged 5 years). There are two kitchens, one used by J.H.H., his wife and five children. The second kitchen is used by J.H., his son, J.H. (aged 17 years), P.H. (19 years), and E.G.H. and his son, E.H. (the patient) and aunt, T.H. When the child E.H. was taken ill on 9th October, his aunt T.H. stopped sleeping with her neice P.H., and slept with the child E.H. 33 Full enquiry was made into the possibilities of infection by milk, mussels, watercress, etc., but with no connecting link. Serum tests and examination of faeces gave no assistance, but on the removal to hospital, for purely observation purposes, of J.T.H. and his daughter, P.H., the typhoid bacillus was found in the urine of both. This completed the chain. The father contracted the disease in 1912 in Tucamen. His daughter contracted the disease from the father in 1920. His wife contracted the disease in August, 1923, either from the father or daughter. Unfortunately I was away on holiday at the time and the connection was not traced. The child E.H. contracted the disease from father or daughter. I found that the daughter was baking the bread for the family. The aunt, T.H. was next taken ill, probably infected by the child E.H., with whom she slept. All the members of the family were inoculated against the disease and no other cases occurred. These had been the first cases in the Borough for many months ; the discovery of the B. Typhosus in the urine of father and daughter left no doubt as to the source of the trouble. Whooping Cough. The number of deaths from this disease was 17; the disease is not notifiable in this Borough, but the Health Visitors visit as many known cases as their duties permit. Epidemic Cerebro-Spinal Meningitis. Three cases were notified of which two proved not to be so suffering. R.C., male, age 3 years, had attended at Guy's Hospital for nasal discharge. In April he became ill with abdominal pain and vomiting and became drowsy and convulsed; he developed retraction of the head, coma, delirium, exaggeration of reflexes. Two families occupied the house and the patient's family had two rooms, four persons occupying the sick room. In addition to patient's father, mother and brother of 5 years, the house contained:– Six males, four of whom were over 16 years, and one adult female. The child died in hospital two days after admission. The cases which occurred in the Army during the war were numerous, and the exciting causes were said to be fatigue, mental strain and overcrowding. In civil life the disease occurs sporadically, mostly in children. The overcrowding in the above case certainly did not help matters. 34 It is desirable that Resident Medical Officers in city hospitals should he informed that in cases in which death has occurred, the body must not be allowed to be taken home for burial. In cases which have died from an infectious disease, the body can only be removed direct to the place of burial. Acute Pneumonia, Malaria and Dysentery. The deaths from pneumonia numbered 114, and with 153 notified, this serves to show that probably 200 cases were not notified. Urgent representations have been made to the medical profession locally. It is obvious that housing and atmospheric conditions are again at work. Forty-one of the notified cases occurred in the East Ward and 51 in the North-west Ward. Only 16 cases were removed to hospital. As each case is notified the physician in charge is asked whether he wishes the case removed to hospital. Dysentery—No cases occurred. Malaria—Five cases were notified, due steps being taken to see that quinine was being supplied. Public Health (Small-pox Prevention) Regulations, 1917. No vaccinations were performed by the Medical Officer of Health. Cancer. Cancer leaflets are distributed. Disinfection is carried out in case of death from this disease, upon a request being received. Measles Became notifiable under the Deptford (Measles) Regulations, 1922, on September 11th. This disease strikes the Borough with lancinating, search-ray thoroughness every two years. Again in 1925 the Borough Council appointed a special nurse at the peak of the epidemic to visit and advise in the homes. Where the contacts are at the dangerous age, say from one to three years, these should be protected by isolating the sufferer. In Deptford this is not practicable; the old story, overcrowding. The Metropolitan Asylums Board with its brilliant clerk, Mr. Powell, organised a scheme whereby children from overcrowded homes, and complicated cases could be admitted to hospital. There is nothing fresh to be said about measles. Measles and Diphtheria are two of the greatest threats to child life to-day. 35 Rats and Mice (Destruction) Act, 1919. Complaints received 37 No. of drains found defective 15 No. of Notices served 24 No. referred to Borough Surveyor 6 Rat Week. In collaboration with the Borough Surveyor 6½-gallon bottles of "Liverpool Virus" were procured at a cost of £8 18s. 6d. This poison was mixed with a quantity of oats and a small quantity of aniseed, and placed in 69 side entrances leading to brick sewers. After an interval of 8 days an inspection was made of these side entrances, and it was discovered that all the poison had disappeared and over a dozen rats were found lying dead. In view of the fact that "Liverpool Virus" is well known as an effective rat destroyer, there is no doubt that the poison had been eaten by the rats, a considerable number of them having been washed away by water in the sewers. Increase of Rent and Mortgage Interest (Restrictions) Acts. No applications for reports and certificates were received during the year. Physical Features and General Character of the Borough. It would be better if we considered these in connection with London as a whole, but taking the town itself, it is situated on one side of a long ridge, at the top of which ridge is Telegraph Hill and extending in the South-East direction we have Hilly Fields. From this ridge there is a wide sweep down into the Thames valley, until in the North-East (Deptford Park, Evelyn, St. Paul's, Vale, Clifton and Canterbury wards) we come to low-lying land. In the Southern district the soil is practically all clay, but the gradual slope forms an ideal drainage area. In the South-West (Pepys, St. Catherine's and Hatcham wards) there is gravel to the north of New Cross and clay to the south. In the South (St. Peter's and part of Town Hall wards) and South-East (St. John's and part of Town Hall wards) there is clay. So much clay has a serious effect on the houses and drains after a very dry or very wet season, in which the clay shrinks or expands, the 36 foundations being seriously interfered with. There is also an interference with the foundations owing to the sliding movement which takes place on a big slope. Back-to-Back Houses. There are very few houses of this class in the district and practically no houses built in courts. Open Spaces. The Borough has several parks in the neighbourhood but requires more small open spaces in the congested area. Every opportunity should be taken of acquiring small plots of land for the purpose of providing playgrounds and small gardens. Such provision would enable streets to be opened up which at present do not make for the health of the people. The permanent open spaces existing, which cannot be built upon, are:— Situation. Size Maintained by 1. Deptford Park Evelyn Street 22 acres L.C.C. 2. Ravensbourne Recreation Ground Brookmill Road 1¼ acres Borough Council. 3. Hilly Fields Brockley 45½ acres L.C.C. On S.E. boundary of the Borough) 4. Telegraph Hill Recreation Ground Telegraph Hill 9¾ acres 5. Railways and adjoining land 234 acres 6. Mill wall Football Ground 5½ acres 7. Canals 8 acres 8. Reservoir 1 acre Met. Water Board. Density. In the Census of 1921 the density, or number of persons per acre, numbered 60 for the County of London, the worst Boroughs being Southwark, 163; Shoreditch, 158; Bethnal Green, 154; whilst in the South-east the density of Deptford was 72. While the acreage density affects certain medical and social questions such as the control of infectous 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 for London. While overcrowding can and does occur in areas with a dense population, it is possible to 37 find the association of high density with a relatively good housing position, and of the converse association of overcrowding with low population density. Buildings, Dwellings, Rooms and Families. In the 1921 Census a new term was 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 by several. But where a private house has been structurally 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 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 (allowing for war deaths) an increased 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. The following table illustrates the housing of private families in 13 metropolitan boroughs and the City:— 38 Table XVI. BOROUGH. 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. Malsonettes, 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 -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 39 With reference to average size of family, the inhabitants of the poorest eastern boroughs have 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 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. Social conditions and chief occupations of the inhabitants. Influence of anv particular occupation on health. Overcrowding. The following table gives the proportion per 1,000 of the population of occupations of males of twelve years and upwards in Deptford illustrating from 1, 2, 3, onwards the Borough's chief industries: — Industry. Numbers per 1,000 males occupied in 1. Metal work (not including electro plate and precious metals) 123 2. Unoccupied and retired 119 3. Other and undefined work 113 4. Commercial, Finance and Insurance occupations 86 5. Clerks and draughtsmen (excluding civil servants and employees of local authorities) 68 6. Water transport workers 53 7. Road transport workers 51 8. Workers in wood 36 9. Railway workers 35 10. Builders, bricklayers, stone and slate workers, contractors 34 11. Other workers in transport, etc. 33 12. Public administration 30 13. Warehousemen, storekeepers, packers 25 14. Persons engaged in personal service 24 15. Electrical apparatus makers and fitters 20 16. Printers, bookbinders, photographers 19 17. Painters and decorators 18 18. Professional occupations excluding clerical staff 18 19. Makers of foods 13 20. Stationary engines, dynamo and motor attendants 12 40 21. Makers of textile goods and articles of dress 11 22. Workers in chemical processes, makers of paints, oils, etc. 7 23. Workers in mixed or undefined materials not elsewhere enumerated 7 24. Persons employed in gas, water and electricity undertakings, not elsewhere enumerated 6 25. Defence 6 26. Persons employed in entertainment and sport 5 27. Furriers, skinners, tanners and leather dressers 4 28. Makers of glass and glassware 4 29. Makers of leather and leather substitute goods 3 30. Makers of watches, clocks and scientific instruments 3 31. Agricultural occupations 3 32. Workers in other materials 2 33. Upholsterers 2 34. Makers of drinks 2 35. Makers of stationery, cardboard boxes and other workers in paper 1 36. Makers of bricks, pottery and earthenware 1 37. Workers in precious metals and electro-plate 1 38. Textile workers 1 39. Workers in treatment of non-metalliferous mine and quarry products 1 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), and Poplar (109). As regards "Unoccupied" and "Retired," only five Boroughs have fewer than Deptford, viz:—Woolwich (118), Bermondsey (116), Hammersmith (115), Southwark (111), and the City of London (95). The Registrar General gives a nil return under the following occupations for males in Deptford:—Fishermen, mining and quarry, makers of tobacco, cigars, cigarettes and snuff, makers of paper, pulp, straw and cardboard. 41 The following table gives important single occupations of males in Deptford:— Occupation. per 1000 occupied males 1. Labourers 95 2. Dock labourers 31 3. Salesmen and shopkeepers 27 4. Proprietors, managing directors, managers of wholesale and retail businesses 27 5. Warehousemen, storekeepers and their assistants 19 6. Retired (not naval or military) 17 7. Civil service officials and clerks 16 8. Drivers of lorries, vans, waggons and carts (horse drivers) 16 9. Erectors, fitters, tool setters, millwrights 15 10. Messengers 14 11. Mechanical engineers, engineers, etc. 13 12. Carpenters 13 13. Motor car, omnibus, van and lorry drivers 10 14. Porters, not elsewhere enumerated 8 15. Locomotive engine drivers 12 Occupations of Females in Deptford per 1,000 occupied, aged 12 years and upwards. Occupations. No. per 1,000 Occupied. 1. Personal service (domestic service, charwomen, laundry, waitresses) 252 2. Clerks and draughtsmen (not civil servants or employees of local authorities) 160 3. Makers of textile goods and articles of dress 125 4. Commercial, finance and insurance 102 5. Professional occupations 71 6. Metal workers (not electroplate or precious metals) 61 7. Warehousemen, storekeepers and packers 40 8. Makers of foods, drinks and tobaccos 33 9. Makers of and workers in paper 28 10. Other and undefined workers 26 11. Public administration and defence 24 12. Transport and communication 21 13. Workers in wood and furniture 9 42 14. Textile workers 9 15. Skin and leather workers, makers of leather and leather substitute goods 8 16. Electrical apparatus makers and fitters 7 17. Chemical processes 5 Occupations of Females. The most important Single Occupations. Occupations. No. per 1,000 Occupied. 1. Domestic servants, indoor 130 2. Saleswomen and shop assistants 76 3. Sewers and stitchers 45 4. Teachers 42 5. Charwomen 33 6. Packers, labellers and ticketers 33 7. Dress and blousemakers 31 8. Makers of food 28 9. Laundry 27 10. Press workers, stampers, drawers (metal) 25 11. Printers, bookbinders, photographers 21 12. Civil Service officers and clerks 21 13, Sick nurses 19 14. Waitresses 19 15. Proprietors and managers of wholesale or retail businesses 17 16. Milliners 14 17. Barmaids 12 18. Tailoresses 11 19. Telephone operators 9 Deptford has solderers and braziers at the rate of 8 per 1,000 and tinsmiths 12 per 1,000. 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. 43 POOR LAW RELIEF. Hospitals and other forms of Gratuitous Medical Relief. The amount of Poor Law Relief is given herewith in the form of the Guardians' Precepts for the last five years. I am indebted to the Borough Treasurer, Mr. Charles, for his kindness in giving me the figures:— 1921-22 169,698 1922-23 179,830 1923-24 165,393 1924-25 155,200 1925-26 153,297 The extent to which hospitals are used can be roughly estimated by stating the number of deaths of inhabitants which occur in these institutions. Only a small proportion, of course, terminate fatally; consequently, judging from the percentage of deaths which occur in such institutions as compared with the total deaths for the borough it is clear that a very large number of the inhabitants avail themselves of the facilities provided by, not only the Greenwich and Deptford Hospital (Poor Law), but also the London voluntary hospitals. The total deaths for the borough numbered 1399, and of these 723 occurred outside the borough, mostly in hospitals. The Miller Hospital is the local hospital, though it is situated in Greenwich; it is a great boon to our people. Other inhabitants go to Guy's, King's College, St. Thomas' and St. John's Hospital, Lewisham. The latter, like the Greenwich and Deptford Hospital, is highly spoken of by the people (as well, of course, as the other hospitals). The Albury Street Babies' Hospital, situated in Albury Street, is supported by voluntary funds. Dr. Kellett, the visiting physician, died during the year. He was a faithful friend to the poor and he will be missed. The Borough Council paid £50 a year during 1925 for each of eight beds, the cases to be sent in by Dr. Hill or the Medical Officer of Health. The Home has been of great use in the treatment of marasmic or wasting babies and dietetic cases, as well as in sub-acute cases generally. The Home is too small to have a resident physician, which is somewhat of a limitation. 44 Causes of sickness or invalidity specially noteworthy: occupational or environmental conditions which have a prejudicial effect on health. There are no occupational diseases peculiar to the borough. Under "Housing" the relationship of environment to disease will be discussed, whilst special articles on Measles and Diphtheria, especially the last mentioned, will be found in the course of the report. Enquiry has been made into the occupations of rag dealers, but no association with disease has been defined. A number of people collect rags, and these are taken to Messrs. Dandridge in Creek Street. Eventually the material finds its way to paper and shoddy makers. I feel driven to state that the special causes of sickness and invalidity in one or two parts of Deptford are those resulting from miserable environment, principally in the East-end, and I would draw attention in this connection 'to my remarks under "Housing." It is a pity slow headway has been made respecting the clearance of slum areas, concerning which your Medical Officer or his predecessors have made "Representations." The East-end of Deptford was condemned years ago and it is still there. In my report for 1922 I said:— "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 Giffin 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 . . . . How can you expect to raise folks living under conditions of overcrowding and despair and in cheerless surroundings? Unemployment, poverty and despair knock the heart out of many." I have little to add to the above in this survey report. Every week I go to Hales Street and discuss Infant Welfare, Housing and what not with over forty mothers. Look at the death rate and infant mortality rate for our East-end. Of course, the gross infant mortality rate for the whole borough is excellent, but the East-end rate is relatively bad. I know all about those views that if you put some people into a palace it would be dirty in a year. One is not asking for 45 a palace. Would it not be possible to build some blocks of houses with reasonable sanitary amenities, with distempered room walls— never mind wall paper—all near the work of our East-end folks? There is room to build a block or two, thereby freeing some people from one or two tenements; such could be destroyed. Carry out this policy steadily from one end of the East-end to the other, and when that is done I may have some difficulty in answering the Ministry of Health's question as to "Causes of sickness and invalidity specially noteworthy." General Provisions of Health Services in the Borough. 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 where. (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 Homeless 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. Ambulance Facilities. (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, City 7200, 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. 46 (b) Non-infectious 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 High Road, Lee Woolmore Street, Poplar. Peckham Road 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 mcthers 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. . General Sanitary Administration. 48 Sanitary Circumstances of the Area. Closet Accommodation. The closet accommodation in Deptford is entirely of the water carriage type. During the year under report 1,141 defects were remedied or improvements effected in water closets as the result of inspections and notices served by the Sanitary Inspectors. Scavenging. House refuse is removed once weekly from all premises in the Borough. During the year 1925, 654 new dustbins were provided by owners as the result of inspections and notices served by the Sanitary Inspectors. A twice-weekly removal of house refuse is desirable in the east end of the Borough and also in the Pomeroy-Besson Street area. A canvas or other covering should be placed on the top of the carts to prevent dust, etc., from being blown off the same. An occasional tendency to overfilling of the carts might be counteracted by providing more of them. Sanitary Staff. While a list of the staff will be found at the front of the Report, I wish here to make reference to two changes which have have taken place in the last year. Inspector Shelley died in hospital in the month of December, 1925, several days after an operation. Mr. Shelley had been in the service of the Borough Council for many years, and though far from well in the last few months he held on faithfully to his task. Inspector Snowdon had for some time past been in failing health and felt it incumbent upon himself to retire and enjoy the pension he so richly deserved. Mr. Snowdon combined the dignity of the older days with a firm devotion to duty. His work as Food and Factory Inspector in the Borough was of a high order and he will be missed. Work of Sanitary Inspectors. During the year the District Sanitary Inspectors made 19,068 visits in all to 4,939 premises. 1,832 systematic house-to-house inspections were made. Numerous sanitary improvements and repairs were effected, as shown in the following table:— 49 METROPOLITAN BOROUGH OF DEPTFORD. ANNUAL REPORT OF SANITARY INSPECTORS FOR THE YEAR 1925. Table No. XVII. Number of District. Inspections— 1 2 3 4 5 6 7 Totals On complaint 7 14 35 25 29 24 19 153 House-to-house 209 254 329 249 186 279 326 1832 Infectious diseases 173 78 144 100 125 126 132 878 Notice from builder 27 21 37 18 33 17 32 185 New houses for water certificate ... ... ... ... 1 ... ... 1 Other inspections 332 249 297 224 259 289 240 1890 Total 748 616 842 616 633 735 749 4939 Re-inspections, Calls, etc.— Total 1994 1921 2381 1761 1816 2225 2031 14129 Notices Served— Intimation (Public Health Act) 418 328 582 403 378 474 466 3049 Statutory ( Do. ) 11 3 43 27 16 11 28 139 Under Rats and Mice (Destruction) Act ... ... ... ... ... ... ... ... Housing, Town Planning, etc., Act, 1919, Sec. 28 ... ... ... ... ... ... ... ... Cleansing and Repairs— Number of premises, etc., cleansed 293 270 225 252 245 316 286 1887 Ventilation improved (number of premises) ... ... 6 15 2 3 2 28 Number of roofs repaired 101 57 157 75 103 111 110 714 Dampness abated (number of premises) 25 11 26 32 58 83 39 274 Gutters and rainwater pipes provided or repaired 56 52 69 60 64 100 90 491 Yards and forecourts paved ... 2 ... 8 17 ... ... 27 Yard and forecourt paving repaired 55 20 40 18 24 23 33 214 Scullery floors paved, or paving repaired 17 5 9 1 16 11 12 71 Coppers provided and repaired 47 24 42 20 23 30 42 228 Other repairs and improvements 195 92 216 136 170 202 165 1176 Water Supply— Re-instated ... ... ... 3 3 4 2 12 Fittings repaired (number of premises) 9 ... 31 42 ... 9 6 97 Cisterns cleansed ... ... ... ... ... ... ... ... ,, provided ... ... ... ... ... ... ... ... „ covered ... ... ... ... ... ... ... ... ,, abolished ... ... 1 ... ... ... ... 1 Potable water supply provided from Service ... ... 1 ... ... ... ... 1 Additional facilities provided in tenement houses ... ... ... ... ... ... ... ... Other improvements ... 26 6 ... 1 ... ... 33 50 ANNUAL REPORT OF SANITARY INSPECTORS FOR THE YEAR 1925—continued. Table—continued. Number of District. 1 2 3 4 5 6 7 Totals Drainage — Drains re-constructed (number of premises) 2 5 27 5 1 12 ... 52 Drains cleansed and amended 59 58 49 32 30 20 29 277 Gully traps fixed 15 4 48 9 21 ... 5 102 Soil and Vent Pipes fixed 6 6 23 8 13 1 3 60 Do. repaired ... 1 11 ... 7 8 12 39 New Covers provided to inspection chambers ... ... ... 3 1 ... 4 8 Waste and rainwater pipes disconnected from drains 2 ... 22 ... ... ... ... 24 Chambers provided and access eyes 5 ... 16 3 8 ... 1 33 New sinks provided 10 ... 6 32 ... ... 12 60 Water Closets- Old waterclosets abolished 2 1 ... ... ... ... ... 3 New waterclosets provided 4 3 1 ... 3 3 ... 14 New pan and trap only, provided 28 24 58 34 54 21 12 231 Defective flush remedied 97 26 49 2 31 35 40 280 Pans cleansed ... 3 1 2 3 7 11 27 Seats provided or repaired 5 1 3 ... 1 8 7 25 Roofs repaired 18 7 20 14 5 12 13 89 Walls, etc., repaired or cleansed 77 5 66 35 38 92 37 350 Doors repaired or renewed 9 9 7 ... 3 5 4 37 Ventilation improved ... ... ... ... 1 4 ... 5 Floors repaired 4 ... 6 ... 1 6 6 23 Other repairs or improvements 4 21 12 ... 4 16 ... 57 Urinals— Cleansed ... ... 2 2 ... 1 3 8 Repaired ... ... 2 ... 2 ... ... 4 Dung Receptacles— Provided ... ... 1 ... ... 1 ... 2 Repaired ... ... ... ... ... 1 ... 1 Abolished ... ... 1 ... ... ... ... 1 Overcrowding- Cases abated 1 11 ... ... ... 1 ... 13 Nuisances arising from the keeping of animals— Number of nuisances abated 1 ... 2 4 ... ... 6 13 Offensive accumulations— Number of accumulations removed ... 11 14 1 9 5 5 45 51 ANNUAL REPORT OF SANITARY INSPECTORS FOR THE YEAR 1925—continued. Table—continued. Number of District. 1 2 3 4 5 6 7 Totals. Smoke Nuisances- Number of observations of shafts made 1 ... 31 18 ... 4 8 62 Number of nuisances from black smoke discovered ... ... 10 7 ... ... ... 17 Number of notices served ... ... 3 2 ... ... ... 5 Dustbins— Provided or repaired 85 93 166 85 80 60 85 654 General— Other miscellaneous nuisances abated 2 2 3 20 ... ... 13 40 District No. Inspector. District. From Jan. to Sept. From Oct. to Dec. 1 Inspector Simpson E. Ward N.W. and S.W. Wards 2 „ Shelley ,, S. and S.E. ,, 3 ,, Kemp N.W. and S.W. Wards N.W. Ward 4 „ Hewett N. Ward E. „ 5 ,, Allam S. and S.E. Wards N, „ 6 ,, Yates N. and N.W. „ „ E. „ 7 ,, Mayo N.W.Ward N. „ 52 Legal Proceedings Under the Public Health Act and Bylaws. Premises. Nature of Offence. Result of Proceedings. 10 Junction Road. Unsound beef deposited for sale. Fined 20/- and £5 5s. 0d. costs. 77 Watergate Street. W.C. pan and trap fixed without notice to Sanitary Authority. Fined £3, inclusive of costs. 20 Malpas Road. Absence of ashpit (dustbin) accommodation. Dustbin installed prior to hearing. Fined 5/- and 21/- costs. 236 Drakefell Road. Non-compliance with sanitary notice. Fined 40/- and 21/- costs and order for necessary work to be carried out within 14 days. 115 Brookmill Road. Non-compliance with sanitary notice. Order for necessary work to be carried out within 1 month. Defendant ordered to pay £3 3s. 0d costs. HOUSE-TO-HOUSE INSPECTIONS. House-to-house inspections were made in the following streets during the year 1925:— Inspector Simpson.—East and South-west Wards. Street or Road. Total premises inspected. Number in which defects were found. Hyde Street 25 25 Addey Street 33 32 Ffinch Street 16 16 Hosier Street 8 8 Hales Street 33 30 Bronze Street 6 6 Alvar Street 10 10 Knott Street 2 2 Benmore Street 14 14 Reginald Street 11 5 Faulkner Street 34 34 Foxwell Street 17 17 Total 209 199 53 Inspector Shelley—East, South and South-east Wards Amersham Vale 64 36 Adolphus Street 72 28 Baildon Street 27 27 Hereford Place 8 6 Malpas Road 17 6 Mornington Road 12 8 Providence Place 7 5 Stanley Street 28 16 Vance Street 13 6 Wybourn Cottages 5 5 Total 253 143 Inspector Kemp—North-west and South-west Wards. Monson Road 4 2 Bousfield Road 47 19 Kender Street 53 39 Powers Place 9 8 Rose Cottages 4 4 Prospect Place 15 12 Reaston Street 36 25 Kender Grove 4 3 Kender Place 3 2 Dennetts Road 57 34 Pomeroy Street 17 13 Silwood Street 2 2 Blockhouse Street 43 27 Fawcett Road 26 25 Erlam Road 9 3 Total 329 218 Inspector Hewett—North and East Wards. Gosterwood Street 53 40 Etta Street 16 12 Rolt Street 82 47 Prince Street 30 24 Walpole Road 36 32 Warwick Street 17 14 Snead Street 15 6 Total 249 175 54 Inspector Allam—South, South east and North Wards. Heston Street 7 4 St. Nicholas Street 11 10 Florence Cottage 1 1 Revelon Road 2 1 Fisher's Rents 11 11 Wilson Street 17 15 Florence Street East 7 7 Martin's Buildings 8 2 Summer Street 15 13 Spring Street 11 8 Ship Street 8 6 Lucas Street 27 22 Crooke Road 20 15 Edward Street 29 23 Vansittart Street 12 9 Total 186 147 Inspector Yates—East, North and North-west Wards. Chubworthy Street 72 63 Bawtree Road 8 8 Childeric Road 55 52 Ludwick Road 4 4 Lee Terrace 3 2 Alexandra Street 39 27 Reginald Street 11 7 Reginald Road 6 6 Church Street 34 33 Amelia Terrace 9 8 Hales Street 8 8 Crooke Road 9 8 Reginald Place 21 17 Total 279 243 Inspector Mayo—North and North-west Wards. Rollins Street 23 19 Reculver Road 79 66 Haydock Road 57 44 Canterbury Road 64 46 Fawcett Road 15 13 Prince Street 10 5 New King Street 30 19 Czar Street 40 32 Grove Street 8 8 Total 326 252 Grand Total 1832 1377 55 HOUSING. 1. General. Number of houses erected during the year 1 2. Unfit Dwelling Houses. (a) Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) ... 4939 (2) Number of dwelling-houses which were inspected and recorded under the Housing (inspection of District Regulations) 1910 1832 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 41 (4) Number of dwelling-houses (exclusive of above) found not to be in all respects reasonably fit for human habitation 3049 (b) Remedy of defects without service of formal notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers Nil. (c) Action under Statutory Powers. (1) Proceedings under Sec. 28 of the Housing, Town Planning, &c., Act, 1919. (a) Number of dwelling-houses in respect of which notices were served requiring repairs Nil. (b) Number of dwelling-houses which were rendered fit:— (1) By owners — (2) By Local Authority in default of owners — (c) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close — (2) Proceedings under Public Health Acts. (a) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 3049 (b) Number of dwelling-houses in which defects were remedied:— (1) By owners 3049 (2) By Local Authority in default of owners — (3) Proceedings under Sections 17 and 18 of the Housing, Town Planning, &c., Act, 1909 Nil. 56 In the east end of Deptford there are from two to three thousand houses forming an area which was condemned by the Medical Officer of Health for Deptford some five to six years ago. The houses are still there, all of them. The area was not dealt with by the London County Council, it may be because the area "represented" was too large and its demolition would have cost a vast sum of money. The people who live east of High Street belong to the very poor; they are casual and unskilled labourers, men who work at the docks, and men who live off the barrow. It is the correct thing in some quarters, when speaking of slum dwellers, to refer to them as the submerged tenth, to speak of them as if they and their surroundings must be accepted as inevitable, as if, in effect, they were a definite part of the scheme of things and to disturb which would be an interference with the plans and intentions of an all-wise Creator. Now, how are these people being housed? Is the story about overcrowding a true one, and, if so, is it serious as regards health and happiness ? Are they to be left as they are ? East of High Street, many of these houses are tenement houses or houses let-in-lodgings. Here for example are the housing inspection record cards for Hales Street. The first card tells of three families consisting of eight people living in 4 rooms (this record was made on the 9th July, 1925). As the result of this inspection, the Inspector sent an intimation notice for minor defects, four items in which related to such things as defective copper, defective W.C., etc., and five items regarding dirtiness of staircase, passage, etc., etc. The families were paying rents as follows:—9s. for two rooms, 4s. for one room, etc. In one of the three families there was overcrowding. In another tenement house the rents were (a) 10s. for two rooms, 5s. for one room, (c) 5s. 6d. for one room. Turn now to the results of the house-to-house inspections made in 1925 by the Sanitary Inspectors throughout the Borough. Over 1800 houses were so inspected, and these were not confined to the east end. On another page will be seen lists of streets where such inspections were made. In submitting the undermentioned evidence regarding overcrowding, it should be observed that the Inspectors did not pick upon certain houses or groups of such with a view to discovering serious conditions. It should further be observed that by "overcrowding" we mean the presence of over two people per room in a 57 house; thus a house of three rooms and a scullery (the latter is not counted) occupied by seven or more occupants, would be considered overcrowded. The following is the result of a scrutiny of 1733 such house-to-house record cards:— 2950 families were found living in 1733 houses. 671 „ had a house each. 1804 „ were living two families per house. 459 „ „ three „ „ 16 „ „ four „ „ The vexation of spirit to which 2279 families are subjected daily through lack of family privacy can be imagined. 47 families were living overcrowded in one room per family. One such room was occupied by a family of six people. Six such rooms were each occupied by a family of five people. 17 „ „ „ „ „ four „ 23 ,, ,, „ „ „ three „ Thus 173 people were living in 47 rooms. 10 families were living overcrowded in two rooms per family. In one case the family consisted of eight people. In two cases ,, „ seven „ In four cases „ „ six „ In three cases „ ,, five „ Thus 61 people were living in 20 rooms. 17 families were living overcrowded in three rooms per family. In two cases the family consisted of ten people. In five cases „ ,, nine ,, In five cases „ ,, eight „ In five cases „ „ seven „ Thus 140 people were living in 51 rooms. Many of these cases occurred amongst the very poor, the destitute, though a number of the families were of the goodly artisan order. The moral effects of this state of affairs can be imagined. The fact that our poorer fellow citizens have taken matters so quietly, apart from pathetic complaints, is a tribute to their courage and endurance. The housing of the very poor, and some not so poor, then remains in a parlous condition. Not a day passes but what those engaged in the public health service receive letters asking for a house. In all such 58 cases immediate enquiry is made into the home circumstances. The London County Council has opened up new estates at Downham, Becontree and elsewhere, but the relief afforded thereby to Deptford has had little effect in reducing overcrowding. It is of course an ideal thing to desire a house for each family, but two circumstances make it essential that, as the east of High Street area is cleared, tenements shall be erected. The reasons are (a) that the dehoused must live near their work; and (b) that the inhabitants of such area cannot pay the rent for houses such as those erected on the Downham estate. I do not see where the difficulty comes in. We have room in parts of the Borough where one or two tenements could be erected. This would enable the tenement houses in Hales Street, etc., to be pulled down piecemeal, provision having thus been made for the dehoused tenants before such demolition It only needs a start. These old east end houses have long outlived their span. Of the inhabitants, one can but say it is the case of the soul of a man in the house of a beast. Of course some are dirty in their habits and are not good tenants, but only the insane say that these people are no worse housed than they should be. When the Great War came, the men of brawn in the east end were embraced by the army and navy as fine fellows; there were great promises made as the men marched away. And so to-day!!! Dr. Hastings, Medical Officer of Health of Toronto, recently wrote: "Was it not unfortunate that Lord Nelson when lie said at the battle of Trafalgar, 'England expects that every man this day will do his duty,' did not add, 'And every man expects England will do its duty.' " Education and religion are the two principal things which will raise humanity. Neither of these will effect much so long as children come to schools from slums. Unemployment, of course, is a heartbreak, a great problem, but surely some tenement houses could be built at once. It is to the London County Council we look; the Borough Council has done its share. I have not here attempted to set forth a comparative statement illustrative of the toll in disease which residence in the east of Deptford exacts. These tables can be found in the pages of this Report, and they are sordid facts which cannot be gainsaid. So far I have dealt to a certain extent with the east end, though not wholly, for the housing statistics given refer to all parts of the Borough. 59 But whereas the statistics were framed from routine house-to-house inspection cards, i.e., they were not specially chosen, the following details refer to cases which have been selected purely because they are examples of bad overcrowding. They refer, with few exceptions, to wards other than the east end. Some Examples of Bad Overcrowding. Address. No. of Rooms. Age of Occupants. Wages. No. of Beds. 59 C Street 1 Husband and Wife, 4 Children, 7, 5, 3, l½ £2 14s. 6d. 2 19 K Street 1 Husband and Wife, 4 Children, 13, 10, 7, 5. - - 17 B Street 2 Husband and Wife, 2 Children, 6 and 4 Mother expectant. - 2 43 D Street 2 Husband and Wife, 4 Children, 7, 4 and infant twins — 1 bedstead 1 chairbed- stead, 1 cradle. 50 S Street 1 Husband and Wife, 4 Children, 18, 11, 9, 6 £2 15s. 0d. 1 bedstead 1 bed on floor 1 chair bedstead 57 N Street 2 Husband and Wife, 4 Children: Males, 17 & 13 years; Females, 23 and 11 years. (All sleep in one room) 1 bedstead 1 bed on floor 20 L Street 1 Husband and Wife, 3 Children, 8, 6, 4. - - 19 L Street 1 Husband and Wife, 6 Children, 13, 11, 8, 7, 4, l½ - 2 97 E Street 1 Husband and Wife, 4 Children, 6, 4, 2, 1. - 1 26 B Road 1 Husband and Wife 5 Children: Males, 11, 3; Females, 9,6, l½. Wife expecting. - 2 6 E Terrace 2 Husband and Wife, 5 Children. - 2 Do. 1 Husband and Wife, 2 Children. - 1 Do. l½ Husband, 2 Adult Children. - 2 Do. 1½ Husband and Wife, 4 Children. - 1 60 Address. No. of Rooms. Age of Occupants. Wages. No. of Beds. 16 C Street 1 Husband and Wife, 3 Children, 6, 3, 1. - 2 26 C Street 1 Husband and Wife, 6 Children: Males, 8, 6, 5; Females, 3, l½, ½. £2 17s. 6d. 1, Others made up on floor. 6 H Place 1 Husband and Wife, 3 Children, 17/12, 310/12, 410/12 - 2 19 A Road 1 Husband and Wife. =- 1 1 Females, 17, 15, 3. Males, 3 over 10 years. - 2 1 2 Children under 10 years. - 1 6 F Road 1 Husband and Wife, 2 Children, 16, 19. - 1 bed and couch. 47 B Road 2 Husband and Wife, 4 Children, 2 over 10 years. - 1 double. 1 single. 13 W Street 1 Husband and Wife, 3 Children, 6, 4, 2. - 1 double. 9 St. N Street 1 Husband and Wife, 1 child, under l0 years. - 1 double. 3 F Street 5 3 Families, 6 Adults, 10 Children. - - 33 F Street 5 2 Families, 4 Adults, 10 Children. - (One a consumptive case.) 39 D Road 2 2 Adults, 5 Children. - - 25 B Street 6 2 Families, 4 Adults, 18 Children. - - 39 W Road 3 2 Adults, 6 Children. 71 N Street 3 1 Adult, 5 Children. - - 3 P Place 3 2 Adults, 6 Children. - - 38 B Street 2 2 Adults, 5 Children. - (Father tubercular) 15 E Road 3 13 People. - - 35 S Road 3 10 Occupants. - (Girl of 14 sleeps in same room as brothers 16 & 11 years) Factory and Workshops Act. 62 FACTORIES, WORKSHOPS, WORKPLACES, OUTWORKERS, etc. These premises were periodically inspected during the year, special attention being paid to the sanitary accommodation provided for the use of persons employed, Sec. 38 P.H. (L) Act, 1891, etc., also to cleansing, the reception, checking and issuing of outworkers' lists and the keeping of the necessary registers. The outworkers' register entails much work, owing to the constant change of address and to removals. Notes by Mr. Snowdon. The sanitary conveniences in the majority of cases have been fairly well kept, and several new tiers of W.C.s have been provided for each sex. No reports were received from H.M. Inspector of Factories in respect of defects in sanitary accommodation, and this speaks for itself. May I suggest the importance of constant inspection of food factories ; there has, I think, been a tendency to inspect factories more with a view to observing the condition of the sanitary conveniences than to watching the processes of food preparation and manufacture in operation. Such processes, I feel, require constant and close inspection. In this connection I would instance jam factories, where pulp of some rather doubtful origin may be in use. Workshops.—The number of workshops shows a tendency to decrease, particularly in the drapery and millinery trades; other methods seem to have been adopted whereby a considerable proportion of the made-up clothing comes direct from the factory. One shop manager informed me that whereas a few years ago he could sell 100 yards of a certain material he can now hardly sell one. There is a tendency on the part of shopkeepers to reduce their working staffs. Restaurants.—I have found little cause to complain of the general condition and business methods in restaurants. The most important matter here, as in bakehouses, is the question of refuse removal. The small eating house, or coffee shop, has been hit hardly by the changed hours of labour. One shop in pre-war years supplied some 200 cups of tea in the early morning, whereas now 20 cups would 63 be above the normal number. The food supplied in such small shops is of a wholesome character. The kitchens of the larger premises require close inspection. Fried fish shops and fish-curing premises.—The general condition of these premises is fairly satisfactory. The placing of the offal immediately in the tins supplied by the contractors and keeping it covered is important; also, the condition of the tins requires frequent examination. This is particularly important during the summer months. Bakehouses.—The condition of bakehouses has been generally good throughout the year, and very little difficulty has been experienced in getting the bi-annual cleansing carried out. I may point out one matter which is not satisfactory, i.e., the removal of refuse. This should be done more frequently—say three times a week. Another improvement would be the more frequent substitution of paint for the ceilings : the limewashing of ceilings leads to flakes peeling off and falling on the lower benches. The introduction of more mixing machinery (for eggs, etc.) has, I think, greatly benefited the public and the trade. Slaughterhouses.—The bye-laws applicable to these premises entail a good deal of burden on the proprietors, but still they are carried out with goodwill. The Public Health (Meat) regulations have been met. Offensive trades.—These premises have been kept in good order, and the old-time nuisance from offensive effluvia seems to be almost a thing of the past. Better methods have been adopted. I had no complaint during the year. Factories. The number of factories on the register at the end of the year was 242, made up as follows:—Factory Laundries 3, Factory Bakehouses 17, other Factories 222. Other Factories include Offensive Businesses 2, Food Premises 22. The number of Factories shows a net increase of 11. Number of visits paid 427. Workshops. The number of Workshops on the register at the end of the year was 157, made up as follows: Workshop Laundries 4, Workshop Bakehouses 34, other Workshops 119. Number of visits paid 404. 64 Workplaces. Workplaces include any place where work is done permanently and where people assemble together to work permanently. The kitchens of Restaurants, Hotels, etc., come within the meaning of the term "Workplace"; also included are Stables, Builders' Yards, Timber Stores, etc. The number of Workplaces on the register at the end of the year was 201; this number includes 131 food premises. Number of visits paid 523. Outworkers. This system of home work is in a fluctuating condition, one cause being the poor remuneration, and a continual alteration of the registers results, though not solely from this cause, but also from the frequent removal of the outworkers to different contractors and to change of address and change of employers. The cases of Infectious disease notified each day are checked with the outworkers' lists. Five cases of infectious disease occurred on the premises of outworkers during the year. In only one case was wearing apparel found in course of manufacture; 128 shirts were removed from the house, disinfected and returned to the factory. The number of outworkers on the register at the end of the year was 322; 41 new names were added and 20 names removed from the register. There has been a marked decline in the number of persons actively employed during the year, which decline has continued during the period of making up this report. 65 Table XIX. METROPOLITAN BOROUGH OF DEPTFORD. PROCEEDINGS DURING 1925. PREMISES. NUMBER OF PLACES— Number of inspections Number of notices Number of proceedings On register at end of 1924 Added 1925 Removed 1925 On register at end of 1925 Milk premises 155 8 .. 163 421 11 .. Cowsheds .. .. .. .. .. .. .. Slaughter-houses 2 .. .. 2 109 1 .. Other offensive trade premises 2 .. .. 2 30 .. .. Ice cream premises 143 26 .. 169 309 24 .. Fried fish, etc., shops 48 .. 1 47 174 14 .. Restaurants 51 2 1 52 77 6 .. Other food premises 28 .. 2 26 186 2 .. Hairdressers' premises 51 .. 1 50 15 .. .. Table XX. 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 1925. CLASS OF WORK. Number of Places Number of Inspections. Number of Notices. Number of Prosecutions. On Register at end of 1924. Added 1925. Removed 1925. On Register at end of 1925. Under Factory Acts. Under Public Health Acts. Premises. Rooms Factories Factory Laundries 3 3 17 9 Factory Bakehouses 16 1 17 31 89 2 Other Factories 212 19 9 222 619 329 23 Workshops Workshop Laundries 4 4 17 10 Workshop Bakehouses 43 9 34 80 209 4 Other Workshops ... 126 66 13 119 226 185 13 Workplaces Places where Food is prepared for Sale 126 6 1 131 238 456 22 Workplaces other than the above 73 1 4 70 89 67 2 Home-workers' Premises 301 41 20 322 337 128 2 Total 904 74 56 922 1654 1482 68 66 Table XXI. METROPOLITAN BOROUGH OF DEPTFORD. This Table is by request of the Secretary of State. Annual Report of Medical Officer of Health for the year 1925. 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) 427 25 Workshops (including Workshop Laundries) 404 17 Workplaces (other than Outworkers' premises included in Part 3 of this Report) 523 24 Total 1354 66 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 31 31 Want of Ventilation Overcrowding Want of Drainage of Floors Other Nuisances 12 12 Sanitary Accommodation Insufficient 1 1 Unsuitable or defective 20 20 Not Separate for Sexes 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) 5 5 Other Offences (excluding offences relating to outwork which are included in Part 3 of this Report) Total 69 69 67 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. Out. workers. Lists. Outworkers. Failing to keep or permit inspection of lists. Failing to send lists. Contractors. Workmen. Contractors. Workmen. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Wearing apparel— Making, etc. 45 11 243 5 11 61 5 1 Cleansing and Washing 1 Fur-pulling 1 2 Total 46 11 246 5 11 61 5 1 68 Table–continued. 4.–REGISTERED WORKSHOPS. Workshops on Register (s. 131) at the end of year. Number. Bakehouses 34 Dressmaking 12 Laundries 4 Millinery 14 Tailoring 14 Wheelwrights (Smiths, &c.) 23 Others 56 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) 14 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 1 Reports (of action taken) sent to H.M. Inspector 1 Other - Underground Bakehouses (s. 101):— Certificates granted during the year - In use at the end of the year 1 69 CANAL BOATS ACTS. Annual Report for the Year ended 31st December, 1925. To the Medical Officer of Health, Sir, I beg to report for the year ended December 31st, 1925, that for the purpose of Canal Boats inspection, I made 13 visits, on the following dates, viz.:— January 8th, February 3rd, 18th and 27th, March 20th, April 23rd, May 5th, June 10th and 25th, July 7th and 13th, September 2nd and 29th. No boats were found for inspection during the year; there is no doubt that this method of conveying goods has been superseded as far as the portion of the Canal situated in this Borough is concerned. This Council is not a Registration Authority under the above Acts. 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, 1926. UNSOUND FOOD. 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. Anchovies 56 lbs. Apricot pulp 220 lbs. Apple pulp 44 lbs. Beetroot l½ baskets Blackberries 213 lbs. Cherries 8 baskets Cods' Roes 1 box Cod 1 trunk Condensed Milk 49 tins Haddock 4 boxes Hake 1 box Potatoes 14 lbs. Tomato Puree 11 tons 16 cwt. 2 qrs. 2 lbs. Winkles 2 bags SALE OF FOOD AND DRUGS ACTS. 698 samples were purchased and submitted to the Public Analyst for analysis. Of this number, 15 or 2.1% were adulterated. In three instances legal proceedings were taken, conviction being obtained in two cases. The remaining summons was dismissed, the vendor successfully pleading warranty. 70 Table XXII. Proceedings Taken in regard to Samples Purchased during the Year 1925. Sample No. Article. Particulars of Adulteration or Infringement. Fine. Costs. Remarks. £ s. d. £ s. d. 61 M Brawn Boric acid 0 7 grains per lb - — Vendor cautioned. 64 M Madeira Cake Boric acid 14 9 grains per lb. — — Vendor cautioned. 59 M Madeira Cake Boric acid 114 grains per lb. — — Vendor cautioned. 55 K Lemon Squash Benzoic acid 31 grains per pint. — — Vendor cautioned. 61 K Milk 2 per cent. fat abstraction — — Vendor cautioned 49 M „ 2 ,, „ „ — — Vendor cautioned. 3O A „ 8 „ „ „ — — Summons dismissed. Warranty proved. 11 K „ 2 „ „ „ — — Vendor cautioned. 12 K „ 1 „ „ „ — — Vendor cautioned. 13 K „ 8 per cent. added water 2 0 0 3 3 0 Sample purchased in course of delivery. 14 K •• 11 „ „ „ 2 0 0 3 3 0 Sample purchased in course of delivery. 24 M „ 1 per cent. (at abstraction — — Vendor cautioned. 8 S „ 3 „ „ „ — — Vendor cautioned. 71 Table XXIII. Samples taken during 1925. Articles. Number Genuine. Number Adulterated. Total. Percentage of Adulteration. Ale 2 .. 2 .. Almonds, ground 1 .. 1 .. Arrowroot 2 .. 2 .. Baking Powder 3 .. 3 .. Barley, pearl 5 .. 5 .. Beef, minced 1 .. 1 .. Boracic Powder 1 .. 1 .. Borax 1 .. 1 .. Boric Ointment 1 .. 1 .. Brawn .. 1 1 100 Butter 37 .. 37 .. Cake 2 .. 2 .. Cake, Madeira .. 2 2 100 Camphorated Oil 3 .. 3 .. Castor Oil 2 .. 2 .. Cheese 8 .. 8 .. Chocolate, sweetmeats 3 .. 3 .. ,, Easter eggs 22 .. 22 .. Cocoa 16 .. 16 .. Coffee 6 .. 6 .. Coffee and Chicory 1 .. 1 .. Cornflour 2 .. 2 .. Cream 7 .. 7 .. „ preserved 4 .. 4 .. Curry Powder 2 .. 2 .. Custard Powder 1 .. 1 .. Dripping 5 .. 5 .. Desiccated Cocoanut 2 .. 2 .. Epsom Salts 1 .. 1 .. Eucalyptus Oil 1 .. 1 .. Flour 2 .. 2 .. „ self-raising 2 .. 2 .. Gin 2 .. 2 .. Glauber Salts 1 .. 1 .. Glycerine 2 .. 2 .. Ground Ginger 3 .. 3 .. Jelly, table 1 .. 1 .. Lard 10 .. 10 .. Lemonade Powder 5 .. 5 .. Lemon Squash 1 1 2 50 Lime Juice 2 .. 2 .. Linseed Oil 1 .. 1 .. Liquorice Powder, compound 1 .. 1 .. Margarine 14 .. 14 .. Medicine 6 .. 6 .. Carried forward 195 4 199 •• 72 Samples taken during 1925—continued. Articles. Number Genuine. Number Adulterated. Total. Percentage of Adulteration. Brought forward 195 4 199 Milk 384 9 393 2•3 ,, separated 1 .. 1 .. ,, dried, full cream 2 .. 2 .. ,, ,, ,, ,, modified 1 .. 1 .. ,, ,, machine skimmed 1 .. 1 .. ,, condensed, full cream sweetened 1 .. 1 .. „ ,, skimmed 3 .. 3 .. Magnesia, Citrate of 1 .. 1 .. Meat Paste 1 .. 1 .. Mincemeat 2 .. 2 .. Mustard 10 1 11 9•0 ,, compound 2 .. 2 .. Nutmegs, ground 1 .. 1 .. Oats, rolled 2 .. 2 .. Olive Oil 1 .. 1 .. Paregoric 2 .. 2 .. Pepper 15 .. 15 .. Rice 4 .. 4 .. Rum 2 .. 2 .. Sago 4 .. 4 .. Sausages 4 .. 4 .. Syrup, Golden 1 .. 1 .. Shredded Wheat 1 .. 1 .. Sulphur Ointment 2 .. 2 .. Salmon Paste 1 .. 1 .. Semolina 2 .. 2 .. Sherbet 2 .. 2 .. Tapioca 4 .. 4 .. Turpentine 1 .. 1 .. Whisky 2 .. 2 .. Vinegar 12 .. 12 .. ,, malt 2 .. 2 .. Zinc Ointment 2 .. 2 .. Informal Samples. Apples 1 .. 1 .. Liquid Eggs .. 1 1 100 Castor Sugar 1 .. 1 .. Fat 1 .. 1 .. Flour 1 .. 1 .. Baking Powder 1 .. 1 .. Vanilla Flavouring 1 .. 1 .. Chocolate and Chocolate Powders 6 .. 6 .. Totals 683 15 698 2•1 73 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 not used during the year. 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 1,540. 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. Table XXIV. SHOWING NUMBER OF ROOMS DISINFECTED AFTER THE FOLLOWING DISEASES. Date 1925 Small Pox. Scarlet Fever. Diphtheria. Erysipelas. Enteric Fever. Puerperal Fever, Pulmonary Tuberculosis Measles. Pneumonia. Cancer. Cerebo-Spinal Meningitis. Encephalitis Lethargica. Whooping Cough. Scabies. Chicken Pox. Requests. Influenza. January .. 51 40 .. .. .. 24 .. .. 3 .. 1 2 .. .. 3 .. February .. 18 58 2 .. .. 32 .. .. 1 1 1 .. 1 .. .. 1 March .. 15 60 .. .. 4 30 .. 1 2 .. .. .. .. .. 2 .. April .. 22 40 .. .. 1 21 3 1 7 2 .. .. .. .. 3 1 May .. 17 25 1 .. 1 28 1 .. 3 .. .. .. 1 .. 1 .. June .. 18 38 1 .. .. 26 4 .. 2 .. .. 1 .. .. 1 .. July .. 18 56 .. .. .. 30 2 .. 2 .. .. .. 1 .. 4 .. August .. 12 29 .. .. .. 22 1 .. 1 1 .. 2 .. 1 .. 3 September .. 27 36 .. .. 2 25 4 1 3 .. .. .. 2 .. 2 .. October .. 37 107 .. 1 .. 21 A .. 3 .. .. .. .. .. 2 .. November .. 36 87 .. .. 2 21 11 l .. .. .. .. 1 4 .. .. December .. 26 57 .. 1 3 31 3 l 3 .. .. .. .. .. .. .. Total .. 297 633 4 2 13 311 33 5 30 4 2 5 6 7 18 5 74 Table XXV. SHOWING THE NUMBER OF PREMISES. ROOMS AND BEDDING DISINFECTED DURING THE YEAR 1925. Date 1925 Premises. Rooms. Beds. Pillows. Bolsters. Mattresses. Sheets. Blankets. Odd articles Articles destroyed. January 125 128 77 147 48 21 59 129 137 4 beds, 5 palliasses, 3 mattresses, 2 pillows, 2 sheets, 6 odd articles February 114 117 60 134 48 25 79 126 152 1 bed, 1 odd article March 117 121 63 133 45 20 69 106 159 4 beds, 3 mattresses, 4 pillows, 2 sheets, 1 blanket, 32 odd articles April 90 108 49 100 37 20 51 83 128 2 mattresses, 2 palliasses, 1 bed, 1 pillow, 13 odd articles May 96 114 37 71 30 16 36 50 196 3 beds, 2 mattresses, 2 palliasses, 4 odd articles June 104 123 44 88 41 15 53 49 91 4 beds, 4 palliasses, 1 mattress, 3 pillows, 1 bolster, 13 odd articles July 111 132 47 110 32 24 42 45 65 3 beds. 4 mattresses, 1 bolster, 2 palliasses, 10 odd articles August 82 98 38 86 28 10 33 24 34 1 mattress, 2 pillows September 111 121 65 138 38 19 78 97 195 October 172 184 115 225 75 36 125 166 274 1 bed, 1 mattress, 1 blanket, 2 odd articles November 154 165 78 139 58 43 102 146 179 December 190 12??? 52 155 45 41 78 158 166 2 blankets, ,3 odd articles, 1 mattress, 2 bolsters, 1 pillow Total 1396 1540 725 1526 525 290 805 1179 1776 verminous premises 99 premises consisting of 164 rooms were fumigated during the year. books. 266 Library books were fumigated during the year. cleansing station. 2,138 articles of clothing, etc., were disinfected during the year. 2,049 children were treated. In 20 instances a second treatment was required within a month, making a total of 2,069 given during the year. 75 Summary. Total number of Premises disinfected 1396 ,, „ Rooms „ 1540 Beds „ 725 ,, ,, Pillows ,, 1526 ,, ,, Bolsters ,, 525 „ „ Mattresses ,, 290 ,, ,, Sheets ,, 805 ,, ,, Blankets ,, 1179 ,, ,, Odd Articles ,, 1776 Total articles 6826 Total number of Beds destroyed 21 ,, ,, Mattresses ,, 18 ,, ,, Palliasses ,, 15 ,, „ Pillows ,, 13 ,, ,, Sheets ,, 4 ,, „ Bolsters ,, 4 ,, ,, Blankets ,, 4 „ ,, Odd Articles ,, 84 Total 163 N.B.—The above Articles were destroyed at the request of the owners. Special Cases. Jan. 14th—Scawen Road. Cancer. 1 bed, 1 bolster, 2 sheets, 1 blanket— disinfected. ,, ,, —Trim Street. Cancer. 1 bed, 4 pillows, 2 bolsters—disinfected. ,, 15ih—Windmill Lane. Cancer. 1 bed, 2 pillows, 3 sheets—disinfected. Feb. 12th—Evelyn Street. Cancer. 5 pillows. 1 bolster, 4 blankets, 1 odd article—disinfected. March 18th—Breakspears Road. Cancer. 2 mattresses, 1 pillow, 1 bolster— disinfected April 6th—New Cross Road. Cancer. 1 mattress, 5 pillows, 1 bolster, 4 sheets, 2 blankets, 13 odd articles disinfected. ,, 29th—Erlanger Road. Cancer. 1 bed, 1 mattress. 1 pillow, 13 odd art icles—destroyed. May 6th—Friendly Street. Cancer. 1 bed, 2 pillows, 1 bolster, 2 odd articles —disinfected. ,, 23rd—Ashmead Road. Cancer. 1 pillow, 3 sheets, 3 blankets, 10 odd articles—disinfected ; 1 mattress—destroyed. June 9th—Breakspears Road Cancer. 1 mattress, 4 pillows—disinfected. July 6th—Trundleys Road. Cancer. 2 beds, 1 bolster—disinfected. 27th—Egmont Street. Cancer. 1 bed, 1 bolster, 3 pillows, 1 cushion —disinfected. August 21st—Wickham Road. Cancer. 5 pillows, 2 odd articles—disinfected. Sept. 21st—Rokeby Road. Cancer. 1 mattress, 2 pillows, 1 bolster, 3 odd articles—disinfected. ,, 22nd—Gellatly Road. Cancer. 2 beds, 6 pillows, 2 bolsters, 3 odd articles— disinfected. ,, 24th—Desmond Street. Cancer. 1 bed, 3 pillows—disinfected. Dec. 16th—Jerningham Road. Cancer. 1 mattress, 2 bolsters, 1 pillow, 1 blanket, 3 odd articles—disinfected. ,, 31st—Drakefell Road. Cancer. 1 mattress, 1 bolster, 4 pillows, 4 blankets—disinfected. 76 Mortuary Report for the year ended 31st December, 1925. Bodies Received, etc. Total. Male. Female. Inquests. Postmortems. Under 1 year of age. Unknown. Deposited to await burial only. Infectious. 113 64 49 111 69 12 1 1 1 Eight bodies were detained after inquests to await burial owing to lack of accommodation at the homes, and three owing to advanced decomposition. Boroughs of which deceased persons were residents Deptford 65 Greenwich 15 Lewisham 9 Camberwell 2 Bermondsey 16 Wimbledon 1 Poplar 2 Lambeth 2 Northfleet 1 INSPECTION AND SUPERVISION OF FOOD. (a) Sale of Milk. In December, 1923, the attention of the Public Health Committee was drawn to the milk shops. To begin with, it was explained that in the City of London very considerable alterations of the Register had resulted from the survey of milksellers in consequence of the 1922 Milk Amendment Act. Further knowledge as to action taken elsewhere obtained, as follows:— At Westminster, the Medical Officer of Health wrote to me that "several new applicants have been refused on the grounds of the unsuitability of the premises, or that other articles are sold liable to contaminate milk." At Woolwich, one man was struck off owing to "general shop conditions and methods of the retailer." At Lewisham, " several persons were removed owing to unsuitable premises, other articles being sold, such as paraffin." At Fulham, two men were struck off owing to "unsatisfactory condition of the milk premises, and both men had several convictions registered against them for selling adulterated milk." At Holborn, the Council discussed a case in which "milk premises, fixtures and utensils were found to be in a dirty condition." In Marylebone, 70 to 80 were struck off in the last five years, mostly owing to the sale of milk, plus paraffin, pickled herrings, sauer-kraut, open pickles, firewood, coal blocks, loose vinegar, etc." In Kensington, in 1921 and 1922, 30 retailers gave up the sale on being 77 asked to do so, or altered their premises to make them suitable; four or five were struck off. In Hammersmith, 54 retailers were removed from the Register in 1920. Until the Milk and Dairies (Amendment) Act, 1922, Sec. 2(1) came into being, Local Authorities had acted on the London County Council (General Powers) Act, 1908, Part II, Sec. 5(1), which gave power to a Sanitary Authority to remove from or refuse to enter on the Register names of dairymen, etc. The 1922 Act gives power to refuse registration and remove from the Register. With these points in mind, your Medical Officer of Health visited every one of the milk premises in the Borough with the following results:— No. on Register, 155, of whom 33 were dairymen and 122 purveyors. Purveyors 122: satisfactory 38; fair 57; unsatisfactory 27. This was a very unsatisfactory state of affairs. Many of these were small shops which in addition to selling milk, sold an array of other goods, such as coal, sticks, vinegar, clothes, sweets, paraffin oil, etc. This Council felt that this would not do, but bearing in mind that many of the retailers would be severely penalised as regards their living, the Council decided not to press for wholesale removal from the Register, but contented itself for the time being by sending the following letter to every milk trader in the Borough :— "Notice to Milksellers. "The Deptford Borough Council is gravely concerned at the unsatis"factory conditions prevailing at many premises in which milk is sold. "Milk is an article of food which is particularly liable to become the "breeding place for disease germs, and, being the staple food of young "infants, it is very essential that the strictest cleanliness should be "observed in its storage and handling. The sale on the same premises "of such articles as paraffin oil, coal, firewood, vinegar and pickles, is "particularly liable to contaminate the milk; it is also very necessary " that the premises should be free from dust and dirt of any description. "It is proposed at an early date to revise the Register of Milksellers "with a view to the removal therefrom of any person who, either by "reason of the state of his premises, the quality of the milk sold, the "methods used, or for any other reason, is deemed to be unsatisfactory. "The Council will base its action in each instance on the reports received 78 "from this department as to the conditions existing on inspection of the "shop or store in question, and also on the results of the analyses of "samples of milk taken by the Food and Drugs Inspectors. "I am directed to hand a copy of this notice to all milksellers, as it "is felt that unless considerable improvements are effected, many "persons will be struck off the Register." The Borough Council is fully alive to the fact that milk should not be regarded as a commodity which can be handled and sold like groceries, and that there is risk in allowing anyone to sell milk who does not fully understand the dangers to which contamination may lead. At the same time the Council has in view that whereas in residential towns or suburbs it is eminently desirable that milk should only be sold from premises devoted entirely to the sale of milk, cream, eggs, etc., a proper dairy centre in fact, the case in Deptford is somewhat different. Here we have quite a number of poor people who are in the habit of going to small shops where they can buy one pennyworth of salt, sugar, pepper, milk and so on. There is, in fact, a tradition, and the Council is resolved in the interests of the public health, to effect a change, but not violently. To do this in a spirit of equity the Borough has been mapped out into blocks : each will be taken in turn and groups of cases will be taken together. This work is now proceeding. There are no cowsheds in Deptford. (i) The examination of milk for tubercle bacilli devolves upon the London County Council. On enquiry it was learned that no milk destined for Deptford had been found to contain tubercle bacilli during 1925. The Council has recently resolved that a sample of the milk supplied to the Municipal Maternity Home should be tested every two months for tubercle bacilli. (ii) Licences were granted in January, 1925, to Messrs. Edwards & Sons, Ltd. (United Dairies), to sell (a) Pasteurised Milk, (b) Certified Milk, (c) Grade A (Tuberculin Tested) Milk at the following premises: 84 Endwell Road; 95 High Street; 295 New Cross Road. Licences were also granted to Messrs. R. Higgs & Sons Dairies, Ltd. (United Dairies), to sell at their premises at 389a Queens Road (a) Pasteurised Milk, (b) Grade A (Tuberculin Tested) Milk, (c) Grade A Milk, and (d) Certified Milk. 79 Messrs. Edwards & Sons, Ltd. also were licensed to sell Grade A Pasteurised Milk at the same addresses as above. The actual pasteurisation is not carried out in the Borough in the above cases. (iii) In no instance was an applicant refused a licence under (ii), nor was any licence revoked. Both at a public lecture at the Town Hall and in the Press, your Medical Officer has endeavoured to impress upon the public that they should not buy milk sold loose in cans but insist upon having their milk supplied in bottles. An attempt was made to ascertain the position in the Borough with reference to milk sold in bottles, and a few other points by means of a questionnaire which was sent out to the dairymen. The milk supply in Deptford is provided principally by a few big firms, viz.; Edwards & Sons, Ltd.; The Royal Arsenal Co-operative Society; C. Marlow & Son; Express Dairy Co.; Higgs & Sons, Ltd. The first and last of these are members of the United Dairies. Omitting these big firms (whose views are discussed below), here is a representative table which gives an idea of the progress made in the much to be desired direction of bottled milk. Address of Firm. No. ot bottles supplied Bottled on Premises Extra Charge No fancy names used Remarks. S Road 250 Yes No No Few cans H Street 60 do do do P Street 80 do do do W Street 80-90 do do do W Street 50 do do do C Street 90 do do do F Street 70-80 do do do C Road 100 do do do Few cans A Mews 125 do do do M Road 450 do do do No cans N C Road 30-40 do do do N C Road 70 do do do M Road 200 do do do Minority 'loose' milk R Grove No D Road No Serves 400 customers 80 Only two of these are so backward as not to supply bottled milk. The replies of the big firms are interesting:— 1. We sell ordinary milk in bottles at the same charge as for loose milk. Roughly, twenty per cent. of our milk is sold in bottles. A very few bottles of "nursery milk" are sold, and at present no extra charge is made for this. This nursery milk is Grade A milk, bottled at the farm. In my questionnaire the question had been asked, Do you sell any milk under the title or name of "Invalid Milk," "Nursery Milk" or any other such name; if so, what price do you charge for it? What special preparation does it undergo? What is the reason for the higher charge in such? "All our ordinary milk is cleaned, pasteurised by the 'Holding' system, and cooled." "You are of course aware that a great deal of milk is sold in bottles which have been washed in a very crude and haphazard manner. All our bottled milk is bottled at-Farm in clean, dry and sterile bottles. During the process of cleaning, bottles are subjected to a temperature of 350° F." 2. The second firm says their bottled milk is also sold at the same price as loose milk, and states that there is a demand for bottled milk in Brockley, but not down in Deptford. Twenty per cent. of their sale is in bottles. The usual straining, cooling and pasteurising are carried out. 3. As under (2), only that fifty per cent. of sales is bottled. 4. Twenty-five per cent. in bottles. "I find a steady, increasing demand for ordinary milk bottled." 5. "Milk is treated by the retarding system as advocated by the Ministry of Health, but we have no certificate so cannot use the word ' pasteurised.'" It will be seen from the above that we are moving in a more hygienic direction in respect of the public milk supply. (b) Meat. 1. With the exception of two small private slaughterhouses all meat is conveyed into the Borough. Full arrangements have been made for the inspection of meat in these two private places on dressing the meat. 81 2. The Public Health (Meat) Regulations, 1924, as regards stalls, shops, stores and vehicles, gave rise to an endless amount of work. Instructions were issued to all concerned after prolonged consideration by the Council, and at this moment it can confidently be said that not one inch of meat can be found anywhere in Deptford projecting beyond the front line of an open window. Trestles in front of shops are things of the past. Four retailers were prosecuted successfully in Court, fines and costs being made and awarded. The magistrate ruled that meat should be kept behind the window line and should be covered with gauze. He would not enforce the putting in of windows, but this point is not acute in Deptford as we had persuaded some to put in windows before going to court, and many already had windows. Comment was made in court and elsewhere as to the ambiguity of the Regulations, but your Medical Officer thinks too much has been made of this. At the commencement of the Regulations in April, 1924, a record was made with the following result: 1. Shops. (a) Butchers with windows, 51. (b) Butchers without windows, 15. (c) Bacon dealers with windows, 166. (d) Bacon dealers without windows, 2. (e) Butchers and cooked food shops 66, with windows (51 of them are butchers, as above; there are only 2 purely cooked food shops in the borough). (f) Beef and bacon shops with windows, 3. 2. Stalls. Butchers, 7. Bacon, 1. By the close of 1925 the shops without windows were:— Butchers 9. Offal 2. Bacon 2. Stalls not complying:— Butchers 1. The question now before us is as to requiring gauze to protect the meat from contamination from flies. Contamination from mud and dust is now a thing of the past locally. Meat is no longer hung out to cool or exposed for any other reason. 82 A great deal of your Medical Officer's time (and Food Inspectors) has been devoted to the Meat Regulations,so further observations will not be made here. Re Private Slaughter Houses. In 1920. In January, 1925. In December, 1925 Registered — — — Licensed 2 2 2 Total 2 2 2 (c) Other Foods. Referred to elsewhere in the Report. The condition of the bakehouses as to cleanliness was good, though some of the premises are old. The Home Secretary was asked to require the provision of towels and adequate washing arrangements. (d) No case of food poisoning occurred in 1925. (e) Food and Drugs Act. See Table for record of over six hundred samples. No prosecution was contemplated under the Public Health (Condensed Milk) Regulations, 1923, or the Public Health (Dried Milk) Regulations, 1923. A canvas of shops in the Borough as to proper labelling, etc., was made with satisfactory results. (f) Milk and Cream Regulations, 1912 and 1917. 1. Milk and cream not sold as preserved cream:— (b) No. in which pre(a) No. of samples preservative was examined for reported to be present preservative. and percentage in each sample. Milk 394 Nil Cream 7 Nil 2. Cream sold as preserved cream. (a) Instances in which samples have been submitted for analysis to ascertain if the statements on the label as to preservatives were correct. (1) Correct statements made 4 (2) Statements incorrect Nil Total 4 One applicant for registration as a milk seller was refused in 1925. The Milk and Dairies Consolidation Act, 1915, did not come into force until the 1st September, 1925, 83 Under the provisions of this Act, notices were received by the Food and Drugs Inspectors demanding that samples should be taken in course of delivery to retailers, but, actihg on instructions, the Inspectors did not find it necessary to take any such samples on delivery because the Public Analyst was able to inform them within a reasonable time that the original samples, i.e., those purchased from the retailers, were genuine. Requests received from other authorities for milk to be sampled in course of delivery, Nil. Samples taken in course of delivery at our request by other authorities, Nil. NOTE.—-During the present year, 1926, we have had two requests for such sampling to be done. We have not yet found it necessary to make requests to other authorities. TUBERCULOSIS. To the Medical Officer of Health. Sir, I have pleasure in submitting herewith the Annual Report on Tuberculosis work in the Borough. Notifications. The following Table gives a summary of the Notifications received from 4th January, 1925, to the 2nd January, 1926, and is prepared in accordance with the requirements of the Ministry of Health. 84 Table XXVI. Public Health (Tuberculosis) Regulations, 1912 and Public Health (Tuberculosis) Regulations (No. 2), 1918. Summary of Notifications for the period from 4th January, 1925 to 2nd January, 1926. Notifications on Form A. Notifications on Form B. Number of Notifications on Form C Age Periods. Total Notifications 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 LawInstitu tions. Sanatoria. Under 5 5-10 10-15 Total Primary Notifications Pulmonary— Males ... 2 3 2 7 16 21 27 21 10 2 114 152 ... ... ... ... ... 23 134 Females 1 ... 4 6 12 19 27 9 10 3 2 93 127 ... ... ... ... ... 27 79 Non-Pulmonary Males 3 17 2 8 4 1 2 1 1 ... ... 39 43 ... ... ... ... ... 6 18 Females ... 8 6 8 3 1 3 1 1 1 ... 32 35 ... ... ... ... ... 1 16 85 TUBERCULOSIS DISPENSARY. Summary of Work carried out during past 5 years. 1921 1922 1923 1924 1925 A. Examined for the first time 709 631 761 633 633 No. of these who were Contacts examined for the first time 156 231 281 193 153 No. of A who were found to be suffering from Pulmonary Tuberculosis 149 106 108 106 126 No. of A found to be suffering from NonPulmonary Tuberculosis 20 21 34 33 27 No. of A found to be not suffering from Tuberculosis 373 474 618 467 432 No. of A who were Doubtful Cases 167 30 26 41 77 Total attendances 5053 4559 5491 5537 5790 Total Systematic Examinations 1929 2301 3009 2987 3202 Home visits by T.O. 281 427 380 331 262 Home visits by Nurses 3001 3343 5079 4571 4139 Consultations at Homes of Patients with Practitioners 3 8 11 42 62 Cases put on observation 349 356 319 271 214 Cases more than two months on observation 65 24 48 69 123 Insured patients on Domiciliary Treatment 43 31 39 211 Other patients on treatment or supervision 485 573 511 707 No. of Sputum Examinations 859 780 665 709 913 86 TUBERCULOSIS. Particulars of New Cases and of Deaths during the Year 1925. Age Periods. New Cases.* Deaths. Pulmonary Non-Pulmonary Pulmonary Non-Pulmonary m f m f m f m f 0 - 1 5 1 - - 2 1 1 3 - 17 10 2 - 3 3 5 3 4 2 7 — 1 - 1 10 2 7 8 9 — 2 — 2 15 7 13 4 3 2 5 1 - 20 17 20 1 1 4 9 1 - 25 31 32 2 3 12 6 1 - 35 30 10 1 1 17 9 1 1 45 23 10 1 1 12 3 — _ 55 11 4 — 1 9 6 — 2 65 and upwards 6 3 — — 4 1 1 — Totals 133 104 41 37 62 42 10 10 *Note—Including 37 cases which came to the knowledge of the Medical Officer of Health otherwise than by notification. In 1925, 24 deaths occurred in cases of Pulmonary Tuberculosis not notified during life, as compared with 10 in 1924, 7 in 1923, 25 in 1922 and 43 in 1921. The following shows the interval between notification and death in the 104 deaths from Pulmonary Tuberculosis during 1925. Pulmonary Tuberculosis. Interval between Notification and Death in 1925. Not notified 24 Died before receipt of notification 3 Died within one week of notification 1 „ „ one week to one month 6 „ „ one month to three months 12 „ „ three months to six months 12 „ „ six months to one year 17 „ „ one to two years 11 „ „ two to three years 3 „ „ three to four years 5 „ „ four to five years 2 „ „ five to six years 3 „ „ six to seven years 2 „ „ seven to ten years 3 104 Pulmonary Tuberculosis. Interval between Notification and Death in 1925. Not notified 24 Died before receipt of notification 3 Died within one week of notification 1 „ „ one week to one month 6 „ „ one month to three months 12 „ „ three months to six months 12 „ „ six months to one year 17 „ „ one to two years 11 „ „ two to three years 3 „ „ three to four years 5 „ „ four to five years 2 „ „ five to six years 3 „ „ six to seven years 2 „ „ seven to ten years 3 104 87 Cases notified after the death of the patient are not now regarded as notified cases. Frequent reminders have been sent to the doctors attending these un-notified and late notified cases calling their attention to their duty to notify all cases of Tuberculosis which they attend. The notifications of non-Pulmonary Tuberculosis were as follows:— Glands 37 Wrist 1 Peritoneum 3 Meninges 5 Spine 3 Fingers 2 Hip 9 Hand 3 Abdomen 1 Lupus 3 Abscess of Chest 1 Knee 3 Total 71 Analysis of Notifications and Deaths According to Wards. Year 1925. Wards e. N. N.W. S. s.e. s:w. Whole Borough Estimated Population 21,965 24,658 24,805 13,453 13,465 17,534 115,900 Persons per acre, Census 1921 131 83 69 45 75 57 72 Cases of Pulmonary Tuberculosis notified 47 33 50 12 28 37 207 Cases of Non-Pulmonary Tuberculosis Notified 30 7 12 7 6 9 71 Total Cases Notified 77 40 62 19 34 46 278 Rate per 1,000 population 3•5 1•6 2•5 1•4 2•5 2•6 2•4 Deaths from Pulmonary Tuberculosis 32 24 13 5 19 11 104 Deaths from NonPulmonary Tuberculosis 7 4 3 1 1 4 20 Total Deaths 39 28 16 6 20 15 124 Death rate per 1,000 population 1•8 1•1 0•6 0•4 1•5 0•9 1v1 88 Notifications and Deaths for the 5 Years 1921-1925. Notifications— 1921 1922 1923 1924 1925 Pulmonary Tuberculosis 225 208 242 244 207 Rate per 1000 2•0 1•8 2•1 2•1 1•8 Non-Pulmonary Tuberculosis 66 75 94 78 71 Rate per 1000 0•6 0•7 0•8 0•7 0•6 Deaths— Pulmonary Tuberculosis 121 133 95 104 104 Rate per 1000 1•1 1•2 0•8 0•9 0•9 N on-Pulmonary Tuberculosis 31 31 17 23 20 Rate per 1000 0•3 0•3 •1 0•2 0•2 In comparing the number of notifications during the 5 years 1921 to 1925, it is seen that there was a definite increase in the years 1923 and 1924. This is probably due to a more complete compliance with the Regulations following the issue of the Ministry of Health's Circular to all practitioners drawing attention to the statutory duty of a medical man to notify a case within 48 hours of his first becoming aware of the existence of the disease. In 1924 the number of cases dying unnotified or before receipt of notification was 13. In 1925, the figure was 27. Though these quantities are rather small to draw any definite deductions yet taken with the fact that the number of deaths is the same as for 1924, they may indicate that the drop in notifications for 1925 is due to relaxation again in respect of notifying. There has been a considerable decrease in deaths from Pulmonary Tuberculosis since 1921. The slight increase in Deaths from Pulmonary Tuberculosis in the years 1922, 1924 and 1925, over the total for 1923, agrees with the increase in the figures for the whole country and is ascribed to so much unemployment causing lack of sufficient nourishment and to overcrowding owing to insufficient housing accommodation. No definite cause of the reduction in 1923 is evident. 89 Compared with 1921 and 1922 there is a definite fall in the deaths from Non-Pulmonary Tuberculosis. This is general to the whole country and is ascribed to 1. Increased facilities for the institutional treatment of such cases; 2. The efforts to lessen the danger from living tubercle bacilli in milk; and 3. The removal of advanced cases of Pulmonary Tuberculosis from the homes. As regards the latter point there is still occasional difficulty in dealing with these cases. The County Council are sometimes unable to provide treatment. A large number of patients refuse to go to the Poor Law Hospitals. Even when sent to County Council Hospitals, advanced cases, seeing other patients around them die, get depressed and return home. This is the case even when the Institution is not solely used for advanced or dying cases, but takes also chronic cases capable of improvement or observation cases, for the chronic cases also get depressed by deaths and dislike staying. Revision of Notification Register. During the year 76 cases of Pulmonary and 16 cases of NonPulmonary Tuberculosis were removed from the Register of Notifications either as cases in which the diagnosis was not confirmed or cases which were considered "cured" and not needing further supervision or as having died or left the district. With the addition of transfers from other areas and new notifications the Register stands at the end of 1925 as follows:— MALES FEMALES Total Under 15 Over 15 Under 15 Over 15 Pulmonary Tuberculosis 4 16 111 390 112 1029 Non-Pulmonary Tuberculosis 46 151 62 170 429 Totals 462 262 452 282 1458 Disinfection was carried out in 311 rooms, and articles of bedding, clothing, &c., were removed for sterilization. Institutional Treatment. 217 cases were recommended to the London County Council for Institutional Treatment. For 7 the Council was unable to provide accommodation, and in the case of 9 the accommodation offered was refused. 90 In several cases Institutional Treatment other than in the hospital was provided by the Guardians. Dental Treatment was given to 46 patients. It is hoped in the coming year, if the proposed expenditure is approved by the Ministry of Health, to supply to or assist to get dentures a limited number of patients who would be unable otherwise to obtain them. Of the 633 new cases who attended the Clinic during the year, 227 were sent by local practitioners, 18 were referred by hospitals, 24 were referred by school medical officers, 183 attended on their own initiative and 160 on the advice of the P.H. staff. Four were transfers, 8 seen in Greenwich and Deptford Hospital and 7 sent by the Ministry of Pensions. 79 deaths occurred during 1925 among Dispensary cases. The period which elapsed between first attendance and death varied between one month in one case and 11 years in another. 21 cases attended for the first time within 3 months of death. 11 do. do. do. 6 do. 12 do. do. do. 12 do. 35 do. do. do. 24 do. 91 Table XXVII. Metropolitan Borough of Deptford. Returns of work carried with the Tuberculosis Dispensary for the year 1925. Number of Under observation at the Dispensary on Jan. 1st pending diagnosis. Examined for the first time during the year. Total. 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 Tuberculosis. Pulmonary. Non-Pulmonary. (a) All persons (including "Contacts") Adults M 11 190 201 72 2 97 12 18 F 8 185 193 46 5 117 10 15 Children under 15 M 4 151 155 3 13 123 8 8 F 6 107 113 5 7 95 2 4 Total .. 29 633 662 126 27 432 32 45 (b) "Contacts" included in (a) Adults M 1 37 38 2 — 32 1 3 F 5 36 41 6 — 33 1 1 Children under 15 M 1 51 52 — 3 47 1 1 F 1 29 30 2 — 27 1 — (c) Insured persons ineluded in (a) M 8 155 163 57 2 77 11 16 F 4 61 65 22 3 28 4 8 1 Number of patients under treatment or supervision (excluding persons under observation or domiciliary treatment) on the 31st December 707 2 Total number of ances of patients at the} Insured 2248 Dispensary during the year } Uninsured 3542 3 Number of persons placed under vation at the Dispensary during the year for the purpose of diagnosis 214 4 Number of cases in which the period of observation at the Dispensary exceeded two months 123 5 Number of insured patients under domiciliary treatment on Dec. 31st 211 6 Number of reports received trom surance Practitioners in respect of insured patients under domiciliary treatment during the year 13 7 Number of parsons referred to ated hospital for consultation — 8 Number of consultations with medical practition-} Insured 18 ers at the homes of patients }Uninsured 49 9 Number of other visits paid by Tuberculosis Officer to the homes of patients 262 10 Number of visits paid by Nurses or Health Visitors to the homes of patients for dispensary purposes 4139 11 Number of specimens of sputum amined in connection with the work of the Dispensary 913 92 It will be seen that in the last three years the number of persons, excluding contacts, examined for the first time is from 440—480, but that the number of contacts examined at the Dispensary has fallen off. This would appear to be due to the fact that the attendance of school children was not urged as it was known they would be examined at school under the arrangements now existing. Instructions have now been given to the Tuberculosis Health Visitors that they are to endeavour to persuade all contacts to come to the Dispensary for examination. If school age contacts do not attend within two weeks, a second visit is to be made to urge attendance. Two weeks later reports are sent to the School Medical Officer stating the results in cases examined at Dispensary and informing him of those who had not attended for examination. The total attendances and number of systematic examinations shew a progressive increase. Cases on observation for more than two months.—Of these a large number are cases who ceased to attend before diagnosed or who attended irregularly so that a satisfactory diagnosis could not be arrived at in two months from date of first attendance. The figures for patients on Domiciliary Treatment and for others on Treatment or Supervision shew as much increased. This is explained by the fact that an attempt was made at the end of 1925 to arrive at as exact figures as possible in view of new returns required by the Ministry of Health for the future. Many cases not previously numbered as under supervision, owing to non-attendance for a long time, are now included under this heading as they were not examined and definitely discharged as not needing further supervision. Similarly a number of cases are now included as on Domiciliary Treatment though they may not have been recently seen and considered still in need of Domiciliary Treatment. In some of these cases the doctors have said they have not seen the patients for a long time. An endeavour is being made to secure the re-attendance of these patients for proper classification and get the figures as accurate as possible. As regards Home Visits by the Tuberculosis Officer and the Dispensary Nurses the figures vary considerably, due largely to changes in staff. A change of Tuberculosis Officer took place in 1922 and in 1925. Till 1921 there was only one Nurse employed at the Dispensary. Visits to notified cases were done chiefly by the general Health Visitors, 93 the nurse visited as required for Dispensary purposes and took clinics. In 1921 an additional nurse was appointed part time. Next year the appointment was made a whole time one. The nurse appointed became ill in the following year and later resigned. Another nurse was appointed, but remained for only a short time so that a fresh appointment had to be made early in 1925. Changes in a satisfactory staff carry many disadvantages. New Visitors lack the accumulated knowledge of old patients and their circumstances and require time to get acquainted with patients and conditions in their districts. Changes in Tuberculosis Officer bring the same disadvantages, and in addition there is a loss in continuity of Clinical experience and knowledge of individual cases over a period of years. It is of much interest and instruction to see cases again after a lapse of 4 or 5 years, and learn how some have done unexpectedly well, and some unexpectedly badly, and more particularly to see how those cases of doubtful disease, especially in children have turned out. Experience gained in this way by prolonged knowledge of cases is of very great value to the Tuberculosis Officer and his patients and is lost when changes are frequent. The number of Sputum examinations is now larger than ever. Owing to the increase in co-operation with General Practitioners and School Medical Officers, Hospitals and local bodies, (such as the Guardians, Red Cross Society, Invalid Children's Aid Association, Charity Organisation Society), in addition to reports to the Ministry of Health and London County Council, there has been a great increase in the volume of clerical work in keeping registers, sending reports, copying, filing, compiling statistics, etc. This work is now carried out largely by Miss Greig who has also to do dispensing for the Tuberculosis Dispensary, and orders and allocates drugs, etc., for the Infant Welfare Centres. She also prepares Sputum tests, not only of dispensary patients, but also of specimens, sent by doctors, of persons residing in the Borough, even though they may not be dispensary patients. Much purely clerical work is also done by the Tuberculosis Officer, the Nurses, and the Secretary of the Care Committee. As an example of the amount of Clerical work involved, possibly in a single case—An ex-service man may present himself for examination with a card from his own doctor asking for an opinion. A report on the condition is made to the doctor, and if the case is one requiring 94 observation, a further report is necessary when a definite opinion is arrived at. If a diagnosis of active tuberculosis requiring say, Sanatorium treatment is arrived at, a detailed report with recommendation is sent to the London County Council. The patient is referred to the Secretary of the Care Committee who may have to refer him to the Red Cross Society, the Guardians, the Charity Organisation Society or other body for assistance for himself or family during his period of incapacity for work, or the L.C.C. may have to be approached on the question of boarding out of children, etc. Details of the case have to be entered in the Dispensary register, giving diagnosis and classification and an entry made in a diary as to date when next attendance is due. A separate card index for classifaction is now kept, and cases are to be reclassified at the end of each year. If the patient is insured, entry is made on a further card index register for patients put on Domicilary Treatment, and this has to be kept up-to-date re reports received or. required from the local doctor. If reports are not received, a form with patient's name, etc., has to be sent to the doctor when due. The Ministry of Pensions may require a detailed report on the condition of the patient, and later on if he is granted a pension and is on treatment, quarterly reports are required as long as he is as a matter of treatment considered unfit for work. If the patient is sent to a Sanatorium a full report is sent to his doctor on discharge when he goes on Domiciliary Treatment. Subsequently short reports are required yearly by the L.C.C. on the patient's condition. In addition to the above the case has to be notified to the Medical Officer of Health, and a register of Notified Cases kept and classified according to whether the disease is Pulmonary or Non-Pulmonary, and the age and sex of the patients. In this register are entered all particulars about the patient and his home conditions with notes re admission and discharges from Institutions, subsequent home visits, etc. It must be kept up to date and a quarterly return made of new additions and removals. If the case is notified by a Practitioner, he is sent a communication re examination of contacts, and, where necessary, another as to whether or not he desires the case to be seen by the Tuberculosis Officer. All this requires much copying, filing, noting and letter writing. At present several people must use the filing arrangements; one person should be responsible for a file. The present system allows of the shifting of responsibility for errors or papers missing. 95 A competent shorthand typist, to deal with correspondence and assist generally, is needed for the proper carrying out of the work, and to give others more time for their own particular sphere. Re Tuberculosis Care Work. Up to 1922 the work of Secretary of the Tuberculosis Care Committee was carried out by a voluntary Secretary, Mrs. Monk, (now the Chairman of the Care Committee), who was deeply interested, and laid such an excellent foundation. The work grew to such an extent and required so much visiting of homes and correspondence, that in 1922, a whole-time paid secretary was appointed and carried out the duties till, owing to ill-health, she resigned in 1924, and the present secretary, Miss Lewellin was appointed. Miss Lewellin has had extensive experience of this kind of work, as previous to her appointment she had been in charge of the Widows and Orphans Section of the Ministry of Pensions in this area. A report on the work for the year is appended. Note on Co-operation with Practitioners. When a Notification of Tuberculosis is received, the doctor is written to re examination of contacts. Unless he replies that he proposes to examine these himself, the Tuberculosis Visitor, on calling at the home, urges the attendance of the contacts at Dispensary For examination. If it is not clear from her enquiries that the doctor wishes the case to be seen by the Tuberculosis Officer he is sent a communication asking him if he wishes to consult with the Tuberculosis Officer as to the form of treatment suitable, or wishes the case to be seen by the Tuberculosis Officer at Dispensary or at patient's home if too ill to attend. In the case of Insured persons 3 forms exist for use by the Panel Doctor. 1. "G.P. 35" when the doctor refers a case to the Tuberculosis Officer as a suspected case for opinion. The use of this form is not obligatory, and it is seldom used though it would be very helpful. 2. "G.P. 17" for use when a case is first diagnosed as suffering from Tuberculosis and is referred to the Tuberculosis Officer. This form also is seldom used. 96 3. "G.P. 36" which is the form for use when the practitioner is sending a quarterly report on a case on domiciliary treatment. In December, 1923, the Ministry of Health issued a Memorandum re Co-operation between the Tuberculosis Officer and Insurance Practitioners giving 6 model forms for use by the Tuberculosis Officer. With slight modification these cards are now in use. The number has been reduced to 4 by combining certain items of four cards on two, and the original forms were altered to allow of the insertion of a diagram shewing chest signs. One card is used in reply to a doctor who sends a case for opinion and informs him if the case is considered tubercular or not, or whether a period of observation is necessary to decide, and gives proposals for treatment if considered tubercular. A second card is used with regard to condition, with proposals in the case of a person who has been under observation or supervision. A third card is used to give report and recommendation about a patient who has just returned from a period of Institutional Treatment. When a patient is recommended from Dispensary for Domiciliary Treatment, the doctor is asked to send a report in 3 months time. As there is difficulty in many cases in getting these reports, patients placed on Domiciliary Treatment are, as a rule, asked to attend quarterly at the Dispensary. The fourth card is used to acknowledge receipt of a report from the doctor on G.P. 36, stating that his recommendations have been noted and recommendation made for the future. In June 1923, the Ministry of Health issued a circular on the subject of co-operation between the Boards of Guardians and the Local Authorities' Tuberculosis Officers re Poor Law Cases of Tuberculosis. As a result of this it was arranged in the Borough that the Tuberculosis Officer should visit weekly at the Greenwich and Deptford Hospital to see all Deptford patients who were in the hospital for Tuberculosis. There are advantages in this inasmuch as some cases are seen earlier by the Tuberculosis Officer than they otherwise would be, and dispensary cases who go there for treatment can be observed as regards their progress. 97 As regards the arrangements for co-operation with the Unemployment Exchange and King's Roll Committee, very little satisfaction has resulted as regards obtaining work for tuberculous adults considered fit to take up some occupation, nor could it be expected that there would be satisfactory results in the present state of wide-spread unemploy- ment among the general population. Co-operation with the School Medical Officer. When a notification of Tuberculosis is received the Visitor, as explained previously, on calling at the home, urges, unless the patient's doctor has expressed a wish to examine the contacts himself, that all the contacts should attend at Dispensary for examination. In the case of school child contacts the results are sent to the School Medical Officer in the case of children examined at Dispensary and he is informed of contacts who have not attended. These children are then examined periodically at school. Informxtion is also sent where available as to whether Tubercle germs have been found in the sputum of the notified person, if a Pulmonary case, as of course contacts of such cases require more careful and prolonged watching. In the case of these or any other children who present suspicious symptoms the School Medical Officer refers them to the Tuberculosis Officer for opinion. Similarly any school children seen at Dispensary requiring treatment for minor defects such as carious teeth, tonsils, adenoids, etc., are recommended for treatment at the school clinic. Suitable cases either of definite Tuberculosis or of delicate children not definitely tuberculous are recommended for Open Air School. Children such as those last mentioned are also recommended in many instances to the Invalid Children's Aid Association for Convalescent Treatment. In 1922 the County Council issued a circular on the subject of boarding out of children from homes, where a case of Pulmonary Tuberculosis was in the terminal stages and under conditions likely to cause infection. This scheme was extended somewhat later in a further circular. This is an excellent work, and a number of children have been removed from massive infection and had their resistance to Tuberculosis and other disease raised by residence in improved surroundings. Considering the views of infection now widely held it would seem that extension of work in this direction, and more particulary work on 98 the lines of the Grancher system in Paris—the removal at birth of children from homes with cases of tuberculosis—offers the best means of prevention. It has been shewn that during the first year of life if infection occurs, it is likely to result in acute or sub-acute disease proving fatal in nearly all cases. The danger is, of course, particularly great where the mother is suffering from Pulmonary Tuberculosis, and some statistics have shewn that three quarters of the children born during the last year of life of tuberculous mothers die. In a series of 787 children born or living in 175 families, one or more of whom were tuberculosis 323 were placed in the country and did well, 396 were not removed, and of them 328 developed tuberculosis. These and similar figures published recently giving further results of this system in Paris shew the immense importance of removing children at once from Tuberculous parents. The removal should be for the first two years of life, as by this time the child will probably through unavoidable but small doses of infection have acquired a considerable resistance to further infection and disease. Yours faithfully, N. M. Donnelly, Tuberculosis Officer. Public Health (Prevention of Tuberculosis) Regulations, 1925. These Regulations came into operation on the 31st July, 1925, with the object of preventing anyone suffering from tuberculosis of the respiratory tract in an infectious state, from handling milk. Until the passing of these Regulations no steps could be taken against anyone so employed. Section 3.—Calls upon the local authority to enforce the Regulations and to that end to make enquiries and take such steps as may be deemed necessary for securing their due observance in the district. Section 4.—Forbids anyone who is aware that he is suffering from tuberculosis of the respiratory tract from entering upon any employment or occupation in connection with a dairy which would involve the milking of cows, the treatment of milk, or the handling of vessels used for containing milk. Section 5.—Enables the local authority to forbid anyone so affected (Pulmonary tuberculosis with a positive sputum) from continuing the occupation. 99 . Section 6.—Allows the person aggrieved to appeal within 14 days to a Court of Summary Jurisdiction. Section 7.—Relates to compensation for damages sustained by reason of the exercise of the powers of the Act. During 1925 a copy of the Regulations was sent to all employees engaged locally in the milk trade. Watch was kept over the employment of all persons notified for tuberculosis of the respiratory tract and the tuberculosis officer paid attention to the occupation of all persons visiting the Dispensary. In no case was any action found necessary. It is desirable that all who are engaged in the trade should be examined by the Tuberculosis Officer, and that no one should be allowed to commence such work without such examination. General Observations. Arrangements for following up patients in cases in which the diagnosis is doubtful:— In doubtful cases every effort is made to diagnose the case at the latest, before the expiration of two months. A difficulty in a number of such is that their attendance at the Tuberculosis Clinic is unsatisfactory and irregular. The Tuberculosis Health Visitor calls at the home in all these cases to point out the importance of regular attendance. Special methods of diagnosis and treatment and the value of such treatment :— Forty-eight diagrams were made at the Miller Hospital. Two cases received Finsen Light treatment at the London Hospital. One patient received Artificial Pneumo-thorax refills at the Brompton Hospital, paid for by the Council, while two others had this treatment at Guy's Hospital, but not under the Council's arrangements. One case receiving A.P. refills is progressing satisfactory. Arrangements for the provision of nursing or of extra nourishment for patients living at home :— The Council does not supply home nurses directly for home nursing. Fifty cases received a grant for extra nourishment, the total cost amounting to £146 6s. 4d. A large proportion of necessitous cases are being maintained by the Guardians. The nature and extent of any dental treatment provided by the Council for tuberculous patients :— As £70 was the amount allowed for the year, only 46 were treated. Extractions and fillings were carried out, no dentures being supplied. 100 Four hundred and forty-nine visits were made by the 46 patients. Extractions numbered 224 ; Fillings 24, the balance being made up with Scalings, Gum Treatment, Dressings, etc. The arrangements for treating non-pulmonary tuberculosis, especially tuberculosis of bones and joints in adults and in children, and for the provision of surgical apparatus :— Through the County Council cases of surgical tuberculosis are removed chiefly to Carshalton, one of the Metropolitan Asylum's Board Institutions. The Invalid Children's Aid Association play their role. Finding Employment for Patients :— The Care Committee and the Labour Exchange co-operate, but in this, as in private efforts, the results are disappointing. Provision of Shelters :— Four are provided and are kept in constant use throughout the year. Special methods proposed for the prevention of T.B.:— The answer to this question is that as we pull down slums, particularly in the East End, and provide accommodation for the many who are overcrowded, so may we hope to reduce the incidence of Tuberculosis. Report of Miss Lewellin, Secretary of the Tuberculosis Care Committee. The Tuberculosis Care Committee, as is probably known, consists of representatives of public and social agencies in the borough. The very fact that such a Committee exists is valuable from more than one point of view. For one thing it means that a body of experienced men and women are in a position to know and talk with authority about the effects of tuberculosis on the lives and in the homes of those suffering from this disease. This is a different and more human knowledge than can be obtained from mere statistics, it brings a realization of the unhappiness and misery caused, implants a sense of responsibility and an earnest desire to think of ways and means to at least alleviate the sufferings of those already striken, and to prevent the spread of the disease. The work of the Committee, lying chiefly in the home, makes obvious the fact that to an extent social and economic causes are responsible for much of the trouble—armed with this knowledge an active Care Committee can do much to assist the great work of 101 dealing with this scourge. Conferences held periodically provide an opportunity for suggestions, and persistent and urgent recommendations of Care Committees receive the consideration of Public bodies, with whom lies the responsibility of dealing with and treating tuberculosis. To new readers may I point out that the report submitted in 1924 outlines in detail the work of the Care Committee, and can be referred to. It would be wearisome for those who have read it to repeat this. The work varies little in character from year to year : the main idea being to help patients in any and every way possible. This year as will be noticed by the Dispensary returns 217 cases have been recommended for treatment: each case has been visited by the Care Committee representative. Intimacy has been established, and tactful enquiries made to ascertain if assistance was necessary. In a large number of cases clothing has been obtained, and other forms of help, if required, thus enabling patients to go away with an easy mind, and the feeling that those left behind can, in trouble or difficulty, apply to the Care Committee for advice. The larger proportion of these cases are new ones, the patient going away for the first time, this means that our circle has become enlarged. New features of the work arise and more become possible as time goes on. This past year for instance a scheme for boarding-out children living in infected homes under bad conditions was brought forward by the London County Council, the scheme to be on trial for one year from March, 1925. Cases were at first limited to homes where a member of the family was in an advanced and infectious state. The number put forward for consideration was 26, which were accepted by the County Council. In three cases parents withdrew their consent after acceptance. In two cases children were found unsuitable for placing, leaving 21 actually placed. Of the 21, nine were boarded out to enable the mother to leave home to undergo residential treatment. Two were boarded out after treatment under the London County Council, in view of home conditions. Ten were boarded out as contacts of tubercular patients living at home. Deptford has taken full advantage of this scheme—which has been found particularly useful in cases where the Mother has been ordered Sanatorium treatment, and would have been unable to accept if provision could not have been made for the children during her absence. The homes for the children are provided by the I.C.A.A. working in cooperation with the Borough Council and London County Council. 102 It has now been decided to continue the scheme for a further experimental period of 12 months. As a smaller amount of money is available the London County Council state that the number of children sent away must be reduced. We must be grateful that such a helpful scheme continues—even in an abridged form. Also during the past year the Care Committee have been asked to obtain grants for dentures for patients who have had teeth extracted free of cost at the dental clinic established at the dispensary. Both the features are new developments and from their nature tend to show that further schemes for the welfare of tubercular patients and their families can be looked for. The societies on which we rely for help have been generous as ever and grants have been substantial and numerous. We go on asking and invariably meet with response, sometimes, perhaps, because of our importunity. It was pointed out last year that the after-care work of the committee, which is considered so important, was exceedingly. difficult, owing to existing conditions as regards unemployment, housing, etc. No improvement in the situation can be said to have taken place. Patients still have to return from sanatorium to crowded, uncomfortable home conditions. Suitable work in cases where patients are unable to return to former employment is practically impossible to find. This situation, apart from the economic side, tends to depress a patient, and goes a long way to undo the good gained by treatment. Of course the difficulty as regards work is increased by the fact that so often a patient is only fit for light employment, and with more than enough healthy persons seeking work one can hardly expect an employer to take the risk of employing some who may have to give up as soon as he becomes useful. We must not, however, regard the position as hopeless, although at present it seems so. The Care Committee and public bodies dealing with tuberculosis are always trying to solve the problem. Suggestions have been brought forward from time to time—for instance, the question of special workshops has been under discussion. There are, however, many difficulties in connection with any solutions, financial or otherwise; we can only hope that it will be solved in time, and that the urgent need will ultimately bring fulfilment. At present all that can be done is to ascertain if help is required in any form, if so, to refer the case to an appropriate society or body, suggest any little alteration 103 in the home that may be beneficial, and keep the case under observation. Every case is visited on discharge from sanatorium by the Secretary, and a report on the home conditions and circumstances is submitted to the Care Committee. It may be interesting to readers to cite a few instances in which the Care Committee has been able to help :— 1. We will take the case of a patient recommended for residential treatment. The home was visited by the representative of the Care Committee, who found that the patient was an ex-service man. In course of conversation it became apparent that the man had a reasonable chance of proving his disease to be due to army service; he actually had to be pressed to make an application for pension, and finally did so. He was also found to be exceedingly worried as to how his wife would manage if he went away, doubly so because the shock of his illness and worry over the future was affecting her health. This difficulty was overcome by putting the patient in touch with the Red Cross Committee, who agreed to allow the wife sufficient to maintain herself and the home pending decision as to his claim for pension—the man was also supplied with clothing and was able to go away with an easy mind. In due course the Ministry of Pensions found that he was suffering from tuberculosis in consequence of war service and awarded pension. When this patient returned home—greatly improved in health—it was suggested that, now he was in an independent position, he should try and live away from London. The idea appealed to the husband and wife, and it was not very long before information was received that they had found rooms at the seaside and were removing. The patient called at the dispensary before leaving to say that he felt that he must express his gratitude to the Care Committee for their help and advice, without which he would never have thought of claiming pension or removing from what he now knew were unsuitable surroundings, and that he felt his whole life had been altered for him. 2. Another patient recommended for sanatorium treatment was paid the usual visit. He and his wife were a comparatively young couple with no children. The little home was beautifully kept and comfortable. As, however, the patient had been very ill, he had been obliged to give up his work some time ago, and had been forced to use his small savings to supplement National Health Insurance benefit, which constituted his sole income. The savings were now coming to an end, and the patient did not feel that he could go away and leave 104 his wife alone with insufficient means to maintain the home. This patient was also an ex-service man, but had no grounds for claiming pension. Application was made to the United Services Fund who granted an allowance to the wife, which together with sick benefit, enabled her to manage during her husband's absence. In about a couple of months the London County Council was notified by the Medical Superintendent of the sanatorium that this patient was worried over home affairs and contemplated discharging himself. The Care Committee was asked to do anything possible to prevent this. A visit was paid to the home and it was found that insurance benefit had been reduced and that the wife was in difficulties, also that she was lonely and unhappy, and was needing a reason to urge her husband to come home. A successful effort to improve the situation was made. The United Services Fund increased their allowance, frequent visits were made to the wife who was persuaded that it was in her husband's interest that he should complete his treatment; he himself was written to and assured that there was no need now for him to worry and the man settled down again content. His letters of thanks made pleasant reading. In due course he returned home having done exceptionally well. His former employer found suitable work for him, and at present he is still working and keeping well. 3. The patient, in this case a boy of 17, returned from a course of treatment for T.B. kneejoint. Treatment was completed and disease quiescent, but it was necessary for the boy to wear irons and splint for a time He was consequently unfitted for employment at the moment, and it was felt by the Care Committee that some effort must be made to fill up his time usefully. In discussion with the boy and his parents it became evident that the patient was interested in clerical work and figures, and a commercial course at an L.C.C. centre was suggested. The boy was full of enthusiasm and the matter was arranged. The case was carefully watched, and the result as far as the boy was concerned exceeded expectations. It was evident, however, that the parents were feeling the strain of keeping a lad of this age ; clothing also was difficult, as the boy felt it if he went to school in a noticeably shabby state. It became evident that if the experiment was to be a success help must be sought. A report was first obtained from the school, to justify any request. This report, both as to progress and conduct, was excellent. Help has been now obtained, and it is hoped that within a reasonably short period the boy will be fit to undertake 105 employment as a junior clerk, preferably locally. He has now left off his irons and only limps slightly, and, it is understood, can even take part in school games. Space will not permit further instances, but perhaps these few cases mentioned will serve to show the opportunities that a Care Committee has—and how it uses them. The work is absorbing, and cannot help but enlist the sympathy and devotion of those engaged upon it. 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 2080 9181 11261 Still Births 51 — 51 Infant Deaths 149 — 149 Expectant Mothers 413 225 638 Ophthalmia Neonatorum 19 30 49 Measles 568 252 820 Infantile Diarrhœa 48 42 90 Scabies in children 1 3 4 Verminous Children 14 3 7 Puerperal Fever 15 14 29 Pneumonia 58 139 197 Miscellaneous 627 66 693 Unsuccessful visits 499 569 1068 Scarlet Fever recoveries 214 111 325 Encephalitis lethargica 1 6 7 Poliomyelitis 3 4 7 Totals 4,750 10,645 15,395 In addition to the above visits, the Health Visitors spent in all 540 afternoons at sessions of the Infant Welfare Centres and 150 mornings at sessions of the Ante-Natal or Special Clinic ; 6 attendances were also made at Dental Clinics. Feeding.—In the 2,080 births visited it was found that 1,934 infants were being breast fed and 78 partly breast fed. Only 68 were entirely hand fed. Births Notified, Year 1925. Ward. Births Notified. Alive. Dead. By whom Notified. Total. Male Female. Parent. Doctor. Midwife Other Person. East 501 248 253 492 9 31 99 366 5 North 408 223 185 399 9 34 148 223 3 North-west 326 165 161 322 4 49 103 171 3 South 445 240 205 436 9 57 38 346 4 South-east 198 102 96 191 7 41 60 92 5 South-west 169 85 84 167 2 29 52 86 2 2047 1063 984 2007 40 241 500 1284 22 106 Milk supplied to Necessitous Mothers and Children. During the year 7,381 applications were received and were dealt with as follows:— Granted free 5595 „ at half-price 1759 Refused (over scale) 27 7,381 Dried Milk, Virol, &c. The following amounts of dried milk, &c., were distributed to the mothers attending the Infant Welfare Centres, during the year 1925 and previous years. 1925 1924 1923 1922 Ambrosia 3,195 11b. packets 2,656 1,697 822 Cow and Gate 1,903 „ 1,897 2,104 152 Glaxo 1,356 „ 2,819 3,172 3,891 Lactogal 69 tins 68 84 292 Lacta — 29 1,736 319 Trufood 191 1 lb. tins 188 39 — Recolac 36 „ 9 — — Virol 28 28 lb. tins 36 42 56 "Winsome" — — 48 — Maternity Home. Particulars of cases admitted during the year 1925 :— Cases admitted, 254. Average stay, Two weeks. Cases delivered by midwives, 243. „ „ „ doctors, 11. Cases in which medical advice sought, 25. (a) Ante-natal, Nil. (b) During labour, 15 (Prolonged labour, post partum, haemorrhage and adherent placenta). (c) After labour, 2 (pneumonia). (d) For infant, 8 (Convulsions and dangerous feebleness). Cases notified as puerperal sepsis, Nil. Temperature rose above 100.4 for 24 hours with rise in pulse, 3. Cases of Pemphigus Neonatorum, Nil. Notified as Ophthalmia Neonatorum, 1 (transferred to M.A.B. Hospital). Inflammation (eyes), Nil. Infants not entirely breast fed, Nil. Maternal deaths, Nil. Foetal deaths, Stillborn, 4. Foetal death, 1. 107 Table XXVIII. clinics and treatment centres. Maternity & Child Welfare. •Venereal Diseases. (l) Infant Consultations. Daily from 2 p.m. Miller Hospital, Greenwich, S.E. 10. 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 Thursday, Goldsmiths' College Male and Female, Daily, 9 a.m. to 10 p.m. Do. Princess Louise Institute, Hales Street Guy's Hospital, St. Thomas Street, S.E. 1. Friday, Besson Street (2) Ante Natal Clinic. Various hours, daily, except Saturday. From 9 a.m. to 1 p.m. King's College Hospital, Denmark Hill, S.E. 5. Various hours, daily, except Saturday. Tuesday, Napier Street Wednesday do. Thursday do. special infant consultations. Wednesday, Napier Street. 10 a.m. School Clinics. Dental Inspection. Deptford School Treatment Centre Deptford Green Eye and Minor Ailments (Eye) Tuesday and Thursday 2 p.m. Alternate months at Tuberculosis Centre. Dental Treatment. Do. Ear. Minor Ailments Friday. 2 p.m. Operations Monday. 2 p.m., at Cyril Henry Centre. Woolwich Alternate months, Albury Street Clinic (Rachael McMillan). 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 Hilary House, 78 Amersham Vale. Monday, 9.30 a.m. to 1 p.m. Men Tuesday, do. Women (Thursday, 2 p.m. to 3 p.m., Children not at School) Day Nursery. Tuesday, 6.30 p.m.-7.30 p.m., Men and Women at work. Albury Street (closed at present) Wednesday, 9.30 a.m. onwards, Secretary's Consultations. Day Nursery School. Thursday, 9.30 a.m.-l p.m., Men (Open Air) Friday, 9.30 a.m.-l p.m., Women. The " Rachael McMillan " Memorial School. 108 Clinics and Treatment Centres. napier street clinic. 1925. 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 14 .. 2 3 19 233 252 125 February 4 12 .. 1 5 18 201 219 108 March 5 16 4 5 4 29 299 328 180 April 3 22 1 4 2 29 172 201 84 May 4 13 1 3 1 18 255 273 121 June 4 10 4 2 1 17 242 259 83 July 4 10 1 2 3 16 209 225 93 August 3 16 2 2 1 21 165 186 108 September 5 17 •• .. 2 19 236 255 127 October 4 10 1 .. 2 13 237 250 129 November 4 9 4 1 3 17 194 211 120 December 4 6 .. .. 3 9 160 169 92 Total 48 155 18 22 30 225 2603 2828 1370 ERLAM ROAD CLINIC. 1925. 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 2 .. 2 17 237 254 117 February 4 6 .. .. 5 11 208 219 92 March 4 11 .. •• 1 12 246 258 107 April 4 6 .. 1 3 10 260 270 98 May 4 5 .. 1 3 9 207 216 84 June 4 4 .. .. 1 5 197 202 65 July 5 12 2 1 • • 15 270 294 123 August 4 7 .. 1 2 10 208 218 90 September 4 4 .. .. .. 4 166 170 77 October 4 9 1 .. 3 13 209 222 96 November 4 2 .. .. .. 2 154 156 79 December 5 3 •• .. •• 3 137 140 79 Total 50 82 5 4 20 111 2508 2619 1107 109 GOLDSMITHS' COLLEGE CLINIC. 1925. 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 27 1 4 1 33 345 378 179 February 4 16 .. 1 4 21 344 365 164 March 4 16 2 2 .. 20 348 368 166 April 4 15 .. 4 4 23 323 346 127 May 4 12 .. 5 4 21 321 342 144 June 4 15 2 1 4 22 263 285 92 July 5 18 2 3 4 27 386 413 168 August 4 19 .. 2 2 23 318 341 150 September 4 16 .. 6 6 28 359 387 163 October 4 19 3 2 3 27 373 400 162 November 4 14 1 3 2 20 324 344 132 December 4 19 1 1 3 24 244 268 141 Total 50 206 12 34 37 289 3948 4237 1788 BESSON STREET CLINIC. 1925. 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 14 1 6 3 24 280 304 148 February 4 10 1 3 4 18 270 288 126 March 4 9 .. 1 .. 10 264 274 127 April 3 5 2 .. 3 10 182 192 63 May 4 10 2 1 2 15 253 268 106 June 4 15 .. 1 1 17 238 255 52 July 5 6 2 2 4 14 288 302 130 August 4 19 1 2 .. 22 268 290 113 September 4 9 2 •• 1 12 287 299 109 October 4 12 1 .. 4 17 286 303 113 November 4 10 1 .. 5 16 260 276 127 December 3 7 .. 1 .. 8 173 181 83 Total 48 126 13 17 27 183 3049 3232 1297 110 GOSTERWOOD STREET CLINIC. 1925 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 4 .. 4 24 236 260 111 February 4 17 4 .. 5 26 260 286 124 March 5 26 2 3 3 34 378 412 167 April 3 9 3 .. 4 16 187 203 73 May 4 16 .. 1 2 19 263 282 120 June 4 10 1 5 .. 16 235 251 83 July 4 25 .. 1 1 27 247 274 133 August 4 22 .. 1 2 25 246 271 124 September 3 11 .. 1 .. 12 179 191 97 October 4 15 1 3 .. 19 265 284 121 November 5 17 1 1 4 23 291 314 148 December 3 3 1 .. 1 5 124 129 64 Total 47 187 17 16 26 246 2911 3157 1365 HALES STREET CLINIC. 1925. 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 January 5 20 .. 8 2 30 270 300 147 February 4 10 .. .. 1 11 237 248 103 March 4 15 1 .. 4 20 276 296 131 April 4 21 3 4 1 29 239 268 135 May 4 19 .. 2 3 24 307 331 101 June 4 15 1 2 5 23 321 344 27 July 5 12 2 3 .. 17 324 341 95 August 4 11 1 2 .. 13 238 251 48 September 4 9 2 1 4 16 252 268 101 October 4 11 .. 1 2 14 278 292 116 November 4 7 .. .. 3 10 237 247 131 December 4 10 1 1 3 15 249 264 83 Total 50 160 11 24 28 222 3228 3450 1218 111 Table XXIX. Table showing Attendances at the Ante-natal Centre and Special Clinic for Babies During 1925. Ante-natal Examinations. Period. Number. Babies' Special Clinic. Number. Two weeks ended Jan. 15 (6 sessions) 117 (2 sessions) 7 „ ,, ,, ,, 29 (6 „ ) 92 (2 „ ) 4 „ „ „ Feb. 12 (6 „ ) 102 (2 „ ) 4 ,, ,, ,, „ 26 (6 „ ) 97 (2 „ ) 5 „ „ „ Mar. 12 (6 „ ) 95 (2 „ ) 1 ,, ,, ,, „ 26 (6 „ ) 90 (2 „ ) 3 Four „ „ Apr. 23 (9 „ ) 111 (4 „ ) — Two „ „ May 7 (6 „ ) 115 (2 „ ) 2 Four „ „ June 4 (11 „ ) 183 (4 ,, ) 3 Two „ „ „ 18 (6 „ ) 52 (2 „ ) 2 ,, ,, ,, July 2 (4 „ ) 58 (2 „ ) 2 ,, ,, ,, „ 16 (6 „ ) 119 (2 „ ) 2 Six „ „ Aug. 27 (17 „ ) 240 (3 „ ) 6 Two „ „ Sept. 10 (6 „ ) 93 (2 „ ) 3 ,, ,, ,, ,, 25 (6 „ ) 94 (2 „ ) 1 ,, ,, ,, Oct. 8 (6 „ ) 82 (2 „ ) — Six „ „ Nov. 19 (18 „ ) 273 (6 „ ) 5 Two „ „ Dec. 3 (6 „ ) 91 (2 „ ) 1 Four „ „ Jan. 4, 1926 (11 „ ) 222 (3 „ ) 2 The Infant Welfare Centres are held in halls let to us by different religious organisations. There are two exceptions, viz : the Goldsmiths' Centre, held in a class-room at 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 allowed to undertake the Thursday afternoon session. The doctor who had officiated did the work well, but funds were not overflowing, hence the change. This Centre is a voluntary one, except that the Council provide two Health Visitors as well as the Medical Officer. In the six Infant Welfare Centres there are voluntary workers whose services are prized by the Council and officers. It is, of course, realised that the value of a Centre depends largely on the ability, conscientiousness and sympathy of the presiding doctor (and of course the health visitors), and such centres should be within fairly easy reach of the mothers; still it would be an asset if one fairly 112 central Centre could be specially built for the purpose, while retaining the remaining five. The present accommodation is fair, and but once the financial stringency of the times will admit of it, some advance might be made on the lines indicated. Until 1922, one Ante-Natal Centre was held in the morning at the Napier Street Centre. A second session was opened on Wednesday forenoons in view of the increasing numbers attending. Yet again a third session had to be opened on Thursday mornings. The numbers attending have now made it necessary to consider the question of a fourth morning session. Dr. Hill attends from 10 a.m. 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. Professional Nursing in the Home. (a) General. 1. 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 admitted, but surgical and medical cases form the great bulk. Nurses can be obtained from this home to visit at patients' own homes. No definite statement can be made, but as Deptford is an industrial borough, it is fairly certain to say that the overwhelming majority of serious surgical and many medical cases are removed to hospital for treatment. 2. Much valuable work is carried out by the St. John the Divine Nursing Association, situated in Watson Street, New Cross Road. 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. 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 mid-wifery is undertaken. 4. The Deptford Mission has a nurse whose sphere of work is mainly east of High Street. 5. Two nurses are attached to St. James' Church, their headquarters being in Pagnell Street. 113 6. Seven or eight years ago a Nursing Association, on the Provident principle, was established for Brockley and Crofton Park. This Association is closely associated with the name of that kindly gentleman, Councillor Aucutt. The Association covers a wide area and is connected with Ranyard House. One of the nurses is resident and there is a visiting sister who attends the monthly Committee meetings. Excellent work is accomplished. 7. The Borough Council pays for the service of a Ranyard Nurse in certain cases approved by the Medical Officer, such as pneumonia in children under five years. The fee paid is 1s. 3d. per visit. (b) Infectious Diseases, Measles, etc. Practically all cases of the major forms of infectious disease are sent into hospital. Of the so-called minor diseases, such as measles and whooping cough, a number are sent to the M. A.B. hospitals. The Council provides a whole-time nurse during an epidemic of measles, and the Health Visitors also visit cases. The general rule is that if the home surroundings are insanitary, overcrowded, etc., or if complications are threatened, and provided the family doctor is willing (many can only pay for one visit by a doctor), the patient is sent into hospital. Circumstances decide the action necessary, thus the services of a Ranyard Nurse may be requisitioned. Measles became notifiable in Deptford in September, 1922, so that little time is lost in ascertaining cases. Information concerning whooping cough is derived mainly from head teachers. The Health Visitors visit such cases as their already extensive duties permit. In all cases where any sanitary defect is found, information is promptly conveyed to the department for necessary action. 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. Chemical Work. The report concerning Food and Drugs will be found in the tables given hereafter. 114 Laboratory Work at Seamen's Hospital, Greenwich. Material. Total Specimens examined. Number Positive. Number Negative. Swabs for Diphtheria 1687 231 1456 Blood for Enteric Fever 17 1 16 Sputum for Tuberculosis 100 42 58 Urine for „ 1 — 1 Pus from gland in neck 1 - 1 Potted Meat 1 — 1 Contents for food poisoning organisms — (a) Duodenum 1 — 1 (b) Liver 1 — 1 (c) Spleen 1 — 1 (d) Kidney 1 — 1 (e) Ileum 1 — 1 Total 1812 274 1538 In addition to the above, 913 specimens of sputa were examined at the Council's Tuberculosis Dispensary, of which 140 were " positive " and 773 were " negative." Diphtheria anti-toxin 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 on 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, knackers' yard, butcher's shop or fishmonger's shop or dunghill into any 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. 115 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. Conveyance of carcases of dead horses through streets. 11. Regulations as to Dairies, Cowsheds and Milkshops. Summary of Visits paid by Health Visitors. Ward (approximate) E. N. N.W. S. & S.E. S. W. Total. Miss Robus (May—Dec.) Visits .. 904 .. .. .. 904 Revisits .. 1627 .. .. .. 1627 Total •• 2531 .. •• .. 2531 Miss Holland Visits .. .. .. 832 .. 832 Revisits .. .. .. 1580 .. 1580 Total .. .. .. 2412 .. 2412 Miss Smart Visits 876 .. .. .. .. 876 Revisits 614 .. .. •• .. 644 Total 1520 .. •• .. .. 1520 Miss Stowell Visits .. .. 759 .. .. 759 Revisits .. .. 2557 .. .. 2557 Total •• .. 3316 .. .. 3316 Miss Reynolds Visits 855 .. .. .. .. 855 Revisits 2122 .. .. •• .. 2122 Total 2977 .. .. .. .. 2977 Miss Clubbe Visits .. .. .. .. 524 524 Revisits .. .. .. .. 2115 2115 Total .. •• .. •• 2639 2639 Total Visits 1731 904 759 832 524 4750 Revisits 2766 1827 2557 1580 2115 10645 Total 4497 2531 3316 2412 2639 15395 116 MUNICIPAL MATERNITY HOME. A Survey Report affords a useful opportunity for describing the origin and the developing administration as well as the subsequent work of the Maternity Home. In September, 1918, it fell to the lot of Acting Medical Officer, Dr. Macdonald, to draw the attention of the Public Health Committee to the Maternity and Child Welfare Act, 1918, a circular on which had been sent out to Local Authorities by the Local Government Board. It was suggested by Dr. Macdonald, that hospital beds might be provided for the treatment of complicated cases of pregnancy, as such cases were dependant upon the various lying-in homes and Maternity hospitals situated in different parts of London (Poor-law beds excepted.) Long journeys had to be taken by patients who had first to obtain hospital or other letters, and as admission was not sanctioned until labour had commenced, many were confined at home, with, in some cases, unsatisfactory results. Dr. Macdonald suggested that a large vacant house, affording eight to ten beds, might be provided for the needs of the Borough. The first meeting of the newly constituted Maternity and Child Welfare Committee was held on 4th December, 1918, and a letter was read to the members from the National League for Health, Maternity and Child Welfare, embodying an offer from the American Red Cross of a small lying-in home to be selected in a London Borough by the League. The Red Cross proposed to equip and maintain the institution for one year. This fell through. The Borough Council then decided to enquire as to suitable premises in the Borough. The Committee visited and examined the Hospital Supply Depot and Red Cross hall adjoining, at the corner of Breakspears Road, but as the County Council purchased this for a definite educational purpose, they were unwilling to sell it. They agreed to let the premises to the Borough Council, but as the probable period of tenancy was only for a matter of six months, it became necessary to seek for another building. Brockley Lodge, in Upper Brockley Road, next attracted attention but in the valuers' opinion the price was not satisfactory. Still another building was examined before the Committee finally settled on Waltham House, 52 Wickham Road. The cost of acquiring the premises, £1,800, included certain fixtures. The cost of conversion was carefully gone into, and it was agreed that there would be accommodation for twelve beds or twenty cases a month. Many Alderman Mrs. G. E. GREEN, Chairman of the Maternity and Child Welfare Committee. 117 matters required thought, such as electric lighting, hot water installation, provision for escape from fire, and the purchase of furniture, from Lawson Tait beds and cots to desks, cupboards, chairs and so on. One can imagine the consideration, the plans in effect, the long hours spent by all concerned in bending themselves to this task. Curiously enough there were not wanting some people (not Councillors) who feared that the proposed Maternity Hcme might prejudice the amenities of Wickham Road, and it is on record that the darkling fears thus harboured and expressed were soothed by the Mayor and Committee. Experience was sought by visits to other Homes in London, and doubtless from such, and from a study of local conditions, it was wisely decided that preference should be given to those whose lack of accommodation or home conditions made confinement at home undesirable. Other provision was to be made for abnormal cases. Tentatively the Committee decided on a minimum fee of 2 guineas a week with a registration fee of ten shillings and sixpence, the latter to merge in the first week's fee. It was felt that the staff should comprise a nurse-matron, four trained nurses, with a cook and two maids, and it was arranged that the rough laundry work should be done at the Public Baths and Washhouses in a specially reserved cubicle. It would be unfair to the past to skim lightly over the alterations made on behalf of generations of mothers and babies yet unborn ; the work was deemed to be worth doing well. Consider the Borough Surveyor's responsibilities for a moment. He reported on the need of a coal heated cooking range fitted with a hot water boiler in the kitchen to connect up to the existing hot flow and return pipe, this system to be supplemented by a pair of gas heated " Potterton " boilers fitted with thermostatic automatic gas regulating valve, hired from the South Metropolitan Gas Company, at 7s. 6d. a year. For central heating, a new tubular boiler was needed with boiler range, flue and circulating pipe, with 20 radiators in place of existing fireplaces. Sanitary appliances and drainage, also gas heating to supplement coal heating, were duly installed. Asbestos jointless flooring, distempering of walls and installation of the telephone were completed, and the day of the opening ceremony, July 9th, 1921, by H. R. H. Princess Louise, drew near. 118 A caretaker was put in charge for the time being, and directions were given for the Medical Officer to receive applications on behalf of the ladies Sub-Committee, so that the latter might consider the fee to to be charged on the merits of each case. Close touch was kept with the Ministry of Health who sanctioned loans for altering and equipping the Home. The Ministry's Officials came and inspected the building and expressed their approval. A Rota of the ladies Sub-Committee was appointed to inspect the Home—each couple to act for a month.' The visiting days decided upon were Sunday, from 2 to 4 p.m., and Wednesday, from 5 to 7 p.m., and the number of visitors in any one day to a patient was limited to two. In July, 1921, the Council decided to accept payment of fees by instalments, the same to be paid to Health Visitors at the Clinics; here it may be mentioned that this policy was changed in the light of experience, and fees are now paid before entering the Home. The wards were named, " Louise " Ward, after H.R.H. Princess Louise ; " Grace " Ward, after the Mayoress; and " Beatrice" Ward, after the Chairman of the Committee. One of the first purchases was 12 sets of babies' clothing. It was agreed that applications from Deptford expectant mothers should receive priority over those coming from outside the Borough, an arrangement which holds good to-day. It may be suggested by the reader that all this is historical and of little interest, but it is well that a record should be made so that future generations may look back with interest and respect upon the memories of those who thought no detail too trivial, to the end that the fullest possible provision might be made for womankind at a serious crisis in their lives. The old records, the Minutes, are not without joy to any with a sense of humour, thus the Cemetery Committee was invited to " maintain the garden " at the rear of the Home. Can it be wondered that the gentlemen comprising this Commitree, used as they were to giving reverend and sympathetic attention to last obsequies, should gravely ponder over a message from the recently-born Maternity Committee ? Maintain the garden ! What could it mean ? The Cemetery Committee sought enlightenment and were duly informed that this maintaining the garden meant " keeping the garden in a decent condition." The Medical Officer was requested to report on the system of rationing patients and staff in the Home. 119 Arrangements were made for an ambulance to remove patients to the Home if required by telephone between 11 p.m. and 8 a.m., the London County Council Ambulance Service to do the work without fee. In each case a card was given to the expectant mother with full directions as to calling the ambulance. The establishment of the Home was not without interest to medical men practising in the Borough. Two medical representatives came before the Committee, and amongst other things suggested that any patient should be attended by her own doctor in the Home. The Committee did not sustain this plea, but agreed that any case recommended by a local medical practitioner for admission would be favourably considered. It was agreed that if an occasion arose when an anaesthetic was required, a medical practitioner living in the immediate vicinity should be called in. Provision was made for a Register of cases to be kept on the table at the Committee meetings, and for a return to be made of the cost of the Home, a capital account and an account of running expenses, so that the financial position might be understood. From this it became clear that if the Home was full, that is if 286 cases were received during the year, the actual cost to the rates of the Home would be considerably less than one farthing. The purchase price of the Home was £ 1,800, the cost of alteration £"2,400. Considerable attention was gi ven to the medical arrangements in connection with the Home. The matron and staff, in addition to being trained nurses, hold the Certificate of the Central Midwives Board. Dr. Hill, the Maternity and Child Welfare Medical Officer, lives opposite the Home and is available in any case requiring her services ; she also visits the Home daily. In the event of any case occurring where two doctors might be required, a very rare eventuality, a rota of local doctors was formed. Medical men who were willing to attend were placed on the rota, the principal condition being that they should be on the telephone. Each doctor in turn acts for a week, and is provided with a rota calendar indicating his particular weeks of duty. The rota doctors only cost the Borough two guineas for the first eighteen months the Home was open. It was further resolved that arrangements should be made for the services of a consultant in the event of an emergency calling for a specialist's attention, and to this end an agreement was made with Dr. Gilliatt, an obstetrician on the 120 staff of King's College Hospital. No retaining fee was to be paid to Dr. Gilliatt. If called in consultation to the Home by Dr. Hill his fee was to be £5 5s. If an operation was required at the Home he was to receive twenty guineas, half his usual fee; a charge of forty guineas would be made in the case of a cæsarean section. If Dr. Hill and Dr. Gilliatt agreed that the patient could be moved with safety for operation to King's College Hospital, then no charge would be made for the operation by Dr. Gilliatt, but the hospital would charge the Council a maintenance fee of eleven shillings per day for the first twenty-one days' residence in hospital, provided that in Dr. Hill's opinion the illness arose out of the confinement. If a case is removed from the Home to King's College Hospital, at the instigation of Drs. Hill and Gilliatt, the Borough Council will not be asked to pay if, after observation of the case, and either after or without an operation, it is ascertained that the illness had nothing to do with the confinement. In such latter cases the husband would have to make his own arrangements with the hospital as to payment. These points are made quite clear to applicants for admission to the Home, the facts being stated on the application form, and the following is agreed to by the applicant:— " In the event of a patient while in the Council's Home contracting any illness or disease not associated with the confinement, the cost of any treatment incurred by reason of such patient having to be transferred from the Home to a general or special hospital is not included in the fee charged by the Council, and I fully recognise that any charge made under such circumstances by a Hospital is a matter to be settled by me direct with the Hospital concerned." The Ministry of Health agreed to a maximum expenditure of £25 a year in connection with the expenditure involved relatively to Dr. Gilliatt. As will be seen below, this expenditure has never been incurred. The applications for admission to the Maternity Home are made in the first place at the Ante-Natal centre where a form is obtained. When filled in they are considered carefully by the ladies Sub-Committee which latter comprises the lady members of the Council. The duties of this Sub-Committee were framed as follows :— To interview applicants and determine their fitness for admission to the Maternity Home: to assess payments in respect thereof: to appoint a rota of ladies to visit the Home periodically : to report decisions arrived at on the above matter (to the Maternity and Child 121 Welfare Committee): to present a fortnightly report on cases in the Home : to state the number of applications received for admission, the number accepted for admission, the number refused, the number assessed at various amounts, the number received from the Ante-Natal clinic : to give financial details presented by the Matron each 14 days. Subsequently it was agreed that applicants need not attend the SubCommittee meeting when their applications were being considered. Any desirous of interviewing the Committee could do so after receiving intimation of the assessments made. Prior to being passed for the Home all applicants have to attend the Ante-Natal Centre for examination and supervision by Dr. Hill. In the event of any abnormalty of a major kind being diagnosed, prompt and sympathetic steps are taken with a view to treatment. Such cases are usually referred to Dr. Gilliatt at King's College Hospital, no charge being made to the Borough Council. As regards the fees charged to the expectant mothers by the Councd, there is no printed form or scale of fees; it was felt that elasticity was needed, hard cases might need special consideration; moreover, the Ministry of Health had laid it down that poverty should not be a bar to acceptance for admission. The Committee, however, consider the answeis given on the application form as to the wages, rent, number and ages of children, and maternity benefit, whilst special expenditure incurred, say, through travelling to work, is taken cognisance of. As a rule, the rent is deducted from the earnings and 10s. is deducted for each child, the balance forming the necessary fee. An average charge is about £2 15s. Od. a week; though in all cases admitted from outside the Borough, a charge of £4 4s. Od. per week is made. If a mother, for some reason, stays over the usual 14 days in the Home, a charge of three shillings a day is made, from and including the seventeenth day. There is more than one way in which comparisons can be made between various Metropolitan Maternity Homes respecting their running costs. One method is misleading; this is the comparison on the " per patient week " basis. The natural heads of expenditure in a home vary. Establishment and administration charges remain at full, whether the home is full or not, while provisions and medical requisites move with the number of patients. It is because of this fact that unless a series of homes are full for a given period, comparison on the cost " per patient week" basis is misleading. The better way of 122 making comparison is to take the number of beds. This is a known and stable factor and provides a basis whereby the expenditure of homes can be measured and compared. Comparing the running cost of our Municipal Maternity Home on this basis, with others, our relative position is a very satisfactory one. Before giving the various tables in connection with the Home, one or two scattered items of information fall to be mentioned. In the past a number of items have been reported to the Committee from time to time, such for example as painting woodwork and walls, whitening ceilings, and so on. It was decided in July, 1925, to obviate these occasional requisitions for repairs, furniture, etc., so in future, just before the annual estimates are prepared, the Sub-Committee will meet at the Home to consider any repairs or replacements required during the ensuing year. This policy was followed out in 1925. Ordinary small items, of course, such as " replenishing of babies' clothing," can be presented at the usual fortnightly meeting, in the Requisition Book. As regards the laundry work, while a whole-time employee does such at the Baths, a woman attends daily for three hours at the Home to do minor laundry work. Owing to the increase in the number of cases now admitted to the Home, an extra nurse had to be engaged in October, 1925. The staff therefore consists of matron, sister, 4 nurses, cook and 2 housemaids. The additional nurse occupies a room which was engaged, in Manor Road, the Home accommodotion being fully taken up. The maximum annual capacity of the home is 286, and as this number was being closely approached in 1925, the Committee decided not to accept any out of the Borough applications. More recently, however, it was felt that this point should not be rigidly held to, should the number of local applications admit of the acceptance of outside cases. Year ended Rota Doctor's fees cost of Specialist's fees cost of Fee paid to King's College Hospital. £.s.d. £.s.d. £.s.d. March 1922 — — — „ 1923 2 2 0 — — „ 1924 24 3 0 10 10 0 15 8 0 „ 1925 3 3 0 — — „ 1926 4 4 0 — 11 11 0 123 Maternity Home. Particulars of cases admitted during the five years 1921-25. 1921 1922 1923 1924 1925 Cases admitted 35 129 200 176 254 Average stay 2 weeks 2 weeks 2 weeks 2 weeks 2 weeks Cases delivered : By Midwives 34 120 188 168 243 By Doctor Hill 1 8 12 8 11 Cases in which medical advice was sought (especially Dr. Hill) Nil 11 23 Nil 25 (a) Ante-Natal (l) Ante-partum Hæmorrhage Nil 1 Nil Nil Nil (2) Threatened abortion, Albuminuria and Influenza Nil Nil Nil 4 Nil (3) Excessive vomiting Nil Nil 1 Nil Nil (b) During labour (1) Prolonged labour Nil 8 12 Nil 15 (2) Uterine inertia 1 1 4 Nil 2 (c) After labour. (1) Post-partum Hæmorrhage Nil 1 Nil Nil Nil (2) Adherent placenta Nil Nil 1 Nil Nil (3) Puerperal insanity Nil Nil 1 Nil Nil (4) Pneumonia Nil Nil Nil Nil 2 (d) For Infant. (l) Malformation Nil Nil Nil Nil Nil (2) Asphyxia Nil 1 1 Nil 8 (3) Feebleness Nil Nil 3 4 Nil Cases notified as puerperal sepsis Nil Nil Nil Nil Nil Temperature rose above 100·4 for 24 hours with rise in pulse 1 Influenza 6 2 1 3 Notified as Ophthalmia Neonatorum 1 (Recovered fully) Nil Nil Nil 1 Inflammation (eyes) 1 Nil Nil 1 Nil Not entirely breast fed 1 Nil Nil Nil Nil (1) Insufficient breast milk Nil 2 1 1 Nil (2) Phthisis Nil Nil 1 Nil Nil Maternal deaths Nil Nil Nil Nil Nil Fœtal Deaths. (a) Still born 1 1 2 3 4 (b) Premature Nil 1 4 2 Nil (c) Congenital defect Nil 1 Nil Nil Nil (d) Fœtal death Nil Nil Nil Nil 1 124 Dp. Hill's Report on the Ante-Natal Clinic for 1925. 1. Total number of cases examined was 588 ; of these 480 were new cases, and 108 had attended previously in 1924. 2. Total number of re-visits paid by these patients was 1,680. 3. Making the total number of attendances 2,268. 4. Number of patients visited ante-natally in their own homes by the Health Visitors, 413. 5. Number of patients admitted to Maternity Home, 254. 11 patients delivered at the Maternity Home required instruments, and all these were delivered by Dr. Hill. Doctors on the rota were called in four times, twice to give anaesthetics, once for consultation, and once for a case of post-partum haemorrhage. The services of the specialist, Dr. Gilliatt, were only required for 1 patient during the year, and she was transferred immediately to King's College Hospital. Seven patients were sent from the ante-natal clinic to see Dr. Gilliatt, at King's College Hospital. Total number of patients referred to hospitals from the ante-natal clinic 40 Number of cases referred to private doctors for treatment 7 Number of cases referred to the Tuberculosis Officer 7 Number of letters written to midwives about their patients 12 Number of letters written to doctors about patients 11 Number of patients found to be quite normal 136 Number of patients suffering from dental caries but otherwise quite normal 72 Number of patients suffering from dental caries in addition to other defects 67 Total number of cases of dental caries 139 This shows an improvement upon last year's figures as the proportion of the total number of mothers requiring dental treatment is less than 24 per cent, as against 30 per cent. in 1924. A good number of patients still have to be advised to seek treatment either at Guy's Hospital Dental Clinic or at the Miller General Hospital, as it is not possible for all to be treated by the Council's dentist. Patients examined and found to be not pregnant 21 Patients examined post natally 10 The ante-natal clinic is now held on three mornings weekly, the Tuesday morning session being reserved for new patients. On Wednesdays and Thursdays the mothers attend by appointment, those 125 coming on Thursday being Maternity Home cases only. This makes it possible to regulate the numbers and avoid overcrowding at any one session, with the consequent long waiting. It is, however, quite obvious that the 20 or 25 mothers attending at one session cannot all be seen at once, and valuable time might be saved if lectures could be given and a sewing class held concurrently with the ante-natal clinics, so that the mothers could be usefully occupied while waiting their turn to see the doctor. Some excellent sets of model garments for children were prepared for the Health Exhibition, and these could be used for demonstration purposes if the accommodation at the centre was suitable. Unfortunately, we have no permanent quarters in which to exhibit these models at present, and so their usefulness has been limited. The Health Visitors give informal talks to the mothers as opportunity offers, and give them patterns of clothing, etc., but this side of the work needs further development. We also urgently need better dressing room accommodation, and this is particularly felt when patients with different standards of cleanliness happen to attend on the same morning. Example is so much better than precept that we cannot but realize how some of our mothers do a real service to the community in attending the centre, because they demonstrate so much more clearly than our words what ought to be and can be done in matters of personal cleanliness and hygiene. But it is our duty to protect those who trust us with their welfare, from all risk of infection or annoyance, and the accommodation which we have at the ante-natal centre can only be described as a makeshift. Note by the Medical Officer :— Dr. Hill's report was written some months before the plans for the new centre in Harton Street were proposed. Once this new building is erected, this will meet the difficulties referred to, and which latter, paradoxical though it might seem, are partly due to the increasing success of the work. The question of instruction in sewing is receiving the Committee's consideration. Ante-Natal Statistics for past years. 1922 1923 1924 1925 No. of new cases examined 311 369 463 480 Revisits 627 1070 1034 1788 Total attendances 938 1439 1497 2268 126 Ante-Natal Statistics—continued. 1922 1923 1924 1925 Ante-natal home visits by Health visitors - - 483 413 Cases referred to Hospital from the ante-natal clinic - 52 40 Letters to midwives re patients - - 13 12 Letters to private practitioners - 20 11 Patients with carious teeth - - 75 72 Patients with carious teeth and other defects - - 80 67 Total with dental caries — — 155 139 Abnormalities and Defects other than Dental Caries:— 1924 1925 1924 1925 Albuminaria 31 11 Glycosuria 6 Anæmia 40 48 Haemorrhoids 15 15 Ante-partum Hæmorrhage 11 9 Hydramnios 1 10 Hernia 2 1 Bronchitis 2 4 Hepatitis 1 Blepharitis 2 Infantile paralysis Sequela 2 Chorea 1 Contracted pelvis 4 3 Lipoma 1 1 Congenital dislocation of hips 1 1 Lumbago 1 Mastitis 1 Conjunctivitis 1 1 Morbus cordis 23 37 Carbuncle 1 Mental deficiency 1 Curvature of spine 1 Neuritis 1 2 Cystitis 1 Oedema 12 24 Deformed or depressed nipples 5 3 Pulmonary tuberculosis 2 7 Pruritus 2 12 Dead fœtus 1 Prolapse 1 3 Dyspepsia 23 16 Psoriasis 2 Delusional insanity 2 Pyelitis 1 External version for malpresentation 12 19 Retroversion 8 8 Scabies 1 Excessive vomiting 5 12 Sciatica 3 5 Eczema 2 Venereal disease 4 10 Fibroid 3 1 Varicose veins 58 59 Goitre 1 2 Patients examined anc not found pregnant 24 21 Glossitis 1 Readers who have not had a medical training cannot fully appraise the meaning of this table in the measures of human suffering relieved. Think, however, of the cases of heart disease, tuberculosis, venereal disease and threatened convulsions detected and treated. Without exaggeration, it is a scandal that women, mostly of the "better-off" class, should face their confinements without ante-natal supervision. 127 Further Observations on Maternity and Child Welfare. The circular of the Ministry of Health on the Survey Report specifies the subjects upon which information is requested under the above. The work is fully set out in the preceding pages and Tables, but a few words are necessary on certain subjects named. The Midwives Acts, 1902 and 1918. The London County Council is the supervisory authority. In the case of Puerperal Fever enquiry is made locally to see that the midwife concerned has taken the necessary steps concerning disinfection. Co-ordination with the School Medical Service. In all cases where children are examined at the Infants Welfare Centre records are kept on cards of their medical history, treatment, &c. It is very desirable that copies of these records should follow the child on to school life. The clerical work in connection with this step would be considerable, and once provision for the purpose is made, this necessary advance could take place. Maternal Mortality : Still-births and Infant Deaths. The Maternal Mortality Rate for the past five years, is:— 1921 1922 1923 1924 1925 Per 1000 births 3·0 3·0 3·3 2·9 4·1 Enquiry is made into all cases of Puerperal Septicaemia but not into deaths arising through confinements, e.g., difficult labour. Enquiries are made in the case of infant deaths and still-births. Orthopcedic Treatment. In all cases where surgical treatment is required (or seems to be required) for deformities arising congenitally or from tubercle, infantile paralysis, or rickets, steps are taken at once to have the child admitted to hospital, and the cases are followed up at the Infants Welfare Centres, Tuberculosis Clinic, and the homes. Voluntary Societies and Workers. The only voluntary Infant Welfare Centre is that at Hales Street, though here the staff is provided by the Borough Council. In each of the Welfare Centres, voluntary workers give valuable assistance at the weekly sessions. 128 Incidence of Certain Diseases. 1921 1922 1923 1924 1925 Puerperal Fever 11 7 7 6 17 Ophthalmia Neonatorum 19 10 15 25 20 Measles Not Notifiable 28 204 1282 1207 Epidemic Diarrhœa 109 5 33 20 48 Poliomyelitis 4 0 3 2 4 Neo-Natal (first 4 weeks of life) Death Rate. Per 1,000 Births. 1921 29·6 1924 31·6 1922 27·7 1925 24·8 1923 21·8 Methods Adopted to Diminish the Mortality and Permanent injury to Health in Certain Diseases. Puerperal Fever. Fifteen of the 17 cases were removed to hospital; there were seven deaths. Enquiry into the cases and circumstances associated with the cases produced useful information. It is difficult to prove the exact cause of any case of Puerperal Septicaemia, but general causes or association of events and circumstances are known. One can deduce that several of these cases were due to complicated labour, and there is not wanting a doubt as to the skill exhibited at the confinement in a few instances. Enquires proved that cleanliness of lying-in room and the house was almost the invariable rule. Overcrowding was present in one-third of the cases. The remedy for the conditions is obvious. It is pathetic to find that case after case was removed to hospital. Would it not be more sensible if all confinements were carried out in Lying-in Hospitals and Maternity Homes, where the most favourable conditions obtain. Any woman who is confined at home in cramped surroundings has to take a bigger risk than one confined in a nursing home. The following facts are eloquent, at least to the medical reader. Attended by, Nature of Delivery. Overcrowding. Condition 1. Midwife and Breech. Torn perineum No. 2 families Good doctor 2. Do. Miscarriage at 3rd month Yes. 3 families Dirty through fall from chair 3. Do. Twins. Retained placenta Yes. 5 rooms Good and ruptured perineum 13 adults, 4 children 129 4. Midwife and Breech. Premature. Still Yes. 2 families Fair doctor born 6 rooms, 8 adults, 6 children 5. Midwife Ruptured perineum, post No. 2 families Good partum haemorrhage 6. Do. Slight rupture perineum No. 3 families Good 7. Midwife and Instrumental delivery No. 2 families Good doctor 7 rooms, 6 adults and 5 children 8. Midwife Haemorrhage, midwife No. 1 family, Good had attended another 5 rooms, 6 case of puerperal fever adults and 5 children 9. Midwife and Normal Yes. 6 rooms, Good doctor 2 families, 9 adults and 7 children 10. No attend- Miscarriage No. 1 family Good ance for 3 days 11. Midwife and Instruments, ruptured No. 2 families Good doctor perineum, haemorrhage 12. Do. Normal Yes. 2 families Good 2 rooms, 4 4 adults, 4 children 13. Do. Miscarriage No. 2 families Good Ophthalmia Neonatorum. Cases Treatment Vision Vision Total Notified At home In hospital Unimpaired Impaired Blindness Deaths 20 10 10 20 — — — Enquiry is made at once to ascertain whether a doctor or nurse are in attendance, and as to the nature of the treatment. If there is any evidence of slackness on the mother's part, and if the general circumstances require it, and if the family doctor is agreeable, the case is sent to hospital. Four cases were treated in St. Margaret's Hospital, Kentish Town, two in the Royal Eye Hospital, and four in St. John's Hospital, Lewisham. The treatment which, on enquiry, it was ascertained that family doctors were giving in the home, varied from painting the eyes daily to drops and ointment. In the cases treated at home a nurse from St. John's was visiting from two to four times daily. 130 All these cases are visited heavily by the Health Visitor for obvious reasons—the process is so devastating, rapid and grave in its end results. Two of the cases were illegitimate. Only 4 mothers were found to have a vaginal discharge, but I take little notice of a denial in such cases as it is well-known that a woman can have a gonorrhæa with but little pain. Acute Anterior Poliomyelitis. Cases of this disease are just as important as those of Ophthalmia Neonatorum. This disease is insidious in onset and may be easily missed, the first intimation of the fact of the disease being the commencement of a deformity. All cases are visited at once and at least once a quarter thereafter. Four cases were notified in 1925. Short resume of Cases. V.W., October, 1925. Irritability, drowsiness, loss of power left leg, fretfulness. Attended Miller Hospital as out-patient. Final report: quite well, no muscular shrinking, no paralysis. J.P., January, 1925. Commenced with " severe cold," delirious at night, loss of power left leg. Sent to St. Bartholomew's Hospital. Later : left leg slightly thinner than right. Massage at St. John's Hospital. A year later : child discharged from hospital quite well. D.L., September, 1925. Drowsiness and fever, tenderness lower limbs and loss of power right leg. Child was sent to Evelina Hospital, Southwark. Later: now at Queen Mary's Hospital, Carshalton, where Dr. Pugh has every hope of child being able to walk eventually. R.S. was notified from St. Bartholomew's Hospital. Cases and Disposal for Five Years. Number Notified. Received Hospital Treatment 1921 4 4 1922 0 0 1923 3 *2 1924 2 2 1925 4 4 *Third not genuine case; died of Pneumonia. In all cases while co-operating with the family doctor, it is kept in view that full provision has been made at Queen Mary's Hospital, Carshalton, for the treatment of cases three months after onset (entering the second stage), and for those requiring correctional operations for deformities resulting from it. 131 Zymotic Enteritis. The number of deaths from this disease in 1925 was 17, and of these 11 occurred in children under one year of age and 1 in an infant between one and two years of age. With the commencement of June in each year a special lecture is given and is repeated by the Medical Officer of Health in each Infant Welfare Centre, drawing attention to the seriousness of summer diarrhæa; the rapidity with which it can kill is stressed, and, accordingly, the mothers display anxiety as to how this threat to their babies' lives may be warded off. Flies, filth, fingers and dirt are at the root of the whole trouble. Germs pass into the child's intestinal tract and multiply to an enormous extent. The poisons or toxins given off by these germs profoundly disturb the baby's system; sickness and violent purging are followed by rapid wasting and the child sinks into a semi or totally comatose condition. In a matter of twelve hours a child, well to the outward eye, commences to exhibit the fearsome train of symptoms which does so often bespeak the beginning of the end. Zymotic enteritis, or summer diarrhœa, is at its worst in hot, dry summers. The year 1921 was the last of the hot summers. The number of deaths for the past five years is as follows:— Year. Total deaths from diarrhœa and enteritis. Number of deaths in infants under two years. 1921 65 55 1922 12 11 1923 22 18 1924 21 16 1925 17 12 Notification of zymotic enteritis is carried out in eight boroughs in London in addition to Deptford, viz., Fulham, Finsbury, Poplar, Southwark, Kensington, Greenwich and Woolwich. Prevention. The means adopted to prevent this disease are refuse removal, street scavenging and street washing every morning in the east end of the borough. This is the part of the borough usually the hardest hit by summer diarrhoea. Many of the houses are of the old tenement type, and a number are overcrowded. A number of the tenants are 132 dirty in their habits, and frequently the streets, though washed and scavenged in the morning, are littered in the afternoon. These streets are narrow and the backyards are mean. The sanitary inspector for this district has instructions to exercise the most rigid supervision over the general cleanliness of the backyards and such open spaces as exist. To promote public health in this district it is desirable that there should be a twice-weekly collection of refuse. The same recommendation applies to the Besson—Kender—Pomeroy Streets sector of the borough, though in this latter area it is diphtheria and not summer diarrhoea which engages attention. Further, the dust carts should be covered over with a canvas or other covering. In the following streets the road surfaces are slightly in disrepair: Bronze Street, Frankham Street, Addey Street, Dugald Street, Ffinch Street, Hyde Street, Hales Street, Reginald Road. Crossfield Street and Hamilton Street are in urgent need of relaying. These matters, of course, pertain to the Borough Surveyor's Department and the Works Committee, to whom praise is due for the improvement in past years, which has helped to reduce the infant and general mortality rates. In the month of June leaflets on the fly, its dangers, and means whereby its breeding can be prevented and the means whereby its destruction can be encompassed, are widely disseminated throughout the borough. Breast feeding, of course, is continually advocated ; it is the bottlefed baby which suffers most from the disease we are now considering. We advise dried milk as opposed to " wet " milk in all cases where the home surroundings are questionable. The occurrence of a case is the signal for an immediate visit by the health visitor of the district concerned. The steps taken by her are dependent upon the class, as outlined in the following list of instructions:— Zymotic Enteritis or Summer Diarrhæa. Where a case is notified, the Health Visitor will visit, taking with her (l) The Epidemic Diarrhcea Enquiry Card; (2) A bottle of disinfectant from the office ; (3) The leaflet on Treatment. Enquiry should be made so as to define to which of the following classes the case belongs :— 1. Doctor in attendance and nursing assistance from the Council not needed. 133 Such cases are rare in Deptford. In these, the Health Visitor's duties are limited to filling the Enquiry Card, leaving disinfectant and advising as to the preventive aspects, e.g., hands to be washed after touching soiled napkins, and the latter to be put in disinfectant, etc. 2. Doctor in attendance who will treat throughout, but who will welcome nursing assistance through the Council. In such cases the Health Visitor should recommend the case to the Medical Officer of Health for the assistance of a nurse, in addition to carrying out as in (l). 3. Doctor in attendance who wishes the case removed to hospital. The Health Visitor should see the case and, using her judgment, advise either the Greenwich and Deptford Hospital or the M.A.B. Hospital. The M.A.B. now admit certain cases. Hospital treatment (intestinal lavage, etc.) is imperative in any case at all serious or becoming serious. 4. No doctor in attendance. The greatest care is needed in such. Send to hospital if case at all serious. Mild cases might be advised as per leaflet. General. In all cases the completed enquiry cards should be handed forthwith to the Medical Officer of Health. Charles S. Thomson, July, 1926. Medical Officer of Health. The actual or existing causes of summer diarrhoea, as given by the Health Visitors on their enquiry cards are illuminating. The following are some of them :—Chill, dirty dummy, flies, food exposed on dining table instead of in the cupboard, general dirt, verminous, wrong feeding, the pernicious practice of toffee apples, etc. Ice Cream Makers. In September, 1921, the Borough Council urged the compulsory registration of retailers and wholesalers of Ice Cream, and the County Council replied enquiring in what respects the Borough Council considered that the existing powers of local authorities with respect to this commodity were inadequate. A reply was sent to the County Council pointing out that it was impossible to enforce the existing regulations if the local authority was unaware of the extent to which Ice Cream was being manufactured or sold within their area, and that only by means of compulsory 134 registration could this information be made available; further, an opportunity would thus be afforded for insisting on a reasonable standard of cleanliness before the registration of the premises, instead of the present procedure which merely tends to alleviate unsatisfactory conditions already existing. The position to-day so far as registration is concerned remains the same. On the Deptford Register we have a list of 136 Ice Cream Makers, but it is notorious that vendors can stroll in from any outside area with their barrows. The London County Council General Powers Act, 1902, forbids the manufacture, sale or storage of any ice cream in any cellar, shed or room having a drain inlet, or used as a living or sleeping room. Also anything done or left undone likely to expose ice cream to infection or contamination is liable to lead to a fine. The name and address of the person supplying the ice-cream must be on each itinerant vendor's barrow. The present regulations are quite out of date. Ice cream is now being increasingly manufactured on a large scale by firms who are thoroughly alive to the hygienic side of the subject. 1 recently inspected the premises, the preparation and packing of ice cream in a large factory solely devoted to the purpose, situated near to Waterloo Station. I was particularly struck with the attention paid by the women employees to the cleanliness of hands, nails, etc. The ice cream is put up in packets and containers and sold by lads who cycle throughout London. If it is too much to hope for the manufacture and sale of ice cream only by such firms, the public might well deal only with trustworthy firms. The use of small glasses by street vendors or shopkeepers who cannot or do not use hot water or clean towels to cleanse the glasses, is a practice which cannot be countenanced, as such are liable to be vehicles for contamination. The use of perishable wafers should be made compulsory. Despite the fact that a close watch is kept by the Inspector and myself over the " sculleries," " sheds in the yards," and kitchens in which ice cream is made locally, I am satisfied that it would be a good thing if the industry could be confined to firms and people whose premises and hygienic instincts are above suspicion. (The question of registration is being raised again with the County Council.) 135 The Organisation of a Health Week. The survey report affords an opportunity whereby a record may be made of the Health Exhibition now held annually in the Borough. Each succeeding year sees new features, of course, but a statement on the organisation may be useful to others and of interest to the Council. The object of a Health Week is :— (a) To teach every householder to be his own Medical Officer of Health. Public Health should begin at home and not at the Town Hall. (b) The man who safeguards his family's health protects his neighbour's highest interests. (c) The Public Health Department of the Borough is the G.H.Q., or Health Intelligence Centre, with which every citizen is cordially invited to keep in touch, by calling or writing for information on any subject within the ambit of preventive medicine. (d) Every week in the Borough is a Health Week; the present venture is an outward and visible manifestation of the silent but powerful forces which are at work, day after day, throughout the year, to care for the citizen and those dear to him. (e) A citizen has definite rights. He can call upon the Ante-Natal Department to tend his expectant wife and chase away the fears which mingle with the joyful anticipation of the day. He can stand at the gate of the municipal maternity home and see the Council's nursing staff welcome his wife into his own maternity home. He can call upon his own Council's doctor and Health Visitor to stand over his baby boy until he is a little man of five, when his school doctor takes his son's hand and sees him through school life. And so on, through the gamut of Clinics, Dispensaries, etc.—a new world, my masters, which a well organised Health Week can bring home to Mr. and Mrs. John Bull. It must be inborn upon the citizen that to a very large extent disease is preventable, and it rests with him, and not with the other man, to see that it is prevented. The central feature of Health Week is the Exhibition, held in Deptford in the Borough Hall. The following brief descriptions of the stalls may be useful to beginners. A Dental Stall is imperative. Consult the Maternity and Child Welfare or school dentist, usually the same officer, as to this exhibit. Get in touch with a big firm such as Messrs. D. & W. Gibbs, City 136 Soap Works, Wapping, London, E. 1, one with a library of films, magic lantern slides, charts, literature and even experienced lecturers available for Health Weeks, Educational and Welfare Authorities, in the provinces as well as in London. Briefly, this firm has an hygienic screen, a little folding exhibit fitted with a small shelf carrying specimens of the products they manufacture, and having space for posters, placards, charts, mouth hygiene mottoes, etc. Samples of tooth powder, tooth paste and literature are given away in profusion. There are large charts measuring 28 ins. by 32 ins. for blackboard use, and a typed lecturette is sent with these if required. Smaller charts can be obtained showing the lower jaw, structure of a tooth, development of a tooth, decay in teeth, the upper jaw, teeth that go and teeth that stay, etc. Films should be given each evening, say from 6.30 or 7 until 7.30. just before the big evening lecture. Films are of two kinds, "flam" (celluloid) and " non flam." Communicate in July with the authority in London (the County Council) whose sanction is necessary for the use of cinema films. Disappointment and inconvenience may be caused at the eleventh hour if a good " flam" film has been booked and permission for its use is withheld. Another point about films. Some firms may send a " non-flam " film but may not provide the apparatus or the operator. Most big health exhibitions have short films from two or more sources. Take early steps therefore to arrange with the firms so that an operator with apparatus from one source can supply all the films. "The Ivory Castle" film is an artistic production of a very high order. The ivory castles are, of course, the teeth. Another good teeth film is "A Fight in Fairyland." Organisers who commence business a month before Health Week is due will not stand much chance of securing a film. A Milk Stall can make a good appeal. Endeavour to engage a firm licensed to sell Certified or Grade A (tuberculin tested) milk. This will teach the public to appreciate the desirability of having all milk sold in bottles. The price of Certified Grade A milk, as a whole, is prohibitive for most people, but even if a divine discontent with the present public supply is created, this will be something gained. This stall should display a household pasteuriser, and the presence of peg-topped pails, curry combs, modern churns and score cards, will 137 teach the public that many dairy farms are aiming at a pure milk supply. The stall could exhibit butter, fresh eggs, honey, chocolates, etc. The V.D. Stall forms part of the armamentarium of that splendid body, the British Social Hygiene Council, Carteret House, Carteret Street, S.W. Much cant and humbug surround this subject. Are our lads and girls of 14 to learn about sex matters and their aberrations in an unsavoury manner, or is the subject to be presented to them in a clean and wholesome way associated with the first rank lecturers and staff of the National Council ? The National Council makes, at least, a threefold appeal to our interest. Take the film, " The Public Health Twins." This will be given, with a running explanation, by the film secretary of the National Council. The National Council has branches in all the big towns and cities throughout the country. Of course, if any special journey has to be made to an outlying district, the local authority would have to pay the cost of transit of the apparatus and the operator's expenses. The V.D. stall is petite and very instructive. I have noticed that men and women pick up literature here with avidity and pocket the same, with a view to a quiet perusal far from the madding crowd. All to the good, of course. There is nothing fearsome about the stall. The " Empty Cradle " is by the way of becoming a hardy annual; its appeal is based on the fact that V.D. may cause sterility and, of course, heartburnings, where either or both putative parents are fond of children. Within the stall there is a baby film dealing eloquently with facts and figures and this film, lasting a few minutes, is shown by the superintendent as each fresh group gathers round. The National Council offers the services of a brilliant lecturer each evening if desired, to address an audience of great dimensions, and with or without a film. I strongly advise that one evening should be set aside in a large hall for a lecture to men only, using the film " Whatsoever a man soweth." Another evening could be given up to women only, a lady doctor speaking on this occasion and using an appropriate film. The exhibition hall is not very suitable, for two reasons. Many people come to see the exhibition as a whole, and walking round is held up during the lecture. Again, the audience here is a mixed one, and consequently the lecturer cannot let himself go as he or she would, where the sexes are separate. Devote 138 therefore one evening to each, and boom the forthcoming lectures and speakers with might and main. The Rodent Stall, affectionately termed the Rat Show, is ringed round by boys and girls from 10 to 60 years old! from start to finish. People like to be in at the kill. The mill lass and the factory girl appeal to their swains to hold them back in case they touch a " dead-un. It's good to look upon the chap in't bottle that skeered us so often." There are many good rat firms, and the Rodent and Insect Pest Destruction Co., Ltd., 2a Elm Park, Brixton Hill, London, S.W. 2, gave us a fine display, including, by good fortune, specimens loaned by a certain Ministry. It might be well to mention the exhibits, lest some may think that the stall is made up of the carcases of the late Mr. Rat. 1. Red Squill Rat Biscuits, Liquid Extract of Red Squill," Rodesco" Liquid Insecticide, varieties of paste and powder Rat Baits, Barium Carbonate Rat Baits, " Klearwell " insect powder. 2. Samples of Red Squill Bulbs and Barium Carbonate. 3. Specimens of rats—Mus Decumanus or common sewer rat, Mus Rattus or black or ship or old English rat, Mus Musculus the common house mouse, also the Water Vole (not a true rat) for comparison. 4. Dark ratlime and photographs, etc., showing the methods of use. 5. Photographs, etc., showing damage done by rats, etc. 6. Photographs, etc., showing methods of using rat baits. 7. Mummified rat and mouse, also specimens showing the results of the poisons. 8. Posters, pamphlets and general propaganda. The Rodent Co. might not be able to go all over the country and exhibit, and it would be a mistake to expect the particular Ministry to be able to spare their specimens to any great extent. A Virol Stall is a reasonable proposition, as Virol has won its place as an infants food accessory or medicament and is approved by clinicains in the upbringing of delicate, marasmic or "backward" children. A Toilet Stall, presenting soaps, etc., is a nice addition. The Pure Products Co., Ltd., Sapon House, 24-25 King William Street, London Bridge, E.C. 4, have a fine Sapon House Exhibition Stand, for which I fear, early application would need to be made. These seven stalls will give an idea of the lines upon which assistance from outside sources might be obtained. The most important stalls are those of the Health Department. 139 Health Department's Exhibit (each Health Visitor presides over her own stall). (a) Infant feeding for the first year of life. Sample of breast milk in clear glass bottle. Sample of prepared dried milk do do Sample of cows' milk do do Mothers warned that the comparatively thin or watery appearance of breast milk is misleading and should not cause mothers to take baby off the breast because " my milk was so watery." Taught that " dried " and cows' milk are only substitutes for the breast. Leaflets, charts and posters insisting on breast feeding. Demonstrations to mothers on Truby King methods of promoting and restoring flow of breast milk ; even after weeks of absence. Feeding hours and intervals between feeds, on cards. No feeds allowed during night. Card on Constipation, causes and treatment, use of fruit juice, judicious massage. Paintings of Stools. Right and wrong colour. Causes and cure. Modified Cows' Milk for 3, 6 and 9 months, with hours of feeding, (explanatory reservation—baby is not a machine.) Prepared Dried Milk. Composition of forinfants 3 and 9 months, etc. (with reservations as above.) Diet for Infants, 9 to 12 months. Samples qf foods with vitamines suitable to age. Feeding Bottles. Samples of right and wrong kinds. Dangers of long tubing and "comforters"; adenoids, deafness, indigestion and infant diarrhoea. How to cleanse feeding bottles and teats, and how to keep them clean. Practical demonstrations. Hints on Teething. No soothing " powders." (6) Six Model Meals Ready for Children from One to Five Years of Age, the diets varied and the caloric value of each meal explained. Meal for child of 12 to 18 months (two models), ditto 18 to 24 „ ditto 24 months to 4 years, ditto 3 to 4 years, ditto 4 to 5 years. Oral explanation to groups, and explanatory cards. 140 Rickets. Photographs of rickety children. Oral explanation and cards on causes, prevention and cure (bad feeding, jam, white bread, margarine). (Lack of sunlight, fresh air, open spaces, exercise). (Correct feeding, fruit juice, fresh milk, butter, brown bread, use of Marmite, cod liver oil, out of doors, large kicking pen). Hygiene of the Mouth and Nostrils. Morning clearing of nostrils. Every child a hanky. Early cleansing of teeth. Photographs of children with adenoids, etc. Care of the Hair. Nit under microscope. How to remove nits from hair. Value of keeping hair short. Alternative plaiting. Numbering of school pegs for hats. Pediculus Capitis and Corporis under microscope. Dangers of head and body vermin. (c) Clothing Stall. Garments made by mothers attending the various infant welfare centres. Prize competition in groups :— Class 1 ... New hand-sewn garments. Class 2 ... New knitted and crocheted garments. Class 3 ... Converted garments. Clothing to avoid for baby : flannellette, stiff binders, etc. Risks from overclothing. Competition exhibits made by fathers of infant welfare babies— toys, cots, kicking pen6, cradles from banana crates, boxes, etc. (d) Ante-natal and Maternity Home Stall. Cards on care of expectant mothers' health. Right Food. Basket, showing water bottle, brown bread, vegetables, meat, milk, eggs, apples, pears. Wrong Food. Basket, shewing bottle of stout, white bread, pickles and pastry. Clothing for Expectant Mothers. No corsets, no garters, Westminster Health Society's non-constricted skirt, bodice, stocking for varicose veins, square-toed boots. Exercise, care of teeth, avoidance of crowded meetings. Clothing for toddlers from one to two years. Model garments for these, also for new born babies and for children of school age. Some organisers have a gift for producing fine diagrams. See that they are striking and that the " shot " goes home. Use diagrams three 141 or four feet by two or three feet. Find an artist on your staff or amongst the voluntary workers. Explain what you want, carefully, thus:— Diagram 1. Paint in top half of diagram typical English lady doctor in white coat with left hand on shoulder of artisan's wife and right hand pointing to portrait of baby on wall. Expectant mother looks happily at baby's portrait. Words below :—Supervision at ante-natal centre before baby is born ensures safe and easy confinement and a healthy and vigorous baby. (Give address and days and hours of ante-natal centre.) Diagram 2. Painting of fine baby boy about one year old. Print below :—Since the ante-natal centre commenced work there have been fewer miscarriages, fewer still births, fewer deaths of recently born babies. New born babies are healthier and weigh more. More mothers can breast feed their babies. Diagram 3. Painting of sturdy 18 months baby, standing, laughing and pushing chair. Print:-The ante-natal centre gives babies a splendid " push-off" in life. Diagram 4. Painting of curly-headed baby in bath. Print:—A warm bath carries off waste products of the body, keeps the skin clean and tones up the nervous system. Give bath with screen protection to avoid draughts. Give before eating and not before going out. Use clean soft water, pure unscented soap. Dry gently and thoroughly. Diagram 5. Painting of doctor dropping solution into new-born baby's eyes. Print below:—Blindness in thousands of babies is prevented by dropping in solution of silver salts into the eyes as soon as baby is born. Insist upon this when engaging a doctor for confinement. These diagrams can make a striking display at the ante-natal stall at every health exhibition. Our neo-natal mortality rate is regrettable and is almost stationary, whereas the general infant mortality rate is falling steadily. Purchase or hire cartoons, charts, etc., on "Flies," all about "Consumption" and "Smallpox" from the Editor of The Medical Officer, 36 Whitefriars Street, off Fleet Street, London, E.C. The safeguard of vaccination is strongly brought home, and the causes and treatment of Tuberculosis can be grasped by the simplest from the 142 pictures showing infection from expectoration, overcrowding, bad ventilation, poor food, late hours, drink, etc., and the converse—open air, good food, etc. The relationship of flies, manure heaps and lidless dustbins to summer diarrhoea in infants must be emphasised. (e) Municipal Dental Stall. Models of teeth. Models of right and wrong way of keeping tooth brush. Photographs of school dental clinics. Model of school clinic. Samples of wrong food and and their effects on children's teeth. Charts and mottoes. (f) A Tuberculosis Shelter is attractive and instructive. Fix posters to its walls explaining causes as described above. Place a slide of the tubercle bacilli under a microscope and exhibit micro-photographs taken by the super microscope made by Messrs. Davidson & Co., Manufacturing Opticians, 29 Great Portland Street, W. These microphotographs bring home the story effectively and on a scale which I have not seen before. (g) Sanitary Inspectors' Stall. Models of sanitary fittings obtained from pottery. Diagrams showing dangers of defective and improper sanitary fittings. Make clear the necessity for cleansing sinks and traps. Model or diagram of destructor. Display of disinfectant fluids, powder, soaps and appliances from the Sanitas Co., Ltd., Locksley Street, Limehouse, London, E. (h) Enquiries. Either a small stall or box at which enquiries can be made on all Health subjects, or a letter box with writing materials at hand,.into which enquiries can be dropped to be answered by the Medical Officer of Health in due course. (i) Magazine Stall. Copies of health journals for sale, such as "The Hospital and Health Review," "Maternity and Child Welfare," " National Health," also a few popular editions of books such as " Housing and Public Health (Robertson), (Scurfield), (Scharlieb). A final word on Exhibitions. If your Council will allow it, spend £7 10s. (and £2 for carriage) on the travelling exhibition of the Central Council for Infant and Child Welfare, Carnegie House, 117 Piccadilly, London W. This should be booked nine or twelve months in advance. It is the world's finest exhibition in this line, better even than Deptford's. Decorations for the Hall must be simple and hygienic; avoid draperies and flags. Use screens extensively, obtaining the same from 143 infant welfare centres, ante-natal centres, maternity homes and hospitals. On these should be hung mottoes, diagrams and cartoons. Write to the National League for Health, Maternity and Child Welfare, 4 and 5 Tavistock Square, London, W.C. 1, the publishers for their rhymed poster series (copyright). Once purchased they are yours for subsequent years. They cost 2s. per set of six, post free, less 25 per cent, discount to affiliated institutions. These mottoes and rhymes deal with everything from Diet and Exercise to Dummies and Ventilation. They are all pretty, printed and precise. Signs vary from, say, half-a-foot to 3 ft. by 2 ft. I have used large sheets of brown paper pasted together to form a background on which diagrams are pasted. The Principal features of Health Week are :— 1. The Public Health Department's section of the Health Exhibition, because— (a) Through the channels of the eye and ear it is the effort of the week most calculated to educate and leave its impression on the minds of the people, thereby creating a demand for better things, for a higher standard of communal and personal hygiene. (b) It deals with fundamental health principles which are expounded and driven home again and again during successive demonstrations by trained and experienced professional workers. (c) It deals with subjects which people wish to know and must know. 2. The Elementary School Children's Addresses and Demonstrations, because— (a) The young are impressionable and will talk over and think about what they had heard and seen, until next year's exhibition. (6) If you train a child in the way it should go in Hygiene, the root of the matter will never leave him, and in the plentitude of his manhood, he and his fellows will demand and practice a higher standard than that of their forebears. (c) The child is the father of the man in Hygiene as in other things. (d) If you wish to raise your fellows, hand on the torch to youth with its enthusiasm. 144 (e) All things considered, Elementary School Children come from homes and surroundings where the need is greatest. 3. The Special Lectures at the Exhibition Hall, because— (a) There is a resolute, insistent and insatiable desire for knowledge on the part of men and women who realise that knowledge is power, and that the chance of hearing men and women of experience and ripened judgment speaking on their special subject, should not be missed. (b) Each special subject is an irresistible appeal to many who themselves or their friends have suffered or are suffering from the particular disease expounded. (c) The hours at which these special lectures are given are ideal for the sexes; three o'clock is the women's hour and seven-thirty p.m., the men's hour. The Addresses and Demonstration to Elementary School Children. In London, the schools are under the control of the County Council and not the local borough councils. The Town Clerk should write to the Education Officer of the County Council asking permission to approach the head teachers of public elementary schools in the district to send pupils of ten years of age and upwards, with a teacher in charge, to receive an address of 15 minutes' duration, followed by a demonstration. The County Council will cordially agree, and the head teachers are informed that the attendance at the Exhibition may be regarded as an " educational visit." Care should be taken to give the address punctually at the time stated, as an inspector from the Board of Education may attend. It is no exaggeration to say that the enthusiasm and excitement of the school children is immense. Take the boys and girls separately. Use diagrams and models, the Medical Officer of Health speaking. Deal with the teeth and toothbrush; hygiene of the nostrils ; "nose" breathing; adenoids; enlarged tonsils and deafness ; cleanliness, remembering the nails. Ask questions, here and there, amongst the scholars and see that your clear and careful explanations have been understood. Dismiss the class, to the care of the Health Visitors, for demonstrations. Then carry on with class 2. Over one thousand scholars attend Deptford's addresses and demonstrations annually. Any organiser with a heart and imagination 145 must be moved as he looks upon the sea of upturned eager faces; it is a golden opportunity. The soil is there; it only needs the man and the hour. Whenever possible, fit in an exhibition of dancing or "movements" by the pupils. This will add numbers of the parents to the throng. The Special Lectures at the Exhibition Hall. There is a welter of choice here. A word of warning. Engage lecturers whom you have heard yourself or concerning whom you have reliable evidence that they have the voice and equipment. The metallic voice, the awkward pause, the lack of personality, the man or woman without confidence, the prosy party, all may wreck an evening. The people will say " Never again." Aspiring Assistant Medical Officers should start their oratorical career by teaching ambulance to boys' brigades or boy scouts' classes and so on through men's clubs, pleasant Sunday afternoon meetings, etc., until they gain their platform legs. Loyalty to a fellow colleague is not loyalty, but folly if he or she is pushed on to a platform on a big night, without experience. In engaging lecturers, the question of expense may bulk largely. Remember too, that many prefer to listen to their own health staff. The Medical Officer of Health, Tuberculosis Officer, School Medical Officer, Maternity Medical Officer and V.D. Officer may suffice, when the Borough and staff is large enough. There should always be a lecture on Tuberculosis, with lantern slides. A lecture to men, and another to women, in Venereal Disease is desirable and will occupy two separate evenings. These will not cost anything. The prime importance of the public's milk supply makes it impossible for a Health Week to be contemplated without reference to this subject. The National Clean Milk Society, 3 Bedford Square, London, W.C., and their Chairman, Mr. Wilfred Buckley, C.B.E., will occur to the organiser's mind. If approached some weeks in advance, Mr. Buckley or an able substitute, might be available for a lecture on " The Production of Certified Milk on an English Farm." This lecture is accompanied by a film. A short film is available if there is a lecturer, and a long film, containing explanatory matter, if no lecturer is present. The Society look to the local authority to supply the apparatus and operator. The cost of such a lecture might work out at two guineas plus travelling expenses. If a lantern and operator have to be hired, 146 this itself may cost three guineas, if electric light is available ; if no electric power is handy, there would be 6/- or 7/- to pay in addition for oxygen, or 16/- if oxygen and hydrogen were required. The National Clean Milk Society's lecturers will speak on any aspect of the milk question that might be required. The school Dental Surgeon can hold an audience with his subject for an evening. One last word on the subject of engaging a " big gun " to come and lecture. Be careful in your selection, or he may turn out a " damp squib." The afternoon addresses and talks to women should be held at 3 p.m., and should last from 15 to 20 minutes. Either the Maternity and Child Welfare doctor or the Medical Officer of Health could speak, or one could visit the matron of a large general hospital and ask her to come. Another plan is to write to Miss Halford, Carnegie House, 117 Piccadilly, asking for one or more speakers. In such case, a fee of half-a-guinea and expenses might be asked for the lecturer. A talk by a warm-hearted hospital matron goes well, especially if she brings a miniature model cot and doll, and exhibits some baby clothing. Each organiser knows the capacity of his women's audience best, hence it is wise to confer with the lecturer a fortnight in advance as to the subject of the address. How would you ensure the success of your " Health Week " ? By advertising and by judicious use of prizes for certain competitions. The Council's Minutes are printed. As soon as the Council has passed the Public Health Committee's report (synopsis of) and recommendations for a Health Week, button-hole the journalist present at the Council meeting at once. Every organiser should be well and favourably known to the pressmen, alike for his personal character and geniality. There are two types of local newspapers ; there is the fine old staid country journal, always safe, sometimes stodgy, invariably respectable and dignified. There is the popular breezy organ which has a "better sale than all the other local organs put together." Sometimes it is known as the local " rag," but it is found in every home. Both types have their uses from the organiser's point of view. The breezy paper generally has a column entitled " Town Talk," "Current Topics," etc. This is the man to enlist. Tell him everything within discretion. On Friday, when Paterfamilias or Ratepayer sits down to 147 read the " Town Talk " column, he will read all about the forthcoming Health Week. In this way the necessary atmosphere is created and public interest aroused. Keep the public on the tip toe of expectation with some fresh morsel of information every other week until the advertisement columns finally burst into a blaze, with the programme, in the two issues of the paper actually preceding Health Week. The Town Clerk should write to the editors asking them to print a pointed leader, providing him with the necessary ammunition for the job. Obtain sanction for the posting of large bills or placards on the Corporation dustcarts and other vehicles. Make free use of the hoardings. Print small handbills and see that these are circulated at the Infant Welfare, Tuberculosis, and School Clinics. At each Infant Welfare Centre, advertise to the mothers that there will be five prizes (per Centre) for the best new hand-sewn garments, new knitted and crocheted garments and converted garments. Give two prizes per Centre for fathers for the best home made toys, kicking pens, cradles, etc. To obtain all these prizes, either the lady Councillors or the voluntary workers will be glad to collect money, etc. Never give prizes for a Baby Show; it is folly and causes heartburnings ; but on the last night, prize evening, give special certificates, signed by the Mayor, to those mothers who during the past year, have pulled a baby through a serious illness. Seek the co-operation of shopkeepers to place large bills in their windows. Such bills will announce that the Mayor, Aldermen and Councillors, accompanied by the local Member of Parliament, Clergy, Doctors, etc., will open the Exhibition on the first day. In starting a Health Week, the organiser, if keen, will find pleasure in preparing the ground for the Outside Propaganda. Politicians who speak from trains to crowds at railway stations, during elections, enjoy no greater exhilaration than the enthusiast who passes from meeting to meeting to preach the gospel of health and answer the hecklers at the end. Begin with the Churches where there will be no cross-examination. Send a letter to the Clergymen of all denominations;— " Dear Sir, The Borough Council will be grateful if you would kindly mention our forthcoming Health Week in your place of worship 148 on Sunday, either as a special announcement or, if you prefer, in the course of your sermon. Health Week will include a Health Exhibition in the Hall, from to both dates inclusive, from to p.m. Expert lecturers will speak each day at and and there will be interesting and instructive films each evening at Reference to the above and to open-air and other meetings will be found in the editorial and advertising columns of the local press and on posters. I am to express to you the Council's thanks for your kind co-operation" An offer by the organiser to preach special sermons on Health Week Sunday will be favourably met, and an address could be given at one or two of the men's or women's Sunday afternoon meetings. Approach the proprietors of the town's Cinema Theatres and arrange for a half-hour's health film to be shown throughout the week before the usual big film is screened. As this costs a few pounds, those who are arranging their town's first Health Week may prefer to defer such a proposal until the initial venture has, so to speak, convinced the Council of its value. The new Era Films, Ltd., 26 and 27 D'Arblav Street, Wardour Street, have two outstanding films, "The House Fly, and " Where Flies go in the Winter Time." Edited by Professor Maxwell Lefroy, of the Imperial College of Science, the bacteriological work by Mr. K. B. Wiliiamson, M.A. The organiser, or a friend in general practice, could give the audience the story as the film is wound off. The films are printed on celluloid and, being so inflammable, are perhaps barred from some halls. The cost runs from two to three guineas. If it is decided to bring the films to the exhibition hall in preference to the local Cinemas, an operator and machine would be required and would cost extra. If the throw, i.e., the distance from the machine to the screen is more than thirty or forty feet, a professional Arc lamp would be necessary ; otherwise an excellent educational machine with cold light would do. Other films and firms occur to the mind. There is a good one displaying the destruction caused by rats and the methods adopted (actually screened) of destroying them. 149 Write to the Secretary of the local Head Teachers' Association asking them to nominate a subject upon which they would like a special address for all teachers and pupil teachers in the district. This generally calls for close preparation, as our teachers are keen hygienists. Remember the scholars in the large Private Schools. The Headmaster will gladly arrange for two short addresses to upwards of 100 boys. Take command of the situation (and the boys), and deliver impressive addresses on " The Care of the Teeth (and toothbrush)", Pyorrhoea, Mouth Breathing and Adenoids, Deafness, etc. Use large diagrams fixed on the blackboard. In large cities, approach the proprietors of the Normal Training Colleges. I have addressed from 30 to 200 of the students on " Pure Food Supplies," "Common Infectious Diseases." If there is a museum or institute with hygienic exhibits, approach the Council for permission to demonstrate to parties of twenty. Explain the sanitation of a building, Refuse Destructors, give the cycle of the different Taeniae and if permitted by the Head of the Tropical Diseases Section, arrange for a microscopical demonstration of the parasites of Malaria, Dysentery, Sleeping Sickness, etc. Each year take one section of workers for a special address on the diseases peculiar to their occupation. For example, I have lectured on " The Health of the Clerk." His and her special ailments are – Indigestion, Neurasthenia, Defective eyesight, Tuberculosis and sometimes Writer's Cramp. Discuss the remedies and encourage exhaustive discussion. Approach Working Men and Women's Clubs, irrespective of their political views, seeking their wishes. The men will ask for a lead and subsequent debate on housing and house repairs, for a visit to the Disinfecting Station and the Refuse Destructor; the women will request an address on the raison d'etre and operation of the ante-natal clinic and for a visit to an infant welfare centre. What mills and factories are there in your district? What is or what are the main industries? Look up part of the 75th Annual Report, recently published, of the Registrar-General, and study the diseases which each occupation group is subject to, as evidenced by the mortality figures. See the proprietor or manager of the large factory first; thereafter consult with representatives of the employees. A pointed fifteen minutes' address will never fail to evoke a keen discussion, and questions. 150 Never omit the general hospital. Beseech the governors to allow the Matron, House Governor and Resident to meet parties of twenty, with a view to a demonstration in the X Ray, Finsen Light, Electrical and any other available Department. Bring people together ; understanding and enlightenment evoke sympathy and respect. Suspend a line of flags and advertisement right across the principal thoroughfares. Post a typed letter of invitation also a typed programme of the week's activities to clergymen, doctors, county councillors, members and officials of boards of guardians, education committees, teachers, social workers, prominent citizens, etc. To encourage the attendance of mothers, do not hold the customary infant welfare clinics at the usual centres, but hold them at the Exhibition. The actual consultations can be held from 2.30 p.m. onwards in a side room or screened off space. The usual cup of tea and cake can be purchased at the buffet. The mothers will receive their " talk " at 3 p.m., from the special speaker of the day. Councillor E. G. SIMMONDS, J.P. 151 THE LONDON WATER SUPPLY BY E. G. Simmonds, j.p. represented deptford on the metropolitan water board over 14 years. Chairman—The Appeal and Assessment Committee. Member—The General Purposes Committee. Do. Law and Parliamentary Committee. Do. Staff Committee. Do. Estates Committee. Do. Special Committee. In the Church of St. Andrew Undershaft, Leadenhall Street, there is a monument to John Stow, who was born in the year 1525, and died in the year 1605 at the age of 80. He is shown on his monument sitting at a table writing with a quill pen. He commenced his working life as a tailor, and at the age of 40 abandoned it for antiquarian pursuits, which only brought him want and beggary. In his old age, after he had spent all the powers of his mind and all his worldly goods in the service of his country, he was awarded by his Sovereign, James I, with his royal licence to beg. To-day his admirers visit his tomb to do him honour, and from time to time renew the quill pen in his hand. Of his numerous and monumental works the best-known to-day is his " Survey of London under Elizabeth,'' written in the year 1598. In that work he gives the following account of the water supply of London at that date:— "Anciently, until the Conqueror's time, and two hundred years after, the City of London was watered, besides the famous river of Thames on the south part, with the river of Wells, as it was then called, on the west; with the water called Wallbrook running through the midst of the City in the river of Thames, serving the heart thereof ; and with a fourth water or bourn, which ran within the City through Langbourne Ward, watering that part in the east. In the west suburbs was also another great water, called Oldbourne, which had its fall into the river of Wells ; then were there three principal fountains, or wells, in the other suburbs: to wit, Holy Well, Clement's Well, and Clerk's Well. Near unto this last-named fountain were divers other wells, to wit, Skinner's Well, Fags' Well, Tode Well, Loder's Well and Radwell. All of which said wells, having the fall of 152 their overflowing in the aforesaid river, much increased the stream, and in that place gave it the name of Well. In West Smithfield there was a pool, in records called Horsepool, and one other pool near unto the parish church of St. Giles without Cripplegate. Besides all which, they had in every street and lane of the City divers fair wells and fresh springs ; and after this manner was this City served with sweet and fresh waters, which being since decayed, other means have been sought to supply the want." Since the reign of Elizabeth the water supply to the City of London had become very deficient owing to the partial failure of the springs supplying the conduits. The so-called conduits were what we should to-day call fountains, where the water was always running. Some were very elaborate structures. Stow describes one built in the year 1478 by the inhabitants of Fleet-street near the bridge over the Fleet River as " A fair tower of stone garnished with an image of St. Christopher on the top, and angels lower down with sweet sounding bells before them whereupon by an engine placed in the tower the divers hours of the day and night chimed such an hymn as was appointed." London had so increased in size, and the population had become so numerous that the existing supplies were quite inadequate for the wants of the people, notwithstanding the sixteen conduits and the great supply from the Thames. The earliest records of private enterprise for supplying water in London was in 1581 or 1582 when Peter Maurice or Morris, a Dutchman, conceived the idea of raising water from the Thames by means of a water wheel placed in one of the arches in London Bridge which was worked by the ebb and flow of the tide, and forced the water through pipes as far as the Standard on Cornhill. The enterprise was successful and subsequently became the London Bridge Waterworks Company which continued their useful service for 240 years until London Bridge was pulled down and removed to another site in 1822, when the area supplied by them was taken over by the New River Company. Elm Tree Pipes. In 1594, one, Bevis Bulmer, built an engine at Broken Wharf, between London Bridge and Blackfriars for forcing and conveying Thames water to serve in the middle and west parts of the City. The so called engine was at first a windmill, and later a horse engine. When these works ceased to exist is not known, but were most likely taken over by the London Bridge Waterworks Company. 153 In 1605-6, the Corporation of London being alarmed at the decreasing supply from the springs, obtained powers from Parliament to enable them to bring water from the well known springs at Chadwell and Amwell in Hertfordshire, to London, by means of a cutting or trench referred to as a New River. Although the Corporation obtained these powers they did not take advantage of them, and it-was left to a private individual, Hugh Myddelton, a Welshman, and member of Parliament for Denbigh, to offer to undertake the work. With the help of his relations and friends he commenced work in April, 1609, and in spite of considerable opposition and derision, succeeded in bringing the channel as far as Enfield, when all available capital had been expended. Myddelton then applied to the Corporation of London for help, but was refused. He next applied to the King, James I, who agreed to bear half the whole expense, both past and future. With this help the work was completed, and the water flowed into the New River Head, Clerkenwell (where the Board's Head Offices now stand), on Michaelmas day, 1613. The next difficulty was to convey the water from Clerkenwell to the houses in the City. That was done by gravitation through pipes made of elm trees, bored to the required size and one end sharpened for insertion into the butt of the next log. This method of supply remained in force until the beginning of last century when iron came into more general use. The loss of water from the defective wooden pipes was about one-fourth of the quantity supplied. In 1810, it was estimated that the New River Company alone had used 211,000 trees and required over 10,000 trees a year for repairs and extension of supply. With the growth of London the supply from the springs proved insufficient and an additional supply was taken from the River Lea. The area covered by the New River Company comprised the City of London and as far as Westminster, and most parishes north. As London grew and houses and inhabitants increased, other Companies were formed to supply them with water. Overlapping powers to supply in certain areas were obtained from Parliament with the result that keen competition took place between rival companies. Sometimes two companies would have mains side by side in the same street, and as there was no authorised charges, companies were able to undersell each other. The competition became so keen, that ultimately the companies mutually agreed to defined areas of supply. 154 The companies supplying north of the Thames, which came into existence after the New River Company, were as follows : — The Chelsea Company, 1722. Supply taken from the Thames. The Grand Junction Company, 1798. The supply was originally taken from the Grand Junction Canal, which was fed from the Colne and Brent Rivers, and subsequently from the Thames. The West Middlesex Company, 1806. Supply taken from the Thames. The East London Company, 1808. This Company purchased the Shadwell Company which was established in 1679 and the West Ham Water Works, also a business started in 1745. Sayes' Court Privileges. Companies supplying south of the Thames included. The Lambeth Company, 1785.-—Supply from the Thames, and The Kent Company, 1809.—The Kent Waterworks Company possessed the rights of an old established institution which dates back to the reign of William III. The Company also absorbed quite a number of small undertakings. In 1701, letters patent were granted to the inhabitants of Sayes Court and East Greenwich, giving them power to lay pipes for conveying water for a period of 500 years, all other persons being prohibited from doing so on pain of penalties. The result of this privilege was that waterworks were made at Ravensbourne which were worked until 1808. In 1809 an Act of Parliament was passed establishing the Kent Waterworks Company and investing them with the powers of the letters patent on purchase of the undertaking. In addition, the Company in 1811 took over the supply to Woolwich from the Town Commissions. About 1850 the Company took over the area supplied by a company called the Plumstead, Woolwich and Charlton Consumers Pure Water Company, which had become bankrupt; in 1860, the North Kent Company which supplied Chislehurst, Eltham, Erith, Dartford, Crayford and Bexley ; in 1867, the Local Board of Dartford sold their works to the Company; in 1877 the Bromley Rural Authority and Dartford Rural Authority requested the Company to supply their area, and an Act of Parliament was obtained in 1888 giving the Company powers to supply 155 in these districts. The Company's area of supply was thus extended to cover an area of about 178 square miles, of which about 30 are within the County of London. The original works were situated on the bank of the Ravensbourne and consisted of a pump worked by a water wheel. In 1857 the water of the Ravensbourne was insufficient, and a deep well was sunk in the chalk. New wells have been sunk as occasion required. Later the whole of the water supplied by the Kent Company was obtained from deep wells thus obviating the necessity of filtration. The area supplied by this Company extended from Deptford to Swanscombe, Chislehurst, Westerham, Knockholt, Eynsford and Southfleet. The Southwark and Vauxhall Company was the amalgamation of two Companies called the Southwark and the Vauxhall Company. The Southwark Company had taken over part of the London Bridge Company's area supplied from the Thames by a wheel in one of the arches of London Bridge, placed there in 1767 for the supply of Southwark. The area of supply was Bermondsey, Rotherhithe, Battersea, Barnes, Kew, Roehampton, Wandsworth, Clapham, and Camberwell. The supply was taken from the Thames. In 1852 an important Act of Parliament was passed which required all Companies supplying the Metropolis to filter the water taken from any source other than wells, and to provide covered reservoirs for all filtered water. Under the same Act Companies taking water from the Thames were not allowed to take a supply from the river lower than Teddington Lock. Thames Drinking Water. At the beginning of last century, water was drawn from the Thames for domestic use as low down as London Bridge and was delivered to consumers without filtration of any kind. The Thames at that time was the common sewer of London. There were no less than 145 sewers discharging their contents into the river above the intake for the supply for domestic purposes to a considerable part of the City. The supply to the Metropolis was the subject of numerous inquiries in Parliament during the latter half of last century. Several bills were brought before the House for the purchase or control of the water companies, but it was not until 1902 that the Metropolis Water Act was passed which constituted the present Metropolitan Water Board. The Board as constituted under that Act 156 consists of 66 members appointed by the County Councils of London, Essex, Herts, Kent, Middlesex and Surrey, and by the Borough Councils and Urban District Councils within the 563 square miles of the statutory area of the Board. The Board were empowered to raise money to compensate the eight companies to be taken over, and were required to promote an act for equalising the charges made by the late companies. The undertakings were transferred to the Board on the 24th June, 1904, and the cost of the transfer in accordance with the decision of the Arbitration Court was £46,939,257, The stamp duty on vesting of the undertakings was perhaps the largest paid and amounted to £"214,707. In accordance with the provisions of the Act of 1902, the Board in 1907 obtained an Act for making uniform charges. The effect of the Act was that 91,684 consumers obtained a reduction of their rates amounting to .£21,712. Since the Board have been in office they have completed a service covered reservoir for filtered water at Honor Oak of over 14 acres, capable of holding upwards of 56 million gallons. In 1913 the Board constructed a reservoir at Chingford which was inaugurated by the King and named the " King George Reservoir," which covers 425 acres, and is capable of holding upwards of 3,073 million gallons. Only last June the King and Queen opened a new reservoir at Littleton near Staines called the " Queen Mary Reservoir," which covers 723 acres and has a capacity of 6,750 million gallons, the largest reservoir of its kind ever constructed. A walk round it would cover four miles. The cost was approximately £"2,000,000. The quantity of water supplied last year was 92,892 million gallons or a daily average of 254.5 million gallons. The population supplied is estimated at over 7,000,000 persons, of which 64 per cent. reside norch of the Thames and 36 per cent. south. The population supplied is equal to that of the Commonwealth of Australia or of Greece or Holland. The average supply per head was last summer over 40 gallons per day. Thus in one way or another every Londoner consumes or uses in a day more than twice his weight of water. It is very difficult to appreciate the magnitude of the quantities quoted, but some idea may be gained by way of comparison. If St. Paul's Churchyard was made into a tank and filled with water to a depth of 20 inches you would only have half-a-million gallons. Again, if Trafalgar Square were made into a tank and filled to the height of 157 Nelson's Column, London would empty that tank two-and-a-half times every day. The total consumption for a year would fill a canal 600 miles long, 200 feet wide and 25 feet deep, or if it were as wide as the Thames at London Bridge, it would be 7 feet deep. The water rental received for last year was ,£"4,452,500. Of every 20s. received, 9s. 2d. is required for payment of interest and stock, 3s. Id. for rates and taxes, 3s. for wages, 1s. 5d. for fuel and 1s. 3d. for salaries. The cost of fuel alone for the last financial year was £317,000 for 179,000 tons. Purity of Water. Laboratory, under the control of Sir Alexander Houston, K.B.E., G.V.O., M.B., C.M., D.Sc. Daily samples are taken. 12,400 per annum. Analysed, both chemically and bacteriologically. Water consumers in the Board's area may be assured the purity of the water is in good hands. Intercommunication of Water Supply. Staff. Total staff and employees 5,219. Mileage of Main. 6,783 miles. 57 miles added last year. Services. Total Number 1,177,375, which are increasing. New Buildings. Total capital value for water purposes last year £31,000,000. Extraction. Thames 59.1 per cent. Wells 17.3 „ „ £90,000 per annum to Thames Conservancy. Maximum quantity per day not to exceed 1,200 million gallons. Wells. 55 in the Kent area and part of the Lea Valley. 158 Storirge. 49 Reservoirs for unfiltered water which hold 20,000,000 gallons. 91 Reservoirs for filtered water. In 1904 storage was for 4,116,000 gallons. To-day storage for 20,000.000 gallons. Charges. Act, 1921, permitted to charge 10%, but not to exceed 8½ without consent of Minister of Health." Charges reduced this month from 7% to 6% on rateable value. May, 1926. INDEX. INDEX A PAGE Acute Pneumonia 21, 34 Acute Influenzal Pneumonia 21 Acute Poliomyelitis 22 Albury Street Babies Hospital 43 Ambulance Facilities 45, 46 Ante-Natal Clinic Table 111 „ „ Statistics 124/5/6 Ante-Natal work 1 Area of Borough 5,9 Average size of family 39 B Back-to-back houses 36 Bacon shops 81 Bakehouses 63 Baths Filtration Scheme 2 Births 9, 13 „ illegitimate 10 „ Notification Act, 1907 10 Birth-rate 9 „ Table 10 Books disinfected 74 British Red Cross Ambulances 46 Butchers' Shops 81 Buildings, Dwellings and Families 37 Bylaws 114 c Cancer Death Rate 4 Canal Boats 69 Causes of Sickness and Invalidity 44 Census 5,36 Census Table 38 Cerebro-Spinal Meningitis 21,33 Chemical work 113 ii. C—continued. PAGE Children's Hospitals 45 Circulars (Official) 4 Circular No. 648 1 Cleansing and Repairs 49 Cleansing Station 74 Clerical Staff 3 Clinics and Treatment Centres 107/8/9/10 Cowsheds 78 D Deaths 5,11,13 Death Rate 5 Deaths in Hospitals 43 „ Table of 11,15 „ in Wards 12 „ at various ages 12 „ of Infants 12 Density 5,36 Diarrhoea and Enteritis 21 Diarrhoea 13,128 Diphtheria 3, 20, 25 „ contacts 3,25 „ carriers 3,25 „ avirulent 26 „ and dirt 26 „ antitoxin 28 „ and overcrowding. 26 „ and obsolete methods 29 „ and leaflets 28 „ and schools 29 „ and Schick Test 25,27 Disinfection ... 73 Table 73,74 „ of Books 74 „ of Goods 75 Drainage 50 Dustbins 50 Dysentery 50 iii. E PAGE Enteritis 13,21 Enteric Fever 20,30 , and shrimps 30 ,, and watercress 30 Encephalitis Lethargica 22, 24 Epidemic Cerebrospinal Meningitis 21,23 F Factories • 62,63 „ Tables 65,66 Fever Hospitals 45 Fish curing premises 63 Food Inspection 76 Food and Drugs Act 69 „ Table 71 ,, Prosecutions 70 Fried Fish Shops 63 H Hales Street Centre 2,44 Health Services 45 Health Visitors Work 105 „ Visits Health Week 2 Health Week Organisation 135/150 Hospitals for Tuberculosis 45 Hospitals 43 „ for Children 45 „ for Infectious Diseases 45 Housiiig Tables 55 House-to-house Inspections 52 Housing Representations 44 Housing and Sickness 44 „ and the East Ward 44 „ Act, 1925 4 ,, Problem 3 iv. I PAGE Ice Cream Makers 133,134 Inhabited Dwellings 5 Infectious Diseases 113 Infectious Diseases Tables . 17, 18 „ Notified 20 ,, Seven Piincipal 20 „ Table for 5 years 23 „ Shelter 73 Infant Mortality 5, 12, 13 „ Rate 12 „ Tables 12, 16 Increase of Rent Ac 35 Institutions for Children 45 Inspections 49 Invalidity, Causes of 44 L Laboratory Work 114 Legal Proceedings 52 Leaflets 2 L.C.C. Ambulances 46 „ General Powers Act 1908 77 London Ambulance Service 46 " Liverpool Virus" 35 London Water Supply 151/158 M Maternity Home 1, 106, 45, 46, 116/123 Marriages 5 10 Marriage Rate 10 Marriages, Celebrated in 10 Maternal Mortality 127 Malaria 22, 34 Measles 21, 34, 113, 128 V. M—continued. PAGE Measles and overcrowding 34 Meat Regulations 4,24,81 Meat 80, 81 Metropolitan Asylums Board 45 Midwives Acts, 1902-18 127 Midwives 113 Milk, Dried 106 „ Sale of 76 „ Purveyors 77 „ Notice to Purveyors 72 „ for Necessitous Mothers 106 ,, Licences 78 „ and Tuberculosis 78 „ Supply 79, 80 „ and Dairies Act, 1922 77 and Dairies (Consolidation) Act, 1915 82 and Cream Regulations 1912, 1917 82 Mortuary Report 76 N Notices, Sanitary 49 Nursing in the Home 112 O Occupations 39.41 „ of Women 41,42 Offensive Trades 63 Ophthalmia Neonatorum 128,129 Orthopoedic Treatment 127 Outworkers 64 Overcrowding 3,34,56,57,59,60 P Paratyphoid B 30 Pemphigus Neonatorum 4 Physical Features of the Borough 35 vi. P—continued. PAGE Pneumonia 21 „ and Practitioners 23 „ and Housing 34 Poliomyelitis 128, 130 Population 5, 9 Preserved Cream 75 Public Health Act, 1925 2 „ ,, Meat Regulations, 1924 4 „ „ (Preservatives in Food) Regulations, 1924 4 „ ,, (Tuberculosis) Regulations, 1912, 1918 84 „ „ (Prevention of Tuberculosis) Regulations, 1925 4,98 „ „ (Dried Milk) Regulations, 1923 82 „ ,, (Condensed Milk) Regulations, 1923 82 „ „ Lectures 2 Public Press 2 Puerperal Fever 21 R Rag Dealers 44 Ranyard Nurses 113 R;it Week 35 Rats and Mice (Destruction) Act 35 Rent Aqts 35 Repairs and Cleansing 49 Restaurants 62 5 Sanitary Inspectors' Work 48 „ „ Visits 48 „ Circumstances of Area 48 ,, Staff Changes 48 „ Notices 48 Scarlet Fever 20,29 ,, „ and Milne Treatment 29 „ „ and Streptococcus Antitoxin 29 Schick Test 3 vii. S —continued. PAGE School Clinics 107 Scavenging 48 Separate Occupiers 5 Sewers and Rat Destruction 35 Sickness and Invalidity 44,45 Slaughterhouses 63,82 Smallpox 20 Smoke Nuisance 51 Soil 35 Sputum Tests 114 Stalls 81 Structually Separate Dwellings 37 Survey Report 1 T Tuberculosis, Dr. Donnelly's Report 83/98 „ Clinics 2,85 „ Care Committee 2 Care Work 95, 100, 105 Clerical Work 93 „ Co-operation work with General Practitioners 93,95 „ Disinfectants for 89 ,, Dental Treatment 90, 99, 100 ,, Deaths from 86 „ Following-up work 99 ,, Home visits 92 „ and I.C.A.A. 97 „ Institutional Treatment 89 „ Miss Lewellin's Report 100/105 „ Notifications and Deaths 86 ,, „ in Wards 87 ,, Non-Pulmonary Notifications 87 „ Observation of Cases 92 „ Order, 1925 4 „ Revision of Register 89 „ Shelters 100 „ Special Diagnostic Methods 99 ,, Sputum Tests 114 Viii U PAGE Ultra-Violet Rays 2 Unfit Dwellings 55 Unsound Food 69 V Verminous premises 74 Venereal Diseases 107 Visits of Health Visitors 115 „ Sanitary Inspectors 48 Vital Statistics 14 Voluntary Societies and Workers 127 w Watergate Street Area 2 Water Fittings 48 Water Closets 50 "Water Supply 150, 157 Whooping Cough 33, 115 Workplaces 62,64 Workshops 62,63 „ Register 68 z Zymotic Enteritis 131, 132 „ „ Death Rate 5 JR2/68