STO 26 . . THE . . Metropolitan Brough of Stake Wellington Report OF THE Medical Officer of Health and Public Analyst, FOR THE YEAR 1 922. BY HENRY KENWOOD, c.m.g., m.b., f.r.s.e., d.p.h., f.c.s., Chadwick Professor of Public Health, University of London, Medical Officer of Health and Public Analyst. LONDON: Printed by WILKINSON BROS., LTD., 37.43, Green Lanes, N. 16. 443 REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1922. To the Mayor, Aldermen, and Councillors of the Metropolitan Borough of Stoke Newington. Ladies and Gentlemen,— In this short Report for the year 1922, details as to conditions which do not vary from year to year have been omitted, and it contains little more than the particulars suggested by the Minister of Health in Circular 269 of December 28th, 1921. The suggestion is an excellent one, as there will be no reduction in the value of Annual Reports as records, whereas the conclusions arrived at and the recommendations made in a fuller Five Yearly Report will make these of far greater value than the usual Annual Reports. The Public Health Committee having approved of the suggestion made by the Minister, I have, compiled my Report for 1922 accordingly. The Vital Statistics of the Borough for the year 1922 are not so satisfactory as those for 1921, for both the general death.rate and the rate of infantile mortality were higher. These higher rates were entirely due to the exceptional mortality during the first quarter of the year, owing to the bad weather conditions and the prevalence of influenza, which were together responsible for 100 deaths (17 of which were of infants) during that quarter. On the other hand the Infectious Sickness Rate was less than one.half of that for 1921. Valuable services were rendered by those Medical Officers associated with me in the work of Maternity and Child Welfare and of Tuberculosis; and the record of work performed by all the officials of the Public Health Department is a very satisfactory one. I am, Ladies and Gentlemen, Your obedient Servant, HENRY KENWOOD. March, 1923. 444 TABLE OF CONTENTS Page The Borough of Stoke Newington 445 Vital Statistics— Population of the Borough 446 Births and Birth.rate 44 6 Mortality. Death.rates and causes of Mortality—with notes thereon 447, 452 Infantile Mortality 453,455. Communicable Diseases and the Measures taken to Prevent their Spread— The Infectious Sickness Returns for the Year 455 Diarrhoea and Enteritis 458 Tuberculosis 458 Cancer 448 Maternity and Child Welfare 465 Sanitary Administration— The Disinfecting and Cleansing station 466 Food Inspection 437 Housing 468 Scavenging 471 Factories and Workshops 471 Food and Drugs 472 Report of the Chief Sanitary Inspector 474 Streets in the Borough of Stoke Newington 478 445 THE BOROUGH OF STOKE NEWINGTON. The Borough of Stoke Newington is mainly a residential area, a considerable proportion of the population being employed elsewhere. The residences comprise those of the well.to.do and the tenements of the low.wage earner. There is no special industry carried on in the Borough, the factories and workshops are for the most part small, and the work engaged upon is of various kinds. A notable feature of the Southern portion of the Borough has been the considerable amount of " tenementation " within recent years of houses which were originally built for, and occupied by, one. family. There are two very large open spaces in the Borough, viz., Clissold Park and the area of the New River Water deposition ponds, filter beds and works. GENERAL STATISTICS. Area (Acres)—863. Population (Middle of 1922)—52,620. Number of Inhabited Houses (1922)—8,599. Number of Families or Separate Occupiers (1922)—8,942. Rateable Value—£343,874. Sum Represented by a Penny Rate—£1,390. THE STAFF OF THE PUBLIC HEALTH' DEPARTMENT. Medical Officer of Health (Part.time)—Dr. H. R. Kenwood. Sanitary Inspectors—D. W. Matthews (Chief). A. P. Piggott. R. F. Rogers. Clerks—R. F. Rogers and S. G. Armstrong. Disinfector, &c.—F. C. Screach. 446 Maternity and Child Welfare— Clinic's MeHdical Officers—Dr. J. S. New and Dr. M. Muncey. Superintendent—Miss H. Reeve. Health Visitors—Nurse F. Stamford. Miss Sandeman. Tuberculosis— Dispensary Medical Officer—Dr. L. U. Young. Tuberculosis Nurse—Nurse Ager. Measles, Whooping Cough, Etc. Borough Nurse (Ranyard Nurse) and Nurse Ager. POPULATION. The population at the last census (1921) was 52,167. The following estimate of population for the middle of 1922 has been adopted by the Register.General for the calculation of the death.rate and birth.rate of the Borough for the year 1922 :— 52,620. BIRTHS. During the year 1922 there were 937 births, viz:—490 males and 447 females. The birth.rate per 1,000 per annum was therefore 17 8, as against 20 4 for the preceding year. Year. Birth.rate. Rate for London generally Rate for England and Wales. 1918 14.0 1.61 17.7 1919 16.8 18.3 18.5 1920 23.1 26.5 25.4 1921 20.4 22.8 22.4 1922 17.8 21 .0 20.6 447 The illegitimate births numbered 34 ; 18 males and 16 females. During the year the births notified under the Notification of Births Act have been compared with the births registered by the Registrar of Births, and the respective figures are 821 and 937. MORTALITY. General Mortality.—There were 392 deaths of residents registered in the Borough, and 287 of residents who died in Public Institutions outside of the Borough, making a total of 679 deaths. Of these 348 were of females, and 331 were of males. Year. General Death.rate. Rate for London generally. Rate for England and Wales. 1918 16.0 18.9 17.6 1919 12.2 13.4 13.8 1920 12.4 12.4 12.4 1921 11.5 12.4 12.1 1922 12.9 13.4 12.9 The recorded general death.rate is therefore 129, as against 11.5for the preceding year. The liberal relief which is being granted throughout a period of great industrial depression is the chief factor—more especially by maintaining the food supply of those who are out of work—in securing the favourable state of the public health, whatever its other effects may be upon the economic life of the community. THE CAUSES OF DEATH.—These are fully set forth in Table I., in which it will be noted that the deaths are also apportioned to different age periods. 448 Comparing this table with the corresponding table of the preceding year, the following facts are noteworthy : An increase in the deaths from Influenza, Diseases of the Lungs, Heart Disease, and Congenital Debility and Premature Birth ; and a decrease of those from Diarrhoea and Enteritis, Diphtheria, Nephritis and Cancer. CANCER. The death.rates from Cancer in England and Wales during recent years have been as follows : England and Wales. Year. Rate per thousand of population. 1913 1.064 1914 1.069 1915 1.121 1916 1166 1917 1.210 1918 1 218 1919 1145 1920 1.161 Cancer nowadays contributes one to every 12 deaths registered. It is now as fatal as that other great scourge, Pulmonary Tuberculosis or Phthisis. Cancer is most prevalent among those of 40 years of age and upwards. An excess of cancer in the female sex is accounted for by the prevalence of cancer of the female breasts and generative organs. The increase in cancer mortality is world wide ; and better diagnosis, improved statistics and the increase in the mean duration of life will explain much of this increase. Taking an equal number of persons living above the age of 15 years, exactly the same proportion is destined to die from cancer whether the individuals live in a rural district, an urban district, or in a county borough. 449 The problem is to get the case into the hands of a competent medical adviser while it is still in the early and curable stage, or even more fortunately, while the patient exhibits merely those conditions which are now widely recognised as predisposing factors in the causation of Cancer. The evidence of the relationship of Cancer to irritation and local injury is overwhelming. The prolonged irritation caused by smoking clay pipes which stick to the lips, by broken jagged teeth which irritate the tongue, by gall.stones and stones in the kidney. The scratching of moles and warts and their irritation by clothing, or the application of irritating liquids, ointments and pastes to innocent growths. Chimney sweep's Cancer is now almost unknown, Tar Boiler's Cancer is rare, Cancer of the lips is much rarer since clay pipes went out of fashion. Many cases of Breast Cancer were clearly due to mid.Victorian taste in corsets. Cancer of the Liver was very often due to habits of constipation. The Danger Signals of Cancer. It must be emphasised that none of these signs necessarily signify Cancer. They may be due to Cancer ; and all middle.aged individuals must realise this and act accordingly. In middle.aged women any irritating, malodorous or biood. streaked discharge needs to be investigated. It must not be simply ascribed to " the change of life." Any marked increase of menstruation setting in during middle life or bleeding during the periods, or an increased flow at change of life, or recurrence after it has stopped, are also to be suspected. A " lump " in the breast is a serious symptom. In either sex, in middle.aged persons, the following symptoms call for action : Prolonged disturbance of the 450 digestive tract in one previously in good health, any bleeding from the back passage, or blood in the urine, or recurrent bleeding from the nose or throat. Any formerly innocent growth which begins to rapidly enlarge and become harder ; any wart, mole, old scar which changes in appearance or slight ulceration on the face, or a persistent crack or scaly patch on the lips which do not heal. Loss of weight and Ana:mia. Cancer is generally painless for many months. Pain is a late symptom. To wait until pain occurs is to make cure almost hopeless. It always begins as a local disease, and while still localised, any case can be cured by surgical, X.rays, radium, or other treatment. When the disease has spread and involved outlying parts, the prospect of cure is remote. If people will only pay attention to these danger signals and early seek medical advice, thousands of premature deaths can be prevented. Popular education as to these matters is a serious need, and for this and other reasons it is a question whether Cancer Clinics in large towns would not fulfil a very useful purpose. It is calculated that there is an average loss of about one year before submitting to skilled treatment, and that not one person in ten comes sufficiently early for effective treatment. It is recorded that 40 per cent, of all cases of Cancer of the Rectum are quite incurable by the time appropriate treatment is submitted to. Hundreds every year pay the penalty of death for shrinking from surgical interference. The money that is made every year by capitalising the hopes and fears of Cancer sufferers is without doubt very great. These quacks, large in pretence and promise, encourage the patient to expect relief till his money is 451 exhausted and his disease too far advanced for cure by operation or other recognised methods. Bottles of medicine, and the application of ointments and paste cannot cure Cancer. Some Further Facts. There is no clear evidence that Cancer is inherited. The disease is so frequent that by the very law of chance more than one case may occur in some families. Life Insurance Companies do not regard Cancer in the family as a reason even for increasing premiums. It is no more frequently found in married couples than chance may account for. The disease is not contagious to others. There are probably no true " Cancer houses" or " Cancer villages." The circumstance that the disease has been unusually prevalent in a house or village is sufficiently explained by coincidence or the exceptional favourable ages of the dwellers. A village from which the younger people have gone to obtain work elsewhere would naturally furnish a larger number of cases of cancer than another village of equal population with the usual proportion of young people. The strong and healthy are often attacked. There are grounds for believing that some protection is conveyed by attention to personal hygiene, by being cheerful, interested and free from anxiety, and by partaking of a simple and moderate diet, and with plenty of fruit and vegetables. Cancer, then, is a disease which can often be prevented, if the predisposing factors are recognised and removed ; and if dealt with in time, it can often be cured. 452 TABLE I. CAUSES OF AND AGES AT DEATH DURING THE YEAR 1922. Causes of Death. Nett Deaths at the subjoined ages of " Residents" whether occurring within or without the Borough. Total Deaths whether of " Residents " or " NonResidents " in Institutions in the Borough. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and upwards. Cerebro.spinal Meningitis 1 . . 1 . . . . . . Encephalitis Lethargica . . . . . . . . . . Enteric Fever . . . . . . . . . . Acute Polio.myelitis . . . . . . . . . . Measles 3 2 . 1 . . . . . . Scarlet Fever 3 — — — 1 1 I — — — Whooping Cough 1 1 . . . . . . . . Diphtheria and Croup 8 — 2 2 3 1 — — — — Influenza 29 — — — — 2 6 9 12 — Erysipelas — — . — — — — — — — Phthisis (Pulmonary Tuberculosis) 40 . . . . 4 21 11 4 — Other Tuberculous Diseases 7 . 1 2 1 1 1 1 . . Cancer (Malignant Disease) 70 . . . 2 . 6 32 30 3 Rheumatic Fever 2 — — . 1 — 1 — — 1 Meningitis 3 2 1 — — — — — — — Organic Heart Disease 72 2 — — 3 1 11 22 33 10 Bronchitis 62 3 — — — — 4 10 45 14 Pneumonia (all forms) 74 13 8 4 — 0 7 16 21 4 Other Diseases of Respiratory Organs 9 1 1 1 1 5 Diarrhoea and Enteritis 3 2 — — — — —. 1 . — Appendicitis and Typhilitis 3 . . . 1 2 . . . . Cirrhosis of Liver 3 . . . . . . 1 2 3 Alcoholism . . . . . . . . . . Nephritis and Bright's Disease 20 . 1 . 1 . 5 7 6 3 Puerperal Fever 1 . . . . . 1 . . . Other Accidents and Diseases of Pregnancy and Parturition 4 . . . . 1 3 . . . Congenital Debility and Malformation (including Premature Birth) 30 29 1 . . . . . . 2 Violent Deaths (excluding Suicide) 15 . . 1 2 1 3 1 7 1 Suicide 4 — —. — — — 2 — —• Other Defined Diseases . 203 6 — 4 1 4 18 55 115 23 Diseases ill defined or unknown 9 2 . 1 . . 1 3 2 . Totals 679 63 15 16 17 23 92 169 284 64 453 INFANTILE MORTALITY. There were 63 deaths registered of infants under one year of age, as against 937 births ; the proportion which the deaths under one year of age bear to 1,000 births, is therefore, 671 as against 531 in the preceding year. Year. Rate of Infantile Mortality. Rate for London generally. Rate for England and Wales. 1918 87.2 107 97 1919 62.6 85 89 1920 80 0 75 80 1921 53 1 79 83 1922 67.1 74 77 A comparison of the causes of Infantile Mortality in 1922 with those of the preceding year shows a slight increase during last year in the deaths from Bronchitis and Pneumonia, Congenital Defects and Weaknesses, and Measles ; whereas there was a decrease in the deaths from Diarrhoea and Enteritis. The causes contributing to a high rate of mortality have been discussed in previous reports, and it will suffice to call attention to the fact that of 63 children who died under the age of one year, 28 deaths were ascribed to Prematurity, Wasting, and Congenital Defects, and 16 to Bronchitis and Pneumonia, a total of 44 deaths resulting from these two groups. Our mean Infant Mortality Rate for the past 14 years is one to be proud of. For this long period, embracing the difficult times of the Great War, it is only 77. If the rate of mortality of London generally had applied to Stoke Newington we should have lost considerably more infants. The mean rate of mortality among infants in Stoke Newington during the past 14 years represents a saving of some 500 infant lives as compared with those which would have been lost if there had been no improvement upon the mean rate of mortality during 1901.1908, when previous to 1907 our rate of infant mortality had never fallen below 108, it was not considered likely that in only a few years a mean rate of 77 would be reached. It is now safe to predict that the rate can never again approach to its former dimensions so long as our present.day public 454 TABLE II.—INFANT MORTALITY. NETT DEATHS FROM STATED CAUSES AT VARIOUS AGES UNDER ONE YEAR OF AGE, 1922. 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 3 months. 6 months and under 9 months. 9 months and under 12 months. Total deaths under 1 year. Influenza . . . . . . . . . . Cerebro.spinal Meningitis . . . . . . . . . . . Chicken.pox . . . . . . . . . . Measles . . . . . . 1 — 1 2 Scarlet Fever . — . . — — — . — — Whooping Cough . . . . . 1 . . . 1 Diphtheria and Croup . . . . . . . . . . Erysipelas . — . . — — — — — —. Tuberculosis Meningitis . . . . . . . . . . Other Tuberculous Diseases 1 — . . 1 . — . — 1 Meningitis (not Tuberculous) 1 — 1 . 2 — — 1 — 3 Convulsions 1 — . . 1 — 1 . — 2 Laryngitis . . . . . . . . . . Bronchitis . — 1 . 1 1 — . 1 3 Pneumonia (all forms) . 1 . . 1 5 1 4 2 13 Diarrhoea . — . . — — — — — — Enteritis . 1 . . 1 — 1 — — 2 Gastritis . — . . — 1 — — — 1 Syphilis . — . . — — — — — — Rickets . . . . . . . . . . Suffocation, overlying . — . . — — — — — — Injury at Birth . — . . — — — — — — Atelectasis 1 — . . 1 — — — — 1 Congenital Malformation 3 — . . 3 1 — —. — 4 Premature Birth 7 1 1 1 10 1 — — — 11 Atrophy, Debility and Marasmus 2 1 1 . 4 5 3 1 . 13 Other Causes 3 2 . . 5 . . . . 6 Totals 19 6 4 1 30 15 7 6 5 63 455 health efforts continue. But if a further substantial reduction is to take place it will, in my judgment, be due to the adoption of fuller measures in the direction of ante.natal work; for practically the whole of the deaths during the first month of life are due to ante.natal circumstances. It will be noted that during 1922 these deaths during the first month of age amounted to nearly 48 per cent, of the total infant mortality during the first year of life, in Stoke Newington. These excellent public health results have been obtained at a very low cost to the community ; for, when the Government grant is credited against our local expenses, the net cost of the whole of the work to the ratepayers of Stoke Newington has not exceeded one.fifth of a penny rate. THE MORTUARY. During the year, 61 bodies were deposited in the Public Mortuary. Post.mortem examinations were performed upon 32 of these. INQUESTS. 51 Inquests were held upon Deaths of Parishioners during the year 1922. COMMUNICABLE DISEASES. It will be seen from Table IV. that 376 Notification Certificates of Infectious Illness were received from medical practitioners. The Infectious Sickness Rate of the Borough, excluding the notifications from Tuberculosis, Cerebro.Spinal Meningitis, Acute Polio.Myelitis, Encephalitis and Ophthalmia, so as to make the rate comparable with that of former years, was 51 to each 1,000 of the population, as against 121 for the preceding year. Year. Infectious Sickness Rate. 1918 3.8 1919 5.4 1920 8.0 1921 121 1922 51 456 TABLE IV. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1922. Notifiable Disease. At all Ages. Number of Cases Notified. Total Cases Notified in each Locality—(e.g., Parish or Ward) of the District. Total Cases removed to Hospital At Ages—Years. Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 65 and upwards 1 North Division 2 South Division Small Pox — - - - - - - - - - - Cholera — — — - — — — — —. —. - Plague — - - - - - - - - - - Diphtheria, including Membranous Croup 93 2 25 49 9 6 2 - 36 57 81 Erysipelas 1.1 — 1 1 3 2 4 — 3 8 - Scarlet Fever 158 — 31 95 25 6 1 - 42 116 142 Typhus Fever — — — — — - — — - - Iinteric Fever - - - - - - - - - - - Relapsing Fever - - - - - - - - - - - Continued Fever - - - - - - - - - - - Puerperal Fever 6 - - - 3 3 - - 1 5 5 Cerebro-spinal Meningitis - - - - - - - - - - - Polio-myelitis - - - - - - - - - - - Ophthalmia Neonatorum 4 4 — — — — — — 2 2 - Pulmonary Tuberculosis 70 — — 7 17 31 14 1 8 62 54 Other forms of Tuberculosis 8 — 1 2 2 2 1 — — 8 8 Measles — — — — — — — — — — — Influenza - — — — — — — — — — - Pneumonia 26 — — 2 8 12 4 - 9 17 - Malaria — — — - — — — - — — — Dysentery — — — — — — — - — — — Encephalitis Lethargica — — — ~~ — — — — — — — Totals 376 6 58 156 67 62 26 1 101 275 290 457 BACTERIOLOGICAL DIAGNOSES. The "diagnosis outfits " supplied by the Council to the medical practitioners in Stoke Newington are of great service. The following is a statement of the applications received during 1922, together with the results of the examinations performed at the Lister Institute of Preventive Medicine, London. Disease. Results. Total. Positive. Negative. Phthisis 19 55 74 Diphtheria 14 118 132 Enteric 2 2 Total 33 175 208 Many applications have been made at the offices for tubes of " antitoxin," which I store for the convenience of local practitioners. A limited amount of "antitoxin" is supplied free of cost to those who are judged to be unable to pay for it. The expenditure on this account is limited to £10 per annum, except in years of epidemic prevalence of Diphtheria. During the year there were no occasions on which there was delay in securing the removal to hospital of notified cases of Scarlet Fever and Diphtheria. The arrangements made in 1919 for securing the services of a visiting nurse in connection with cases of Measles, Whooping Cough, Summer Diarrhoea and Ophthalmia, occurring amongst infants and young children. proved very useful during the year. It is, however, certain that during a severe epidemic of Measles or Whooping Cough the arrangement with a nurse who is already undertaking other nursing duties will not suffice, and the Ranyard Nurses Mission have undertaken on these occasions, if and when so ordered by the Borough Council, to provide temporarily an additional nurse at the low cost of two guineas per week. 458 DIARRHOEA AND ENTERITIS. There were only 2 deaths from this disease among children under 2 years of age. The death-rate is best expressed as the proportion which the deaths under two years of age from these diseases form to a thousand births. The rate is only 2T, which compares favourably with the rate for London generally (6.2) In 1922 meteorological conditions favoured a low rate. INFLUENZA. The deaths directly ascribed to this disease numbered 29. Nurse Ager paid visits to several cases reported to various officials of the Council. MEASLES. Measles in a mild form was prevalent during a part of the year, and Nurse Ager paid 85 visits to infected homes. PHTHISIS (CONSUMPTION) AND OTHER FORMS OF TUBERCULOSIS. The death-rate from Consumption (Pulmonary Tuberculosis) in the Borough for 1922 was 0.76 per 1,000, as against 0 98 for London generally. Seventy cases of Phthisis were notified under the Public Health (Tuberculosis) Regulations, 1912. Twenty of the notified cases were insured under the Insurance Act. Nurse A. Ager, who is appointed to give part-time services in connection with the Tuberculosis work within the Borough, has, acting under the instruction of the Medical Officer of the Tuberculosis Dispensary and myself, dealt with 63 fresh cases during the year, and has made in all 698 visits. 459 The Tuberculosis After-Care Committee appointed by the Borough Councils of Hackney and Stoke Newington rendered valuable services during the year. The address of the Secretary is 38, Pembury Road, Clapton, E.5. Medical practitioners in Stoke Newington may be said to be notifying the disease better than in many districts—for whereas the number of notifications of Tuberculosis does not much exceed that of the deaths registered from the disease, in Stoke Newington they are generally about double. It is, however, probable that the actual number of sufferers in any year approximates to three times the number of deaths. THE WORK OF THE TUBERCULOSIS DISPENSARY IN 1922 IN REFERENCE TO STOKE NEWINGTON. The following facts show the work done in connection with the Dispensary, so far as Stoke Newington is concerned, during the year 1922. The figures recorded on the following page compare favourably with those of the preceding year. (Vide my annual report for 1921.) The number of attendances of Stoke Newington patients were 1,544 during 1922, as compared with 1,437 during 1921. The total number of Stoke Newington contact cases examined at the Dispensary was 80. At the end of the year I ascertained the home circumstances of the cases of Pulmonary Tuberculosis who were at that time resident in Stoke Newington, and known to be expelling the germ of the disease in their spit. There were 40 such cases, and in 12 instances they occupied a bedroom that was shared by from one to three children under 12 years of age. Altogether there were 21 children under 12 thus exposed to infection under specially dangerous circumstances ; for although the majority of the patients had been in Sanatoria, it is impossible to avoid the spreading of some infection throughout the night. The infection in these bedrooms would certainly continue present and active week after week, and the resistance of the children to the possibility of the repeated infection was doubtless in most cases lowered by the poor feeding and housing conditions. 460 It is but logical to maintain that any scheme for the reduction of Tuberculosis which neglects the fundamental need of either removing such children from the danger of infection or of removing the danger of infection from the children, is quite out of perspective. It is because so little is done to protect those who are specially exposed to infection that the death-rate from Pulmonary Tuberculosis shows no greater decline since our special schemes were introduced than that which was taking place for many years previously. To deal with the disease more on the principles of prevention is to face the problem on the lines of greatest resistance. It is admittedly a difficult problem ; but if attacked it would prove far less difficult than is generally believed. I am convinced that if suitable provisions existed for removing the patient, or alternatively removing the children, in most, if not all, of the 12 homes I refer to above, those provisions would be gratefully availed of. The beds of most centres for the isolation and treatment of advanced cases are at all times occupied, and there is generally a demand for further accommodation. Such a removal from a generally impoverished family withdraws a member who is absorbing too much of a very limited income; and where others are placed at grave risks there should be powers for compulsory removal. Probably resident institutions for children who are specially at risk when the advanced case, poorly housed and cared for, cannot be removed, would be one of the wisest provisions that could be made for checking the onslaughts of this disease. In such institutions they would be properly fed, clothed and housed, and suitably educated and trained while the source of danger remains in the home— a period which would not exceed an average of 12 to 18 months. The early recognition of infection and the skilled treatment of sufferers in sanatoria and outside of them is, of course, essential from the preventive standpoint ; but I am convinced that next to improved social and industrial conditions, which will always continue to play the major part, must come the adoption of measures of dealing with those who are running special risks in early life; and until this is done no scheme for the reduction of tuberculosis can satisfy. 461 BOROUGH OF STOKE NEWINGTON TUBERCULOSIS DISPENSARY. Year 1922. Insured Persons. Male. Insured Persons. Female. Uninsured Persons. Male. Uninsured Persons. Female. Contacts. Male. Female. Total. I. U. I. U. New Patients Attending 33 16 16 36 12 20 12 36 181 Attendances of Old Patients 449 172 228 331 16 34 35 98 1,363 Home Consultations 10 5 4 4 - - - - (new) (old) 6+17 = 23 Sputa Examined 124 20 27 33 4 - 6 3 217 Original Cases found Pulmonary Tuberculosis 46 Contact „ „ „ „ 2 48 Original „ „ Non-Pulmonary Tuberculosis 10 Contact „ „ „ „ 1 11 Original ,, ,, Doubtful 9 Contact „ „ „ 3 12 Original „ „ Not Tubercular 42 Contact „ „ 74 116 Total of new cases 187 L. U. YOUNG, m.d., d.p.h., Medical Officer. 462 Dr. L. U. Young (the Tuberculosis Medical Officer) reports: "With regard to Institutional treatment, for which the London County Council is responsible, it appears to be easier to obtain vacancies in Sanatoria during the winter months. In the summer months many cases have been refused Institutional treatment, owing to lack of beds. Patients recommended for Sanatorium treatment from the Dispensary have been requested to attend at the County Hall, Westminster, for further examination, and, in some instances have, without apparent reason, been referred back again. This procedure has proved disappointing and disheartening to many patients, and they have complained of the unavailing trouble and expense entailed. "Accommodation for advanced cases is still inadequate, and there are many 'open' or infectious cases, whose home conditions are bad, who would be safer in an institution, if provision for their segregation could be obtained. "Stormont House Open Air School, at Hackney Downs, has entirely justified its existence. The classes remain full, and there is still material to be found if more accommodation could be provided. The benefit derived from this form of treatment has been apparent in the children attending from this Dispensary. "A scheme has quite recently been evolved by the London County Council, with regard to children of school age, by which a still closer co-operation between the School Medical Officer and the Tuberculosis Officer will be effected. Under this scheme, cards are issued by the London County Council (M O. 333) upon which the Tuberculosis Officer will enter the name, address, date of birth, school, borough and dispensary, and in the case of an ' unsatisfactory' child, brief medical particulars relating to the case. The procedure at the Dispensary relates to:— (a) All 'unsatisfactory' children, whether contacts or not, who, after a period of observation at the Dispensary, are considered to be probably Non-Tuberculous, but who require supervision. 463 (b) All contacts who on first examination are apparently healthy, and also, as far as possible, all other contacts who have not been examined. "Each case will be classified by the Tuberculosis Officer under one of the following headings, and the card then sent on to the Divisional School Medical Officer:— Class 1. An 'unsatisfactory' child, whether contact or not. Class 2. An apparently healthy contact, or Class 3. A contact who has not been examined. "Procedure in the School:— Class 1 shall be (a) Examined by the School Medical Officer quarterly and referred back to the Dispensary if at any time, in his opinion, the child should be regarded as probably Tuberculous. (b) Weighed approximately monthly, and the weight recorded on the chart on M.O. 333. Class 2 shall be (a) Examined once a year. (b) Weighed quarterly. Class 3 shall be Examined as soon after reference as possible, classified by the School Medical Officer, and dealt with as Class 1 or 2, as the case may be. "A conference will be held once a year between the Divisional Medical Officer and the Tuberculosis Officer, at which the records of all cases referred under the scheme will be reviewed, and the cases re-classified or discharged from observation. "In order to suit the requirements of the Education Authorities, an extra session, for school children only, will in future be held at the Dispensary on Fridays, from 5 to 6 o'clock. 464 "The London County Council requires that more home visiting should be done by the Tuberculosis Officer, and suggests that 'he should visit at least once the home of each patient, unless he considers that in the interest of the patient a visit would be undesirable.' As so much time has to be spent by the Tuberculosis Officer in writing up reports and attending Committee Meetings, apart from the routine work of the Dispensary, the time available for extensive home visiting, within such a large area as that covered by the Dispensary, is limited. "The Borough Health Visitors continue to attend the Dispensary once a week, and submit reports on the home conditions of the patients, and also report on any cases which require special attention. Thus a close working arrangement is carried out, under the supervision of the Medical Officers of Health, between the Dispensary and the Public Health Departments of the Boroughs. "All cases requiring the attention of the Borough After Care Committee are reported by the Tuberculosis Officer, and he attends all the meetings of the Committee. "Many cases have been referred to the Medical, Surgical, Ear and Throat, Dental and X-ray Departments of the Hospital for diagnosis or treatment. During the year, through the kindness of Dr. Loughborough, five cases of Gland Tuberculosis were treated by the application of X-rays, and showed much improvement. "I am greatly indebted to the members of the Hospital Medical and Surgical Staff for their kind co-operation, and to Mr. Rutherford and Matron for supervising the needs of the Dispensary. "I wish to express my thanks also to the Medical Officers of Health, Drs. Kenwood and Dart, for their guidance and kind assistance in administrative problems. "Miss Fellowes, Secretary-Dispenser, has worked well and conscientiously, and the Nurses have proved most satisfactory." 465 MATERNITY AND CHILD-WELFARE WORK. As in past years, Maternity and Child Welfare took a very prominent place in the public health work of the Borough Council, and I have pleasure in testifying to the fact that all those officials employed upon it rendered high-quality services. The work continues to grow, and is therefore increasingly valued by the mothers. Indeed the work at the two Centres could not be conducted on Monday and Thursday afternoons, but for the much-valued assistance of the six voluntary workers who attend on those days. The following facts will indicate the scope of the work undertaken. 1920 1921 1922 Infants born 1223 1073 937 Home visits paid—Primary 1156 1143 1073 Home visits paid -Secondary 1932 2424 3042 Children on Register of Welfares 853 1059 1032 Attendances of Children at Centres 6727 9198 7640 Attendances of Mothers at Needlework Class 608 580 382 The attendances at the Children's Consultations are fewer— partly on account of the smaller number of births, and partly on account of the bad weather during the first quarter of the year. Mothers are advised not to bring delicate infants when winds are keen. ANTE-NATAL WORK. The number of new cases attending during the year was 74— a much higher proportion than last year, in relation to the number of births in the Borough. 466 The attendances amounted to 176, some of the cases needing special supervision as difficulties during labor were suspected. The number of cases removed from current list during the year was 66. Of these, there is no record of 5, and 9 were found not to be pregnant. Of the remaining 52 cases, 49 resulted in normal confinements, and 3 miscarried. Six cases were put on the Milk Order list for free milk. Dr. Muncey directs attention to a real need which is always felt by those who have to deal with nursing mothers and their children, and Tuberculosis. There is a vast amount of handicapping and unnecessary suffering, malnutrition and disease, resulting frorm the neglect of dental advice and treatment; and so many Health Authorities are now providing for dental services in connection with the above-mentioned branches of public health work. Under paragraph 24 of the Maternity and Child Welfare Circular of the Local Government Board of the 9th August, 1918, a grant of half the expenditure on dental treatment is repayable, and the Board stated that "a dental clinic should, whenever practicable, be available for expectant and nursing mothers and for children under five." The most economical method of providing the necessary treatment would appear to be either by arranging with the Education Authority for the use of a joint clinic, or by making special arrangements with a local dentist, by which he would treat at his own consulting room patients sent by the Medical Officers of the Welfare Centres and Tuberculosis Dispensary. The latter arrangement would save all expenses of equipment and maintenance of dental instruments and appliances, and could probably be put into operation more quickly. THE DISINFECTING AND CLEANSING STATION. During the year ending December 31, 1922, the following disinfecting and cleansing work was performed at the station:— Total number of textile articles disinfected 15,243 Total number of books from Public Library disinfected 59 Total number of verminous persons cleansed 424 All the verminous persons cleansed were children of school age. 467 In addition to the disinfection of rooms on account of the notified infectious diseases, 64 were fumigated on account of vermin, 15 on account of Consumption, 5 on account of Cancer, and a few on account of Measles and Whooping Cough. During the year the Borough Council continued its agreement with the Education Department of the London County Council to bathe and cleanse verminous school children, and 424 of such children were cleansed. SANITARY ADMINISTRATION. It will be seen from the accompanying Report of the Chief Sanitary Inspector that a large amount of sanitary work has been performed during the year; 2,519 premises were inspected for conditions injurious or dangerous to health, and insanitary conditions varying in their nature from slight to grave were discovered to the number of 1,538; 593 Intimation Notices, followed in 46 cases by Statutory Notices, were complied with. 2,697 re-inspections were made, making a total for the year of 5,216 inspections. The slaughter-houses (4), bake-houses (27), and dairies (68), situated in the Borough, were all inspected during the year. The Common Lodging House was closed in the year 1918. FOOD INSPECTION. During the year many systematic efforts were made to detect the sale of diseased meat within the Borough, and I. am glad to say that, with few exceptions, our inspections (484) have not called for any seizures. Fifteen hundredweight of unsound food was voluntarily surrendered during the year. Premises where food is prepared and stored have been kept under supervision. The Dairies have been systematically inspected during the year. No cows are now kept in the Borough. RESTAURANT KITCHENS AND EATING HOUSES. There are 15 of these premises in the Borough. The results of the inspections, both of the food and the kitchens, have been satisfactory. 468 HOUSING. No material industrial development of Stoke Newington is likely, and the demand for houses will continue to come from those who are industrially employed elsewhere. But there is an urgent need of more dwellings in Stoke Newington in order to reduce the excessive occupation of many existing ones. Of the dwellings in the Borough (8,599), 3,978 are of a workingclass rental and type. Although the average annual increase of population for the five years before the War was about 8 per 1,000, no new working-class dwellings were erected for over ten years. During the year 1922 many of the least satisfactory dwellings within the Borough were inspected. Some of these are old and unsatisfactory in sanitary respects. It cannot be said that their closure and demolition is urgent. They are kept under frequent inspections and in most of them we have imposed restricting conditions as to occupancy. During the year 1921 the Council Flats (18 Tenements) were occupied; but no suitable site was available for further building by the Council. The houses in Masons' Court and Place were very much improved by structural and repairing work, and these dwellings have in my opinion been rendered fit for human occupation for several years to come. STATEMENT ON HOUSING CONDITIONS. Statistics. Year ended 31st December, 1922. 1. Number of new working-class houses erected under Municipal Housing Scheme 18 2.—UNFIT DWELLING-HOUSES. I.—Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1,870 469 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 36 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation — (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 569 II.—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 569 III.—Action under Statutory Powers. A.-—Proceedings under section 28 of the Housing, Town Planning, etc., Act, 1919 — B.—Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 569 470 (2) Number of dwelling-houses in which defects were remedied:— (a) by owners 569 (b) by Local Authority in default of owners — C.—Proceedings under sections 17 and 18 of the Housing, Town Planning, etc., Act, 1909 3.—UNHEALTHY AREAS. Areas represented to the Local Authority, with a view to Improvement Schemes under (a), Part I., or (6), Part II., of the Act of 1890 — 1.—Number of houses not complying with the building bye-laws erected with consent of Local Authority under section 25 of the Housing, Town Planning, etc., Act, 1919 - 2.—Staff engaged on housing work with, briefly, the duties of each officer:— Two Sanitary Inspectors, One Clerk and part-time Sanitary Inspector INCREASE OF RENT AND MORTGAGE INTEREST (RESTRICTIONS) ACT, 1920. SECTION 2 (2). This sub-section provides that "at any time or times not being less than three months after the date of any increased rent permitted by the Act, the tenant is entitled to apply to the County Court for an order suspending the increases if he considers that the premises are not in all respects reasonably fit for human habitation, or otherwise not in a reasonable state of repair. He will be required to satisfy the County Court by a report of the Sanitary Authority, 471 or otherwise that his application is well founded, and for this purpose is entitled to apply to the Sanitary Authority for a certificate." Twenty-nine applications were made to your Authority during the year, and in every instance a certificate was granted. SCAVENGING. The Scavenging of the Borough is satisfactorily provided for and carried out by an efficient weekly collection of the house refuse, which is brought in covered carts to the Destructor in Church Walk. Trade refuse is collected and disposed of on terms agreed upon. The streets and yards are well scavenged. RATS AND MICE (DESTRUCTION), ACT. 1919. In April, 1920, at the request of the Board of Agriculture and Fisheries your two Sanitary Inspectors, Mr. D. W. Matthews and Mr. A. P. Piggott, were appointed Officers under the above Act. During 1922, 50 premises were freed from rats, and 6 remained under observation. FACTORIES, WORKSHOPS, AND WORK-PLACES. The usual inspections of these premises were made during the year. The Workshops and Work-places now number 338, and they are maintained in a fairly satisfactory condition. There are at present 63 out-workers who work for places of business situated within the Borough, and 558 out-workers dwelling in Stoke Newington working for businesses outside of the Borough. 472 TABLE V. ANALYSES PERFORMED UNDER THE SALE OF FOOD AND DRUGS ACTS DURING THE YEAR 1922. Article submitted for Analysis. (176) No. of Genuine Samples No. of Adulterated Samples Remarks as to Adulteration. Baking Powder 2 - Beef Sausage 4 - Borax 2 - Butter 24 - Cocoa 1 - Coffee 6 - Coffee and Chicory 1 - Corned Beef 1 - Cream 1 - Sold without label. Vendor cautioned. Cream, Preserved . 2 - Flour 3 - Green Peas (tinned) 1 — Ice Cream . 2 - Jam, Strawberry . 1 - Lard 3 - Margarine 19 - (1) Nearly 8½% of added water. Summons withdrawn as Warranty pleaded. (2) Faint deficiency in solids-non-fat. Milk 79 7 (3) Slight deficiency in solids-non-fat. (4) Slight deficiency in solids-non-fat. (5) Slight deficiency in fat. (6) Slight deficiency in fat. Paste (Salmon and Shrimp) . 1 - (7) Slight deficiency in fat. Paste (Ham) 1 - Paste (Salmon and Anchovy) 1 - Paste (Chicken, Ham and Ton- gup) 2 - Paste (Ham and Tongue) 1 - Paregoric 1 - Pork Sausage 1 - Sweet Spirit of Nitre 1 1 5-10% deficiency in Ethyl Nitrite. (1) 44.3% under proof. Notice exhibited. (2) 37.25% under proof. Defendant ordered to pay £2 2s. costs. Whisky 3 1 (3) 35.2% under proof. Notice exhibited. (4) 35% under proof. Notice exhibited. Wine, "Muscado" 1 - Wine, "Sarsaparilla" 1 - Wine, "Valento". 1 " 473 Nine of the samples purchased in the Borough in 1922 were not satisfactory; and, therefore, the percentage of non-genuine samples amounted to 5T per cent., which is the same figure as that for the preceding year. This is below the figure for London as a whole. 81 per cent. of the 86 Milk samples were unsatisfactory, as against 5 8 per cent. during the preceding year. In London as a whole, the percentage of Milk samples reported against was above that in Stoke Newington. It should be added that many of the other samples purchased were below the average quality of the Milk supply of London, although they were a trifle above the low legal limits which have been fixed. All the samples of Milk, Butter and Margarine were tested for antiseptics, with the result that no sample of Milk, 12 of Butter, and 18 of the samples of Margarine were found to contain boric acid. In no case was the amount sufficient to warrant a prosecution ; but in one instance the vendor was cautioned. Antiseptics were also found in 3 samples of wine, 3 of sausage, and 2 meat pastes. No informal samples have been taken during the year. Eighteen samples of Milk were purchased on Sunday mornings. THE PUBLIC HEALTH (MILK AND CREAM) REGULATIONS. During the year 1922 three samples were taken under these Regulations. Two were samples of preserved cream, and one was sold as unpreserved. All three samples contained preservative, and the vendor of the cream sold as unpreserved was cautioned. The other 2 samples were sold in full compliance with the Regulations, 474 REPORT OF CHIEF SANITARY INSPECTOR FOR THE YEAR 1922. To the Mayor, Aldermen, and, Councillors of the Metropolitan Borough of Stoke Newington. Ladies and Gentlemen,— I beg to present my Annual Report for the year ending 31st December, 1922:— HOUSES AND PREMISES INSPECTED. After Notification of Infectious Diseases 376 By house-to-house inspection 280 Upon complaint, under Sec. 107 (3), Public Health (London) Act, 1891 530 After Notices from Builders, under Bye-law 14 (London County Council) 118 Stables and mews 186 Slaughter houses 87 Milkshops, dairies and cowsheds 66 Bakehouses 53 Factories and workshops 139 Other premises inspected 684 Re-inspections made to examine and test work, etc. 2,697 Total Inspections 5,216 NUISANCES ABATED AND SANITARY DEFECTS REMEDIED. Dirty premises, cleansed and whitewashed 218 Dampness in dwellings remedied 150 Dilapidated ceilings, stairs, etc., repaired 197 Defective drain inlets remedied 7 Carried forward 572 475 Brought forward 572 Foul traps and pans of w.c.'s cleansed 15 Public-house urinals cleansed (after intimation) 2 Flushing cisterns to w.c.'s provided or repaired, and w.c.'s with insufficient water supply made satisfactory 21 Defective w.c. basins and traps removed and replaced by approved patterns 60 Stopped or choked w.c. traps cleared 4 External ventilation to w.c.'s improved 6 W.C.'s removed to more sanitary positions 7 Separate flushing cisterns fixed to w.c.'s which were previously flushed directly from dietary cisterns - Additional w.c.'s provided in case of insufficient w.c. accommodation 15 Defective soil-pipes reconstructed 16 Unventilated soil-pipes ventilated and Soil-pipes improperly ventilated, improved 45 Dirty yards cleansed 7 Yards paved or re-paved with impervious material 16 yards drained 2 Gully and other traps inside houses removed 1 Sink waste-pipes directly connected to drain, made to discharge in open-air over proper syphon gullies 1 Long lengths of sink, bath, and lavatory waste-pipes trapped, and made to discharge in open-air over gullies 60 Defective waste-pipes repaired 18 Foul water-cisterns cleansed 2 Water-cisterns without close-fitting covers provided with 1 proper coverings 21 Defects in water-cisterns remedied 4 Cisterns removed to more sanitary position 1 New portable dust-bins provided 61 Defective drainage reconstructed in accordance with bye-laws of County Council 111 Choked or stopped drains cleared and repaired 109 Drains ventilated or defective ventilating pipes renewed 1 Carried forward 1,178 476 Brought forward 1,178 Rain water pipes disconnected from drains or soil-pipes and made to discharge over gully-traps 15 Proper water-supply provided to houses or tenements 12 Defective roofs repaired 131 Defective guttering and rain water pipes repaired or renewed 110 Defective paving to floors of wash-houses repaired or renewed 18 Dirty walls of work-rooms cleansed 12 Ventilation under floors improved 3 Proper manure receptacles provided (London County Council bye-laws) 1 Cases of over-crowding abated 3 Accumulation of refuse, etc., removed 13 Areas re-paved and drained 1 Underground dwellings improved 1 Nuisances from animals abated 3 Smoke nuisance abated 1 Miscellaneous nuisances abated 36 Total 1,538 The above list refers only to work carried out on Intimation and Statutory Notices. In addition, a large number of improvements have been made on advice to owners and occupiers. INTIMATION NOTICES SERVED. Sec. 3, Public Health (London), Act, 1891. House to house inspection 166 After inspection on account of complaint 313 After infectious illness 58 With reference to stables and mews 1 „ „ milkshops, dairies and cowsheds - „ „ bakehouses 6 „ „ factories and workshops 24 „ „ slaughter houses After sundry other inspections 25 593 477 STATUTORY NOTICES. Forty-six statutory notices were served by direction of your Committee under Sec. 4, Public Health (London) Act, 1891. DRAINAGE PLANS AND APPLICATIONS. Thirty-one plans and applications were considered and approved by your Committee for alterations to and reconstruction of drains. I am, Ladies and Gentlemen, Your obedient Servant, D. W. Matthews, Chief Sanitary Inspector. 478 A LIST OF THE STREETS SITUATED IN THE BOROUGH OF STOKE NEWINGTON. (For the Guidance of Medical Practitioners, Midwives, Etc.) ADEN Grove Aden Terrace Adolphus Road Allen Road Allerton Road Albion Road „ Grove Alexandra Road Alexandra Villas Amhurst Park (90-100 even Nos. and 93) Arthur Road Ayrsome Road Aldham Place Barn Street Barrett's Grove Beaulieu Villas Belgrade Road Bethune Road (1 to 145) „ (2 to 106) Blackstock Road (5 to 175) Bouverie Road Boleyn Road (94 to 192) Brighton Road Brodia Road Broughton Road (Queen's Rd. to Brownswood Rd.) Green Lanes Brownswood Road Burma Road CROSSWAY (late Castle St.) (2 to 50) N. Side Carysfort Road Chalmers Terrace Chapel Place Chesholm Road Church Walk „ Street Clonbrock Road Clissold Road Coronation Avenue Cowper Road Cressington Road Cumberland Terrace DEFOE Road Digby Road Dumont Road Dynevor Road Eade Road (2 to 66) and 1 to 27 odd Nos. Edward's Lane FAIRHOLT Road Finsbury Park Road Fleetwood Street GAINSBORO Road Glebe Place Gloucester Road Goldsmith Square Gordon Road Grange Court Road Grazebrook Road Grayling Road Green Lanes „ „ (from 2 to 388) „ („ 81„147) „ „ (203 on.) HAMILTON Place Harcombe Road Hawksley Road Hayling Road Heathland Road Henry Road Hermitage Road, 1 to 25a,2tol4 Hewling Street High Street (17 to 217) Hornsey Place Howard Road IMPERIAL Avenue 479 KERSLEY Road King's Road Knebworth Road Kynaston Road „ Avenue LANCELL Street Layer's Road Lavell Street Leconfield Road (l-23a) Leonard Place Lidfield Road Lilian Street Listria Park Londesborough Road Lordship Road Grove Park „ Terrace Lordship Park Mews MANOR Road Martaban Road Marton Road Mason's Court „ Place Matthias Road (2-122) Millard Road Milton Road Mountgrove Road (2-98) NEVILL Road Newington Green (33-42) Newington Hall Villas Newton Villas OLDFIELD Road Osterley Road PAGET Road Painsthorpe Road Palatine Road Paradise Row Park Crescent „ Lane „ „ Terrace „ Street Pellerin Road Petherton Road (106 to 138) Portland Road Prince George Road Princess Road „ May Road QUEEN Elizabeth's Walk Queen's Road REEDHOLM Villas Reservoir Cottages Rochester Place Riversdale Road (92-104) SANDBROOK Road Salcombe Road Seven Sisters Road:— (273-333, 286-296, 430-486) Shakespeare Road Shelgrove Road Shipway Terrace Somerfield Road Spenser Road Springdale Road St. Kilda's Road St. Andrew's Road ,, Mews ,, Pavement, S. Side (11 to 20). Selsea Place Stamford Hill (1-39) Stoke Newington Road (1-175) Statham Grove Summerhouse Road TRUMAN'S Road Town Hall Approach VICTORIA Grove Victoria Grove West Victoria Road WALFORD Road Warwickshire Road Watson Street White Hart Court Wilberforce Road Winston Road Wordsworth Road Woodland Road Woodlea Road Woodberry Down ,, Grove