Woo 71 METROPOLITAN BOROUGH OP WOOLWICH ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH SIDNEY DAVIE S., M.A. , M.D. , Oxon.; D.P.H.CAMB. 1917. SUMMARY OP STATISTICS, 1917. Area of Borough 8,276.6 acres. Population - Census, 1911 121,376 do. estimated to middle of 1917, civil 146,503 Total 157,973 Inhabited Houses - Census, 1911 21,463 Persons to an Acre 14.7 Persons to a House-Census, 1911 5.65 Marriages 1,445 Births 2,698 Birth Rate 17.1 Deaths 1,550 Death Rate 10.6 Infantile Mortality 79 per 1,000 births. PREFACE To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Woolwich. Mr. Mayor, Ladies and Gentlemen, I have the honour to present you with my 17th Annual Report on the Health of Woolwich. The report is much abbreviated owing to war conditions and the usual tables are omitted. They have, however, been prepared and are kept for reference. The general health of the Borough has been wonderfully good in spite of the enforced change of diet and other conditions caused by the war. The reduction in infart mortality has not quite kept pace with that of the general death rate, although for the first time Woolwich had the lowest infant mortality of any metropolitan borough. No doubt the favourable atmospheric conditions, and the reduction in alooholism, as the result of the action of the Liquor Control Board, are largely responsible for the low death rate. I have to acknowledge with thanks the support which you have given to my proposals for improving the public health. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, SIDNEY DAVIES. SEVENTEENTH ANNUAL REPORT on the HEALTH OF THE METROPOLITAN 30 ROUGH OP WOOLWICH Year ending 31st December 1917. PART 1. STATISTICS. Population. 1. The population of the Borough of Woolwich, as estimated at the Census of 1911, was 121,376. The estimated civil population to the middle of 1917 is 146,503. The population of the four Registration Districts at the last three Censuses was as follows:- Census 1891 Census 1901 Census 1911 Estimated to middle of 1917 Woolwich Parish 40,848 41,625 36,710 33,605 Plumstead Parish West) 52,436 (38,569 40,328 43,098 East) (29,758 30,888 39,424 Eltham Parish 5,710 7,226 13,450 30,376 98,994 117,178 121,376 146,503 The estimated increase of the civil population from June 1916 to July 1917 is 9,780. The following figures show how the number of persons to a house in Woolwich and Plurastead has varied during the past four Censuses:- 1  WOOLWICH PLUMSTEAD Census 1891 — 6.08 „ 1096 - 6.14 „ 1901 7.85 6.05 „ 1911 7.27 5.34 2. The estimated population of soldier in Barracks in March 1917 was 11,470, making the total population 15.7,973. The civil population is used for all statistical rates except the Borough birth rate. The Registrar-General estimates the civil population at 130,213. In the Annual Report for 1913, on pages 15 to 19, tables were given showing the age distribution and condition as to marriage of the population, the proportion of males and females compared with London and England, and the classification of buildings, and in the Report for 1914, the number to a house in each Ward. 3. The following table shows the number of new houses certified for water each year since the Census of 1911:- New Houses, April 1st. to June 30th, 1911 34 „ „ July 1st. 1911 to June 30th, 1912 93 „ „ July 1st. 1912 to June 30th 1913 141 „ „ July 1st. 1913 to June 30th, 1914 254 „ „ July 1st. 1914 to June 30th, 1915 170 „ „ July 1st. 1915 to June 30th, 1916 139 „ „ July 1st. 1916 to June 30th, 1917 36 New Houses, 1916-7:- Woolwich West Plumstead 4 East Plumstead 7 Eltham 25 The following are the numbers of new houses and huts erected by the Government for Munition Workers from 1915-1917:- Houses 1,269 Huts 1,904 4. Unoccupied Houses. At the 1901 Census, there were 234 unoccupied houses in the Borough, viz., 46 in Woolwoch, 86 2 In Plumstead, and 102 in Eltham. At the 1911 Census, there were 1,296, viz., 450 in Woolwich, 387 in West Plumstead, 250 in East Plumstead, and 209 in Eltham. In January, 1916, the Rate Collectors found 57 houses unoccupied. viz., 7 in Woolwich, 13 in West Plumstead, 5 in East Plumstead, and 32 in Eltham. There are now practically no houses fit for occupation to let. BIRTHS. 5. The number of births was 2,698, viz., 657 in Woolwich parish, 752 in West Plumstead, 736 in East Plumstead, and 553 in Eltham (corrected for children bom in the Infirmary, and the Wood Street Home for Mothers and Babies, whose parents reside outside the Borough, and births in outlying institutions added on). The birth-rate (calculated on the total population) 17.1 oompares with 21.7 in 1916, and with 23.7 the average for the ten years 1906-15. The rate for the County of London was 17.5. Notification of Births. 2,550 live births were notified under the Notification of Births Act (1,272 males, 1,273 females, 5 not stated). This is at the rate of 95 per cent of the registered births, compared with 94, 92, 89, 97 and 86 per cent in the five preceding years. 1,536 births were notified by midwives, 137 by the Home for Mothers and Babies, 325 by medical practitioners and 552 by other persons. 88 still-births were notified (64, 79, 59, 75 and 77 in 1912 to 1916 respectively). Of the still-born, 44 were males and 44 females. The Notification of Births Act was adopted on March 1st. 1908. There were 148 births last year which were not notified. All the midwives and Doctors who neglected to notify were cautioned. The excuse generally given was that the notification must have been lost in the post. 6. The following table gives the birth rate of the Borough during the years 1901-5, 1906—10, 1911-1915, 1916 and 1917, and, for the purposes of comparison, the corresponding; rates of the neighbouring Boroughs, London, and England:- 3  BIRTH RATE 1901-5 1906-10 1911-15 1916 1917 Greenwich Borough 27.6 26.5 25.1 24.6 21.1 Lewisham 25.7 23.3 20.2 20.4 16.5 West Ham 33.1 31.4 29.7 28.8 23.2 East Ham 33.8 24.4 22.1 18.5 Erith 34.1 24.8 23.1 20.0 London 28.2 26.5 24.7 23.0 17.4 England & Wales 28.2 26.0 23.5 21.6 17.8 Woolwich Borough 29.2 25.3 22.2 21.7 17.1 7. The following table gives the birth-rate for the Borough and each Registration District for the five past quinquennia and for 1916 and 1917, the rates for the Registration Districts being calculated on the civil population. Correction has been made for births in the Infirmary, the Wood Street Heme for Mothers and Babies and outlying institutions, and the births distributed to the parishes to which they properly belong. West Plumstead ana Eltham had the lowest birth-rate of the four Registration Districts. Although the birth-rate in Eltham has fallen very much sinoe 1916, it was still higher than in the five years 1911-15. The greatest decrease since 1911-15 is in the parish of Woolwich. 1891 to 1895 1896 to 1900 1901 to 1905 1906 to 1910 1911 to 1915 1916 1917 Woolwich Borough 32.5 30.2 29.2 25.3 22.2 21.7 17.1* Woolwich Parish 31.1 30.1 29.0 27.9 25.2 21.5 19.6ø Plumstead - West 33.3 31.0 30.1 24.7 20.7 21.6 17.4ø East 22.7 20.5 18.7ø Eltham Parish 22.8 20.6 24.0 21.6 17.3 23.5 18.2ø *Total population used. øCivil population used: number of soldiers not known, but very small. 8. Illegitimate Births. 101 of the births registered were illegitimate, giving a rate of 37 per 1,000 births, compared with 17, 23, 21, 29 and 34 in the five preceding years. The steady increase since 1914 is probably bit a very partial measure of the increased immorality due to war conditions. 4 MARRIAGES. 9. There were 1,44b marriages. The marriage-rate was 19.7 compared with 17.7.27.1 and 23.7, in the three preceding years. The marriage-rate in England and Wales was 13.8 and was the lowest on record. DEATHS. 10. Table 1 gives the gross and net deaths and death rates in 1917 and each of the past fifteen years, and shows how the net deaths are arrived at. 11. The net deaths were 1,550, and the net death-rate 10.6 compared with 13.7 and 12.3 in the two preceding years and 12.5 the average of the ten years 1905-1914. This is the lowest rate ever recorded. 12. The following table shows the death-rate of Woolwich compared with London and the adjoining Boroughs:- 1917 England and Wales 14.4 96 great towns 14.6 London 15.0 Greenwich 15.1 Lewisham 11.6 West Ham 14.5 East Ham 11.4 Erith 9.6 WOOLWICH 10.6 Woolwich had the lowest death-rate of all the Metropolitan Boroughs. 13. The following table gives the average death-rate in each Registration District of the Borough during the past six quinquennial periods, 1916 and 1917. Woolwich parish had the highest death-rate and Eltham the lowest. 5  1886 to 1890 1891 to 1895 1896 to 190C 1901 to 1905 1906 to 1910 1911 to 1915 1916 1917 Woolwich Borough _ 17.2 16.9 13.9 12.5 12.7 12.3 10.6 Woolwich Parish* 20.4 19.3 20.1 16.5 14.8 14.8 14.3 13.9 Plumstead - West 16.4 16.0 15.1 12.9 12.0 13.2 12.6 11.8 East 11.8 10.2 8.4 Eltham Parish - 13.0 14.6 10.2 10.1 8.9 8.5 8.0 London 20.0 19.8 18.5 16.1 14.9 14.7 14.3 15.0 *Three years - 1888. 1889 and 1890. This table shows that the diminished death-rate affected each part of the Borough, hut Woolwich parish least, and that there was an increase in London. The marked fall in the death rate though no doubt largely attributable to the satisfactory sanitary and industrial conditions, absence of poverty and diminished drinking, must not be put down entirely to these causes. It is partially due to the influx of a young adult population with a low mortality. 14. The following table gives the numbers dying at various ages in the past twelve years from all causes, and the deaths at all ages from certain diseases not hereafter referred to:- Annual Deaths — 1903 to 1917. Year Age Period Under 1 1-5 5-10 10-15 15-20 20-25 25-35 35-45 45-55 55-65 65-75 75& over 903-7 aver 402.4 102.8 43.4 27 31.4 44.8 104.2 138.4 155.6 174.8 201.4 171 08-12 (aver.) 250.4 131.4 41.4 23.4 33.2 33.2 87.4 127 146.6 199.2 211.6 203.8 1913 229 93 34 25 44 48 109 134 177 208 240 239 1914 239 141 52 33 47 35 97 147 184 225 246 244 1915 268 136 62 28 47 41 93 170 210 246 269 263 1916 215 105 40 33 41 37 99 160 200 224 269 260 1917 214 113 28 34 41 33 96 116 179 221 243 232 6 Deaths from Average 1903-7 Average 1908-12 1913 1914 1915 1916 1917 Apoplexy and all other diseases of heart and bloodvessels 217.4 258.8 312 332 351 319 283 Nephritis and Bright's disease 44 47 57 46 47 45 48 Respiratory diseases - all foms (except Phthisis) 260.8 228.4 254 287 385 299 302 The deaths under one, from 5-10, from 20-25 and from 35-45 were the lowest recorded, and those from 1-5 much below the average of previous years. The deaths from 10-20 have remained at the same level during the four years of war, but this level is much higher than in previous years. Probably there has been a great increase of population between the ages of 14 and 20, rather than any increase of mortality. There was a further decrease of deaths from apoplexy and diseases of the heart and blood vessels; but respiratory diseases remained at a much higher level than before the war. 15. The natural increase of the population (i.e., the excess of births over deaths) was 1,148 compared with 974 in 1915 and though smaller than in previous years, this increase compares very favourably with conditions in enemy towns. INFAT-II MORTALITY. 16. The deaths under one year were 214 compared with 215 in 1916. The infant mortality (deaths under one year per 1,000 births) was 79. This is the lowest rate recorded with the exception of 1916 and 1912. The following table gives the infantile mortality in the Borough since 1901, compared with the neighbouring Boroughs, London and England:- 7  1901-5 1906-10 1911-15 1916 1917 Lewisham 112 92 81 72 87 Gre enwich 107 112 103 83 101 West Ham 158 126 114 98 105 East Ham 131 106 80 78 85 Erith 112 80 77 60 83 London 138 114 108 89 103 97 great towns 117 117 98 104 England & Wales 135 115 109 91 97 WOOLWICH BOROUGH 119 97 86 70 79 Woolwich had the lowest infantile death rate of any Metropolitan Borough, and for the first time in recent years the rate was lower than in Erith. 17. The following table gives the infantile mortality during the past two years, and the six preceding quinquennia in the Borough and each Registration District:- 1886 to 1890 1891 to 1895 1896 to 1900 1901 to 1905 1906 to 1910 1911 to 1915 1916 1917 Woolwich Parish* 151 157 170 134 109 101 84 97 Plumstead - West) 121 120 132 113 91 75 54 70 East 81 65 84 Eltham 163 160 97 89 67 83 67 Woolwich Borough 140 146 119 97 86 70 79 *1888, 1889 and 1890. Eltham once more had the lowest infantile mortality, and West Plumstead the next lowest, 18. Table IV. gives full details as to the ages as death and causes of death of the infants dying in 1917 under one year. It shows that 42 per cent of those who died under one year were under one month old, compared with 49 per cent in 1916, and 37 per cent in the previous ten years; 49 deaths were from premature birth, compared with 52, 41, 53, 55 and 55, in the five preceding years. The number of deaths under one week in the past five years was 58, 68, 55, 73, and 57 respectively. The number of deaths from suffooation or overlying was 5 compared with six in 1915, and nil in 1916. In the previous 8 four years the deaths from suffocation in bed averaged four a year, and in the four years 1904-7 they averaged 7. Alcoholism among women is no doubt the chief cause of overlying, but, in view of the decrease of alcoholism, it is probable that fatigue due to long hours at industrial occupation may be an important factor. The death-rate per l,000 births from premature birth in Woolwich Borough was 17.8 compared with 18.9, 14.2, 20.5, 19.5 and 17.9 in the five preceding years. In London it was There were 22 deaths of illegitimate infants. The death-rate of illegitimate infants under one year was 218 per 1,000 births (compared with 246 in 1916) and that of legitimate children 74. 19. Compared with 1916, the past year had among infants more deaths from bronchitis and pneumonia, and fewer from premature birth. 20. Deaths between 1 and 5 years. 57 deaths (55 in 1916) occurred between 1 and 2 years, and 56, (50 in 1916) between 2 and 5. The corresponding figures in 1913 were 55 and 38 respectively. The death-rate between 1 and 5 was 10.7 per 1,000 children of that age found at the Census (viz., 10,357), compared with 13.6, 13.1 and 10.1 in the three previous years. 21. Zymotic death-rate. The number of deaths from scarlet fever, diphtheria, measles, whooping cough, enteric fever, and from diarrhoea and enteritis (under 2 years of age as regards diarrhoea and enteritis) was 101 and the death rate per 1,000 population 0.69 compared with 0.98, 0.95 and 0.85 in the three previous years. The zymotic death-rate has fallen greatly since 1901, when it was 1•51. 22. Inquests. There were 131 inquests, compared with 105, 123, 146, 180 and 181 in the five preceding years. The following table gives particulars as to the cause of death: 9 1. Natural Causes 71 2. Alcoholism 1 3. Accidental Causes — Burns and Scalds 7 Drowning 6 Vehicular traffic (a) By road 11 (b) By rail 2 Explosions 4 Suffocation - Overlying 4 Other Accidental causes 18 52 4. Homicidal Cases -Suicide 5 Murder and Manslaughter 2 7 Total 131 The "Accidental Causes" were 35, 37, 39, and 63, in the four preceding years. The "Homicidal Causes" were 11, 21, 13 and 12 in the same years. The reduction of accidents and homicide is very satisfactory. SMALL-POX. 23. Not a single case of small-pox was notified in Woolwich or in London. MEASLES. 24. There were 31 deaths from measles, giving a rate of 0.21 compared with 0.19, 0.33 and 0.17 in the three preceding years. The rate in London County was 0.47. 25. Of the 31 who died from measles, 30 were under five years of age; 16 were males and 15 females. 26. 1,710 notifications were received under the Local Government Board Order, compared with 1,590 in 1916. The mortality per cent of notifications was 1.8 compared with 1.4 in the preceding year. 45 cases were removed to the fever hospital on the certificate of the Medical Officer of Health that isolation was necessary, compared with. 10 27. The following table gives the number of deaths and death-rates from measles for the past four years, and four preceding quinquennia in each parish and the death-rate in London:- Year Woolwich Plumsoead Eltham The Borough London Aver. No. Rate Aver. No. Rate Aver. No. Rate Aver. No. Rate Rate 1891-5 20 0.49 29 0.51 Not recorded 49 0.51 0.59 1896-1900 34 0.81 36 0.57 Not recorded 70 0.67 0.57 1901-5 9 0.22 15 0.22 1 0.13 26 0.21 0.44 1906-10 17 0.43 18 0.23 3 0.20 37 0.30 0.40 1911-15 12 0.30 14 0.19 2 0.13 27 0.21 0.42 1916 8 0.24 15 0.19 — — 23 0.17 0.19 1917 13 0.39 11 0.16 7 0.23 31 0.21 0.48 The actual reduction in measles mortality is not quite so large as appears from the above table, owing to the fact that the falling birth rate has caused a diminution in the number of children living under five years, The following tabic giving the deaths and death-rate per 1,0^0 births shows the reduction more accurately:- No. Rate. 1891-95 (average) 39 14.7 1896-1900 ,, 70 20.9 1901-05 ,, 26 7.2 1906-10 ,, 37 11.8 1911-15 ,, 27 9.8 1916 ,, 23 7.5 1917 ,, 31 11.5 It appears from these tables that whereas from 18911900 Woolwich had a somewhat higher measles' mortality than London, since that date the measles death-rate has greatly diminished, and diminished much more Woolwich than in London. 28. To prevent the spread of measles in school, the Medical Officer of the London County Council continued to close, or exclude unprotected children from classes on the occurrence of one or more cases. The period of exclusion or closure was usually for a few days orJv, in some cases for two weeks. Notification. By Order of the Local Government Board made under S.130,P.K.A., 1875, Measles and German Measles were made compulsorily notifiable from January 1st. 1916, (see Council's Minutes, December 22nd- page 93). 11 1,710 cases of Measles were notified compared with 1,590 in 1916. Of these 713 were under five vears of age, 791 between five and fifteen, and 206 over fifteen. The largest number of notifications was in Eltham, viz., 613. In addition, 868 cases of Genii an Measles were notified. The cost of notification was £86. 19. 0. The case mortality was 1.8. In Woolwich Parish it was 3.3, in Plumstead 1.5 and in Eltham, 1.1. The Health Visitors visited all notified cases, gave advice as to isolation, cleanliness, ventilation, etc., and, where it seemed desirable, and the friends approved, the District nurse was requested to attend. Fewer cases - 139 compared with 236 - were nursed in 1917 than in 1916. This is partly because North Woolwich was but slightly affected last year and in North Woolwich the nurses visit every case notified. Of the 139 cases visited by the District Nurses, 53 were in Woolwich (13 in North Woolwich), 28 in Plumstead and 58 in Eltham. These visits were paid by the Borough Council, according to the arrangements made in 1916, at a cost of £51. 19. 6. It is satisfactory- to note that although the number of cases was probably much above the average, the deaths were below the average of the previous ten years. WHOOPING COUGH. 29. There were 10 deaths from whooping cough. The deathrate was 0.07 compared with 0.19, 0.03, and 0.25 in the three preceding years, and 0.13 in the County of London. Six of the deaths were under two years of age. The following table gives the deaths and death-rates per 1,000 population since the Borough was formed, compared with London:- Woolwich London No. Rate Rate 1901-05 (averages) 34 0.28 0.35 1906-10 26 0.21 0.29 1911-15 17 0.14 0.21 1916 34 0.25 0.18 1917 10 0.07 0.13 12 The death-rate per 1,000 births was 3.7 compared with 11.1 in 1916. The death rate was the lowest recorded with the exception of 1911. In 1913 an Order was issued by the Local Government Board giving permission to the Asylums Board to admit to their hospitals children under 14 suffering from whooping-cough, on the recommendation of the Medical Officer of Health. Mo cases were admitted during the year. Instructions printed on cards are left at houses where cases are notified by school teachers. The instructions were printed in the Annual Report for 1910. SCARLET FEVER. 30. There were 145 cases of scarlet fever notified (deducting two cases of mistaken diagnosis), equivalent to a rate of 0.99 per 1,000 population, compared with 1.69 in 1916. This is the lowest rate recorded. 31. The following table shows the case-rates of scarlet fever in the Borough and each Registration District during the past fifteen years, compared with London:- Average 1901 -5 1906 -10 1911 1912 1913 1914 1915 1916 1917 Borough 3.15 5.90 4.09 3.80 4.80 5.46 4.31 1.69 0.99 Woolwich Parish 2.99 5.66 2.89 2.41 5.44 6.11 4.48 1.94 1.19 Plumstead.West 3.77 4.96 4.68 5.45 4'0 1.30 0.84 3.24 6.33 East 7.51 4.88 5.11 4.18 6.55 1.98 0.74 Eltham Parish 3.21 4.94 2.09 2.64 4.36 7.45 3.85 1.67 1.38 London County 3.57 4.22 2.32 1.76 3.89 5.53 3.94 2.06 1.52 32. Table III gives the age distribution, the number in each parish and the number removed to hospital. Eltham was most affected. 33. Deaths. There was one death, giving a death.rate of 0.01 per cent compared with 0.03 in 1916, 0.06 in 1915, 0.08 in the five years 1908-12, and 0.19 in the ten years 1891-1900. The death-rate in Lordon was 0.02 compared with 0.03 in 1916. The case mortality (or deaths per cent of notifications) was 13 0.7 coampared with 1.3, 1.4 and 1.7 in the three preceding years The death rate is the lowest recorded. 34. Hospital Isolation. Of the 147 oases notified, 125 (or 85 per cent) were removed to one of the fever hospitals, compared with 88, 90, 88, 85 and 91 per cent. in the five preceding years. 35. Home Isolation. Six certificates of efficient home isolation were given to enable men to continue their employment in the Arsenal, and so obviate unnecessary removal to hospital, compared with 31, 15, and 18, in the three preoeding years. In the Annual Report for 1911 a comparison was made between home and hospital isolation, showing that, whereas there were only 1.6 per cent. of failures in home isolation, there were 4.6 per cent in hospital isolation. Failure means the occurrence of secondary cases attributed to the primary case. 36. The Annual Report for 1905 contained a speoial report on a statistical investigation into school incidenoe of scarlet fever and diphtheria during the ten years 1896-1905. DIPHTHERIA. 37. 242 cases of diphtheria were notified (excluding 35 cases of mistaken diagnosis). The case-rate (number of cases per 1,000 popilation), corrected for cases of mistaken diagnosis was 1.65 compared with 2.72, 1.77 and 1.81 in the three preceding years, and 1.99, the average of the ten years 1901-10. This is the lowest oase rate since 1905. 38. There were 16 deaths, compared with 11, in 1916. The death rate was 0.11 compared with 0.26 in 1914, 0.15 in 1915 and 0.08 in 1916. The London death-rate was 0.14. 39. 59 of the total cases notified were in Woolwich parish, 69 in West Plumstead, 59 in East Plumstead and 90 in Eltham. The following table shows the case-rate in each registration district (not corrected for mistaken diagnosis) in the past thirteen years, compared with London and the Borough:- 14  1901 -5 1906 -10 1911 1912 1913 1914 1915 1916 1917 Borough 1.71 2.20 1.68 3.09 1.91 2.72 1.77 1.81 1.65 Woolwich Parish 1.63 2.34 2.40 4.38 4.43 4.92 2.23 2.80 1.76 Plumstead Parish 1.87 2.40 W1.19 3.79 2.32 2.36 1.99 2.11 1.60 E2.33 2.81 1.02 2.39 2.87 1.23 1.50 Eltham Parish 1.62 2.22 2.30 1.71 1.29 3.33 0.88 1.72 2.96 London 1.90 1.63 1.64 1.57 1.70 2.02 2.01 2.04 2.06 The table shows that the rate in Eltham Parish was the highest stnce 1914 & E. Plumstead the lowest. 40. 253 cases, or 91 per cent of total notifications, were removed to hospital, compared with 93, 94, 92 and 91 per oent. in the four preceding years. A certificate of efficient home isolation was given in four cases, compared with 12, 1, 7, 10, and 8, ill the five preceding years. The case-mortality was 6.6 per cent. compared with 5.2, 7.0, 0.7, 8.3 and 4.4 in the five preceding years. 27 carrier cases, with or without slight symptoms, were discovered by your Medical Officer of Health. The usual steps were taksn. 67, or 24 per cent of the cases notified were over 15 years of age. In the last seven years there has been a marked increase in the proportion of Diphtheria notifications over school age. In 1911 the percentage was only 13 and there has been a steady increase since. There is no similar increase in the rest of London, and it is probably conneoted with changed age distribution of the population, and increased provision for discovering infectious disease among munition workers. 41. Mistaken Diagnosis. 35 cases, or 13 per cent of notifications, were, after removal to hospital, stated to be not diphtheria. The percentage of the four preceding years was 19, 16, 15 and 8 respectively. 42. Source of Infection. Six cases occurred at the Elthac Hostel for Munition Workers. There were three Return cases, though the suspicion that they were the source of infection was not confiraed bacteriologically. 15 43. Bacteriological Diagnosis. Since January, 1913, the Council's bacteriologicaT work has been done by the Bacteriological Department of the Seamen's Hospital, Greenwich. 958 (896 in 1916) swabs were examined for the presence of diphtheria bacilli. In 157 (167 in 1916) the true Klebs Leffler bacillus was found, and 620 were found frsa from either the Klebs Leffler bacillus or Hoffman's. Of the 958 swabs examined, 205 were taken from school children by the Medical Officer of Health. Of these, 24 contained the true Klebs Leffler bacillus (so-called positive cases and 41 Hoffman's bacillus. 20 positive cases had seme symptoms, viz., running or sore nose, mild clinical diphtheria or follicular tonsilitis. These were notified and sent to Hospital or strictly isolated. Positive cases without any symptoms were excluded from school and from mixing with other children outside the house. Of the 205 cases, 83 had some symptoms. Diphtheria antitoxin is kept at the Town Hall and the Plumstead and Eltham Free Libraries, and supplied to medical practitioners on application at cost price, or free where there is inability to pay. Last year nine quantities were supplied on payment and nil gratis. ENTERIC FEVER. 44. There were seven cases of enteric fever, not including five cases of mistaken diagnosis notified as enteric. The case-rate was 0.05, compared with 0.09, 0.17, and 0.05, in the three preceding years. For the ten years 1892-1901 the rate never fell below 0.41. The case-rate in London was 0.11. 45. There were three deaths from this disease, giving a death rate of 0.02. The death-rate in London was 0.02. 46. The following are the cases notified in each parish during the past fifteen years (not corrected for mistaken diagnosis ):- Average 1901-5 1906-10 1911 1912 1913 1914 1915 1916 1917 Woolwich 12.6 7.6 10 10 7 6 11 2 5 Plumstead 21.2 11.4 . W. 3 4 3 6 13 3 2 E. 2 2 2 4 5 3 1 Eltham 8.6 2.8 1 4 2 2 2 1 4 16 Three cases occurred at one house in North Woolwich. A brother and his wife were notified some two weeks before in the adjoining borough of West Ham. The mother visited at their house, probably helped to nurse, and no doubt conveyed the infection through unclean hands infecting food. One case was attributed to mussels, one to a soldier carrier, and one to Sittingbourne. One was a soldier in the garrison. Of the 12 cases notified, 10 were removed to a Fever Hospital and 5 were reported as mistaken diagnosis. A report was made in 1916 on the prevention of flycarried infection' of enteric fever (see Zymotic Enteritis). 47. Bacteriological Diagnosis. 9 samples of blood were sent to the Seamen's Hospital to be examined for Widal's reaction. A positive result was obtained in four. DIARRHOEA OR ZYMOTIC ENTERITIS. 48. The deaths from diarrhoea and enteritis under two years of age were 24 or 8.9 per 1,000 births, compared with 9.9, 10.7, and 7.2 in the preceding years. The rate for London was 18.7. The total number of deaths from these diseases at all ages was 39. Notification. Voluntary notification of zymotic enteritis during July, August, and September, commenced in Woolwich in 1905. Compulsory notification commenced August 25th, 1913, and is unlimited as to season. 101 cases were notified in the past year, compared with 199, 173, and 80, in the three preceding years. Seven cases were notified from January to May, 5 in June, 8 in July, 31 in August, 33 in September, 10 in October and 7 in November and December. The fatality rate (deaths under two years per 100 notified cases under two) was 20.7. This high fatality probably points more to neglect to notify rather than to prevalence of a type of disease severer than usual. Medical men, especially locum tenens, are not aware, or forget that this disease is notifiable, in spite of a circular reminder being sent every year. As compared with the County, Woolwicn had a very low death rate from diarrhoea and enteritis during the summer quarter. Per 1,000 births, the death-rate of children under 2 was 28.1 in London and only 17.7 in Woolwich (12 deaths). Only the City, Kensington, Chelsea, and Hampstead, had a lower rate. 17 49. The temperature of the sunnier quarter was above the average and the rainfall below. In spite of these unfavourable conditions the number of deaths and notified oases was below the average. ZYMOTIC MTERITTS AND METEOROLOGY (Summer Quarter 1915 1916 1917 Number of cases notified 142 80 101 Number of deaths 12 14 12 Mean temperature of air 60.7 60.9 61.7 Mean temperature 3 feet below ground 60.6 59.9 62.6 Mean humidity 80 83 81 Number of days on which rain fell 35 42 47 Rainfall in inches 8.5 6.0 3.4 Number of hours bright sunshine 541 - 580 ERYSIPELAS. 50. There were 79 cases of erysipelas notified, compared with 107, 138, and 95 in the three preceding years. There were 4 deaths, one under one year, one 10-15, and two over 65. The case-rate was 0.54 the lowest recorded, and the death rate, 0.03 below the average. The London case-rate was 0.58 and the London death-rate 0.02. CEREBR0-SPINAL MENINGITIS. 51. 46 cases occurred in 1915, 17 in 1916, and 17 in 1917. In addition 5 cases of post basic meningitis were notified. There were 5 deatts, 2 oi which were under two years of age. The case rate was 0.12 in Woolwich, compared with 0.09 in London. Seven cases occurred in Woolwich Parish and four in Eltham. Eight of the cases were soldiers in the garrison and six were under 15 years of age. The large majority of the cases occurred in the first three months of the year. In none of the civilian cases did more than one case occur in the same house. The cases of post basio meningitis all occurred in West Plumstead. Notified cases (with one or two exceptions) were immediately removed to the fever hospital. Contacts in close association were bacteriologically examined 18 by a Medical Officer of the London County Council. Several doubtful oases were seen by the Medical Officer of Health, on request of the medical attendant, and when the former had any doubt as to the diagnosis a bacteriological examination was made. PUERPERAL FEVER. 52. There were 12 cases of pierperal fever notified, compared with 2, 8, 7, 6 and 16 in the five preceding years. There were six deaths. The case-rate per 1,000 births was 4*44 compared with 2.14 and 3.25 in the two preceding years. The death rate was 2.22 compared with 1.05, 1.07 and 1.13 in the three foregoing years. The London case-rate and deathrate per 1,000 births were 2.47 and 1.48 respectively. 53. Irfluenza caused 29 deaths compared with 25, 35, 25. 33 and 29 in the five preceding years. Bronchitis and pneumonia caused 294 deaths, compared with 208, 253, 285, 380 and 290 in the five preceding years. There was again a fall in the deaths from bronchitis and pneumonia in adults but an increase under five years. The increase in children was probably due to increased mortality from measles. The epidemic wave causing an increased mortality from respiratory and tuberculous diseases is slowly ebbing. The following table shows the figures from 1909 to date. The death-rate was 2.0 compared with 1.8 in 1909-12. 1909 - 12 1913 1914 1915 1916 1917 Pneumonia over 5 61 63 78 99 98 95 Bronchitis over 5 80 120 113 160 135 113 Bronchiuis and Pneumonia) under 5 ) 68 70 94 121 57 86 Bronchitis and Pneumonia) over 5 . 153 183 191 259 233 208 Bronchitis and Pneumonia M144 149 196 150 161 ,, ,, F109 136 184 140 133 TUBERCULOSIS 54. Deaths. There were 207 deaths from tuberculous disease, giving a deaths-rate of 1.41, compared with 1.34, 1.69, 1.68, 1.72 and 1.48, in the five preceding years. 19 55. The following table gives the number of deaths from each of the various forms of tuberculosis in the past 17 years and also the deaths from simple meningitis Average 1901 -5 1906 -10 1911 1912 1913 1914 1915 1916 1917 Tuberculous Meningitis 20.0 22.8 20 23 14 29 18 19 19 Simple Meningitis 22.0 15.0 16 13 10 15 16 9 4 Tuberculosis of Intestines and Peritoneum 13.0 10.8 5 5 10 13 5 5 1 Tuberculosis (other forms) 20.8 22.2 29 16 10 11 8 12 18 Phthfcis . 192.0 151.4 146 124 182 163 201 167 172 56. The deaths from phthisis were 172 giving a death-rate of 1.17 compared with 1.01, 1.42, 1.27, 1.49, and 1.22, in the five preceding years. The death rate is the lowest recorded except in 1912. The rise and fail of the phthisis death-rate in recent years has been parallel with that of bronchitis and pneumonia. In each case 1912 showed a minimum, and the three subsequent years a marked rise. London had the highest deathrate since 1905. Deaths - Phthisis (Tuberculosis, Lungs) 1891-5 1896-1900 1901-5 1906-10 1911-15 1916 1917. o.Rat e Aver. No.per year Rate Aver No per Rate Aver No peryears Rate No Rate No Rate No. Rate [Woolwich Parish West - 2.80 92 2.23 89 2.15 56 1.46 65 51 1.70 1.22 63 57 1.88 1.32 55 60 1.64 1.39 Plumstead Hast - 1.78 92 1.42 97 1.34 87 1.20 39 1.20 31 0.86 41 1.04 Eltham Parish - - 9 1.28 6 0.63 8 0.64 9 0.58 16 0.66 16 0.53 The Borough - — 193 1.74 192 1.56 151 1.22 164 1.28 167 1.22 172 1.17 London 1.88 - 1.80 - 1.57 - 1.33 - 1.37 - 1.46 - 1.58 20 57. The decrease of deaths from tuberculous meningitis was maintained, and the deaths from simple meningitis and abdominal tuberculosis were the fewest recorded. 58. Notification Statistics. 543 cases were notified (excluding second notifications), viz., Tubercle of lung, 448; tuberculous meningitis, 12; tuberculosis of the intestines and peritoneum. 6; other forms, 74; Larynx, 3. The 448 cases of phthisis compare with 532, 400, 420 and 392 in the four preceding years. 32 of these were in the Woolwich and Eltham Poor Law Infirmaries; 2 others were notified by the District Medical Officers of the Poor Law Union, 33 by the Medical Officers of the Royal Arsenal and Army, 252 from hospitals and dispensaries, including 221 from the Woolwich Tuberculosis Dispensary, and the remainder by private medical practitioners. £13. 3. 9 was paid during the year for the notification of tuberculosis. 59. Duration. Of the 543 cases notified during 1917, at least 93 have since died, and of 469 cases notified during 1916, at least 136 have since died (February, 1918). 60. The source of infection of the notified cases was probably as follows:- Family or personal:- Father 30 Mother 31 brother 25 wife 1 son 2 daughter 3 sister 14 hu sband 4 members of family not defined 12 122 Workshop and Office 4 Navy and Army 26 Public House 4 Undetermined 387 61. Age and Sex Distribution. The following table, required by the Local Government Board, gives the age and sex distribution of pulmonary and non-pulmonary cases, and shews also the source of notification:- 21 22 METROPOLITAN BOROUGH OP WOOLWICH PUBLIC HEALTH (TUBERCULOSIS) REGULATIONS, 1912. Summary of Notifications during the year 1917. Age Periods Number of Notifications on Form A. from Private Medical Practitioners Total Notifications, ie.including cases previously nofcifed by other doctors Number of Notifications on Form B from School Medical Officers Number of Notifications Form C. Prima-ry Notifications 65 and upwards Total Primary Notifications Total Noties ficatiais, ie. inckxllng casespreviously notified ty other doctors Poor Law Institutions Sanatoria 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 5c to 65 Under 5 5 to 10 10 to 15 Total Pulmonary Males 2 10 33 19 18 30 44 65 22 14 - 257 270 - - - - - 26 139 ,, Females - 4 23 19 27 23 45 28 14 4 3 19C 203 - - - - 1 26 113 Non-Pulmonary Males 1 14 12 7 - 2 7 1 4 — — 48 49 — 2 2 3 4 7 ,, Females - 4 15 8 10 2 5 4 — - - 48 52 - 1 l 2 4 2 3 Total 3 32 83 53 55 57 101 98 40 18 3 543 574 — 3 1 4 8 59 262 62. Visiting. The method of following up cases was described in the annual report for 1915. 63. Bacteriological Diagnosis. Sputum from 286 cases of suspected phthisis was examined at the Seamen's Hospital and tubercle bacilli were found in 63 cases. The number of examinations for the five preceding years was 151, 231, 273, 254, and 269, respectively. In addition, the Medical Officer examined 515 specimens of sputum at the Tuberculosis Dispensary, 73 being found positive. 64. In ray Annual Report for 1904 some figures were given as to the "Public-house as a source of Infection" and "Chronic Tuberculosis in Children" (see page 50 of the Report). 65. Disinfection was performed by the Public Health Department at 301 premises compared with 166,243, and 217, in the three preceding years. Disinfection was performed after the death of the patient, and also after removal to hospital, sanatorium, or other occasion of the house or bedroom being vacated. 66. Sanatorium Treatment. Altogether 270 notified persons were admitted to some sanatorium or hospital for the treatment of tuberculosis. The following table shows the number sent to the chief institutions CASES ADMITTED AS IN-PATIENTS TO SANATORIA. HOSPITALS, ETC, 1917. Male Female Total Infirmary 30 29 59 Downs Sanatorium 49 — 49 Northern Hospital (Winchmore Hill) 2 40 42 Nayland Sanatorium and Maltings Farm 15 11 26 Treloar's Home, Alton 2 1 3 Herbert Hospital 8 - 8 Ventnor 11 8 19 Brampton Hospital and Frimley 13 4 17 Carshalton Children's Hospital 5 5 10 All others 19 18 37 Total 154 116 270 23 There were fewer admissions to the Infirmary and Herbert Hospital, but an increase of cases treated at Sanatoria. There was much delay in obtaining Sanatorium treatment. On the average the non-insured patients who finally were admitted had waited ten weeks before going to the Sanatorium. 67. Shelters for Consumptives. The use and provision of these shelters has been described in previous Reports. There are 13 shelters available. Seven are now occupied by men and four by women. The demand has been less since the air raids deterred the nervous; most of them, however, have been in continuous use, and nine were occupied in December. Shelters were lent to 16 persons last year, 10 men, 3 women, 1 boy and 2 girls. Two of these had the shelter free, three paid 3d. and 11 paid 6d. Most of the patients using shelters are under the supervision of the Tuberculosis Dispensary. £3.17.3 was paid as shelter rent during the year. Three bedsteads with bedding are also being lent to needy cases too poor to provide such. 68. Tuberculosis Dispensary. A Dispensary for the treatment of tuberculosis was opened in September, 1911. The following is the summary of the work referring to the period 1. January to 31st. December 1917:- Insured persons treated 775 Uninsured ,, ,, 1,710 In attendance on January 1st. 1915:- Treatment Observation Insured Uninsured Insured Uninsured 163 424 29 407 Total attendances year ending December 31st. 11,157 Number of new patients examined 1,482 ,, with definite pulmonary tuberculosis 304 ,, with surgical tuberculosis 190 ,, of suspect and observation cases 394 ,, found non-tuberculous 574 ,, of home visits of medical officers 1,285 ,, ,, ,, ,, nurses 1,735 „„sputum examinations 515 ,, found positive 73 ,, of children new cases 688 ,, of contacts examined 592 24 There was a diminution in the number of contacts and of new oases examined, and an increase in the number of those found definitely tuberculous. The Medical Officer of Health acts as Administrative Tuberculosis Officer, and is a member of the Tuberculosis Dispensary Committee. The Borough Council's scheme for the Treatment of Tuberculosis — particularly for the provision of a Tuberculosis Dispensary — was set out in the Annual Report for 1914. The work of the Tuberoulosis Care Committee was described in the Annual Report for 1915. CANCER 69. There were 129 deaths from cancer (malignant tumour), giving a death-rate of 0*88 compared with 1.01, 1.06, 0.90 and 0.95 in the four preceding years. 57 of the deaths were in males and 72 in females; 80 or nearly two-thirds of the deaths were in persons over 65. The highest mortality was in West Plumstead. One-third of the deaths occurred in public institutions. The death rate in England and Wales in 1916 was 1.17 There were three deaths from sarcoma and 126 from carcinoma. The deaths from carcinoma have been classified under the organs affected, since 1903, and the following table shows the result for males and females respectively:- Carcinoma Males. Seat of Primary Disease Aver. 1903-5 Average 1906-10 Average 1911-15 1916 1917 Head and face 1.7 1.2 1.2 3 1 Mouth, jaw and tongue 4.0 4.8 7.2 7 4 Pharynx, oesophagus, larynx and neck 5.0 8.6 10.4 8 11 Pleura, lung, mediastinum 0.3 0.4 0.4 — — Stomach and Pylorus 5.3 10.4 9.2 14 13 Intestines (excluding rectum) 2.7 3.2 4.6 4 8 Rectum and anus 4.0 4.8 5.8 5 3 (Peritoneum and omentum 0.7 - - ) 3 6 ( ) (Liver 8.0 6.4 7.0) Kidney and Bladder - 1.6 1.8 3 3 (Genital organs, - - (Prostrate and external urinary 2.7 0.8 2.8 - 2 Pancreas 0.3 1.4 1.8 3 2 Undefined and all other 0.6 2.2 2.2 1 1 35.3 45.8 54.4 51 54 25 Females. Seat of Primary Disease Average 1903-5 Average 1906-10 Average 1911-15 1916 1917 Head and face 0.7 1.4 0.6 1 2 Mouth and tongue 1.7 0.6 0.6 1 — Pharynx, oesophagus, larynx and neck 1.7 1.4 2.0 2 Pleura, lung, mediastinum 0.7 0.6 0.6 1 — Stomach and Pylorus 5.7 7.6 9.0 5 11 Intestines (excluding rectum) 0.7 4.2 4.2 4 7 Rectum and anus 3.0 6.8 6.8 7 2 (Liver 7.3 8.6) ( 8.4 14 14 (Peritoneum and omentum 0.3 0.4 Kidney and bladder — 1.2 1.0 - 2 Genital organs 16.0 13.6 14.0 23 15 Breasts 9.7 8.6 13.6 14 12 Pancreas — 02 0.8 Undefined and all other 1.4 2.0 2.8 1 5 48.9 57.2 64.4 72 72 Last year had the lowest cancer death-rate for five years; the reduction was greater in men. As compared with 1913, and previous years, in men there has been a decrease under carcinoma of the throat and intestines; and in both men and women an increase of cancer of the stomach. 70. Causes of Cancer. The special inquiry into the habits of persons suffering and dying from cancer sinoe 1912 was continued. For the scope of this and the' standards taken, see previous Annual Reports. The following gives the parts affected for males and females:- CARCINOMA. Cases specially investigated and parts affected. Seat of Primary Disease Hale Female Total Face, mouth, jaw and tongue 35 7 42 Pharynx, Oesophagus, Larynx and Neck 37 6 43 Stomach and Fylorus 29 22 51 Intestines (excluding Rectum) 16 14 30 Rectua and Anus 17 17 34 Liver 9 4 13 Breasts - 8 8 Uterus — 4 4 All other 11 2 13 154 84 238 26 Cancer Cases. 74 of the patients were stated to be excessive users of alcohol, 22 took the standard quantity, and 127 below the standard. There were thus 33 per cent of excessive alcohol drinkers. 91 smoked excessively, 18 consumed an average quantity of tobacco, and 113 below the average, giving 41 per cent of excessive smokers. 65 were excessive tea drinkers, 89 moderate and 54 small tea drinkers, giving 31 per cent of excessive tea drinkers. 99 were large eaters. 72 moderate and 48 small eaters. giving 45 per cent large eaters. 71 were large meat eaters, 86 moderate and 57 small meat eaters, giving 33 per cent of large meat eaters. 130 had a daily action of the bowels, and 44 suffered from constipation, giving 75 per cent of persons with a regular action. Control or Non-Cancer Cases. These cases may be compared with those obtained for 218 persons of similar or greater age, living under similar circumstances, who did not die of Cancer. Of these - 37 took aocohol excessively, 24 took the standard quantity and 157 below the standard, giving 17 per cent excessive drinkers. 46 smoked excessively, 19 in moderation, and 157 were non-smokers or slight smokers, giving 21 per cent of excessive smokers. 66 took tea excessively, 96 in moderate amount, and 48 were small tea drinkers, giving 31 per cent of excessive tea drinkers. 28 were large eaters, 22 moderate, and 13 small, giving 44 per cent of large eaters. 19 were large meat eaters, 9 moderate, and 36 small, giving 30 per cent large meat eaters. 166 had a regular daily action of the bowels and 26 suffered from constipation, giving 16 per cent of constipation. Comparison. It will be seen that, comparing persons who suffer from Cancer with those living at advanced ages, or who died at advanced ages through other causes, the great differences are as to habits with respect to alcohol, smoke, and the action of the bowels, thus:- 27 Cancerous persons had 33 per cent of excessive alcohol users, 41 per cent excessive smokers, 35 per cent excessive tea drinkers, 45 per cent large eaters, 33 per cent large meat eaters, and per cent of constipation. Non-cancerous persons, living to a greater age, had 17 per cent of excessive alcohol users, 21 per cent excessive smokers, 31 per cent excessive tea drinkers, 44 per cent large eaters, 30 per cent large meat eaters, and 14 per cent of constipation. Mouth and Throat. These differences are still more marked with respect to alcohol and smoking, if only those who died from Cancer of the mouth and throat are considered. / Of 103 persons dying from Cancer of the lips, tongue, jaws, fauces, larynx, esophagus and cervical glands, 46 (or 45 per cent took alcohol excessively, while 73 (or 71 per cent) smoked excessively. 28 of these smoked chiefly a clay pipe, 27 a briar, 3 cigarettes, and 3 cigars. There were only 5 out of the 37 cases of cancer of the mouth and tongue who did not smoke; 3 of these had bad teeth. Among the non-cancer cases all the smokers smoked pipes (42 clay and 25 briar, and 5 both), except two who smoked cigarettes. Of 161 cases with cancer of other parts than the mouth and throat 39 (or 24 per cent) took alcohol excessively, and 36 (or 22 per cent) smoked excessively. It would appear, then, that both, alcohol and smoking (especially alcohol) have some general effect in promoting cancer, but chiefly exert their injurious influence locally. This is shown also as regards alcohol by the figures given below for cancer of the stomach, which occupies an intermediate position. Of the 103 oases of cancer of the mouth and throat, 28 (or 27 per cent) were excessive tea drinkers. Tea drinking does not seem to be specially injurious locally or generally as far as cancer is concerned. If the injurious effect of smoking were chiefly due to the local effect of heat one would have expected excessive drinking of hot tea to have had a similar result. Of 13 cases of cancer of the stomach, 8 were large eaters and 2 were large meat eaters. Of 52 cases of cancer of the stomach 16 (or 31 per cent) were excessive alcohol drinkers. As regards cancer of the bowels, out of 59 persons dying from cancer of the intestines, 32 had a regular daily action, and 26 had constipation, i.e., 44 per cent had constipation. Thus constipation seems to predispose to cancer of the bowels. The following table gives the above results in tabular f orm:- 28 All Cancer Cases Per cent Cancer of Mouth and Throat Per cent Cancer of other Parts Per cent Control Cases (NonCancer ) Per cent Excessive alcohol drinkers 33 45 24 17 „ smokers 41 71 22 21 „ tea drinkers 35 27 34 31 Large eaters 45 — - 44 ,, meat eaters 33 - - 30 Constipation 25 - - 16 ALCOHOLISM. 71. There were three deaths from alcoholism, one from peripheral neuritis, and 18 from cirrhosis of the liver, making a total of 22 deaths probably due to alcohol, compared with 23, 18, 31, 43, and 38, in the five preceding years. Of the 22 deaths, 15 were males and 7 females. The diminution of alcoholism, especially among women, is very satisfactory whatever its cause. Eight deaths occurred in the first quarter of the year, four in the second, two in the third, and eight in the fourth. 72. The death-rate from alcoholism, peripheral neuritis, and cirrhosis of the liver was 0.15, which is lower than it has been for several years. SYPHILIS. 73. There were 7 deaths from Syphilis, compared with 3, 9, 9, 5 and 5, in the five preceding years. 5 of these occurred in public institutions. All but one were infants under one year. There were, in addition, 14 deaths from general paralysis, tabes dorsalis (locomotor ataxy) and aneurism, (diseases which are considered to be due to syphilis) compared with 29, 23, 27 and 17, in the four preceding years. OPHTHALMIA NEONATORUM (Inflammation of the eyes of the new-born. The bad cases are usually due to Venereal Disease in a parent.) 74. Notification of this disease is compulsory on Medical men, under the Public Health (London) Act, and on Midwives under an Local Government Board Order. Midwives are paid 1/- for each case notified. 41 cases were notified, compared with 14, 18, 19, and 33 in the four preceding years. The case-rate was 15.2 per 1,000 births. Two cases were removed to hospital and two were treated as hospital out-patients. The others were all reported to be receiving effectual treatment at home. The district nurses attended 15. 29 PART II. ADMINISTRATION. water supply 1. No house was provided with an additional water supply last year under the London County Council (General Powers) Act. 2. Defective and foul storage cisterns were found and remedied at nine houses, compared with 93,' 40 and 44 in the three preceding years. At 19 houses the supply was found insufficient or temporarily cut off, and the necessary steps taken for obtaining a proper supply. 3. 457 samples were submitted to the Public Analyst, and 33 or 7.2 per cent were found to be adulterated, compared with 2.7, 5.6, 7.3, 7.9 and 9.4 in the five preceding years. 248 of the samples taken were informal. 17 of these were found to be adulterated. 4. Proceedings were taken in 15 cases; fines were inflicted in 11, in 3 there was proof of warranty, and in one costs were given against the defendant. 5. Over £30 was imposed in fines and £13 in costs. 6. 185 of the samples were fresh milk. 14 of these, or 7.6 per cent, were adulterated, compared with 3.5, 7.9, 9.7, 10.0 and 5.9 in the five preceding years. 91 samples were bought as butter and 6 were found to be adulterated. Of the other articles analysed, 13 were found to be adulterated, viz., 2 samples of preserved cream, 2 margarine. 4 zinc ointment, 2 mustard, 1 coffee and 2 lard. The preserved cream contained boric acid in excess of the amount allowed by the Regulations. The mustard was adulterated with starch, the coffee with chicory, and the lard with cot-ton-seed oil. The zinc ointment was deficient in zinc oxide. 30 ' Milk and Cream Regulations. 151 samples were examined for the presence of a preservative, but none found. Four samples of preserved cream were examined as to" the correctness of the statements on the label; two were found correct and two incorrect. Four samples of cream were found to have over 35 per cent of fat. FOOD INSPECTION. There were 34 surrenders of unsound food. The time of Inspectors Tedham and Shaw and of Chief Inspector Duck was mainly occupied with Food Control work and they were successful in detecting a large number of the Controller's Orders. DAIRIES, COWSHEDS AND MILKSHOPS. 7. On January 1st. 1917, tnere were 96 milkshops on the register; 8 were added, and 8 removed, during the year, leaving a total of 96 on the register at the close of 1917. There were 112 inspections made, and 9 notices were served. There were no prosecutions. 8. One cowshed was closed leaving 12 on the register. There were 39 inspections, and 6 notices were served for dirty conditions, etc. SLAUGHTER HOUSES. 9. The number of slaughter-houses on the register remained the same, viz., 9. 33 inspections were made, and 2 notices served and complied with. NUISANCES. 10. 549 complaints of sanitary defects were received and investigated, compared with 454, 614, and 599, in the three preceding years. 81 complaints of non-removal of dust were made and attended to, compared with 55, 43, and 74, in the three preceding years. 11. Drains and Water-Closets. 291 private drains, found choked and defective were examined, cleared, and re-laid, compared with 450, 475 and 440 in the three preceding years. The largest number, 55, was found in River Ward. 31 213 water-closets and w.c. cisterns were repaired, compared with 782, 843, and 750, in the three preceding years. 151 foul w.c. pans were cleansed by tenants, compared with 181 255, and 205, in the three preceding years. 12. House Inspection. 4,251 houses were inspected, nouse to house compared with 4,538, 4,707, and 5,736, in the three preceding years; 5,392 were inspected re infectious diseases and complaints, compared with 7,267, 7,207 and 6,423. In addition to these, 609 inspections of registered houses were made. 13. At 1,913 houses, interiors were cleansed, or defective roofs repaired, compared with 2,337, 2,703., and 2,906, in the three preceding years. 381 houses with damp walls were remedied compared with 393, 646, and 589, in the three preceding years. Improved ventilation was provided in 15 nouses, compared with 55, 55, and 72, in the three preceding years. 447 new dust pails were supplied, compared with 474, 561, and 530, in the three preceding years. 14. Medical Officer' s Special Inspections. These amounted. to a total of 417. 24 inspections were made of cowsheds and milkshops, 23 of bakehouses, 7 of factories and workshops, 58 inspections were on account of tuberculosis, 48 cancer, 14 diphtheria, scarlet fever and enteric. 17 cerebro-spinal and other forms of meningitis and 51 re infant welfare. Many of these visits were made by request of the medical attendants for the purpose of diagnosing doubtful cases of infectious disease. Other visits re infectious disease were made at the request of school teachers and others. 82 premises were inspected re housing conditions and overcrowding. Inspections, were made of all the houses reported as unfit for human habitation and all those recommended for registration. 15. Overcrowding;. 95 cases of overcrowding were found and remedied, compared with 93, 97, and 111, in the three preceding years. The overcrowding was 2.2 per cent of house-to-house inspections, compared with 2.0, 2.1 and 1.9 per cent in the three preceding years. No persons were convicted of allowing overcrowding . The overcrowding met with is of a more aggravated nature than in former years, though there is no great increase. 32 16. Smoke Nuisance. Two observations re smoke nuisance were made and two nuisances of black smoke observed. The nuisances were abated on service of notice. There was no prosecution. 17. Defective Light. At 12 houses new windows were supplied or existing ones enlarged, or other work done to improve the lighting by daylight, corn-oared with 49 in 1916. 18. Verminous Rooms. 568 verminous rooms were cleansed under the London County Council (General Powers) Act, 1914, or were dealt with as dirty rooms under the Nuisance Section of the Public Health (London) Act compared with 198 and 213 in the two preceding years. HOUSE AND TRADS REFUSE REMOVAL. 19. There was a diminution in house refuse. In Woolwich Parish, 7,087 loads of house refuse, and 143 loads of inoffensive trade refuse were removed by the Borough Council, and in Plumstead, 14,512 loads of house refuse, weighing 12,720 tons were removed by the Contractors, Messrs. Tuff & Hoar, and destroyed at the Plumstead Destructor. This is a decrease of over 30 per cent compared with two years ago and points to a very satisfactory decrease of waste. In addition, 683 loads of trade refuse weigning 340 tons were removed to the Plumstead Destructor and destroyed (the Contractors removed 354 loads and were paid for the removal by the tradesmen at the rate of 2/- per load). £3,493/ 10. 2 was paid for collection in Plumstead, compared with £3,405. 16. 2 in 1916. In Eltham, the sum of £1,676. 12, 5 (£1,364. 16. 6 in 1916) was paid to the Contractors for removal of dust. 20 loads of trade refuse were removed at the tradesmen's cost. 20. 2,863 (2,336 in 1916) receptacles of offensive trace refuse were removed. There are now 24 (26 in 1916) tradesmen on the books. HOUSING OF THE WORKING CLASSES ACTS. 21. Four houses were dealt with under the Housing Act, compared with 18, 16, and 6, in the three previous years. Two houses were closed; one, 16 Martyn's Passage was closed by order, and one, 6 New Street, was closed and demolished 33 by consent of owners. Closing orders were served for 87 Robert Street and 18 Ravine Grove. The work required was done and these houses are now re-opened. HOUSES REGISTERED UNDER THE BY-LAWS. 22. At the commencement of the year, 430 houses were on the register, 6 were newly registered, and 1 taken off the register, leaving 435 on the register at the close of the year. The number has remained about the same for six or seven years. 23. These houses were inspected, some quarterly, others halfyearly or yearly. 609 inspections were made in all, and 316 notices served. The registered houses were under the care of Inspectors Wood and Miss Middlebrook. INHABITED HOUSE DUTY. 24. No certificate under the Inland Revenue Act was applied for. UNDERGROUND ROOMS 25. Two underground rooms occupied for sleeping were found not in accordance with the regulations and the occupation stopped on service of notice. FACTORIES, WORKSHOPS, AND WORKPLACES . 26. There were, at the close of the year, 203 (200 in 1916) workshops on the register. 387 inspections were made and 53 notices served and complied with. 342 (352 in 1916) inspections of home-workers' premises were made and 7 (12 in 1916) notices sent and attended to. Mr. Rance inspected the Factories and Workshops employing males, and Miss Middlebrook those where women are employed; 10 new workrooms were measured up and put on the register. BAKEHOUSES. 27. The number of factory bakehouses is 8, and of workshop bakehouses in use is 37 11 of the latter being underground. They were all inspected twice. I inspected most of them personally and found them generally satisfactory. 14 certified underground bakehouses are not in use. 34 ICE-CREAM SHOPS 28. No ice cream was made or sold. FRIED FISH SHOPS. 29. There are 39 fried fish shops in the Borough. 42 inspections were made, and 7 notices served. DISINFECTION 30. Rooms at 1,064 houses were disinfected in 1917, compared with 1,344, 1,252, and 989 in the three preceding years. The disinfecting apparatus was used 1,064 times for 22,180 articles after infectious disease and 93 times for special disinfection. Books from the Free Libraries and Public Schools were disinfected. The sum of £8. 7.0 was received for disinfection after special cases of illness on request of the occupier. In addition a large quantity of horsehair and blankets was disinfected for the Army Ordnance Store Department for the sum of £79.13.9. THE MORTUARIES. 31. The Pun Street Mortuary was used for 185 bodies compared with 189. 277 and 271 in the three preceding years. 177 were deposited for inquest and 8 for custody. 90 post-mortem examinations were made. No body was deposited in the infectious mortuary, compared with 2. 1, and 3 in the three preceding years. The Eltham Mortuary was used for five bodies compared with 1 in 1914, 3 in 1915 and 8 in 1916. 2 were for inquest and 3 for custody. CEMETERIES. 32. The two Borough Cemeteries were well maintained and no complaint was received. 701 bodies were buried in Woolwich Cemetery, compared with 667, 720, and 694, in the three previous years. There were 665 interments in the Plumstead Cemetery, compared with 842 , 834, and 744, in the three previous years. 36 burials took place in Plumstead Churchyard, compared with 60, 34, 51, 46, and 38, in the five preceding years. 35 CLEANSING OP VERMINOUS PERSONS. 33. The station for cleansing verminous persons was opened in November, 1906. During 1917 it was used by 2,800 persons, compared with 430, 651, 811, 954, and 1,124, in the five preceding years. The users were 17 adults (viz., 8 females and 9 males) and 2,783 children (viz,, 1,652 females and 1,131 males). 568 verminous rooms were disinfected. The adults came mainly from common lodging-houses and the children from County Council Schools. An agreement was entered into with the London County Council, dated August 21st. 1911, to allow the London County Council to use the Borough Council Cleansing Station for cleansing school children. Owing to vermin and scabies introduced by soldiers returning from abroad, there has been a great increase of cleansing required for the children. The station is now reserved for them every day except Saturday and Sunday between 9 a.m. and 4.30 p.m., girls being cleansed between 9 and 1, and boys in the afternoon. The Borough Council must properly oleanse the children and their clothes to the reasonable satisfaction of the London County Council, which pays 1/- for each cleansing. The Borough Council for this purpose employs a female attendant for the five days at a cost of 5/- per day, plus war bonus. £136. 17. 0 was paid by the London County Council for the school children cleansed last year. The cleansing of children is supervised by a school nurse. A box of stavesacre ointment is supplied to each bather, with instructions for its use. The names and addresses of bathers are entered in a book, and the woman inspector calls at the homes and arranges for necessary disinfection and cleansing of verminous bedding and rooms. TENTS, VANS AND SHEDS. 34. During the year, 58 tents, veins, and sheds, were inspected (53 in 1916) and cne notice served under the By-laws for this class of dwelling. 53 were in Eltham, 4 in St. Margaret's .Ward, and one in St. Nicholas Ward. 36 NOTICES AND PROSECUTIONS. 35. Fewer (2,750) intimation notices, but more (867) statutory notices were served. 101 of the latter, not having been complied with in the time specified, were referred to the Town Clerk, who, before taking proceedings, wrote a warning letter in each oase. Finally, 4 defaulters were summoned at the Polioe Court. The results are given in Table XII. Convictions were obtained and orders made in every case. BACTERIOLOGICAL EXAMINATION. 36. The Council's bacteriological work is done by the Bacteriological Department of the Seamen's Hospital. 1,253 bacteriological examinations were made for the Public health Department, viz., 958 for diphtheria, 286 for phthisis, and 9 for enteric fever. The total cost was £199.7.0 compared with £156. 13. 0 in 1915. INFANT WELFARE 37. Much work was done and considerable advance made in Infant Welfare during the year. The Infant Consultation conducted by the Medical Officer of Health at the Town Hall was continued on Wednesday afternoon. The number of attendances shows an increase on the preceding year. The Health Visitors of Woolwich, and Plumstead parishes weigh the infants and assist the Medical Officer. A new Consultation was commenoed at Eltham in April 1917. This is held on Thursday afternoons (at St. Luke's Church Hall, which the Borough Council rents for the purpose. The cost for rent, lighting and heating in. 1917 was £30. Dr. Hawthorne conducts the Consultation assisted by the Health Visitors and voluntary, workers. Dr. Hawthorne was paid one guinea per afternoon. The average attendance at Woolwich was 23, and at Eltham 14. The total attendances at the two consultations were 1,792 compared with 1,408 in 1913. An arrangement was made for children needing medical attendance to be treated at the School Clinic in Brewer Street at the cost of the Borough Council if the parents could not afford a Doctor. The Ante-natal Clinic conducted Jointly with the British Hospital, continued at the Town Hall. The Medical Officer was Dr. Agnes Swanson and the Health Visitors attended in rotation. 48 expectant mothers attended. 37 An additional Health Visitor - Miss Latham - was appointed and commenced work in May 1917. In addition to tnis official work, the Medical Officer of Health and Health Visitors oo-operated in much voluntary work done by the Advisory Committee for Women Munition Workers, the Committee of the Day Nursery and the Invalid Children's Committee. • WOMAN SANITARY INSPECTOR'S WORK. 38. The following is a summary 'of tne work done by Miss Middlebrook:- Women's Lavatories - Inspections 150 Pound dirty and defective 20 Restaurants and Eating-houses - Inspections 100 Defects and dirty conditions found and remedied 16 Factories and Workshops - Inspections 247 Notices served ' 9 New workrooms measured 10 Homeworkers' Premises - Inspections 342 Cases referred to District Inspectors 7 Houses let in lodgings - Inspections 357 Houses found dirty or unsatisfactory 187 Visits re Phthisis, Measles, Scabies, Whooping-cough and Zymotic Enteritis 622 Visits paid for various causes, complaints, etc. 443 Visits, verminous and dirty houses & bedding 506 Re-visits- estimated 1,000 Cases where bedding was found to be in a dirty and verminous condition, and cleansed or destroyed 420 Number of cases referred to District Inspectors 109 Overcrowding - cases found and abated 43 Notices served re dirty conditions on landlords and tenants 238 38 39. The following is a Summary of the work of the Health Visitors Miss Fitzgerald Miss Farmer Miss Latham 8 months Total  ???successful visits (Mothers out) 319 223 542 ???sits re Notification of Births 536 460 351 1,347 ???miciliary visits to Infants ???attending Consultation 272 166 142 580 ???-visits (.Births) 166 226 467 859 ???te-Natal visits 16 6 — 22 ???asles 607 394 120 1.131 ,, Re-visits 15 34 14 63 ???ifant Deaths investigated 20 9 8 37 ???ildren over one year 30 - - 30 ???aotic Enteritis 22 36) 41) 120 ,, ,, Re-visits 6) 15) ???ihthalmia Neonatorum 13 20 10 43 ,, ,, Re-visits 5 12 11 28 ???erperal Fever 7 5 2) 16 ,, ,, Re-visits , 2) ???iberculosis 38 19 22 79 ???mplaints investigated 7 - - 7 ???rty Conditions 11 - - 11 ???isits not otherwise classified 114 48 35 197 ???salth Lectures given 9 3 1 13 ???Cmmittees attended 25 - - 25 ???(Local Advisory and Day Nursery) y) W'ch49) ???temoons at Infant Consultations 50 Eltham 9) 31 139 ???rnings at Ante-Natal Clinic 18 19 13 50 N.B. Owing to queues and other difficulties in procuring food taking Mothers from home there was a great increase in unsuccessful visits. Misses Farmer and Latham make the following observations on their work:- The effect of war conditions during the latter half of the year, (when it was necessary for mothers to spend many hours a day doing the ordinary household shopping) was seen in many homes, by a considerable neglect of ordinary household duties. During the last months of 1917 there was great difficulty in obtaining milk for children. This was before the Milk Priority Order came into being. Milk sellers were asked to voluntarily agree to give priority in supplying milk to nursing mothers and young children. This arrangement was 39 readily agreed to by most of the milk sellers but' it involved much time being spent by the Health Visitors in arranging for each individual case as it arose. STAFF. 40. The following alterations occurred in the Staff:- Mr. Smith Joined the Army and Mr. Britter again > took up the duties of chief clerk. The time of Inspectors Tedham and Shaw, and, to a large extent of Chief Inspector Duck, was monopolised by the Food Control work. thanks are due to the untiring services of Mr. Duck and the devotion of other members of the sanitary staff. The work of the clerical department was very exacting and involved much overtime. Messrs. Britter and Smith deserve special commendation for their assiduity. 40