AC4372 Metropolitan Borough of Woolwich. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR WOOLWICH. 1920. BY J. MACMILLAN, D.S.O., M.C., M.B., D.P.H., Medical Officer of Health. Woolwich: Pryce & Son, Ltd. (T.U. Federation), 31-35 Powis Street. 1921. Metropolitan Borough of Woolwich. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR WOOLWICH. 1920. BY J. MACMILLAN, D.S.O., M.C., M.B., D.P.H., Medical Officer of Health. Woolwich: Pryce & Son, Ltd. (T.U. Federation), 31-35 Powis Street. 1921. 2 Public Health and Housing Committee. His Worship the Mayor (Councillor A. M. Tynemouth, J.P.) Councillor Miss G. E. Walters (Chairman). Councillor A. E. Smith (Vice-Chairman). Aldermen—- Mrs. E. Dormer J. P. Jackson W. C. Martin. Councillors— §W. W. Burr. J. Newman. Miss M. Crout, J.P. §T. Scoble. S. H. Cuff. *P. F. Sheridan. H. A. Hart. Mrs. M. E. T. Smith. V. Lister. *T. H. Thompson. W. C. Montano. Miss S. Turnbull. § To November, 1920. * From November, 1920. Maternity and Child Welfare Committee. Comprising the members of the Public Health and Housing Committee. Visiting Sub-Committee. Councillor Miss G. E. Walters (Chairman). Councillor A. E. Smith (Vice-Chairman). Alderman— Mrs. E. Dormer. Councillors— Miss M. Crout, J.P. S. H. Cuff. Mrs. M. E. T. Smith. 3 Staff of Public Health Department. Chief Sanitary Inspector— Albert G. Duck, F.S.I.A. Sanitary Inspectors— John W. Rance. Thomas Powell. William Little. Harry Shaw. William Wood. Harold W. Pendrill. Alfred G. Potter. Charles W. Prance (Temporary) William Tedham. Miss Alice Middlebrooke. Sanitary Inspectors and Health Visitors— Mrs. Margaret Garside.. Miss Catherine Ware. Health Visitors- Miss Kate Latham. Miss Eleanor Tibbits. Miss Winifred Burnett. Miss Margaret Campbell. Miss Florence Morgan. Clerks— Amyas Britter. Stanley G. Taylor. Harry S. Smith. Miss Gwendoline Marsh (temporary) Harold M. Collyer. Miss Dorothy Stephenson (temporary) Herbert T. Prescott. Leslie Pike (temporary). Mortuary Keeper— Frank Leason. Public Analyst— Sir William R. Smith, M.D., D.Sc. Assistant Medical Officer of Health— Miss Rachael Mackenzie, M.B., D.P.H. Home for Ailing Babies— Visiting Physician Dr. Frederick Dodd. Matron Miss Janet Raymond. 4 SUMMARY OF STATISTICS, 1920. Area of the Borough 8,276.6 acres Population—Census, 1911 121,376 do. Estimated to middle 1920—for birth rate 147,827 do. do. for death rate 141,666 Persons to an acre—Census, 1911 14.7 do. do. 1920 17.9 Marriages 1,240 Births 3,658 Birth Rate 24.7 Deaths 1,487 Death Rate 10.5 Deaths under one year 224 Infantile Death Rate 61 5 TABLE OF CONTENTS. page Public Health and Housing Committee 2 Maternity and Child Welfare Committee 2 do. Visiting Sub-Committee 2 Staff of Public Health Department 3 Summary of Statistics 4 Preface 8 Natural and Social Conditions of the District. Population 11 Social conditions of the District—occupations of inhabitants 12 Vital Statistics. Births 15 Births—Illegitimate 17 Marriages 18 Deaths 18 Infantile Mortality 27 Hospital treatment and other forms of medical relief 31 Sanitary Circumstances of the District. Cleansing of Earth-closets, Privies and Cesspools 32 Scavenging 32 Sanitary Inspection of the Borough 33 Complaints 34 Inspections 34 Drains 39 Nuisances abated 40 Prosecutions 41 Houses Let in Lodging 44 Cleansing of Verminous Persons 44 Underground Sleeping Rooms 45 Offensive Trades 45 Factories, Workshops and Workplaces 45 6 page Mortuaries 50 Cemeteries 50 Inhabited House Duty 51 Destruction of Rats 51 Food. Milk 56 Dairies, Cowsheds and Milkshops Order 56 Milk and Cream Regulations, 1912 and 1917 57 Milk (Mothers and Children) Order, 1919 58 Food Inspection (including meat and other foods) 61 Bakehouses, etc. 62 Food Poisoning 63 Sale of Food and Drugs 63 Prevalence of, and Control Over, Infectious Diseases. Notifications 67 Notifications each year since 1901 69 Small-pox 71 Measles 71 Whooping Cough 73 Enteric Fever 73 Scarlet Fever 74 Diphtheria 78 Pneumonia, Malaria, Dysentery and Trench Fever 80 Anthrax, Glanders and Hydrophobia 84 Erysipelas 84 Cerebro-Spinal Meningitis 86 Tuberculosis—Notifications 87 Deaths and Death-rates 89 Source of infection 90 Administrative Action 90 Woolwich Voluntary Tuberculosis Dispensary—Statistics 94 Administrative action with regard to Infectious Diseases 95 7 page Maternity and Child Welfare. Staff 96 Welfare Centres 96 Treatment 97 Voluntary Work in the Borough 98 Home for Ailing Babies 99 The work of the Health Visitors 101 The work of the Centres 103 The needs of the Borough 104 Infectious Diseases 105 Puerperal Fever 105 Ophthalmia Neonatorum 105 Measles, Whooping Cough, and Poliomyelitis 106 Epidemic Diarrhoea 106 Administrative measures 106 Sanitary Administration. Sanitary Staff 107 Public Analyst 107 Bacteriological Examinations 107 Housing. General Housing Conditions 108 Shortage of Houses 108 Housing Scheme 109 Population 109 Fitness of Houses 109 Overcrowding 110 Unhealthy Areas 114 Government Hutments and Houses 114 New Houses 115 Appendices 116 Metereology. 8 PREFACE. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Woolwich. Mr. Mayor, Ladies, and Gentlemen, I have the honour to submit the Twentieth Annual Report on the health of the Metropolitan Borough of Woolwich. The report follows the lines laid down by the Ministry of Health, in order to ensure uniformity in the Annual Reports of Medical Officers of Health throughout the country. It shews in statistical form the various factors bearing on the health of the Borough, the efforts which have been made by the Council to promote the general health of individuals and of the community as a whole, and the various measures taken for improving conditions both from the personal and the environmental standpoint. The main vital statistics relating to the year are as follows The population of the Borough has increased by 5,909; the birth rate (24.7) is the highest recorded since 1908, and the actual number of births recorded has only been exceeded on two occasions since 1901; the marriage rate (17.5) shews a decrease compared with previous years; the death rate (10.5) and the infantile mortality rate (61 per 1,000 births) are the lowest ever recorded in the history of the Borough. It may be useful to draw attention to the great changes which are taking place in public health work. The Public Health (London) Act, 1891, dealt mainly with the conditions 9 associated with sanitary environment and infectious diseases. As time went on, however, a more personal aspect came into public health work, and personal hygiene, as distinct from environmental hygiene, is now regarded as the more important factor to be taken into consideration in preventive medicine. This is exemplified by such measures as the medical inspection and treatment of school children, the care of the consumptive, and the care and comfort of the mother and the child. This indicates that preventive medicine in the future will be more intimately personal than ever, and it is in this connection that the importance of preventive medicine in the interests of the expectant mother and of the young child cannot be over emphasized. The circumstances associated with infectious diseases seem to suggest that a change of policy with regard to the method of dealing with these diseases is essential. Scarlet Fever and Diphtheria appear to be becoming less virulent in form than they were, while little or no diminution is taking place in the case of Measles, a disease which still appears to be treated somewhat casually by the public, and the danger of which, particularly in young children, is not sufficiently appreciated. There is need to constantly remind the public of the high death rate from Measles, and the fact that attacks which are not fatal leave behind serious after-effects. The provision of adequate hospital accommodation for children suffering from a severe attack of Measles is overdue, but there are many difficulties in the way of providing additional infectious beds in London, and it is therefore a debatable point as to whether or not the best use is being made of the existing beds which are, in the main, reserved for cases of Diphtheria and Scarlet Fever. Many cases of Scarlet Fever can be adequately and safely treated at home, and, personally, I should like to see B 10 more of the existing accommodation in Metropolitan Asylums Board's hospitals made available for the treatment of Measles cases, at the expense of reducing the number of beds maintained for the isolation of Scarlet Fever. This provision would materially lessen the death rate and the complication rate of this disease. I should like, in conclusion, to point out the prime necessity of an enlightened public opinion with regard to preventive medicine, and to quote from a monograph written by Sic George Newman, Principal Medical Officer of the Ministry of Health, in which he says;— "The object of an enlightened public opinion in regard to preventive medicine is threefold:— 1. It teaches you to secure and preserve personal health. 2. It teaches how to avoid disease. 3. It teaches the community how best to give its assent to sanitary reform and its consent to sanitary government." I wish to state that during the year under review the staff carried out their duties in a thorough and conscientious manner, and I desire to thank the two Health Committees for the sympathetic consideration given to the recommendations I have made, and for their keen attention to the health problems which have been brought before them during the year. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, J. MACMILLAN. 11 Twentieth Annual Report ON THE HEALTH OF THE METROPOLITAN BOROUGH OF WOOLWICH, Year ending 31st December, 1920. NATURAL AND SOCIAL CONDITIONS OF THE DISTRICT. POPULATION. 1. The population of the Borough of Woolwich at the Census of 1911, was 121,376. This number included 5,743 soldiers. The estimated population adopted by the Registrar-General for the calculation of the birth-rate and death-rate of the Borough of Woolwich for the year 1920, is as follows : For the death-rate 141,666 For the birth-rate 147,827 The method adopted to arrive at these populations is set out in the Annual Report for 1919, paragraph 1. The estimated population for the different parishes of the Borough is as follows:— Parish. For the death-rate. For the birth-rate* Woolwich 32,495 33,908 West Plumstead 41,675 43,488 East Plumstead 38,122 39,780 Eltham 29,374 30,651 141,666 147,827 12 The above figures are those which have been used throughout the Report for calculating the various rates in the Borough and in the different parishes. During the preceding four years the population of the Borough was estimated by the Registrar-General as follows: Year. For the death-rate. For the birth-rate. 1916 130,313 141,783 1917 131,942 147,078 1918 134,453 150,650 1919 136,237 141,918 1920 141,666 147,827 SOCIAL CONDITIONS OF DISTRICT. 2. The following tables, compiled from the Census returns for 1911, and the National Register, shew the occupations of the inhabitants of the Borough and the number of persons between the ages of 15 and 65 years, employed in each occupation. I am indebted to the Clerk to the Local Registration Authority for his courtesy in furnishing the table from the National Register, 1915. TABLE No. 1. Occupations of Males and Females between 15 and 65 years. (National Register, 1915). Males. Females Agriculture 342 41 Fishing — — Coal Miners — — Other Miners 1 — Quarrying — — Food manufacture and drink 304 151 Tobacco manufacture — 4 Brewers, Maltsters. Distillers 39 — Explosive substances, explosive articles manufacture 1945 242 Salt, alkali, and chemical manufacture 45 — India rubber, gutta percha workers 156 98 13 TABLE No. 1—continued. Males. Females Manufacture of grease, colouring matter, etc. 50 — Paper manufacture, printing and bookbinding, stationcry, paper and cardboard articles 309 64 Wool and worsted manufacture 11 2 Hosiery manufacture 1 — Other makers of textile fabrics and of textile articles (not articles of dress) 284 356 Tanners, Leather Dressers 9 — Furriers, workers in hair, feathers, bone, etc. 4 — Tailors (makers, not dealers), Tailoresses 231 409 Dressmakers, Milliners, Seamstresses — 1608 Boot, Shoe Makers (not dealers) 167 3 Other workers in dress 45 179 Makers of saddlery and harness (not metal workers) and other leather goods 186 174 Makers of other leather goods 184 — Engineers' Pattern Makers (wood) 33 — Woikers in Metal 12532 757 Other workers in Wood 1541 — Glass manufacture and glass workers 28 — Workers in earth, stone, brick, etc. 949 — Brick, china, earthenware manufacture .. — 2 Builders, Decorators, Upholsterers 967 — French Polishers, Upholsteresses — 9 Motor Drivers 172 — Driving and care of horses (not in Agriculture) domestic and other 778 — Others engaged in road transport 144 — Railway workers 418 Merchant Service; Pilots 256 — Harbour, Dock, River, etc., workers 404 — Telegraph, Telephone Operators, Messengers, Letter Sorters, Postmen .. 225 192 Others engaged in storage, porterage, messages 1059 — Other Post Office, Central and Local Government Officials and Clerks — 176 Banking, Finance, Insurance and Commercial Occupations 3133 1620 Shopkeepers (and Assistants) and other Retail Dealers 2220 1706 Public Administration 1090 — Professional Service.. 829 — School Teachers, Governesses (not Nursery) — 807 Midwives, Sick Nurses, Medical Women — 366 Other Professional Workers — 121 Charwomen — 399 Laundry Workers, Washer-women — 455 Other domestic and personal services 561 3217 Stationary Engine Drivers, Stokers, Firemen 714 — 14 TABLE No. 1—continued. Males. Females Unskilled and General Labourers 2371 — Other occupations 1869 571 Unoccupied 673 28771 Total 37279 42503 The following Table No. 2, sets out under generalised headings the total number of males and females engaged in occupations at ages of 10 years and upwards. (Census, 1911.) TABLE No. 2. Males. Females 1. General or Local Government of the Country 2939 248 2. Defence of the Country 4937 – 3. Professional occupations and their subordinate services 1167 1204 4. Domestic offices or services 741 4588 5. Commercial occupations 1903 770 6. Conveyance of Men, Goods and Messages 3826 81 7. Agriculture 445 21 8. Pishing 4 — 9. In and about, and working and dealing in the products of mines and quarries 80 5 10. Metals, Machines, Implements and Conveyances 8312 274 11. Precious metals, Jewels, Watches, Instruments and Games 281 211 12. Buildings and works of construction 3095 – 13. Wood, Furniture, Fittings, Decorations 611 49 14. Brick, Cement, Pottery and Glass 101 12 15. Chemicals, Oil, Grease, Soap, Resin, etc. 1653 177 16. Skins, Leather, Hair and Feathers 175 21 17. Paper, Prints, Books and Stationery.. 495 129 18. Textile fabrics 262 407 19. Dress 1117 2528 20. Food, Tobacco, Drink and Lodging 2841 1086 21. Gas, Water, Electricity supply and Sanitary service 420 – 22. Other, General, and Undefined workers and dealers 4535 261 23. Without specified occupations or unoccupied 8305 35013 Totals 48245 47085 15 VITAL STATISTICS. 3. The chief vital statistics of the Borough during 1920 and during the preceding five years are shewn in the next table. TABLE I. Vital Statistics of whole District during 1920 and previous years. Year. Population estimated to middle of each Year. Births. Total Deaths Registered in the District. Transferable Deaths. Nett Deaths belonging to the District. Nett. of Non-residents registered in the District. of Residents not registered in the District. Under 1 yr. Of Age. At all Ages. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 1915 134,828 2815 20.9 1725 117 233 268 95 1841 13.7 1916 136,723 3074 21.7 1628 158 213 215 70 1683 12.3 1917 146,503 2698 17.1 1450 150 235 214 79 1550 10.6 1918 146,503 2578 16.5 1949 151 294 268 104 2092 14.3 1919 a 136,237 141,918 2737 19.3 1519 116 276 235 86 1679 12.3 b 1920 a 141,666 3658 24.7 1328 113 272 224 61 1487 10.5 b 147,827 Estimate of Registrar General. a Population for Death Rate. b Population for Birth Rate. Area of District in acres (exclusive of area covered by water) 8239.7 Census, 1911. Total Population, all ages 121,376 Number of Inhabited Houses 21,463 Average Number of Persons per House 5.6 BIRTHS. 4. The number of births was 3,658, and the birth-rate, calculated on the estimate of the Registrar-General, was 24.7, as compared with 19.3 last year. The birth-rate is the highest since 1908. 16 Notification of Births.—Notification of a birth within 36 hours of birth is a statutory duty of the father of the child, and of any person in attendance on the mother. During the year, 3,463 births were notified. This is at the rate of 95% of the registered births which compares with 97% in 1919, the highest ever recorded in the Borough. 2,064 notifications were received from midwives, 435 from medical practitioners, 150 from the British Hospital for Mothers and Babies, 43 from the Woolwich Infirmary, 92 from the Military Families Hospital, and 679 from other persons. Cautionary letters were sent to parents, midwives or medical practitioners in each case where no notification had been received of a birth subsequently registered in the Borough. The following table, No. 3, shews the number of births in each year since 1915, the birth-rate for the same period for Woolwich, London, England and Wales, and the number of live and still births notified each year. TABLE No. 3. Year Woolwich. London England & Wales Woolwich. Percentage of births notified No. of births Birthrate Birth- rate No. of live births notified No. of Stillbirths 1915 2815 20.9 22.6 21.8 2445 75 87 1916 3074 21.7 23.0 21.6 2642 77 86 1917 2698 17.1 17.4 17.8 2550 88 95 1918 2578 16.5 16.1 17.7 2418 70 94 1919 2737 19.3 18.3 18.5 2645 67 97 1920 3658 24.7 26.5 25.4 3163 112 95 17 5. The natural increase of the population is the excess of births over deaths. In 1918, it was 486; in 1919, it was 1,058; in 1920, it was 2,171. Table No. 4 shows the number of births in 1920 in each Parish, and the respective birth-rates (after correction for outward and inward transfers) since 1915. TABLE No. 4. Period. Woolwich West Plumstead East Plumstead Eltham The Borough 1915 22.4 20.1 22.8 16.2 20.9 1916 21.5 21.6 20.5 23.5 21.7 1917 19.6 17.4 18.7 18.2 17.1 1918 19.7 15.4 18.0 17.8 16.5 1919 21.4 16.9 19.1 20.6 19.3 1920 30.4 21.9 24.1 23.2 24.7 No. of Births 1920 1,032 954 959 713 3,658 6. Illegitimate Births. The following table, which is partly compiled from statistics given in the Annual Reports of the Registrar General on Births, Deaths and Marriages, shows the number of illegitimate births each year since 1915, and the illegitimate birth-rate per 1,000 births. TABLE No. 5. Year. No. of illegitimate births. Illegitimate birth-rate per 1,000 births. 1915 98 34.5 1916 106 34.5 18 TABLE No. 5—continued. Year. No. of illegitimate births. Illegitimate birth-rate per 1,000 births. 1917 146 53.7 1918 162 63.6 1919 151 55.2 1920 141 38.5 MARRIAGES. 7. There were 1,240 marriages (1,350 in 1919). The marriage rate was 17.5 as compared with 23.7, 19.7, 20.2 and 19.8 in the four preceding years. DEATHS. 8. Table I shows the gross and nett deaths and deathrates in 1920, and each of the last five years, and shows how the nett death figure is obtained. The nett deaths were 1,487 and the nett death-rate 10.5. In 1919 it was 12.3. The following Table No. 6, shows the death-rate of Woolwich as compared with certain other districts in 1918, 1919 and 1920. TABLE No. 6. 1918. 1919. 1920. England and Wales 17.6 13.8 12.4 96 Great Towns 18.2 13.8 12.5 London 18.9 13.4 12.4 Greenwich 18.8 13.5 11.9 Lewisham 13.6 11.4 10.8 West Ham 19.9 13.3 12.7 East Ham 14.5 9.7 9.6 Erith 12.7 10.7 9.1 Woolwich 14.3 12.3 10.5 19 The following table No. 7, shows the death-rate in the Borough and each registration district since 1915. TABLE No. 7. Period. The Borough Woolwich Parish West Plumstead East Plumstead Eltham 1915 13.7 15.5 14.4 13.6 10.1 1916 12.3 14.3 12.6 10.2 8.5 1917 10.6 13.9 11.8 8.4 8.0 1918 14.3 18.1 15.5 12.4 10.8 1919 12.3 16.2 12.7 10.3 10.1 1920 10.5 13.4 10.4 10.1 7.8 In 1917 the death-rate in Woolwich was the lowest of all the Metropolitan Boroughs; in 1918, three Boroughs, Harapstead, Lewisham and Wandsworth, had a lower death-rate; in 1919, four Boroughs, viz., Lewisham, Wandsworth, Hampstead, and Fulham, had lower death-rates than Woolwich. In 1920, only two Boroughs had lower death-rates, viz., Hampstead and Wandsworth. The next tables are self-explanatory. 20 TABLE No. 8.—Birth-rate, Death-rate, and Analysis of Mortality during the Year 1920. (Populations estimated to the middle of 1920 have been used for the purpose of this Table). Birth rate per 1,000 Total Population. Annual Death-rate per 1,000 Population. Bate per 1,000 Births. Percentage of Total Deaths. All Causes. Enteric Fever. Small-pox. Measles. Scarlet Fever. Whoopingcough. Diphtheria. Influenza. Violence. Diarrhoea and Enteritis (under 2 Years) Total Deaths under One Year. Deaths in Public Institutions. Certified Causes of Death. Inquest Cases. Uncertified Causes of Death. England and Wales 25.4 12.4 0.01 0.00 0.19 0.04 0.11 0.15 0.28 0.48 8.3 80 24.3 92.2 6.6 1.2 96 Great Towns, including London (Census Populations exceeding 50,000) 26.2 12.5 0.01 0.00 0.22 0.04 0.14 0.16 0.31 0.43 10.4 85 31.3 92.2 7.1 0.7 148 Smaller Towns (Census Populations 20,000—50,000) 24.9 11.3 0.02 0.00 0.19 0.03 0.10 0.14 0.27 0.38 7.8 80 16.5 93.2 5.3 1.5 London 26.5 12.4 0.01 0.00 0.22 0.05 0.17 0.22 0.30 0.47 9.5 75 46.8 91.2 8.6 0.2 WOOLWICH 24.7 10.5 0.01 0.00 0.14 0.03 0.10 0.18 0.22 0.37 5.49 61 43.5 901 9.8 0.1 21 TABLE II. Deaths Registered during the Calendar Year 1920, classified by age and cause. Causes of Death. Nett Deaths at the subjoined Ages of " Residents " whether occurring within or without the District. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and upwards. A11 causes 1487 224 42 51 66 92 198 372 442 Enteric Fever 2 .. .. .. .. .. .. 2 .. Measles 21 3 12 5 1 .. .. .. .. Scarlet Fever 4 .. .. 3 1 .. .. .. .. Whooping Cough 14 6 4 3 1 .. • • .. .. Diphtheria and Croup 25 .. 1 8 14 1 .. 1 .. Influenza 31 .. 1 .. 2 5 9 9 5 Erysipelas 1 .. .. .. .. .. .. .. 1 Pulmonary Tuberculosis 161 .. 2 1 5 43 74 34 2 Tuberculous Meningitis.. 11 3 2 2 4 .. .. .. .. Other Tuberculous Diseases 16 1 .. 2 4 4 3 .. 2 Cancer, malignant disease 155 .. .. 1 1 .. 14 90 49 Rheumatic Fever 1 .. .. .. .. 1 .. .. .. Meningitis 15 3 l 3 5 3 .. .. .. Organic Heart Disease 162 .. .. .. 4 7 18 58 75 Bronchitis 101 16 6 2 •• •• 1 12 61 22 TABLE II.—continued. Causes of Death. Nett Deaths at the subjoined Ages of " Residents " whether occurring within or without the District. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and upwards. Pneumonia (all forms) 97 26 7 10 3 3 11 20 17 Other Respiratory Organs 16 2 .. 1 1 .. 3 6 3 Diarrhoea, &c. 27 13 2 .. .. .. 2 2 3 Appendicitis and Typhlitis 10 .. .. .. 4 4 1 1 .. Cirrhosis of Liver 6 .. .. .. .. .. 1 4 1 Alcoholism .. .. .. .. .. .. .. .. .. Nephritis and Bright's Disease 45 .. .. 1 1 5 5 16 17 Puerperal Fever 5 .. .. .. .. 1 4 .. .. Parturition, apart from Puerperal Fever 6 .. .. .. .. 1 5 .. .. Congenital Debility, &c. 104 101 1 1 .. 1 .. .. .. Violence, apart from Suicide 53 7 1 6 5 5 6 13 10 Suicide 13 .. .. .. .. 1 3 5 4 Other defined diseases 381 37 2 1 10 7 35 97 192 Causes ill-defined or unknown 4 1 .. 1 .. .. .. 2 .. 23 TABLE IIA. Shewing the nett deaths of Woolwich residents and all deaths occurring in Institutions in the Borough, and deaths of Woolwich residents occurring in Institutions outside the Borough, during the year 1920. Causes op Death. Male. Female. Woolwich. Plumstead. Eltham. Deaths in Public Institutions. In Borough. Outlying Institutions. West. East. Residents. NonResidents. All causes 810 677 436 435 386 230 301 113 263 Enteric Fever 1 1 .. 1 .. 1 .. .. 1 Measles 15 6 10 4 4 3 3 .. 4 Scarlet Fever 2 2 1 1 1 1 .. .. 4 Whooping Cough 6 8 3 7 7 2 1 .. .. Diphtheria and Croup 14 11 9 7 2 7 .. .. 22 Influenza 17 14 4 11 10 6 4 .. 2 Erysipelas .. 1 .. 1 .. .. 1 .. Pulmonary Tuberculosis 102 59 49 53 37 22 29 8 45 Tuberculous Meningitis 7 4 2 1 4 4 1 .. 4 Other Tuberculous Diseases 10 6 6 2 3 5 4 .. 9 Cancer, malignant disease 60 95 38 48 41 28 30 9 27 Rheumatic Fever .. 1 .. .. 1 .. .. 1 .. Meningitis 6 9 6 3 2 4 1 2 6 24 TABLE IIa.—continued. Causes of Death. Male. Female. Woolwich. Plumstead. Eltham. Deaths in Public Institutions. In Borough. Outlying Institutions. West. East. Residents. NonResidents. Organic Heart Disease 82 80 43 48 51 20 23 9 13 Bronchitis 47 54 32 27 30 12 19 6 4 Pneumonia (all forms) 59 38 34 25 24 14 15 5 9 Other respiratory diseases 11 5 2 4 7 3 .. .. 2 Diarrhoea, &c. 16 11 12 5 7 3 2 3 7 Appendicitis and Typhlitis 5 5 2 2 3 3 5 2 4 Cirrhosis of Liver 5 1 3 .. 1 2 3 .. .. Alcoholism .. .. .. .. .. .. .. 1 .. Nephritis and Bright's Disease 26 19 15 17 7 6 17 3 3 Puerperal Fever .. 5 .. .. 3 2 2 .. 1 Parturition, apart from Puerperal Fever .. 6 1 3 1 1 3 2 1 Congenital Debility, &c. 63 41 35 26 24 19 13 7 13 Violence, apart from Suicide 33 20 21 19 8 5 15 13 9 Suicide 11 2 2 7 3 1 4 3 Other Defined Diseases 209 172 104 112 110 55 106 36 73 Causes ill-defined or unknown 3 1 2 1 .. 1 .. .. .. 25 CAUSES OF DEATH. 9. Table II. shews that 162 deaths were due to organic heart disease, 161 to pulmonary tuberculosis, 155 to cancer and malignant disease, 104 to congenital debility, etc., 101 to bronchitis, 97 to pneumonia, and 53 to violence. Cancer and Malignant Disease. 10. The number of deaths due to cancer or malignant disease (including sarcoma) each year since 1915 is shewn in the next table. TABLE No. 9. Deaths. Males. Females. Total. Death-rate. 1915 50 71 121 0.90 1916 54 76 130 0.95 1917 57 72 129 0.88 1918 79 82 161 1.10 1919 76 81 157 1.15 1920 60 95 155 1.09 The next table, No. 10, shows the site of the primary disease in all deaths from cancer (excluding other specified malignant tumours). C 26 TABLE No. 10. Seat of Primary Disease. Male. Female. Total. Tongue 4 - 4 Pharynx 1 - 1 Œsophagus 5 2 7 Stomach 12 11 23 Liver and Gall Bladder 7 12 19 Intestines 4 10 14 Rectum 4 6 10 Penis 1 - 1 Uterus - 19 19 Vagina and Vulva - 5 5 Breast - 14 14 Ovary - 2 2 Larynx 2 1 3 Lung - 1 1 Pancreas 1 2 3 Kidneys 2 - 2 Bladder 2 3 5 Prostate 3 - 3 Testes 1 - 1 Bones 1 - 1 Other specified Organs 6 3 9 Unspecified - 1 1 56 92 148 Respiratory Diseases. 11. 101 deaths were due to bronchitis, 97 to pneumonia, and 16 to other respiratory diseases. The corresponding figures for 1919 were:—bronchitis, 114; pneumonia, 125; other respiratory diseases, 15. The following table shows the number of deaths each year since 1915 from respiratory diseases, the annual death-rate, the number of deaths under 5 years, and the percentage of deaths occurring in children under 5 years of age. 27 TABLE No. 11. Deaths from Respiratory Diseases. Year. Bronchitis. Pneumonia. Other Respiratory. Total. Death Rate. No. under 5 years. Percentage under 5 years. 1915 168 180 18 366 2.7 125 34.1 % 1916 130 130 13 273 2.1 60 21.9% 1917 113 142 17 272 2.1 87 31.9 % 1918 108 208 5 321 2.4 112 34.9 % 1919 114 125 15 254 1.9 71 27.9 % 1920 101 97 16 214 1.5 70 32.7 % Violence and Suicide. 12. 53 deaths—33 of males and 20 females—occurred from violence, apart from suicide. 13 deaths were due to suicidal causes, 11 of males, and 2 of females. Inquests. 13. There were 145 inquests held in the Borough compared with 180, 181, 131, 112, and 135 in the preceding five years. INFANTILE MORTALITY. 14. The deaths under one year were 224 as compared with 235 in 1919, and 268 in 1918. The infantile mortality rate (deaths under one year per 1,000 births) was 61. The infantile mortality rate is the lowest ever recorded in the history of the Borough: the rates for the various parishes 28 are also the lowest. This rate in London was 75; in Hampstead it was 48 and in Chelsea, 52. The following table No. 12, gives the infantile mortality rate in each registration district of the Borough since 1915. TABLE No. 12. Year. The Borough Woolwich Parish, West Plumstead East Plumstead Eltham. 1915 95 123 73 91 84 1916 70 84 54 65 83 1917 79 97 70 84 67 1918 104 125 99 85 109 1919 86 96 82 68 92 1920 61 75 62 51 55 15. Illegitimate Deaths. The number of deaths amongst illegitimate infants was 19. A comparison of the infantile mortality rates of legitimate and illegitimate children shows that the rate for legitimate was 58, and for illegitimate children, 135. 16. Causes of Death. The chief causes of death were, debility and premature birth, 93; pneumonia, 26; diarrhoea, enteritis and gastritis, 18; and bronchitis, 16. The following table No. 13 shows the infantile mortality rate, the number of infant deaths, the number of deaths under 4 weeks and the proportion under 4 weeks per 1,000 births each year since 1905. 29 TABLE No. 13. Year. No. of Births. Infantile Mortality Rate. Infant Deaths. Total Number Infant Deaths under 4 weeks Total Number per 1,000 births. 1905 3549 103 366 130 37 1906 3524 111 391 146 41 1907 3295 111 372 140 42 1908 3082 95 292 116 38 1909 2937 82 240 87 30 1910 2844 84 241 104 37 1911 2814 98 273 92 33 1912 2747 73 201 90 33 1913 2876 80 229 92 32 1914 2824 84 239 97 34 1915 2815 95 268 81 30 1916 3074 70 215 104 34 1917 2698 79 214 89 33 1918 2578 104 268 109 42 1919 2737 86 235 117 43 1920 3658 61 224 101 28 Total 48052 89 4268 1695 35 Table III shows the deaths under 1 year, classified by age and cause, for the year 1920. 30 TABLE III. INFANT MORTALITY. Nett Deaths from stated Causes at various Ages under One Year of Age. Cause of Death. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks and under 3 months 3 months and under 6 months 6 months and under 9 months 9 months and under 12 months Total Deaths under 1 year. Small-pox .. .. .. .. .. .. .. .. .. .. Chicken-pox .. .. .. .. .. .. .. .. .. .. Measles .. .. .. .. .. 1 .. 1 1 3 Scarlet Fever .. .. .. .. .. .. .. .. .. .. Whooping-cough .. .. .. .. .. 3 2 1 .. 6 Diphtheria and Croup .. .. .. .. .. .. .. .. .. .. Erysipelas .. .. .. .. .. .. .. .. .. .. Tuberculous Meningitis .. .. .. .. .. .. 1 2 .. 3 Abdominal Tuberculosis .. .. .. .. .. .. .. .. .. .. Other Tuberculous Diseases .. .. .. .. .. .. .. 1 .. 1 Meningitis (not Tuberculous) .. .. .. .. .. 1 .. 2 .. 3 Convulsions .. 1 .. .. 1 1 2 1 1 6 Laryngitis .. .. .. .. .. .. .. .. 2 2 Bronchitis .. .. 1 1 2 7 3 4 .. 16 Pneumonia (all Forms) 1 .. .. .. 1 10 1 6 8 26 Diarrhoea .. .. .. .. .. .. 2 1 .. 3 Enteritis 1 .. .. .. 1 4 5 2 .. 12 Gastritis .. .. .. .. .. 2 .. 1 .. 3 Syphilis .. .. .. 1 1 3 2 .. .. 6 Rickets .. .. .. .. .. .. .. .. .. .. Suffocation, overlying 1 .. .. 1 2 3 1 .. .. 6 Injury at Birth 1 .. .. .. 1 .... .. .. 1 Atelectasis 5 .. .. .. 5 .. .. .. .. 5 Congenital Malformations 2 .. 1 .. 3 4 1 .. .. 8 Premature Birth 38 2 3 4 47 6 .. .. .. 53 Atrophy, Debility, and Marasmus 15 6 2 2 25 8 6 1 .. 40 Other causes 5 4 2 1 12 4 3 2 .. 21 69 13 9 10 101 57 29 25 12 224 Nett Births registered during the calendar year Legitimate 3517. Illegitimate 141. Nett Deaths registered during the calendar year of Legitimate Infants, 205. Illegitimate Infants 19. 31 HOSPITAL TREATMENT AND OTHER FORMS OF MEDICAL RELIEF. 17. Poor-law cases requiring hospital treatment are admitted to either the Woolwich or the Lewisham Infirmary— those from the parishes of Woolwich and Plumstead to the Woolwich Infirmary and those from Eltham to the Lewisham Infirmary. Other Institutions receiving sick persons in the district are as follows:— Woolwich and Plumstead Cottage Hospital, 12 beds and 2 cots. Eltham and Mottingham Cottage Hospital, 22 beds. Royal Arsenal Hospital, for Arsenal employees. The Auxiliary Hospital, for soldiers and their dependants. There is no general hospital in Woolwich and considerable use is in consequence made of the London General Hospitals, but no actual figures showing the extent are available. It is proposed however, to erect a general hospital as a War memorial. Reference is made in the Maternity and Child Welfare Section (q.v.) to four other Institutions dealing with that aspect of hospital work, namely:— British Hospital for Mothers and Babies. Woolwich and Plumstead Maternity Home. Woolwich Home for Ailing Babies. Convalescent Home, Brent Road. 32 SANITARY CIRCUMSTANCES OF THE DISTRICT. 18. This part of the report, which has been largely prepared by your Chief Sanitary Inspector, deals with the work (excepting food inspection) of the District Inspectors and the Lady Sanitary Inspector. 19. Closet Accommodation. In outlying parts of the Borough where the sewers are not within the statutory distance of the houses, it is still necessary to resort to the temporary expedient of earth closets and cesspools for the disposal of the drainage. The number of earth closets in the Borough is very small. Under the provisions of Section 30 of the Public Health (London) Act, the Council undertake the emptying of cesspools, which number 22, and the cleansing of earth closets. For the emptying of cesspools the Works Department has an equipment of tank carts and pumps, and where necessary the work is carried out during the night time. 20. Scavenging. Removal of House Refuse. The system for the removal of house refuse continued as in the previous year up to the 1st September, on which date the Contractors, Messrs. Tuff & Hoar, Ltd., discontinued the removal of house refuse in Eltham, this work being then undertaken by the Borough Council and carried out by direct labour under the supervision of the Borough Engineer. The arrangements therefore at present are:—house refuse is collected in the Parish of Plumstead by the contractors, Messrs. Tuff & Hoar, Ltd., and in the parishes of Woolwich and Eltham, by the Borough Council. In Plumstead 15,855 loads, in Woolwich, 7,177 loads, and in Eltham, 5,638 loads (estimated) were collected and disposed of. The refuse in Woolwich and Plumstead is taken to the Council's destructor, but the Eltham refuse is still being disposed of by tipping. The total cost 33 of removal and disposal in Plumstead amounted to £5,747 1s. 1d. compared with £5,137 11s. 5d. in the preceding year. The frequency of removal is weekly, although in certain parts of the Borough it is twice weekly. The number of dustbins that have been renewed, as a result of service of notice under the provisions of The Public Health (London) Act, 1891, was 1,363. 21. Removal of Trade Refuse, (a) In-offensive. The arrangements for the removal of trade refuse are similar to those of house refuse, the work being carried out by the Borough Council in the parishes of Woolwich and Eltham and by the Contractor in Plumstead. In Woolwich, 272 loads, Eltham, 23 loads, and in Plumstead, 146 loads, were removed. The charge which was originally 2/- per load has been increased in the case of Woolwich and Eltham to 5/- per load, and an amount equal to the actual cost of removal is charged by the Contractor in Plumstead. (b) Offensive. A systematic collection is made principally from butchers and fishmongers. Specially prepared air-tight receptacles are provided by the Borough Council, each having a capacity of about 2 bushels, and in the scheme an empty one is left by the Council's official whenever a full one is collected. The receptacles when emptied are cleansed and scalded by the special apparatus of the Council. The refuse is retained in the receptacles and taken direct to a guano manufacturer at Poplar. The charge which originally was 3d. per receptacle was increased to 6d. on the 1st April. There are 52 tradesmen on the books from whom refuse was collected, and during the year, 6,183 receptacles were removed as compared with 4,222 in 1919, and 2,317 in 1918. 22. Sanitary Inspection of the Borough. The permanent sanitary staff was increased by one during the year. Mr. H. W. Pendrill commenced work as a district sanitary inspector 34 on the 7th June. A temporary sanitary inspector commenced work on the 21st June, but his duties have been mainly in connection with the housing survey of the Borough, full details of which are given in the Housing Section of the Report. Complaints. The number of complaints received during the year, 1691, compares with 630, 599, and 719 in the preceding three years. 53 of these complaints related to the non-removal of dust. 7 of these were from Woolwich, 19 from Plumstead and 27 from Eltham. 23. Inspections. Tables 14 and 15 shew in tabular form for the whole district and for each ward the various inspections made, and nuisances abated during the year. TABLE 14. PREMISES INSPECTED. Burrage. Central. Dockyard. Eltham. Glyndon. Herbert. River. St. George's. St. Margaret's. St. Mary's. St Nicholas. Total. Milkshops 8 2 15 38 22 11 21 9 8 8 23 165 Bakehouses 16 6 12 19 16 8 30 .. 4 7 14 133 Cowhouses 3 .. 1 36 .. 2 .. .. 1 .. .. 43 Ice-cream premises 11 7 9 36 23 3 47 5 9 15 30 195 Slaughterhouses .. 3 3 3 .. 5 9 .. .. 4 7 34 Premises where food is prepared 9 .. 25 11 11 4 40 2 .. 13 14 129 Shops and Market re Food (estimated) 42 33 .. 74 37 35 714 13 .. 12 96 1056 Factories, Workshops and Workplaces 23 22 9 10 11 24 153 9 5 20 24 310 Outworkers premises 47 36 55 40 9 33 6 9 28 58 321 Homes re Verminous Cases 15 2 2 1 5 .. 10 5 .. 25 19 84 Homes re Scabies Cases 57 74 17 43 43 26 46 28 22 42 44 442 Women's Lavatories .. .. 12 11 16 .. 45 .. 6 7 5 102 Smoke .. .. 2 12 2 .. 2 .. .. .. .. 18 Tents and Vans .. .. .. 6 .. .. .. .. 6 .. 7 19 Urinals accessible to Public 12 9 11 60 8 1 161 24 16 6 .. 308 Animals so kept as to be a nuisance 2 2 .. 68 3 4 4 .. 2 1 "9 95 House-to-House 32 405 95 500 304 160 499 60 192 158 519 2930 35 36 TABLE 14—continued. PREMISES INSPECTED. Burrage. Central. Dockyard. Eltham. Glyndon. Herbert. River. St. George's. St. Margaret's. St. Mary's. St. Nicholas. Total. Re-Inspections 367 323 1007 1006 588 244 1591 923 283 1027 1124 8483 Housing Survey .. .. 181 166 173 206 306 524 219 133 772 2680 Special Inspections, Complaints and Infectious Diseases 242 185 269 1019 368 194 390 451 763 268 729 4878 Special Inspections re Rats 21 2 14 24 6 12 18 16 3 24 7 147 Drains Tested by Smoke Test 8 2 18 10 13 2 6 4 8 11 1 83 Do. Water Test 3 2 3 10 6 4 8 2 3 .. 1 42 Water Certificates; new houses Inspected .. .. .. .. .. 2 .. .. 3 .. 2 7 Registered Houses let in Lodgings 44 2 78 .. 47 9 326 60 16 45 70 697 School Reports re suspected infectious disease 5 6 10 43 21 9 42 6 4 4 109 259 Miscellaneous (Unclassified) 18 .. 32 .. 29 15 23 1 .. 12 30 160 37 TABLE No. 15. NUISANCES ABATED. Wards. Burrage. Central. Dockyard. Eltham. Glyndon Herbert. River. St. George's. St. Margaret's. St. Mary's. St. Nicholas. Total. Interiors cleansed 111 83 125 342 292 117 551 194 118 166 385 2,484 Damp conditions in houses remedied 33 27 38 151 119 34 145 70 32 45 53 747 Defective guttering and rain-water pipes 27 34 31 57 72 44 62 44 40 43 90 544 Improved ventilation 1 1 2 2 3 1 8 - - 1 3 22 Defective roofs 59 39 51 69 135 47 178 80 51 69 104 882 Deficient light; windows supplied or enlarged - 4 - - 4 - - - - 2 - 10 Paving in yards and wash-houses repaired 15 8 30 39 29 24 57 47 3 22 51 325 Underground rooms not in accordance with Act - - 3 - - - 1 3 - - - 7 Waste-pipe from baths, lavatories, and washhouse sinks, repaired or disconnected 12 11 16 19 19 13 29 33 10 10 35 207 Choked and defective drains 34 14 35 56 37 33 65 24 17 35 52 402 Defective traps 3 2 2 6 6 5 8 4 4 S 2 45 Defective or unventilated soil pipes 2 1 1 6 - 1 1 - - - - 12 W.C.'s repaired; new traps or pans provided 27 10 22 32 66 28 47 25 14 19 39 329 38 TABLE No. 15—continued. NUISANCES ABATED. Wards. Burrage. Central. Dockyard. Eltham. Glyndon. Herbert. River. St. George's. St. Margaret's. St. Mary's. St. Nicholas. Total. Foul pans cleansed 6 7 4 14 12 5 39 17 3 9 22 138 Flushing apparatus repaired or renewed 19 31 27 56 46 14 53 42 19 41 82 430 Additional w.c.'s provided to dwelling houses - - 1 1 - - - - - - - 2 Additional w.c.'s provided to Factories. Workshops, &c. - - - - - - - - - - - - Wash-houses provided with sinks 2 - - 2 2 1 - - - 1 - 8 Defective and foul cisterns used for dietary purposes - - 1 3 - - 52 - - - 3 59 Defective and foul rain-water tanks 1 1 - 3 - 1 - - - - - 6 Insufficient supply of water or water cut off by M.W.B. 6 6 1 5 5 3 38 - 8 6 - 78 Additional water supply - - - 1 - - - - - 2 - 3 Cases of overcrowding remedied 4 2 11 20 12 6 32 9 4 2 16 118 Dustbins supplied 69 48 66 125 142 65 220 136 143 85 264 1,363 Verminous rooms cleansed 17 9 13 18 26 7 65 11 12 28 23 229 Accumulations of manure removed 7 3 14 10 7 8 7 2 2 5 4 69 Dung pits provided - - 1 - - - - - - - - 1 Smoke Nuisances - - - 6 - - 1 - - - - 7 Sundry other Nuisances 84 11 92 84 203 82 140 100 19 63 193 1,071 39 Comparison of these tables with similar tables last year shews that there has been a large increase in the number of inspections. The total number of inspections, however, does not actually give the total number of houses inspected, because these included inspections for complaints, infectious disease, house-to-house, etc., and it is inevitable that many of these are in duplicate. The increase can be associated with the rearrangement of the work and the addition of two inspectors, and is general in the various departments of the work, being more or less uniform throughout the Borough. 24. Drains. There were 30 combined drains reported upon at the meetings of the Public Health Committee throughout the year. These related to 192 houses. The investigations in connection with these systems of drains usually arise from stoppages, but, in cases where a stoppage is found on examination to be due to a temporary cause only, no further action is recommended. These circumstances existed in 21 instances. It was, however, found necessary for 9 combined drains to be reconstructed. These were connected with 61 houses and notices were served for reconstruction under the provisions of the Metropolis Management Act. In all cases in which notices are in default by the owners the work is undertaken by the Works Department, and the costs recovered from the owners by the Borough Council. In accordance with the provisions of the Metropolis Management Act, it is necessary for plans to be submitted where any alterations to drains are intended. This provision is only observed when the repair is of such extent that the information furnished by a plan is likely to be of use for further reference, but it is not insisted on where small repairs to drains, w.c., pans and traps, are carried out by owners. An elaborate drawing is not asked for—only a plan reasonably interpreting 40 the nature of the proposed repairs. During the year, there have been 45 plans submitted. It will be noted that in addition to the drains repaired that are referred to on the plans, there were 402 defective drains repaired by the owners. 25. Nuisances abated. In the Annual Report for the year 1919,1 made reference to the effect that the changed economic conditions in connection with the increased cost of labour and materials, and the demand for labour and materials for houses, were factors of difficulty in maintaining houses in a satisfactory and healthy condition, and in getting the necessary work done associated with the notices that are served for the abatement of the nuisances. The analysis of the work that it has been possible to accomplish shews that there has been a very large increase in the nuisances abated. This is in evidence in the following instances:— (1) For some years past the cost of dust bins has been excessive, but there has been a diminution in the price in the past year, and less difficulty was experienced in obtaining the prompt compliance of notices served for the provision of dust bins. Systematical inspection was carried out for dust bins in various parts of the district, and, as a result, notices were served for 1,363 dust bins ; these were supplied. This figure compares with 609 in 1919, 434 in 1918, and 447 in 1917. (2) Damp conditions in houses were dealt with in 2,173 instances. The value and necessity of the remedying of damp conditions in houses need no emphasis ; the knowledge of the injurious effects on health is universal. The extent of dampness that was dealt with was a question of degree. In some instances it was due to the following conditions (a) Absence of or defective damp-proof courses. (b) Defective guttering and down-spouting, 41 (c) Defective roofing, (d) Other miscellaneous conditions. This number, viz., 2,173, compares with 1,392 in 1919, 1,135 in 1918, and 1,474 in 1917. I regard the abatement of this type of nuisance as one of the most important factors in establishing a healthy house and having a permanent effect on the public health of the district. (3) Defective drains. In addition to the 402 defective drains recorded in the tables, there were 45 instances of more extensive repairs of drains for which plans were submitted. This makes a total of 447 drainage repairs executed in the Borough during the past year. This compares with 292 in 1919, 208 in 1918, and 291 in 1917. (4) Verminous rooms cleansed. The number cleansed was 229 as compared with 74 in 1919, 97 in 1918 and 148 in 1917. The total number of intimation notices served was 4,259 as compared with 2,470 in 1919. It was found necessary to serve 1,514 statutory notices as compared with 846 in 1919. The number of cases reported to the Town Clerk for legal proceedings was 190; 19 summonses were taken out. These figures are a better reflex of the difficulties experienced in remedying sanitary defects than any others occurring in the Report. In each case they are approximately double those of 1919. 26. Prosecutions. The following table shews the number of summonses taken out during the year and the result of the proceedings:— D 42 TABLE No. 16. Prosecutions under the Public Health, Housing, Town Planning, and London County Council (General Powers) Acts. No. Date of Hearing. Offence. Situation. Result. 1 4.2.20 Non-compliance with Magistrate's Order 6 Vicarage Road Work done. 21s. costs 2 11.3.20 Dirty and dilapidated interior of house, and foul and defective w.c. 58 Robert Street Order to abate in 21 days. Penalty. £5. Costs, £1 1s. 0d. 3 11.3.20 Defective roofs of house anddilapidated interior of house 11 Glyndon Road Order to abate in 21 days. Penalty, £10. Costs £1 1s 0d. 4 11.3.20 Defective roofs, dilapidated interior of house and choked down spout 15 Glyndon Road Order to abate in 21 days. Penalty, £10. Costs £1 1s. 0d. 5 11.3.20 Dirty and dilapidated interior of house, and defective roof 13 Glyndon Road Order to abate in 21 days. Penalty £5. Costs £1 1s. 0d. 6 11.3.20 Dirty and dilapidated interior of house 78 Barth Road Work done. Costs, 48. 7 8.5.20 Dirty interior of house 12 Glenside Road Order to abate in 21 days. Costs, £1 1s. 0d. Penalty. 40s. 8 8.5.20 Dirty walls and ceilings of all interior. Dilapidated w.c. 81 Robert Street Order to abate in 14 days. Penalty, £5. Costs, £1 1s. 0d. 9 8.5.20 Defective w.c. apparatus 81 Robert Street Penalty, £5. Costs, £1 1s. 0d. 10 8.5.20 Defective roof 34a Glyndon Road Order to abate in 14 days. Penalty £10. Costs, £1 1s. 0d. 11 23.7.20 Dirty and dilapidated interior of house and leaky roof 92 Raglan Road Order to abate in 14 days. Costs, £1 1s. 0d. 43 TABLE No. 16—continued. No. Date of Hearing. Offence. Situation. Result. 12 27.8.20 Dirty and dilapidated interior of house, defective gutters, and defective w.c. pan 14 Bassant Road Work done. Costs, £2 2s. 0d. 13 17.9.20 Dirty conditions of interior of house 39 Artillery Place Work done. Costs, £2 2s. 0d. 14 17.9.20 Defective water-closet drain 10 Chapel Street Work done. Costs, £1 1s. 0d. 15 17.9.20 Defective yard paving Do. Work done. Costs, 10s. 6d. 16 17.9.20 No dustbin Do. Work done. Costs, 10s. 6d 17 20.10.20 Defective roof; dirty and damp conditions. Defective floors 61 Earl Street Order to abate in 14 days. Penalty, 40s. Costs £2 2s. 0d. 18 27.10.20 Defective drain; defective gutters; leaky roof; defective ceiling; damp walls and site of house 94 Raglan Road Order to abate in 14 days. Penalty, 40s. Costs £2 2s. 0d. 19 20.10.20 Failure to comply with Nuisance Order made on 23rd July 92 Raglan Road Work done. Penalty, £5. Costs £1 1s. 0d. It will be noted that during the year there are instances of large penalties being imposed by the Magistrate at the Woolwich Police Court for non-compliance by the owners with the sanitary notices served on them for defects. The Magistrate imposed these penalties in consequence of the continued neglect of the landlords to comply with the notices, and the defects were of a serious character. In all instances in which Nuisance Orders were made, these were complied with without the necessity of further proceedings, with the exception of one case when a penalty of £5 and one guinea costs were imposed. 44 Premises and Occupations which can be controlled by By-Laws or Regulations. 27. Houses let in Lodgings. These houses have been inspected during the year by the Lady Sanitary Inspector and the details of her inspections are given in table 14. The making of by-laws for the regulation of these houses has been considered by the London County Council, the authority for this purpose under the Housing, Town Planning, etc. Act, 1919, and various suggestions have been made by your Council. It is understood that these by-laws have been submitted to the Ministry of Health for approval, but no such approval has been received by the end of the year. The existing by-laws do not operate in the parish of Eltham but the conditions existing in some of the Eltham houses are similar to those in other parts of the Borough, and admit of a remedy under suitable by-laws. The delay in the approval of these new by-laws is regrettable. The number of registered houses at the beginning of the year was 443; 6 were added during the year, making 449 at the close. 697 inspections were made; 68 sanitary notices served ; and no prosecutions were made. 28. Cleansing of Verminous Persons. The Station for cleansing verminous persons was opened in November, 1906. It is situated in White Hart Lane, Plumstead, in premises adjoining the Disinfection Station. The routine followed is fully described in the Annual Report for 1919 and no change has taken place during the year. Table 17 shews the extent to which the station has been used each year since 1916. 45 TABLE 17. Children. Adults. Grand Total. 1124 Year. Boys. Girls. Total. Males. Females Total. 1916 625 410 1065 44 15 59 1917 1131 1652 2783 9 8 17 2800 1918 1930 1737 3667 14 3 17 3684 1919 1919 1816 3735 13 8 21 3756 1920 1955 1678 3633 23 6 29 3662 29. Underground Sleeping Rooms. During the year, 7 underground rooms were discovered to be illegally occupied in contravention of Section 17 (7) of the Housing, Town Planning, etc. Act, 1909. In four cases the Council made orders closing them, on the recommendation of your Medical Officer of Health, and in the case of the other three, consideration was adjourned at the close of the year. TABLE 18. Date of representation Premises. Date of Closing Order. 22.10.20 38 Albion Road 25.11.20 do. 52 Beresford Street 25.11.20 do. 1 Elizabeth Place, James Street 24.11.20 do. 8 Paradise Place 24.11.20 30. Offensive Trades. There are no offensive trades in Woolwich. 31. Factories, Workshops, and Workplaces. The total number of factories, workshops and workplaces on the register at the end of the year was 241. The number of inspections 46 was 310. This compares with 502 last year. It was found necessary to serve 60 notices compared with 67 in 1919. 321 inspections of home-workers' premises were made and 26 notices were sent and attended to. The Lady Sanitary Inspector devoted a large amount of her time to the inspection of workshops, factories, and houses where women are employed. No cases of infectious disease were notified as having occurred in the homes of outworkers. A more complete inspection of outworkers was made during the year by the Lady Sanitary Inspector and it may be said that the conditions under which homework is carried out in Woolwich are fairly satisfactory. The following tables are in the form adopted by the Home Office for the guidance of Medical Officers of Health so as to ensure uniformity in the presentation of statistics. TABLE 19. Factories, Workshops, Laundries, Workplaces, and Homeworkers' Premises. 1.—Inspection. Including inspections made by Sanitary Inspectors. Premises. Number of Inspections. Written Notices. Factories (Including Factory Laundries) 107 15 Workshops (Including Workshop Laundries) 1S5 35 Workplaces 48 10 Homeworkers' Premises 321 26 Total 631 86 47 2.—Defects Found. Description. Number of Defects. Found. Remedied. Nuisances under Public Health Act: Want of Cleanliness,. 41 15 Want of Ventilation 13 13 Overcrowding 1 1 Want of Drainage of floors — — Other nuisances 33 33 Sanitary Accommodation insufficient — — unsuitable or defective 2 2 not separate for sexes — - Total 90 64 48 TABLE 19—continued. 3.—Other Matters. Class. Number. Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act. (S. 133) 1 Action taken in matters remediable under the Public Health Acts, but not under the Factory Act (S. 5). Notified by H.M. Inspector 2 Reports (of action taken) sent to H.M. Inspectors 2 Underground Bakehouses (S. 101):— In use during 1903 24 Certificates granted in 1906 1 in 1910 1 In use during 1920 10 Workshops on the Register (S. 131) at end of 1920:— Workshop Laundries 8 Bakehouses 48 Other Workshops 154 Total number of Workshops on the Register 210 49 TABLE 19—continued. 4.—Home Work. Nature of Work. Out Workers' Lists, Section 107. Number of Inspections of Outworkers' premises. Outwork in Unwholesome Premises, Section 108. Outwork in Infected Premises, Sections 109,110. Lists received from Employers. Number of Addresses of Outworkers received from Other Councils. Number of Addresses of Outworkers forwarded to Other Councils. Prosecutions. Instances. Notices served. Prosecutions. Instances. Orders made (Sec. 109). Prosecutions (Sees. 109, 110). Twice in the year. Once in the year. Failing to keep or permit inspection of Lists. Failing to send lists. Lists. Outworkers. Lists. Outworkers. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Wearing Apparel Tennis Balls, etc. 38 135 1 4 84 19 .. .. . 68 7 7 * * * * * * * * 6 727 .. .. 95 .. .. 253 19 19 * * * * * * * * 44 862 1 4 84 114 •• .. 321 26 26 •• * * •• •• 50 32. Mortuaries. There are two Mortuaries in the Borough one in Sun Street and one in Eltham. The one in Eltham is only regarded as a place for the temporary deposit of a body, the accommodation being limited to one apartment. At Sun Street there is separate accommodation for non-infectious and infectious bodies. There is no Coroner's Court. The following table shows the extent these Mortuaries were used during the year. Sun St. Sun St. Eltham. All Mor(Infectious). tuaries, 1919. Number of bodies removed— (a) for inquest 120 140 (b) for custody 7 — 4 25 Total number 127-4 165 Number of Post-Mortem Examinations 74- - 80 33. Cemeteries. The two Borough Cemeteries were well maintained and no complaints were received. There are two Churchyards still in use, Plumstead and Eltham. The Plumstead Churchyard is subject to certain regulations contained in an Order in Council which has had the effect of making a considerable reduction in the number of interments there. Notice of all interments has been given to the Public Health Department by the Sexton in accordance with these Regulations. During the year it was decided by the Home Office, on the recommendation of the Ministry of Health, that when an exhumation licence is issued the Medical Officer of Health of the District should be notified in order that he may be in a position to take any action which may appear to be necessary 51 in the interests of public health. During the year, one such notice was received. The disinterment was viewed and the arrangements made by the Cemeteries Department were very satisfactory. The following statistics relating to interments have been supplied by the various Cemetery Superintendents and by the Vicar of Eltham:— TABLE 20. Number of interments. 1920. 1919. 1918. Woolwich Cemetery 617 606 839 Plumstead Cemetery 641 740 915 Eltham Cemetery 173 192 218 Plumstead Churchyard 41 37 32 1,472 1,575 2,004 34. Inhabited House Duty. No certificate under the Inland Revenue Act was issued during 1920. 35. Rats. The Council on 12.2.20, appointed the Medical Officer of Health and all sanitary inspectors as Rats' Officers for their respective districts. During the year, 147 complaints were received relating to rats and these were all investigated and dealt with in accordance with the provisions of the Rats and Mice (Destruction) Act. Two Rat Weeks were held, in January and November. Your Medical Officer of Health presented the following report on the work carried out by the Borough Council during the November Rat Week:— "Inspector Shaw, in the week previous to Rat Week, visited all the large warehouses and factories abutting on the River, asking for the co-operation of these firms 52 in the extermination of rats during Rat Week. He found in many instances that rats are regularly dealt with at these premises throughout the year. In some cases a man's time is fully occupied, and in other cases professional rat-catchers periodically call at the request of the firms whenever any rats are seen. On enquiry at a large warehouse on the riverside during the Rat Week in January, 1920, it was found to be overrun with rats. At these premises a large quantity of horse fodder is stored, but as a result of our action in January the occupiers were stimulated to deal systematically with the rats, and as a result the premises are now practically clear. In the week previous to Rat Week an advertisement was inserted in the local Press. It pointed out the obligations on the occupiers of premises with respect to the destruction of rats, and also invited any complaints relative to negligence. Inspector Shaw finds that people now appreciate that they are responsible for rat destruction on their premises, and this possibly accounts for the fact that during the week only 11 complaints were received with respect to rats on premises, as compared with 45 in January last. While investigating these cases, it was found that 14 adjacent premises were involved. It is interesting that complaints are now only made when it is believed there are a large number of rats. In addition to the advertisement, a bill prepared by the Medical Officer of Health, giving instructions relative to the destruction of rats, was distributed throughout the Borough. The chemists in the Borough were furnished with the prescriptions issued by the Ministry of Agriculture for the manufacture of rat poison, and the bills stated that the poison could be obtained from the local chemists. An inquiry has been made of various chemists, and it has been found that proprietary poisons are preferred, and we have not been able to find any chemist who 53 has made up the prescription except the one who prepared the rat poison used by the Borough Council. In connection with the arrangement with the Works' Committee to plant during Rat Week 1,000 baits per day in the Council sewers, 3,668 baits were laid throughout the week in 68 sewer manholes in the areas where the sewers are old and thereby likely to be infested with rats. Two kinds of baits were used, some made of meal and Barium, and others meal and Barium on bread, and experience has shown that bread baits are the more attractive. Careful records were made by Inspector Shaw daily with regard to the number of baits that were removed. It will be appreciated that there is difficulty in ascertaining whether the bait is effective, in view of the fact that the rats disappear and die in their nesting holes (assumed to be on the sides of the sewers), the sewer being used only as a means of communication. It has been found that in the branch sewers which would be practically dry during the night the largest number of baits were taken, but on the main sewers, where there is always a large volume of sewage, the results were practically negative. The following is the summary of results for each day:— Monday (1st Nov.).—288 baits were laid in 12 manholes. Tuesday (2nd Nov.).—202 of these baits had been removed, and were replaced in the same manholes. Also 792 baits were laid in an additional 33 manholes, making a total of 45 manholes, with 1,080 baits remaining that evening. Wednesday (3rd Nov.).—Of the 1,080 baits left, the previous day, 392 had been taken and were rereplaced, in addition to which 552 baits were laid in a further 23 manholes, making a total of 68 manholes and 1,632 baits left. 54 Thursday (4th Nov.).—Of the 1,632 baits left the previous evening, 616 baits had been removed; 1,602 baits were left that evening. Friday (5th Nov.).—Of the 1,602 baits left the previous day, 432 baits had been taken, and these were replaced. There were 1,602 baits left. Saturday (6th Nov.).—Only 54 manholes were examined. Of the 1,288 baits left the previous evening in these manholes, 258 baits had been removed. These were replaced. There were 1,628 baits left by midday. Monday (8th Nov.).—Of the 1,628 baits, 446 baits had disappeared. In 12 manholes the baits were not touched throughout the week. It will be seen from the above particulars that the following were the percentages of the baits that were removed by the rats from the total number of baits .laid:— Tuesday, 2nd November 70% Wednesday, 3rd November 36% Thursday, 4th November 37% Friday, 5th November 27% Saturday, 6th November 20% Monday, 8th November 21% No manholes were opened on the Sunday. From a circular prepared by the Ministry of Agriculture and Fisheries, it would appear that the lethal (or fatal) dose of Barium carbonate for rats is 6 grains. The baits laid in the sewers in actual fact contained approximately 11 grains, so that if Barium carbonate has the efficacy which is claimed for it, a large number of rats must have been killed in the sewers during the week. I think, therefore, that this experiment shows that the laying of poison baits in sewers is justified. I do not 55 think, however, that it is necessary that these baits should be laid regularly, but that it should be left to the Borough Engineer to have them laid when and where it is convenient during the daily examination of the sewers." 36. Increase of Rent and Mortgage Interest (Restrictions) Act, 1920. This Act came into operation on 2nd July, 1920. It provides that at any time not being less than three months after the date of any increase permitted by this Act, the tenant may apply to the County Court for an order suspending such increase on the grounds that the house is not in all respects reasonably fit for human habitation or is not in a reasonable state of repair. After the payment of increased rent as provided by this Act, a tenant may apply to the Sanitary Authority for a certificate, paying a fee of one shilling. Subject to the certificate being granted, the tenant is able to use it in accordance with the Act for the purpose of obtaining a suspension of the amount of increase in the rent. The sanitary authority however may issue a report when the circumstances do not justify a certificate. In cases in which a certificate is recommended by the Medical Officer of Health, an order for the issue is made by the Borough Council and the certificate is issued on the application of the tenant. When a certificate is not recommended the Medical Officer of Health issues a report. Nine applications were made for certificates during the year. In each case the owner was advised that a certificate had been applied for and notices were served on him for the abatement of the nuisances existing at the house. As a result only one certificate was granted, a report being issued in the case of the other applications. 56 FOOD. MILK. 37. The milk supply of Woolwich mainly comes from outlying districts, but a fair quantity is produced locally. There are 14 cowsheds in the Borough, in which there are 367 cows in milk. Cowsheds are subject to annual licensing by the London County Council, and, in consequence, the standard of cleanliness is maintained at a fairly high level. They are subject to systematic inspection. It is estimated that approximately 33,000 gallons of milk are consumed each week in the Borough, but this varies of course from month to month. The number of general shops where small quantities of milk are sold have been reduced and those that are still on the register of milk-sellers are compelled to keep their milk under such conditions as to preserve its purity, and in all instances where milk is sold it is a condition of registration that the storage receptacle should always be covered. At the end of the year, there were 72 milkshops on the register, a decrease of 4 from 1919. 5 were added in 1920 and 9 were removed owing to ceasing to sell milk or closing of business. No special action has been taken in the Borough with respect to tuberculous milk, the London County Council being the authority in this matter. In my report last year, in consequence of food control, I was able to give a very much more accurate record of the quantity of milk consumed in each month. The following are the prices of milk during the past year:— January l1d. and 1/- per quart. February l1d. March l1d. 57 April l0d. May 8d. June 7d. and 8d. July 7d. and 8d. August 8d. September 8d. October 9d. and l0d. November l0d. December l1d. MILK AND CREAM REGULATIONS, 1912-1917. 38. The following is a copy of the report already furnished to the Ministry of Health:— REPORT ON ADMINISTRATION IN CONNECTION WITH THE PUBLIC HEALTH (MILK & CREAM) REGULATIONS, 1912. Report for the year ended 31st December, 1920. 1.—Milk and Cream not sold as "Preserved Cream." Number of samples examined for the presence of a preservative. Number in which preservative was reported to be present. Percentage of preservative found in each sample. Action taken. Milk 237 (including 3 separated milk) — — — Cream 4 4 (1) .37 % boric acid (2) .35 % „ (3) .29 % „ (4) .33 % „ Informal sample „ „ Explanation asked for and accepted „ „ E 58 2.—Cream sold as Preserved Cream. (a) Instances in which samples have been mitted for analysis to ascertain if the statements on the label as to preservatives were correct 3 (1) Correct statements made 3 (2) Statements incorrect 0 (3) Percentage of pre- Percentage stated on servative found in statutory label— each sample— .37% Not exceeding .4% .03% do. .32% do. (b) Determination made of milk fat in cream sold as Preserved Cream— (1) Above 35% 3 Below 35% 0 (c) Instances where (apart from analysis) the requirements as to labelling or declaration of preserved cream in Article 5 (1) and the proviso on Article 5 (2) of the Regulations have not been observed Nil (d) Particulars of each case in which the lations have not been complied with and the action taken - 3. Thickening substances Nil 4. Other observations, if any Nil MILK (MOTHER AND CHILDREN) ORDER, 1919. 39. In December, 1919, the Council put into force the provisions of the Milk (Mothers and Children) Order, 1919. By this Order the local authority is empowered to supply milk at less than cost price, not merely in necessitous cases but also in such instances as are necessary owing to the 59 retail price of milk in the area. The Council, however, resolved to supply milk in necessitous cases only. The quantity of milk is prescribed by the Medical Officer of Health, or the Medical Officer of the Maternity and Child Welfare Centres working in co-operation with the local authority, and the amount does not exceed that set out in a circular letter of the Ministry of Health, viz.— (а) For children under 18 months, 1½ pints daily. (б) For children between 18 months and 5 years, 1 pint. (c) For expectant or nursing mothers, the quantity prescribed by the person certifying. At the same time the Council designated the Medical Officer of Health and the Assistant Medical Officer of Health as the persons to work the scheme. Your Medical Officer of Health was instructed to prepare a hand bill and to distribute it through the local labour exchanges and through the school authorities in order to bring the provisions of this scheme before the public. The dissemination of this knowledge to a large number of the population brought about a large increase in the amount of milk and meals supplied free of cost, and, in actual fact, the cost for the year was £2,431 lis. 5d. as compared with £249 12s. 6d. in 1919. In November, 1919, the Council adopted an economic circumstances scale for the supply of milk free of cost and this scale was in operation during the whole year. In July, 1920, the Council considered the revision of this scale, at the suggestion of the Ministry of Health, and submitted the following scale to the Ministry for approval:— No. in family. Scale per head. s. d. One 20 0 Two 17 6 Three 15 0 60 No. in family. Scale per head. s. d. Four 12 6 Five 12 0 Six or more 10 0 Deductions : rent, fares and insurances. This scale did not receive the approval of the Ministry of Health and the Ministry suggested an amended scale as a proper basis. At the end of the year, the Council had not adopted this amended scale. No arrangements exist in the Borough for the supply of milk on a part payment basis. Experience in the working arrangements for the distribution of milk showed that certain people were obtaining milk when they were not entitled to it under the Council's scale, two such cases being discovered during the year. In both cases the Council resolved to institute proceedings : one case was heard in December, 1920, and the other case being pending at the close of the year. The following table shows the result of the prosecution :— TABLE No. 21. Offence. Result. Obtaining milk under false pretences. Bound over under the Probation of Offenders' Act, 1907, upon the condition that she repaid the value of the milk obtained. The practice in connection with this scheme has been to encourage the use of dried milk, and fresh milk has only been supplied in a relatively few number of cases. The cost has been as follows :— Fresh Milk £184 4s. 5d. Dried Milk £2,247 7s. 0d. 61 Dried milk has been sold at cost price at all the Centres during the year to those who cannot afford to pay the ordinary trade price. The Borough Council provides food other than milk for nursing and expectant mothers when recommended by the Medical Officer in charge of the Maternity Clinics. Arrangements have been made with the proprietors of eating-houses to supply dinners to expectant and nursing mothers. This method of supplying food is popular and is best for the mother. It ensures that the woman herself eats the food, which is not always certain with other arrangements. In connection with the supply of food and milk, the grant of the Ministry of Health of 50% is available for approved expenditure. FOOD INSPECTION, INCLUDING MEAT AND OTHER FOODS 40. It is the duty of each sanitary inspector, whilst on his district, to be on the outlook for unsound food, but, in addition to this, two inspectors specially inspect food exposed for sale in shops, and in the market places, and have made regular inspections of the slaughterhouses in the Borough. No public abattoir exists in the Borough. The number of carcases condemned on account of tuberculosis was 6. On 107 occasions during the year unsound food was surrendered as compared with 120 in 1919. Included in the food surrendered were 2 tons, 13 cwts. of beef; 2 tons 9 cwts. 3 qrs., mutton; 1 ton, 10 cwts., fish; 822 lbs. of bacon; 790 lbs. of dates; 376 lbs. of butter; 390 lbs. of rabbits; 327 lbs. of pork; 2 cwts. of rice; 2 cwts. of potatoes, and smaller quantities of corned beef, offals, fruit, and various canned goods. 62 The following table shows the legal proceedings taken in connection with unsound food during the year:— TABLE 22. Offence. Situation. Date of hearing. Besult. Sold a fowl that was liable to be seized at the time of sale Beresford Sq. 19/2/20 Fined £3; Costs £5 5s. 0d Seven fowls that were exposed for sale and were unsound do. do. Fined £21. When unsound food is purchased by farmers on condition that it shall not be used for the food of man, it is usually consumed by pigs. A notification is received from the Medical Officer of Health of the district in which it is purchased. The farm is then inspected and the consignment kept under observation until it is all disposed of for the purpose for which it was purchased. During the year, the following have been so dealt with t 5 tons of corned beef 179 cases of canned pears. TABLE 23. SLAUGHTER HOUSES. In 1914. In Jan. 1920. In Dec. 1920. Registered Licensed 12 9 9 BAKEHOUSES, COWSHEDS, SLAUGHTERHOUSES, ETC. 41. In concise form is given below various statistics relating to bakehouses, etc. A list of the underground bakehouses was given in the Annual Report for 1919. 63 TABLE No. 24. Premises. On Register at end of 1919. Added in 1920. Removed in 1920. On Register at end of 1920. Number of Inspections. Number of Notices. Number of Prosecutions. Milk Premises 76 5 9 72 165 5 .. Cowsheds 14 .. .. 14 43 3 .. Slaughter-houses 9 .. .. 9 34 .. .. Ice Cream Premises 46 45 .. 91 195 .. .. Bakehouses 48 .. .. 48 59 18 .. These premises have been systematically inspected during the year and the necessary notices served to remedy any insanitary conditions discovered. Generally speaking it may be said that these premises are maintained in a fairly satisfactory condition. Inspection of premises where food is prepared for sale or sold. 42. These premises were inspected during the year, 129 inspections being made. 43. Food Poisoning. No case of food poisoning was reported as having occurred in the district in 1920. SALE OF FOOD AND DRUGS. 44. The following table shows the number of the various analyses made during the year and the result of the analyses :— 64 TABLE No. 25. Article. Formal Samples. Informal Samples. Number Analysed. Number Aldulterated. Milk 231 3 234 6 Separated Milk 6 - 6 6 Dried Milk 3 - 3 — Cream 2 2 4 4 Preserved Cream - 3 3 - Butter 14 18 32 — Margarine 12 1 13 - Lard - 27 27 1 Dripping 2 - 2 - Coffee 28 21 49 1 Cocoa 17 7 24 - Sugar 6 4 10 - Ice Cream - 2 2 - Mustard 8 9 17 — Pepper 13 7 20 - Vinegar 9 - 9 Malt Vinegar 3 15 18 - Golden Syrup - 3 3 - Self raising Flour - 1 1 - Nougat 1 - 1 - Sausages 3 6 9 6 Olive Oil - 2 2 - Baking Powder - 2 2 - Cream of Tartar - 4 4 - Liquorice powder - 3 3 - Epsom Salts - 1 1 - Ammoniated ture of Quinine - 6 6 - Camphorated Oil - 5 5 - Boric Ointment - 2 2 - Zinc Ointment - 3 3 - 358 157 515 20 65 The percentage of adulterated samples 3 9 compares with 1.6 in the preceding year. The number of samples taken on a Sunday was 12, 1 of which was adulterated. 8 of the informal samples were found to be adulterated. In the certificate furnished by the Analyst in the case of milk, a fat precentage figure is given in the case of each sample. The following table shews the fat percentage figures for the years 1919 and 1920. The minimum legal standard is 3 per cent. TABLE No. 26. 1919. 1920. Above 4.5% 2 — 4%-4.5% 20 17 3.5%-4% 95 131 3%-3.5% 92 80 Below 3% 5 6 214 234 66 TABLE 27. Prosecutions under the Food & Drugs Acts during 1920. No. Article. Nature of Offence. Name and Address of Vendor. Result of Proceedings. 1 Milk 18.66 % deficient in fat Eltham Dairies Dismissed—warranty proved 2 do. 39.33 % deficient in fat E. Hiscock, Wickham Lane Pine £2 2s. 0d.; Costs £1 l1s. 6d. 3 do. 71.66 % deficient in fat W. Gill, 398 High Street Plumstead Fine £10; Costs £1 l1s. 6d. 4 do. 7.42 % added water A. Stanwell, 10 Chapel Street Fine £4; Costs £1 l1s. 6d. 5 do. 12.1 % added water and 18.3 % deficient in fat E. Thompson, 127 Plumstead Road Dismissed under First Offenders Act on payment of £1 6s. Od. Costs. 67 PREVALENCE OF AND CONTROL OVER INFECTIOUS DISEASE. NOTIFICATIONS. 45. The total number of notifications (including duplicates) received during the year was 2,743 as compared with 3,461 in 1919. This decrease is largely accounted for by the fact that measles ceased to be notifiable at the end of 1919. The number of notifications of measles shewn in Table IV. below represents voluntary notifications instead of compulsory ones as in the previous year. Table IV. shows notifications in detail for each disease and in the age groups. It also shows the numbers occurring in each parish in the Borough and the numbers removed to hospital. For comparative purposes the number of cases of notifiable infectious diseases occurring in the Borough each year since 1901 is shown in table 28 on page 69. There is an increase in the incidence of scarlet fever, and of puerperal fever, but a decrease in tuberculosis. 68 TABLE IV. Cases of Infectious Diseases notified during the Year 1920. Notifiable Diseases. Number of Cases Notified. Total Cases Notified in each Locality. Mistaken Diagnosis. Total Cases removed to Hospital or Sanatorium. At all Ages. At Ages—Years. Woolwich. Plumstead. Eltham. Under 1 1 and under 5 5 and under 15 15 and under 25 25 and under 45 45 and under 65 65 and upwards West East Small-pox 1 ... ... ... ... ... 1 ... ... ... 1 ... ... 1 Anthrax ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera (C), Plague (P) ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous Croup) 427 2 91 269 36 28 1 ... 132 120 66 109 18 408 Erysipelas 82 ... 2 3 2 23 43 9 15 20 32 15 4 Scarlet Fever 538 3 113 362 38 22 ... ... 100 133 202 103 3 457 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... Zymotic Enteritis 31 19 12 ... ... ... ... ... 16 8 4 3 ... ... Enteric Fever 6 ... ... 3 1 2 ... ... 2 2 2 ... ... 6 Pneumonia 136 12 19 24 18 40 18 5 61 32 16 27 ... 21 Puerperal Fever 13 ... ... ... 5 8 ... ... 4 3 2 4 ... 9 Cerebro-Spinal Men 3 ... 1 ... 2 ... ... ... 3 ... ... ... ... 3 Post Basic „ 3 ... 2 1 ... ... ... ... ... 2 ... 1 ... 1 Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Letharg. 3 ... 1 ... ... 1 1 ... 1 1 ... 1 ... 3 Ophth. Neonatorum 29 29 ... ... ... ... ... 8 9 5 7 ... 2 Pul. Tuberculosis 359 1 9 49 102 144 47 7 100 104 107 48 ... 275 including re-admissions Other forms of „ 69 9 37 12 9 2 22 21 20 6 ... 37 Measles 1013 3 313 694 3 ... ... ... 323 293 239 158 ... 4 Malaria 29 ... 1 1 7 19 1 ... 7 16 2 4 ... ... Dysentery 1 ... ... ... ... 1 ... ... 1 ... ... ... ... ... Total 2743 69 573 1443 226 297 114 21 795 764 698 486 21 1231 69 TABLE 28. Notification of Infectious Diseases, 1901 to 1920. Year. Small-pox. Diphtheria and Mem. Croup. Scarlet Fever. Enteric Fever. Erysipelas. Puerperal Fever. Tuberculosis.* Continued Fever. Cerebro-Spinal Fever. Anterior Poliomyelitis. Ophthalmia Neonatorum. Zymotic Enteritis. Post basic Meningitis. Anthrax. Encephalitis. Malaria. Dysentery. Pneumonia.† Measles.‡ 1901 21 216 311 68 72 8 1 .. .. .. .. .. .. .. .. .. .. .. 1902 228 233 267 50 98 11 189 1 .. .. .. .. .. .. .. .. .. .. .. 1903 6 186 389 42 58 2 165 3 .. .. .. .. .. .. .. .. .. .. .. 1904 6 163 472 25 74 5 186 1 .. .. .. .. .. .. .. .. .. .. .. 1905 7 273 513 27 83 12 145 1 .. .. .. .. .. .. .. .. .. .. .. 1906 .. 387 528 40 97 8 176 .. .. .. .. .. .. .. .. .. .. .. .. 1907 .. 275 1023 27 110 6 150 .. 1 .. .. .. .. .. .. .. .. .. .. 1908 .. 362 596 19 90 6 154 .. 1 .. .. .. .. .. .. .. .. .. .. 1909 .. 268 1027 13 113 9 206 .. .. .. .. .. .. .. .. .. .. .. .. 1910 1 171 524 10 89 7 196 .. 1 .. .. .. .. .. .. .. .. .. .. 1911 .. 239 518 16 82 16 375 .. 1 3 8 .. .. .. .. .. .. .. .. 1912 3 429 474 20 87 2 689 .. 1 3 20 .. .. .. .. .. .. .. .. 1913 .. 321 626 14 70 8 675 .. .. 1 14 338 .. .. .. .. .. .. .. 1914 .. 416 714 18 107 7 498 .. 1 .. 18 199 .. .. .. .. .. .. .. 1915 .. 286 601 31 138 6 489 .. 50 2 19 173 .. .. .. .. .. .. .. 1916 1 271 232 9 95 16 469 .. 14 .. 33 80 3 .. .. .. .. .. 1590 1917 .. 277 147 12 79 12 543 .. 17 1 41 101 5 .. .. .. .. .. 1710 1918 .. 240 222 12 61 14 660 .. 7 2 23 118 4 .. .. .. .. .. 800 1919 4 398 243 26 63 7 474 .. 6 1 34 123 1 1 3 61 7 123 1816 1920 1 427 538 6 82 13 428 .. 3 .. 29 31 3 .. 3 99 1 136 1012 * Voluntary Notification to 1910 : partial to 1912 : all cases thereafter. † Inoludes all forms of Pneumonia ‡ Measles compulsorily Notifiable from 1.1.1916 to 31.12.1919. 70 46. The following table shows the number of deaths and death-rates from various infectious disease each year since 1915. TABLE No. 29. Year. Small-pox Diphtheria Scarlet Fever. Enteric Fever. Puerperal Fever. Measles. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. 1915 ... ... 20 0.15 8 0.06 5 0.04 3 0.02 45 0.33 1916 ... ... 11 0.08 4 0.03 1 0.01 8 0.05 23 0.17 1917 ... ... 16 0.11 1 0.01 3 0.02 6 0.04 31 0.21 1918 ... ... 25 0.17 4 0.03 2 0.01 9 0.06 21 0.14 1919 2 0.01 28 25 0.21 3 0.02 5 0.04 5 0.04 7 0.05 1920 ... ... 0.18 4 0.03 2 0.01 5 0.04 21 0.14 TABLE No. 29—continued. Year. Erysipelas Zymotic Enteritis. Pneumonia Cerebrospinal Fever and Post- basic Meningitis. Encephalitis lethargica. Whooping Cough. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. 1915 8 0.06 30 0.22 189 1.40 9 0.07 ... ... 17 0.13 1916 2 0.01 27 0.20 136 1.00 4 0.03 ... ... 34 0.25 1917 4 0.03 24 0.16 158 1.08 6 0.04 ... ... 10 0.07 1918 2 0.01 26 0.18 225 1.54 7 0.05 ... ... 29 0.20 1919 2 0.01 18 0.13 125 0.92 2 0.01 3 0.02 11 0.08 1920 1 0.01 20 0.14 97 0.68 7 0.05 ... ... 14 0.10 71 SMALL POX. 47. One case only ocurred during the year. The patient, a man aged 45 years, was notified on the 27th March and was removed to hospital on the same day. The patient recovered. The source of infection was traced to Erith, the patient being the working mate of the father of the primary Erith case and being in association with him until twelve days before the rash appeared. All the home contacts were re-vaccinated by the Public Vaccinator. No contacts of small-pox were vaccinated in accordance with the Public Health (Small Pox Prevention) Regulations, 1917, by your Medical Officer during the year. 15 contacts of small-pox, notified as such by Medical Officers of other Authorities, were kept under observation for the necessary period. The Health Shelter has been maintained during the year but it has not been used. MEASLES. 48. Notification Statistics. The number of notifications of measles received during the year was 1.013. Of these notifications 5 were by medical practitioners, 975 by school teachers, 26 were by parents, and 7 were from various other sources. 49. Removals to Hospital. On the certificate of your Medical Officer, 4 cases were removed to hospital, as compared with 12 in 1918 and 2 in 1919. The following table shows the number of cases of measles removed to hospital by the Metropolitan Asylums Board, on the certificate of your Medical Officer each year since 1910. It also shows the number of notifications received from various sources each year, and the 72 number of deaths. Measles (primary cases only) was compulsorily notifiable from 1st January, 1916 to 31st December, 1919. TABLE No. 30. Year. Notifications. Deaths. Removed to Hospital. Nursing Assistance provided Death rate. 1910 396 21 - - 0.16 1911 801 28 — — 0.23 1912 775 30 22 - 0.24 1913 387 9 12 — 0.07 1914 967 25 3 — 0.19 1915 1179 45 5 — 0.33 1916 1590 23 10 236 0.17 1917 1710 31 45 139 0.21 1918 800 21 12 100 0.14 1919 1886 7 2 98 0.05 1920 1013 21 4 39 0.15 50. From Table 29, it will be seen that the death-rate from this disease has always been higher than from scarlet fever, and only in seven years has it been lower than that of diphtheria. Furthermore it must be borne in mind that the aftermath of measles is likely to be more serious than either that of scarlet fever or diphtheria. Unfortunately, very little provision has been made in London for institutional treatment of measles owing to the demand which is made on infectious diseases beds by scarlet fever and diphtheria. In my opinion, it is unnecessary to provide further accommodation for the treatment of measles, and consideration can, with advantage, be given for an increase of the facilities for the provision of measles beds by a method of selection with a corresponding restriction of the number of scarlet fever beds. By this means, the treatment of an individual suffering from measles could be ensured without detriment to the health of the community as a whole. 73 51. Nursing. The Council made arrangements in 1916 for the home nursing of measles patients by voluntary nursing associations. During 1920, 39 cases were nursed at home at a total cost of £14 7s. 6d. The number of visits paid by nurses was 386 thus averaging 10 visits per case. All cases occurring in children under 5 were visited by the Health Visitors. 52. Deaths. The number of deaths due to measles was 21, as compared with 7 in 1919 and 21 in 1918. 20 of these occurred in children under 5 years of age. 53. School Closure. To prevent the spread of measles in school, the London County Council have continued to close schools or departments (14 in 1920 as compared with 24 in 1919), and to exclude unprotected children from school. The period of exclusion or closure was usually for a few days only, but in some cases for two weeks. WHOOPING COUGH. 54. During the year 454 cases of whooping cough came to the knowledge of the department through the school services. One case was admitted to hospital on the recommendation of your Medical Officer. The number of deaths was 14 as compared with 11 in 1919 and 29 in 1918. 13 of the deaths occurred in children under five years of age. ENTERIC FEVER. 55. There were 6 cases of enteric fever notified during the year. The number of deaths was 2, giving a death-rate of 001. F 74 56. Bacteriological diagnosis. Similar facilities as for diphtheria (q.v.) are provided at the Seamen's Hospital, Greenwich, and during the year 6 samples of blood were examined for Widals re-action. A positive result was obtained in one. 57. The following table No. 31, shows the number of cases notified each year since 1901, in the various parishes and in the Borough and the percentage removed to hospital:— TABLE No. 31 (Enteric) Year. The Borough. Woolwich. Plumstead. Eltham. Percentage removed to Hospital. West. East. 1901 68 21 14 18 15 66 1902 50 17 11 13 9 84 1903 42 10 11 11 10 64 1904 25 8 1 8 8 84 1905 27 7 9 10 1 63 1906 40 16 6 15 3 70 1907 27 6 9 7 5 67 1909 19 2 11 1 4 74 1909 13 9 3 .. 1 62 1910 10 3 5 .. 2 50 1911 16 10 3 2 1 94 1912 20 10 4 2 4 65 1913 14 7 2 a 2 71 1914 18 6 6 4 2 78 1915 31 11 13 5 2 87 1916 9 2 3 3 1 89 1917 12 5 2 1 4 83 1918 10 2 5 1 2 90 1919 26 17 2 3 4 88 1920 6 2 2 2 .. 100 SCARLET FEVER. 58. Notifications. During the year 538 cases of scarlet fever were notified as compared with 243 in 1919, 222 in 1918, and 147 in 1917. Table IV. shows the age distribution, the number in each parish, and the number removed to hospital. 75 The following table No. 32, shows the case-rate of scarlet fever in each registration district and in the Borough (not corrected for mistaken diagnosis), and the percentage removed to hospital in each year since 1915. The term " case-rate " means the number of cases occurring per 1,000 population. TABLE No. 32. Year. The Borough. Woolwich. Plumstead. Eltham. Percentage removed to Hospital. West. East. 1915 4.31 4.48 4.00 6.55 3.85 85 1916 1.69 1.94 1.30 1.98 1.67 90 1917 0.99 1.19 0.84 0.74 1.38 85 1918 1.48 2.80 1.25 0.99 1.18 85 1919 1'78 2.62 1.55 1.12 2.06 82 1920 3.79 3.08 3.19 5.29 3.51 85 59. Return Cases. The following table shows the number of return cases, the dates of notification, the dates of discharge from hospital and the history of any infective condition on discharge 76 Primary Case. TABLE No. 33. Return Case. No. Date Notified. Discharged from Hospital. History of Discharge. Notified. Remarks on Primary Case. 189 1. 7.20 16.10.20 - (a) 23.10.20 (b) 25.10.20 218 29. 7.20 8.9.20 Cold in nose. No ear discharge 17. 9.20 9 10. 1.20 16. 2.20 Running at nose 26. 2.20 163 19. 5 20 7. 7.20 Nasal Discharge (a) 12. 7.20 164 19. 5.20 30. 6.20 — (b) 19. 7.20 — 29.11.19 7. 1.20 Running nose and sore throat 3. 2.20 205 14. 7.20 13.10.20 — 21.10.20 25 21. 1.20 24. 4.20 Running ear 17. 5.20 54 12. 2.20 6. 4.20 383 3.11.20 14.12.20 — 18.12.20 Desquamating on admission 66 23. 2.20 16. 4.20 — 22. 4.20 Separate family in same house 136 20. 4.20 23. 6.20 — 28. 6.20 137 20. 4.20 19. 5.20 — 61 15. 2.20 27. 3,20 — 30. 3.20 384 3.11.20 11.12.20 — (a) 19.12.20 (b) 20.12.20 307 8.10.20 home isolatn. — 20.11.20 House disinfected 10.11.20 310 8.10.20 17.11.20 — 22.11.20 236 28.12.19 2. 2.20 Roughness of skin on feet 20. 2.20 159 14. 5.20 25. 6.20 — 9.10.20 93 20. 3.20 28. 5.20 — 5.8.20 355 26,10.20 8.12.20 — 16.12.20 196 9. 7.20 9. 9.20 — 18. 9.20 1.11.20 157 13. 5.20 23. 6.20 — 9. 7.20 238 27. 8.20 22.10.20 — 10.11.20 26.12.20 240 28. 8.20 20.10.20 29.10.20 77 60. Home Isolation. 15% of all cases were isolated at home and, as will be seen from the preceding table, only one return case occurred. All these cases were frequently inspected at home by your Sanitary Inspectors, and, as in last year, in no instance has there been any ground for supposing that the public safety has been endangered by home isolation. The Royal Arsenal authorities require cases to be removed to hospital, or a certificate from your Medical Officer of efficient home isolation, before their employees are allowed to return to work. During the year 21 such certificates were issued as compared with 15,18, and 22, in the three preceding years. 61. Multiple Cases. The following table shows the house distribution of cases of scarlet fever in Wards :— TABLE No. 34. Dockyard St. Mary's River St. George's Burrage Herbert Glyndon St. Margaret's Central St. Nicholas Eltham Total houses Total Cases No. of houses in which 1 case occurred 22 12 46 5 20 20 28 25 31 108 69 386 386 2 cases occurred 3 1 2 .. 1 2 4 5 4 16 13 51 102 3 „ „ .. .. 1 .. 1 .. .. .. 1 5 1 9 27 4 „ „ .. .. .. .. .. .. .. 2 .. .. .. 2 8 5 „ „ .. .. .. .. .. .. .. 1 .. 1 1 3 15 25 13 49 5 22 22 32 33 36 130 84 451 538 62. Deaths. The number of deaths due to scarlet fever was 4. The deaths and death-rate from this disease since 1915 are shown in table 29. 78 DIPHTHERIA. 63. Notifications. During the year 427 cases of diphtheria were notified, as compared with 398 in 1919, 208 in 1918, and 277 in 1917. Table IV. shows age distribution, the number in each parish, and the number removed to hospital. The following table No. 35, shows the case-rate in each parish and the percentage removed to hospital each year since 1915. The term "case rate" means the number of cases occurring per 1,000 population. TABLE No. 35. Year. The Borough. Woolwich. Plumstead. Eltham. Percentage removed to Hospital West. East. 1915 1.77 2.23 1.99 2.87 0.88 92 1916 1.81 2.80 211 1.23 1.72 91 1917 1.65 1.76 1.60 1.50 2.96 91 1918 1.42 2.11 1.74 1.37 1.32 94 1919 2.92 4.77 2.69 2.29 2.02 87 1920 3.01 4.06 2.88 1.73 3.07 96 64. Return Cases. The following table shows the number of return cases, the dates of infection, dates of discharge from hospital, and the history of any infective condition on discharge. TABLE No. 36. Primary Case. Return Case. No. Date Notified. Discharged from Hospital. History of Discharges. Notified Remarks on Primary Case. 369 10.12.19 27.3.20 - 12.4.20 — 18 14.1.20 12.5.20 — 7.12.20 — 79 65. Home Isolation. 4% of all cases were isolated at home and in connection therewith 9 certificates of home isolation were issued to enable Arsenal employees to resume work. 66. Multiple Cases. The following table No. 37, shows the house distribution of cases of diphtheria, in Wards:— TABLE No. 37. Dockyard St. Mary's River St. George's Burrage Herbert Glyndon St. Margaret's Central St. Nicholas Eltham Total houses Total Cases No. of houses in which 1 case occurred 27 20 48 5 21 16 22 40 15 44 70 328 328 2 cases occurred 2 4 2 1 1 .. 4 1 1 1 9 26 52 3 „ „ .. 1 1 .. .. 1 1 1 1 .. .. 6 18 4 „ ,, .. .. 1 1 .. .. .. .. .. .. 4 6 24 5 ,, „ .. .. .. .. .. .. .. .. .. .. 1 1 5 29 25 52 7 22 17 27 42 17 45 84 367 427 67. Contacts. Contacts of cases were examined during the year as in previous years and 4 cases presenting no clinical symptoms were discovered to be carriers. The usual steps were taken in each case. 68. Bacteriological Examination. Since January, 1913, the Council's bacteriological work has been done by the Bacteriological department of the Seamen's Hospital, Greenwich. 845 swabs were examined during the year for diphtheria bacilli and 144 were found positive. 69. Anti-toxin. Diphtheria anti-toxin is kept at the Town Hall and the Plumstead and Eltham Free Libraries and is supplied to medical practitioners, on application, at cost price, 80 or free where there is inability to pay. The amount supplied during the year was 152,000 units, at a total cost of £11 8s. 0d., which was, with the exception of 18/- recovered from medical practitioners. At the beginning of the year the Metropolitan Asylums Board circularised the Metropolitan Medical Officers of Health stating that they would be prepared to supply diphtheria antitoxin, free of charge, in any case, necessitous or otherwise, where admission to the Board's hospitals had to be refused on the ground of pressure of accommodation. 70. Deaths. The number of deaths due to diphtheria was 25. The deaths and death rate of this disease each year since 1915 are shown in table No. 29. OPHTHALMIA NEONATORUM, PUERPERAL FEVER AND EPIDEMIC DIARRHOEA. 71. These diseases are dealt with under the Maternity and Child Welfare Section of the Report. PNEUMONIA, MALARIA, DYSENTERY AND TRENCH FEVER. 72. During the year the following number of cases were notified:— Pneumonia 136 Malaria 29 Dysentery 1 Trench Fever - These diseases are compulsorily notifiable under the Public Health (Pneumonia, Malaria, Dysentery, etc.) Regulations, 1918. In the case of Pneumonia, the value of notification without adequate machinery for dealing further with cases is very 81 doubtful, and little or no experience, except as to incidence, has been gained. There is reason to believe, however, that more cases are now being notified than was the case last year, but there appears to be a good deal of uncertainty amongst medical practitioners as to which cases of Pneumonia are notifiable. For this reason the following extracts from the Pneumonia, etc. Regulations and accompanying memoranda are published. "Article V.—Subject to the provisions of these Regulations and subject to the provisions of Section 5 of the Local Government (Emergency Provisions) Act, 1916, every Medical Practitioner, as soon as he becomes aware that a person upon whom he is in professional attendance is suffering from Malaria, or Dysentery, or Trench Fever or Acute Primary Pneumonia, or Acute Influenzal Pneumonia, shall forthwith make and sign and send or deliver to the Medical Officer of Health a notification of the case in the form and containing the particulars set forth in Schedule A. or Schedule B., as the case may be, of the Public Health (Notification of Infectious Disease) Regulations, 1918, and shall transmit the notification to the Medical Officer of the district. Provided that a Medical Practitioner shall not be required to notify a case of Malaria, or Dysentery, or Trench Fever, under this Article, and shall not be paid a fee for so doing, if the case has already to his knowledge been notified under these Regulations or under the Infectious Disease (Notification) Act, 1889, within the period of six months immediately preceding the date on which he first becomes aware of the disease in that case." In a Memorandum issued by the Local Government Board in January, 1919, it is stated:— (a) "Acute pneumonia may be defined as a febrile disease characterised by inflammation of the lungs, and 82 due to one or more specific micro-organisms. Two forms of the disease are generally recognised:— (a) Acuta lobar or croupous pneumonia, and (b) Acute lobular or broncho-pneumonia. Either of these may be either primary or secondary to some other recognised disease. In a young child, lobular pneumonia is often the equivalent of croupous pneumonia in the adult. Secondary broncho pneumonia is commonly a sequel of the infectious fevers, and as such is more common in the early years of life. As age advances it becomes rare, except as a complication of influenza or bronchitis." "Notification. Pneumonia following whooping cough, diphtheria and the exanthemata is intentionally excluded from the scope of the order for notification of pneumonia as provision is already made, or may be made, for the notification of these diseases. It has been considered desirable, however, to include pneumonia occurring in influenza in view of its high fatality and of the possibility of a recrudescence of the primary disease during the coming year." From a consideration of the two preceding quotations it is clear that all cases of primary pneumonia (lobar or lobular pneumonia), are notifiable and that no secondary pneumonias are notifiable except influenzal pneumonia. The objects of notification of these diseases are stated to be as follows in the same Memorandum:— "While it is not anticipated that in the present state of our knowledge notification and the action consequent thereon will result in any great immediate reduction in the total incidence of pneumonia, it will, it is believed, awaken the public to a sense of the gravity of the malady; will supply valuable statistical information as to its distribution ; and will contribute to a reduction in the mortality 83 from it by bringing to light those cases in which the local authority can help by providing nursing or other assistance or by arranging for institutional treatment. In deciding upon the procedure to be adopted on receipt of a notification of pneumonia, the Medical Officer of Health will be guided by his local knowledge, and by the general prevalence of disease in his district. In whatever action the circumstances of the case call for he should endeavour to assure himself of the cordial co-operation of the medical practitioner in attendance." 73. Nursing Provision. I am informed by the Secretaries of the various Voluntary Nursing Associations in the district, that the following numbers of cases of pneumonia were nursed during the year:— Woolwich and Plumstead Nursing Association 70 St. Luke's Parish Nurse, Eltham 24 Eltham Nursing Association 2 Silvertown and North Woolwich Nursing Assoc. 4 The position with regard to nursing in Eltham is somewhat anomalous. The parish of Eltham is divided into three parts for nursing purposes. All that part lying south of the Blackheath-Bexley Heath railway line is nursed by the Eltham Nursing Association. The northern half of the parish is divided into two by Well Hall Road. That part of the parish lying to the East of this road is nursed by the St. Luke's Nursing Association. On the west side of the parish, no nursing facilities whatever are provided. There are 726 houses in this area. 74. The following table No. 38, compiled from the notifications received, shows the monthly incidence of pneumonia during the year. 84 TABLE No. 38. Month. Male. Female. Total. January 2 4 6 February 8 6 14 March 16 12 28 April 10 7 17 May 10 8 18 June 3 4 7 July 3 3 6 August 5 1 6 September 3 1 4 October 3 3 6 November 10 2 12 December 8 4 12 81 55 136 75. No special action was taken with regard to Malaria, Dysentery or Trench Fever. ANTHRAX, GLANDERS AND HYDROPHOBIA. 76. No cases of these diseases were notified during the year. ERYSIPELAS. 77. There were 82 cases of Erysipelas notified during the year, and one death occurred. The death-rates from this disease since 1915, are shown in table No. 29. The following table No. 39, shows the number of notifications received each year since 1901 (in Parishes) and the percentage of cases removed to hospital. 85 TABLE No. 39. Year. The Borough. Woolwich. Plumstead. Eltham. Percentage removed to Hospital. West. East. 1901 72 26 27 11 8 3 1902 98 48 22 24 4 .. 1903 58 19 21 15 3 .. 1904 74 26 25 11 12 .. 1905 83 24 30 25 4 .. 1906 97 16 32 40 9 .. 1907 110 29 33 42 6 .. 1908 90 17 34 35 4 .. 1909 113 30 33 34 6 .. 1910 89 17 24 44 4 .. 1911 82 20 28 33 1 .. 1912 . 87 26 31 21 9 1 1913 70 21 21 21 7 1 1914 107 29 40 32 6 .. 1915 138 48 41 38 11 2 1916 95 26 24 33 12 11 1917 79 19 27 22 11 .. 1918 61 13 22 15 11 1 1919 63 13 20 22 8 13 1920 82 15 20 32 15 5 86 CEREBRO-SPINAL MENINGITIS, POST BASIC MENINGITIS, POLIO-MYELITIS AND ENCEPHALITIS LETHARGICA. The following table No. 40, shows the age and sex distribution of all cases of these diseases occurring during the year :— TABLE No. 40. Disease. All ages Under 1 1-5 5-15 15- 25 2545 45- 65 65 and over M F M F M F M F M F M F M F M F Cerebro-spinal Meningitis 1 2 ... ... ... 1 ... ... 1 1 ... ... ... ... ... ... Post basic Meningitis ... 3 ... ... ... 2 ... 1 ... ... ... ... ... ... ... ... Polio-myelitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica 2 1 ... ... 1 ... ... ... ... ... 1 ... ... 1 ... ... All the cases of Cerebro-spinal meningitis were removed to isolation hospitals. The number of deaths was:— Cerebro-spinal meningitis 5 Post basic meningitis 2 Polio-myelitis - Encephalitis lethargica - 87 TABLE No. 41. Summary of Notifications of Tuberculosis during year ended 31st December, 1920. Age-periods— Notifications on Form A. Notifications on Form B. Number of Notifications on Form C. Number of Primary Notifications. Total Notifications on Form A. Number of Primary Notifications. Total Notifications on Form B. 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 55 to 65 65 & upwards Total Primary Notifications. Under 5 5 to 10 10 to 15 Total Primary Notifications. Pulmonary Males 1 4 13 12 27 25 48 41 26 10 6 213 217 .. .. 1 1 1 19 161 ,, Females .. 5 12 9 17 33 35 20 8 3 1 143 148 .. 2 .. 2 2 18 77 Non-Pulmonary Males .. 6 14 5 6 2 2 1 .. 1 .. 37 37 .. .. .. .. .. 5 13 ,, Females .. 3 11 6 3 1 4 2 1 .. .. 31 31 .. 1 .. 1 2 7 12 1 18 50 32 53 61 89 64 35 14 7 424 433 .. 3 1 4 5 49 263 88 TUBERCULOSIS. 78. Notification Statistics. The total number of notifications received was 438. This number includes 10 duplicate notifications but does not include notifications on forms C and D, viz., notifications from Hospital doctors, etc., regarding admissions and discharge. The distribution of the various cases (excluding secondary notifications) in the year 1918, 1919 and 1920, was as follows TABLE No. 42. Year. Lungs. Meninges. Intestines and Peritoneum. Glands. Joints. Spine. Other Forms. All Causes. 1918 563 6 14 41 19 6 11 660 1919 394 4 3 35 19 5 14 474 1920 359 7 5 24 17 11 5 428 It is difficult to estimate the number of cases of Tuberculosis at present living in the district. According to the Tuberculosis register, the number of cases is 2,898, but there is reason to believe that that number is excessive. In the parish of Eltham all the tuberculous cases on the register were specially visited during the months of April and May, and the following table shows the actual number in Eltham on the 1st June, 1920:— Number of cases notified since 1912 516 Number removed from register, i.e., by death, removal, etc. 148 Number of cases in Eltham, March, 1920 368 On the 1st June, when the special inspections had been completed, it was found that the number actually in Eltham 89 was 192, 142 cases having left the district or been lost trace of, and 34 being dead. More than one cause accounts for the results shown above, but these results indicate the necessity for more co-ordination in the present machinery for dealing with tuberculosis in Woolwich, and this will be rendered possible by the unification which will be brought about when the Council takes over the Tuberculosis Dispensary. 79. Deaths. The following table No. 43 shows the number of deaths from certain forms of Tuberculosis and the total deaths and death-rates each year since 1915:— TABLE No. 43. Year. Deaths. Death-rates. All Forms. Pulmonary. NonPulmonary. All Forms. Pulmonary. NonPulmonary. 1915 232 201 31 1.72 1.49 0.23 1916 203 167 36 1.48 1.22 0.26 1917 207 172 38 1.41 117 0.26 1918 225 194 31 1.54 1.32 0.21 1919 196 171 25 1.44 1.26 0.19 1920 188 161 27 1.32 1.13 0.19 In 1920 the number of deaths from Tuberculosis was 188: pulmonary, 161, and other forms, 27. The death-rate from all forms was 1.32. This is the lowest death-rate recorded since 1901. The death-rate from pulmonary, 1.13, is the lowest recorded since 1912, when it was 101. The period which elapsed between death and notification is shown in the following table:— G 90 TABLE No. 44. Pulmonary. Non-Pulmonary. No. % No. % Not notified or death before notification 28 17.4 13 48.2 Deaths 0.1 months after notification 18 11.2 7 25.9 „ 1-3 „ ,, 16 9.9 2 7.4 „ 3-12 „ „ 41 25.5 2 7.4 „ 1-2 years „ „ 26 16.2 1 3.7 „ 2—5 „ „ 21 13.0 1 3.7 „ over 5 „ „ 11 6.8 1 3.7 161 27 80. Source of infection. Of the 428 primary cases notified 65 occurred in families where a previous case had been notified either this year or in preceding years. The previous cases (as notified) were as follows:— Father 15 Mother 14 Brother 9 Sister 9 Husband 3 Wife 1 Son - Daughter 1 Other relatives 13 81. Administrative Action. Voluntary Dispensary. A voluntary dispensary, under the Central Fund for the Promotion of the Dispensary system in London is established at Maxey Road, Plumstead. 91 Staff. There are two Medical Officers, Dr. F. J. C. Blackmore, who is Tuberculosis Officer, and Dr. E. O'Connor, who is the Assistant Tuberculosis Officer and commenced duty in June, 1920. The other Officers employed at the Dispensary are as follows:— The Secretary, 2 nurses, 1 health visitor, 1 nurse-dispenser, and 1 voluntary worker. In January, the Tuberculosis Dispensary Committee asked that the grant of the Woolwich Borough Council for the treatment of uninsured persons should be increased from £550 to £1,500. The Council agreed to this grant on condition that an additional Medical Officer be appointed. It was under these circumstances that Dr. O'Connor commenced duty. 82. Co-operation with Hospital and Clinic. The Dispensary is affiliated to the Seaman's Hospital, Greenwich under a yearly agreement whereby difficult cases of diagnosis can be referred for consultative purposes. Tuberculous children suffering from minor ailments, defective teeth, etc., are referred for treatment to the School Clinic in Brewer Street provided they are of school age. Those under school age are referred to the school clinic under arrangements made under the Council's Maternity and Child Welfare Scheme. 83. Co-operation with Medical Practitioners. Every effort is made to secure the co-operation of medical practitioners and the Tuberculosis Officer communicates with the medical attendant in connection with each case notified. Periodical reports on insured persons undergoing domiciliary treatment have been received more frequently than has hitherto been the case, but there is still room for improvement in this respect. Arrangements have been made for the following up of patients in cases where diagnosis is doubtful, a following up book being kept, and, in the event of patients under treatment not turning 92 up on the specified dates, a further endeavour is made to secure the patient's attendance by home visits by the Dispensary nurses. 84. Contacts. Contacts are examined at the Dispensary but, if they do not attend, it is the duty of the Tuberculosis Visitor to re-visit in order to persuade them to attend. Occasionally contacts are examined at home. 85. Diagnosis. For the purposes of diagnosis the ordinary routine examinations are carried out, and, when necessary, cases are referred to the Seamen's Hospital for consultative purposes. During the year no cases were so referred. As regards the examination of sputum, the methods used are the Ziehl-Nielson and the Anti-formin. Ellis's Cutaneous Test is used in a number of cases. 86. Treatment. The Intensive Iodine method is utilised in selected cases (51 in 1920), and is found to be of most service in the cases of the patient with moderately advanced disease. Tuberculin is used in a few selected cases of tuberculous glands of the neck, and in a few pulmonary cases, and has been found of value. 16 cases were treated in 1920. Guaiacol in increasing doses from m5 to m15 was used in 26 cases during 1920. It is difficult to be exact in the relative value of each form of treatment, but Dispensary treatment appears to yield results equal to those attained by the existing sanatorium treatment, while on the other hand domiciliary treatment yields the least satisfactory results. I am indebted to the Tuberculosis Officer, Dr. F. J. C. Blackmore, for the above information. 87. Dental Treatment. No arrangements have been made for the provision of dental treatment. 93 88. Home Nursing. The local Nursing Associations carry out home nursing when necessary. 89. Extra Nourishment is supplied to insured persons only, according to arrangements with the London Insurance Committee. 90. Non-pulmonary tuberculosis. These patients are treated under the London County Council's scheme, some being dealt with by the Invalid Children's Aid Association, and a few in suitable homes through the Board of Guardians. 91. After-care. After-care work in this Borough has not been very successful as the Interim Tuberculosis Care Committee have no funds at their disposal, and great difficulty has been experienced in finding suitable employment for the tuberculous person. During the year some financial assistance has been rendered from a voluntary fund organised by the Dispensary Committee. 92. Shelters. The Council have provided 11 shelters which are loaned out at a charge of 6d. to 1/6 per week. The shelters have been specially constructed in sections so that they can be taken through houses and easily erected in back gardens. They are open on all sides and are valuable in continuing the open-air treatment in the home. During the year, these shelters have been in use 286 weeks out of a possible 572. 93. Sanitary Defects. Any sanitary defects discovered in the homes of patients are referred to the district sanitary inspectors for necessary action. 94. Bacteriological Examination. During the year 202 specimens were examined at the Seamen's Hospital, and 319 at the Woolwich Dispensary. 94 WOOLWICH VOLUNTARY DISPENSARY. Statistics, 1920. 95. The following is a summary of the work referring to the period 1st January to 31st December, 1920:— TABLE No. 45. Insured Uninsured. Total Number Adults Children Patients examined and treated 2,137 1,090 1,930 5,157 Attendances 4,314 2,053 3,106 9,473 Home visits by Medical Staff 569 85 ... 654 Do. Nurses and Health Visitors 2,194 3,554 .. 5,748 New Patients 424 268 597 1,289 Do. with Pulmonary Tuberculosis 147 42 29 218 Do. with Surgical Tuberculosis .. .. .. 27 Do. under observation . .. .. .. 485 Do. non-Tuberculous .. .. .. 559 1,289 Contacts examined .. .. .. 420 Results of examination of Contacts: Pulmonary Tuberculosis 8 5 4 17 Surgical Tuberculosis 1 1 1 3 Observation cases 33 25 65 123 Non-Tuberculous 50 79 138 277 Patients examined for first time .. .. .. 1,289 Sputum examinations 206 92 21 319 Do. found Positive .. .. .. 69 Do. found Negative .. .. .. 250 96. Ex-Soldiers and Sailors. 161 new cases have been examined at the Dispensary during the year 1920 ; of this number 65 were notified as suffering from Tuberculosis. Including new and old patients:— 95 83 received sanatorium treatment. 84 received domiciliary treatment. 22 patients left institutions at their own request. 34 were discharged on expiration of period of treatment. 72 are working. 525 visits were made by the Health Visitors at their homes. GENERAL ADMINISTRATION WITH REGARD TO INFECTIOUS DISEASE. 97. This general action was described in detail last year and no change in the procedure has taken place during the year. Disinfection. The following table shows the various rooms and articles disinfected during the year. TABLE No. 46. No. of rooms disinfected after ordinary fevers 1,056 do. do. Tuberculosis 249 do. do. Verminous cases 30 Total number of articles disinfected 32,041 96 MATERNITY AND CHILD WELFARE WORK. 98. Staff. During the year the Maternity and Child Welfare staff was increased by two Health Visitors and by one temporary female clerk, so that at the close of the year the staff consisted of:— (a) One whole time Assistant Medical Officer of Health— Dr. Rachel Mackenzie. (b) A part time Medical Officer (in charge of cases at the Council's Home for Ailing Babies)—-Dr. P. H. Dodd. (c) Seven Health Visitors (two of whom hold the combined office of Sanitary Inspector and Health Visitor). (d) Two temporary female clerks. (e) The nursing and domestic staff of the Home for Ailing Babies. 99. Welfare Centres. The following schedule shows the Municipal Centres in operation at the close of the year:— Woolwich.—Town Hall, Wellington Street. Monday 2—4 p.m. Wednesday 2—4 p.m. Thursday 2—4 p.m. *Friday 2—4 p.m. North Woolwich.— St. John's Hall, High Street. Tuesday 2.30—4 p.m. Plumstead.—289 High Street. Monday 2—4 p.m. Tuesday 2—4 p.m. Friday 2—4 p.m. *Friday 10.30 a.m. to noon. Eltham.—179 Well Hall Road. Wednesday 2—4 p.m. Thursday 2—4 p.m. * Consultations and advice for Mothers at these times. 97 *Thursday 10.30 a.m. to noon. Friday 2—4 p.m. New Eltham.—Church Army Hut, Southwood Road. Tuesday 2—4 p.m. *Consultation and advice for mothers at these times. In February, 1920, the approval of the Ministry of Health was obtained to the opening of a new Centre at New Eltham. At the end of the year, the number of sessions per week during which all Centres were opened, was 3 Ante-natal and 11 Infant Consultations, as compared with 3 Ante-natal and 9 Infant Consultations at the end of 1919. 100. Treatment. No arrangements for the treatment of mothers and children at the Centres have yet been made, but, by an arrangement with the Woolwich Branch of the British Medical Association, children requiring medical, surgical or dental treatment, are referred to the School Treatment Centre in Brewer Street. The Borough Council pays 5/- for each case so referred. During the year, 78 cases were sent there for treatment. In September, a progressive step was taken by the London County Council with regard to the treatment of school children suffering from enlarged tonsils and adenoids. Children are now operated on for these conditions at the Cyril Henry Home, St. Mary Street, whereas previously these children had been treated at the Brewer Street Clinic and had been sent home immediately after the operation. Under the new arrangement, these children are admitted to the Cyril Henry Home and are detained there for two nights while recovering from the effects of the operation. Owing to the demand made by the school services on the available beds there, it has not been possible to make similar arrangements for the treatment of children under school age suffering from enlarged tonsils and adenoids. 98 VOLUNTARY WORK. 101. Voluntary Centre. The Voluntary Centre at the Victory Club, Beresford Street, has continued to do good work during the year. The total number of children attending this Centre during the year was 129, and the total number of attendances was 1,136. 102. Day Nursery. The Woolwich Day Nursery was closed on the 31st March, 1920. 103. Convalescent Home, Brent Road. This Home is controlled by the National League for Health, Maternity and Child Welfare, and is a Convalescent Home for Mothers and Infants. Accommodation is provided for 4 nursing mothers with their babies and 6 nursery children up to the age of 18 months. Through the courtesy of the Matron, I am able to report that during the year the number of nursing mothers in residence was 50 and their length of stay was about a month. The number of children was 40. The charges are 15/- per week for a nursing mother and baby, and 15/- per week for nursery children. The cases are medically examined weekly. 104. British Hospital for Mothers and Babies. This is a Maternity Hospital and a School for Midwives, providing accommodation for 14 indoor cases. At the present time a new building to replace the existing one in Wood Street is being built in Samuel Street, and it is expected that, in the Autumn of 1921, additional maternity beds will be available. I am informed by the Secretary, Miss Alice Gregory, that the number of cases admitted during the year was 225, the number of births, 203, the number of outdoor cases, 325. There is an ante-natal and post-natal clinic at this Institution at which 947 cases attended during the year. 99 105. Woolwich and Plumstead Maternity Home. For unmarried mothers there is a small home at 23 Vicarage Park, Plumstead. The accommodation is for 8 mothers and babies. Through the courtesy of the Superintendent I am able to give the following information with regard to this Home:— Number of mothers and babies in the Home, 1st January, 1920 8 mothers and 5 babies. Number of mothers admitted during the year 24 Number of mothers with babies admitted during the year 3 Number of births in the Home 17 Number of deaths 1 Average duration of stay of each completed case 4½ months When the girls are due to leave the Home, situations are found for them (usually domestic service) and if possible, the mother takes the child with her. Otherwise a foster mother is found for the child. The Superintendent keeps in touch with the girls after they have left, either by letters, or, when they are near enough, by asking them to visit the Home in their off duty times. Nearly all the girls attended the Ante-natal Clinics of the Borough Council. A grant of £50 was made by the Council during the year towards the funds of the Home. HOME FOR AILING BABIES. " Perran Lodge," Eglinton Road, Plumstead. 106. The following table, No. 47, shows certain statistical information regarding the Home for the year 1920:— 100 TABLE No. 47. (1) No. of cases in hospital on the 1st January, 1920 12 do. admitted during the year 85 do. remaining in on the 31st December, 1920 13 (2) Average duration of stay 47 lays (3) Reasons for admission— Malnutrition, Marasmus and Debility 42 Bronchitis 5 Diarrhoea 9 Vomiting, Dyspepsia 8 Congenital heart disease 2 For observation (ultimately diagnosed Tuberculosis) 3 Miscellaneous, Skin conditions, etc. 11 Rickets 5 85 (4) No. of cases discharged— (a) in good health 47 (6) Improved 10 (c) No improvement 15 72 (5) No. of cases of infectious disease— (a) Measles Nil (b) Whooping Cough 4 (c) Epidemic Diarrhoea 1 (d) Chicken Pox 1 6 (6) No. of deaths 12 101 107. The Work of the Health Visitors. At the beginning of the year there were 5 Health Visitors. 2 additional ones were appointed by the Council in July and commenced work in August, so that at the end of the year there were 7. The duties of Health Visitors are as set out in a Circular of the Local Government Board dated August, 1918, and are as follows:— The visiting and supervision of all children under school age needing this attention: the visiting of expectant mothers who have attended at an Ante-natal Clinic or for whom visits are desirable; inquiry into still-births, and the deaths of young children, and attendance at the Centre to which women and children come for medical and hygienic advice. Table No. 48 gives a classification of the number of visits paid by the Health Visitors during 1918-1919 and 1920, and from that table it will be seen that there has been an extensive increase in the variety and in the amount of work done. 108. Administrative action in connection with the Notification of Births' Act. As soon as a notification of a birth is received, suitable literature is sent to the mother by post and it is the practice for the Health Visitor to visit as soon as possible after the doctor or midwife leaves the patient, usually between the 10th and 14th day. The necessity for subsequent visits is gauged by what is discovered at the first, but, as a general rule, during the latter months of the year, an endeavour was made to work to the following standard:—4 visits during the first year; 2 visits in the second year, and one visit in subsequent years up to school age. This is modified according to whether the baby is in attendance at one of the Welfare Centres or not. If the baby is in regular attendance, the necessity of home visiting is not so urgent. It has been found as a matter of experience, that very few mothers object to these visits and that these objectors very often change when they find that it is not criticism but help and sympathy which is offered. 102 109. Investigation of still-births. During the year, a start has been made in investigating the cases of still-births in Woolwich, and enquiries were made into 50 such cases during the year. In 15 cases the cause of still-birth was found to be due to natal trouble and in 7 others the child was born macerated. 7 cases of prematurity occurred, and in the remainder the enquiry was negative. 110. Other Work. In addition to these visits the Health Visitors have made certain investigations in to the causes of infant deaths, and have visited notified cases of Ophthalmia Neonatorum, Puerperal Fever, and Pneumonia, in children under 5 years of age. They have also made primary visits to notified cases of Tuberculosis, but this is work which should be performed by the Tuberculosis Dispensary, and, when the Dispensary is taken over by the Council in 1921, arrangements will be made to transfer these tuberculosis visits to the Tuberculosis Nurses. Any sanitary defects discovered by the Health Visitors in the course of their duties have been referred to the Sanitary Inspectors for remedial action. The following table No. 48, shews a classification of visits paid by the Health Visitors during the years, 1918, 1919 and 1920. TABLE No. 48. 1918. 1919. 1920. Births—1st Visits 1,145 1,562 2,856 Re-visits 1,183 1,526 3,456 Home visits to expectant mothers 38 74 201 Still-Births investigated - - 50 Infant Deaths investigated - 8 99 103  1918. 1919. 1920. Infectious diseases— Ophthalmia Neonatorum— 1st Visits 22 24 28 Re-Visits 20 17 44 Measles—1st Visits 772 992 256 Re-visits 69 111 36 Puerperal Fever— 1st Visits 11 9 12 Re-Visits - - 3 Zymotic Enteritis— 1st Visits 82 81 31 Re-Visits 11 28 8 Tuberculosis—1st Visits 407 254 215 Re-Visits - - 35 Pneumonia (all forms) under 5 years 12 Visits unclassified 180 327 561 „ unsuccessful—no admission 873 783 1,731 4,813 5,796 9,634 111. The Work of the Centres. The work of the Centres has gradually increased during the year, and the following table shows the details of statistics for the year 1920, and the consolidated statistics for 1918 and 1919. 104 TABLE No. 49. 1920. No. on Roll of Centre. No. of Attendances. Mothers: Children. Mothers: Children. Expectant. Nursing. Expec tant. Nursing. Town Hall 135 201 1,328 418 408 8,253 Eltham 60 107 750 179 240 5,302 Plumstead 112 133 834 188 368 6,146 North Woolwich 106 1 27 673 New Eltham 2 4 104 3 4 1,239 Totals 1920 309 445 3,122 789 1,047 21,613 „ 1918 .. .. .. 152 .. 2,212 „ 1919 178 54 1,263 436 101 7,450 As will be seen from previous years, there has been a large increase in the attendances at the Centres. In consequence of this increase opportunities for special observation of difficult cases have been diminished, and it has been found necessary to institute special consultations in the mornings at which the Assistant Medical Officer of Health sees cases by appointment. At the Centres advice is given to expectant and nursing mothers and to children under 5 years of age, but the treatment is limited to the use of such simple remedies as grey powder and sodium citrate. Mothercraft classes, sewing classes, etc., have been held at two of the Centres (Eltham and Plumstead) but they have not been successful. 112. The Needs of the Borough. It will be necessary in the near future to consider the provision of maternity assistance to necessitous, expectant mothers, the provision of medical and surgical treatment for young children, and of dental treatment for children under school age and for expectant and nursing mothers. 105 Infectious Diseases in relation to this Work. 113. Puerperal Fever. During the year, 13 cases of Puerperal Fever were notified, as compared with 14 in 1918, and 7 in 1919. The case-rate per 1,000 births was 355, as compared with 4.44, 5.43 and 2.55 in the three preceding years. 9 cases received hospital treatment. There were 5 deaths, giving a mortality rate of 0.04. 114. Ophthalmia Neonatorum. During the year, 34 cases were notified. The following table No. 50 shows the eye conditions in each case and the permanent result. It will be seen that in every case a satisfactory result was obtained. TABLE No. 50. Date of Notification. Condition of Right eye. Result. Condition of Left eye. Result. Remarks. 1920. Jan. 2 Infected Cured Infected Cured Feb. 10 do. do. do. do. 23 do. do. do. do. March 18 do. do. Not infected — 24 do. do. Infected Cured April 9 do. do. do. do. 22 do. do. do. do. 22 do. do. do. do. 99 do. do. do. do. May 3 do. do, do. do. 10 do. do. do. do. 17 do. do. do. do. 19 — — — — Left Borough 29 Infected Cured Infected Cured 20/5/20 June 7 do. do. do. do. 23 do. do. do. do. July 29 do. do. do. do. August 3 do. do. do. do. 9 Not infected — do. do. 13 Infected Cured do. do. Sept. 7 do. do. do. do. 11 do. — do. — Left Borough 29 do, Cured Not infected — 17/9/20 29 do. — Infected — Oct. 4 do. Cured do. Cured 23 do. do. do. do. Nov. 19 do. — do. — Left Borough Dec. 2 do. — — — Not visited 24 do. Cured Infected .. Cured H 106 In October, 1920, the Council made arrangements with the local Nursing Associations to provide nursing assistance in the case of Ophthalmia Neonatorum. During the year, 6 cases were nursed, and a total number of 119 visits were made at a cost of £5 19s. 0d., the average number of visits paid to each case being 20. 115. Measles, Whooping-Cough and Poliomyelitis. These diseases are dealt with in the infectious diseases sections of the report (see pages 71-73 and 86). 116. Epidemic Diarrhoea. Zymotic Enteritis or epidemic diarrhoea has been notifiable in Woolwich since 1913. The number of cases notified during the year was 31, and the number notified each year since notification commenced is shown on table 28 The quarterly incidence of these diseases for the years 1919 and 1920 is shown in table No. 51 below:— TABLE No. 51. 1919. 1920. January to March 1 - April to June 13 - July to September 101 26 October to December 7 5 122 31 117. Administrative Measures. Cases of Puerperal fever, Ophthalmia Neonatorum, and Epidemic Diarrhoea are visited by the Health Visitors and in the latter months of the year, a start was made in visiting cases of Pneumonia under 5 years of age. Any sanitary conditions noted by them are reported to the Sanitary Inspectors for the necessary action, and during the summer months special vigilance is exercised by the Sanitary Inspectors for the detection and abatement of nuisances. Nursing assistance is provided by the Council through voluntary agencies in the case of measles and ophthalmia neonatorum. A description of the nursing arrangements is given under Infectious Diseases on page 73. 107 SANITARY ADMINISTRATION. 118. Sanitary Staff. The staff of the Public Health Department is shewn in detail on page 3. 119. Public Analyst. The detailed results of the various analyses during the year are given under the section on the Sale of Food and Drugs' Acts. 120. Bacteriological Examinations. Bacteriological examinations are carried out at the Dreadnought Hospital, Greenwich, by Dr. Arthur Davies. Each examination cost 4/-. The number and nature of the various examinations made during the year is shown below for comparative purposes ; the total number in 1919 is also given. TABLE No. 52. Associated disease Positive result Negative result Total. Total. 1919. Diphtheria 144 701 845 749 Enteric Fever 1 5 6 20 Tuberculosis 54 148 202 190 199 854 1,053 959 108 HOUSING. GENERAL HOUSING CONDITIONS. 121. The general condition of housing in the country as a whole, a subject which has engaged the attention of the Ministry of Health and various local authorities since the Armistice, and the difficulties experienced in providing new houses, have resulted in a stimulus to local authorities to improve the conditions in existing houses. The Ministry of Health issued a Manual on Unfit Houses and Unhealthy Areas in 1919, and in chapter 2 attention is drawn to the fact that under the Housing (Inspection of District) Regulations, 1910, the local authority shall, as part of their procedure, make provision for a thorough inspection to be carried out from time to time according to the varying needs of houses or localities in the district. The Council realised that, owing to war conditions, a large number of arrears had accumulated, and accordingly resolved that two additional sanitary inspectors should be appointed, one permanent, and the other temporary, and, the approval of the Ministry of Health having been obtained, these two men were appointed. A systematic housing survey of the district was begun in February, 1920, although it was not until June that the two additional Inspectors commenced duty. 122. Shortage of Houses. The extent of shortage of houses and the measures taken by the Council are referred to fully in last year's Report. The Housing Scheme of the Borough Council has been proceeding during the year, and, although only 8 houses have been completed, there are 249 in various stages of completion. The houses, up to the present, have been let only to Woolwich residents who were living under unsatisfactory or overcrowded conditions. 109 There have been plans submitted during the year for 152 houses to be built by private enterprise. 4 were completed by the end of the year, and 3 others were in course of erection. 123. Population. There have been no important changes in the population during the year. The figures given by the Registrar General, 147,827, mean an increase over last year of 5,909, but, judging by the information disclosed by the Housing Survey and by the relative fewness of complaints of overcrowding during the last half of the year, it is rather doubtful whether this increase exists. Owing to the rapid change in the housing conditions of the Borough since the last Census, it is very difficult indeed to arrive at any figure with regard to population based on the number of persons per room. I am therefore looking forward to the 1921 Census figures with keen interest. HOUSING SURVEY. 124. (a) Fitness of Houses. (b) Overcrowding. During the year the whole time of two inspectors has been engaged in connection with the Housing Survey of the Borough, and the information obtained is set out concisely below. The worst areas in the District were inspected first. The details recorded of the inspections include not only nuisances liable to be dealt with under the Public Health, and Housing Acts, but also any other circumstance which did not comply with the amenities and ideals of Housing. The records of the inspections were made on cards, the details of the Survey being recorded under the following eight separate headings:— 1. Arrangements for preventing contamination of water supply. 2. Water closet accommodation. 110 3. Condition of house in regard to lighting and free circulation of air. Dampness and cleanliness. 4. Drainage. 5. Arrangements for deposit of refuse and ashes. 6. Underground rooms used as sleeping apartments. 7. Any defects in other matters which may tend to render the house dangerous or injurious to the health of the inhabitants. 8. Further remarks if space is insufficient for details. (Give number of item). The survey inspectors, while inspecting, always have in mind the standard of fitness set out in Chapter 5 of the Manual and the records include any defect in the house under any of the above 8 provisions. The routine work of the district sanitary inspectors was such that it was impossible in the early part of the year for them to at once take up the cards of inspections completed by the survey inspectors, but in all cases where serious nuisances were discovered requiring immediate attention, the defective conditions were at once referred to the district inspector to secure the abatement of the nuisances. Although the possibilities for the abatement of nuisances have much improved, yet the cost of labour and materials continues to prejudice seriously any extensive work being undertaken, a fact which is in evidence even amongst the better class of landlords, who, before the existence of these conditions, were able to take an interest in their property and systematically keep it in order. It is now unfortunately necessary, even with such people, to bring pressure to bear on them to maintain their houses in better condition. The arrears that accumulated during the war have not yet been overtaken, and difficulties are continually arising in getting the necessary work done, owing to the high costs which still exist. The work of the district inspectors was rearranged 111 in November, the house-to-house inspections individually undertaken by them being discontinued, and the work of remedying the defects recorded by the survey inspectors in the survey being commenced. The practice now, therefore, is for the survey inspector to complete a small area in one of the Wards and then hand over the cards to the district inspectors to serve the necessary notices for the abatement of the nuisances when it is possible for these nuisances to be dealt with under the provisions of the Public Health (London) Act, 1891. The housing conditions in the past year have still been so acute as to make it impossible for any recommendations to be made in connection with the closing of any houses, but, in order to be able to take this aspect into consideration in the course of a year or two, the houses surveyed have been classified into five different grades in accordance with the extent of the dilapidations and defects that are found to exist. Results of Survey. Up to the end of December, a total of 2,680 houses were surveyed by the Inspectors specially engaged on this work. These have been periodically reported at the meetings of the Public Health and Housing Committee. The summary for the year under the five headings is as follows Grade 1. In such a state by reason of impossibihty to provide adequate light, ventilation, floor levels, height and size of rooms, and other defects of construction, as not to be capable of remedy, and should be on a schedule or included in an area 46 Grade 2. Unfit for human habitation by reason of extensive dilapidations and dirty conditions, but subject to effective remedy under a Closing Order 17 112 Grade 3. Generally dilapidated, damp, dark, and dirty, but subject to remedies either under Sec. 28 of the Housing, Town Planning Etc. Act, 1919, or the Public Health (London) Act, 1891 988 Grade 4. Few defects, capable of being remedied under the Public Health (London) Act, 1891 1,258 Grade 5. Satisfactory 371 Total 2,680 The above conclusions have been drawn up by the Survey Inspectors from the records on the cards, and from a personal knowledge of the houses inspected, but it must be appreciated that there is always difficulty in drawing a hard and fast line in such an analysis, and the conclusions should be accepted only as a provisional analysis of the work that has been done. For instance, the conclusion that there are 63 houses that are regarded as unfit for human habitation must not be interpreted that they must be the subject of a Closing Order now, but that the extent of the defects in each house indicates the necessity for action with respect to closing or demolition when it is possible for this aspect to be considered. In the case of houses described as unfit for human habitation, the defects that render them in this condition are in many cases associated with the fact that they are old houses, with, for example, small rooms, floors below ground level in congested areas, inadequate hght and ventilation, old structures, dilapidated staircases, or sagging roofs, etc., etc. Any defects, however, such as a leaky roof, requiring immediate attention, have of course been attended to. Only the necessary immediate work has been carried out in such cases so that the spirit and the policy of the Ministry of Health has 113 been observed, as set out in Chapter 4 of the Manual, where it says— "On the other hand, where a house is in such a condition that within a few years it will probably have to be demolished, or is in an area which will soon have to be cleared or re-planned, large repairs or alterations of a permanent nature are likely to be inexpedient, and it may be well to accept work as will make the house habitable for the time being. It would be unwise to require now heavy expenditure which shortly might itself be a hindrance to a more thorough treatment of bad conditions." There have been many instances where the survey inspectors have found that as the result of the survey the landlord has carried out repairs without the necessity of the service of any notice. Survey inspectors in addition to recording the defects existing on the premises, advise and admonish dirty tenants, and have noted, as a result, instances where there has been improvement. These circumstances apply also to the keeping of animals. The records that are made of the inspections include the number of persons occupying the houses, and, in the analysis, for the purpose of ascertaining the extent of overcrowding, the standard recommended by the Registrar General, viz., more than two persons to a room, has been adopted. has been adopted. The following are the details with respect to the 2,680 houses:— Houses or Tenements. No. of persons in excess of two persons per room. Houses originally built for one family now occupied by more than one family. With less than two persons per room. With two persons per room. With more than two persons per room. 2,075 333 272 437 604 114 15,005 persons in 2,680 houses containing 12,520 rooms; = 5.6 persons per house or not quite 1.2 persons per room. Of these houses it was found that 272 were occupied by a number of persons in excess of the two persons per room. Although this standard is convenient for ascertaining serious overcrowding, yet it must be appreciated that the conditions prejudicial to health are dependent upon the size of the rooms and the number of persons actually crowded into the room especially for the purpose of sleeping. But it is invariably the case that overcrowding in a room is associated with an excessive number of persons in the house. 125. Unhealthy Areas. No areas have been represented under Part 1 or 2 of the Housing Act of 1890, and no complaints that areas were unhealthy have been made. 126. General and Miscellaneous. During the War, 3,436 houses (including 1,930 huts) were erected by the Government. These are all still fully occupied. The houses are under the control of the London County Council, who act as agents for H.M. Office of Works; the hutments are still under the control of the Office of Works. It has been found during the year that the deterioration of the huts has slightly advanced, and in consequence a certain amount of repairs is necessary. The roofs and other exposed parts of the hutments are being systematically treated with tar and the guttering is undergoing an overhaul and repair. The keeping of fowls and animals by the occupants is a fruitful source of complaint. These fowls are sometimes kept in a dirty state, or in excessive number, or in too close proximity to hutments, and in certain cases have even been kept in the cavity under the hut. When any of these circumstances are such as to be a nuisance, action is taken by this Department and the nuisance abated. In all cases where the chickens have been kept under the huts, they have been removed. 115 Through the courtesy of the Superintendent and Agent for H.M. Office of Works, I am able to say that he has now a list of 1,800 applicants for accommodation, but it is difficult to appreciate the value of this, inasmuch as applicants may put their names down on every available list, (e.g., the Council's waiting list), and may neglect to have their names removed if in the meantime they be suited. It is however found that the demand for the hutments is a steady one. This is due to the fact that the rent for a hut of 8/11 per week inclusive, compares with the 14/9 or 20/3 for a new house. 127. New Houses. Water certificates were granted during the year for the following new houses erected in the Borough:— Date of Certificate. 10 Pinewood Villas, Wickliam Lane 15th March. The Den, Shooter's Hill 22nd July. Bungalow No. 2, Shooter's Hill 22nd July. 1a Wrottesley Road 8th December. 116 APPENDICES. HOUSING CONDITIONS. STATISTICS. Year ending 31st December, 1920. 1.—General. Estimated population 141,666 General Death Rate 10.5 Death Rate from Tuberculosis 1.32 Infantile Mortality 61 Number of dwelling-houses of all classes 26,211 Number of working-class dwelling houses 22,084 Number of new working-class houses erected 12 2.—Unfit Dwelling-houses. 1.—Inspection. Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 5,610 Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 2,680 Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 63 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 1,734 2.—*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 2,870 * Includes Intimation Notices. 117 3.—Action under Statutory Powers. (a) Proceedings under Section 28 of the Housing, Town Planning, Etc. Act, 1919. Number of dwelling-houses in respect of which notices were served requiring repairs nil Number of dwelling-houses which were rendered fit- (a) By Owners nil (6) By Local Authority in default of Owners nil Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close nil (b) Proceedings under Public Health Acts. Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 1,510 Number of dwelling-houses in which defects were remedied— (a) By Owners 1,138 (b) By Local Authority in default of Owners nil (c) Proceedings under Sections 17 and 18 of the Housing Town Planning Etc. Act, 1909. Number of representations made with a view to making of Closing Orders 5 Number of dwelling-houses in respect of which Closing Orders were made *4 Number of dwelling-houses in respect of which Closing Orders were determined, the dwellinghouses having been rendered fit nil Number of dwelling-houses in respect of which Demolition Orders were made nil Number of dwelling-houses demolished in pursuance of Demolition Orders nil * This figure refers to basement rooms closed. 118 3.—Unhealthy Areas. Areas represented to the Local Authority with a view to Improvement Schemes under (a) Part 1, or (b) Part 2, of the Act of 1890:— Name of Area nil Acreage nil Number of working-class houses in area nil Number of working-class persons to be displaced nil 4.—Number of houses not complying with the building byelaws erected with consent of Local Authority under Section 25 of the Housing, Town Planning, Etc., Act, 1919 nil 5.—Staff engaged on housing work with, briefly, the duties of each officer— This is referred to in the general body of the Report. 119 METEREOLOGY. Meteorological observations taken at the Royal Observatory, Greenwich, during the year 1920. Week ending Temperature of the Air. Average Temperature 4 feet below ground. Departure from average mean air temp, of 65 years. Number of days on which rain fell. Rainfall in inches. Highest during Week. Lowest during Week. Mean Temperature. Jan. 3 54.2 26.7 41.2 44.8 + 2.5 5 0.65 10 53.1 22.1 38.0 43.7 —0.0 3 0.60 17 55.5 32.1 46.8 43.8 + 8.7 4 0.78 24 54.7 29.9 44.0 44.8 + 5.2 4 0.22 31 54.9 32.8 38.1 44.1 + 4.1 6 0.66 Feb. 7 51.5 28.9 42.5 44.0 + 3.0 1 0.13 14 53.9 33.1 45.4 43.7 + 6.4 4 0.12 21 61.8 34.4 44.6 44.0 + 5.0 3 0.23 28 54.4 27.2 41.6 43.6 + 15 2 0.09 March 6 59.3 30.0 40.7 43.7 + 50 3 0.47 13 54.2 27.2 40.3 43.7 — 0.8 4 0.18 20 61.9 34.2 45.2 43.7 + 3.4 3 0.29 27 65.9 34.7 50.1 44.3 + 7.6 2 0.25 April 3 64.6 34.3 49.7 45.6 + 4.9 3 0.53 10 64.1 34.2 49.3 45.9 + 3.1 5 0.40 17 60.0 42.5 50.0 46.8 + 3.4 6 0.99 24 66.2 35.1 48.1 47.5 — 0.4 5 0.57 May 1 63.1 32.9 48.0 47.7 — 0.9 5 0.37 8 67.4 320 49.8 48.0 — 0.4 4 0.33 15 72.3 39.3 54.1 48.7 + 2.0 2 0.05 22 72.9 41.3 55.1 49.8 + 1.5 2 0.12 29 865 45.1 63.6 51.3 + 7.8 1 0.03 June 5 78.7 43.0 57.7 52.6 — 0.0 3 0.17 12 75.7 36.5 54.2 52.9 — 40 3 0.73 19 77.9 46.1 62.3 53.4 + 34 4 0.29 25 75.9 51.9 62.4 54.4 + 1.6 1 0.48 120 METEREOLOGY—continued. Week ending Temperature of the Air. Average Temperature 4 feet below ground. Departure from average mean air temp, of 65 years. Number of days on which rain fell. Rainfall in inches. Highest during Week. Lowest during Week. Mean Temperature. July 3 75.6 49.4 61.3 55.2 — 0.3 4 0.48 10 71.2 48.1 56.5 55.5 — 5.8 4 1.15 17 75.8 49.1 62.4 55.9 — 0.7 2 0.52 24 75.6 46.5 61.7 56.7 — 1.5 3 0.85 31 74.1 44.0 56.3 56.6 — 5.5 5 0.44 Aug. 7 73.0 48.7 58.8 56.7 — 3.3 4 0.65 14 77.6 45.7 60.3 56.8 — 2.1 1 0.01 21 75.6 41.3 57.8 56.9 — 4.1 2 0.93 28 71.8 45.2 55.9 56.2 — 4.9 1 0.03 Sept. 4 72.2 45.8 56.2 55.9 — 3.7 3 0.14 11 72.3 40.3 58.1 56.0 — 0.7 1 0.06 18 76 0 39.2 57.3 55.7 — 0.3 6 1.66 25 66.3 42.0 48.6 55.2 — 1.8 2 1.16 Oct. 2 69.0 45.4 53.3 55.0 + 2.4 3 0.89 9 72.0 44.1 60.6 55.1 + 8.1 3 0.09 16 66.3 39.8 54.6 55.0 + 4.2 2 0.09 23 60.7 34.0 46.9 54.1 — 1.9 1 0.27 30 59.0 30.3 45.7 52.6 1.8 — 0.00 Nov. 6 56.5 27.9 40.5 50.7 — 60 2 0.19 13 37.0 29.2 46.9 49.5 + 2.6 2 0.02 20 59.0 31.4 45.8 49.1 + 3.1 4 0.24 27 55.2 23.4 40.9 47.8 — l.l 4 0.07 Dec. 4 56.5 36.7 45.8 47.1 + 4.7 6 0.70 11 46.0 26.9 37.8 46.9 — 3.2 5 0.35 18 40.2 15.7 81.1 45.6 — 9.4 5 0.08 25 55.9 33.6 43.1 44.9 — 4.5 5 0.78