w002 Metropolitan Borough of Woolwich. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR WOOLWICH. 192I. By J. MACMILLAN, D.S.O., M.C., M.B., D.P.H., Medical Officer of Health. W oolwicii: The Pioneer Press, Ltd., (T.U. -Fed.), 3, New Road. 1922. 2 Public Health and Housing Committee. His Worship the Mayor (Councillor J. A. Turnbull, 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— Miss M. Crout, J.P. J. Newman. S. H. Cuff, L.C.C. P. F. Sheridan. H. A. Hart. Mrs. M. E. T. Smith. V. Lister. *H. Sykes. W. C. Montano. † T. H. Thompson. Miss S. Turnbull. † To November, 1921. * From November, 1021. 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, L.C.C. 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. Harold W. Pendrill. William Little. Charles W. Prance (Temporary) William Wood. (Resigned 28th February, 1921). Alfred G. Potter. Charles W. V. Harris (Temporary). William Tedham. (Appointed 15th June, 1921). Thomas Powell. Mrs. Alice Farrugia. Harry Shaw. 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. 4 Tuberculosis Dispensary. Tuberculosis VisitorsMrs. Lilian Castledine. Miss May Hunter, Miss Norah Mahoney. Nurse Dispenser— Miss Catherine Walker. Clerk- Mrs. Louise Morrison (Temporary). Deputy Tuberculosis Officer. Edward O'Connor, M.A., M.B., B.Ch., D.P.H. Assistant Medical Officer of Health and Tuberculosis Officer Frederick J. C. Blackmore, M.R.C.S., L.R.C.P. HOME FOR AILING BABIES. Visiting Physician Dr. Frederick Dodd. Matron Miss K. M. Moore (Resigned 1st October, 1921). Miss S. Cross (Appointed 5th October, 1921. 5 SUMMARY OF STATISTICS, 1921. Area of the Borough 8,276 6 acres Population—Census, 1911 121,376 do. Census, 1921 140,403 do. do. 1921 (Civilian) 136,307 Persons to an acre—Census, 1911 14-7 do. do. do. 1921 17 Marriages 1,000 Births 3,197 Birth Rate 23 5 Deaths1,594 Death Rate 117 Deaths under one year 197 Infantile Death Rate 62 s 6 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 5 Preface 11 Natural and Social Conditions of the District. Population 11 Social conditions of the District—occupations of inhabitants 12 Vital Statistics. Births 13 Marriages 16 Deaths10 Infantile Mortality 20 Hospital treatment and other forms of medical relief 30 Sanitary Circumstances of the District. Closet Accommodation 31. Scavenging 31 Sanitary Inspection of the Borough 32 Drainage 32 Nuisances abated 33 Prosecutions 38 Houses let in Lodgings 39 Cleansing of Verminous Persons 39 Underground Sleeping Rooms 40 Offensive Trades 41 Mortuaries41 Cemeteries 41 Inhabited House Duty 42 Destruction of Rats 42 Rag Flock Act 42 Increase of Rent and Mortgage Interest (Restrictions) Act 42 Factories, Workshops and Workplaces 42 7 page Food. Milk 46 Dairies, Cowsheds and Milkshops Order 46 Milk and Cream Regulations, 1912—1917 47 Milk (Mothers and Children Order), 1919 49 Food Inspection, including Meat and other foods 52 Slaughterhouses 53 Inspection of premises where food is prepared for sale or sold 53 Food Poisoning 54 Sale of Food and Drugs 54 Prevalence of, and Control over, Infectious Diseases. Notifications 58 Notifications each year since 1901 60 Deaths, and Death Rates from various Infectious Diseases 61 Small Pox 62 Measles 62 Whooping Cough 63 Enteric Fever 63 Scarlet Fever 64 Diphtheria 66 Pneumonia, Malaria, Dysentery and Trench Fever 68 Anthrax, Glanders and Hydrophobia 71 Erysipelas 71 Cerebro-spinal Meningitis, Post Basic Meningitis, Polio-Myelitis and Encephalitis Lethargica 71 Tuberculosis—Notifications 73 Deaths 75 Administrative Action 77 Staff 77 Co-operation with Hospital and School Clinic and with Medical Practitioners 77 Home Contacts 78 Treatment—Dental Treatment 78 Home Nursing 79 Extra Nourishment 79 After Care 80 Sanitary Defects 80 8 Tuberculosis—continued. page Bacteriological Examinations 81 Institutional Treatment 81 Statistics 82 General Administrative Action with regard to Infectious Diseases 83 Maternity and Child Welfare. Staff 84 Welfare Centres 84 Treatment 85 Voluntary work in the Borough 85 Home for Ailing Babies 87 The work of the Health Visitors 88 The work of the Centres 91 The needs of the Borough 94 Feeding of Infants 94 Infectious Diseases 97 Puerperal Fever 97 Ophthalmia Neonatorum 97 Measles, Whooping Cough and Polio-myelitis 98 Epidemic Diarrhoea 98 Administrative measures 108 Sanitary Administration. Sanitary Staff 110 Public Analyst 110 Bacteriological Examinations 110 Housing. General Housing Conditions 1ll Shortage of Houses 1ll Population 112 Government Houses and Hutments 112 Housing Survey 112 Fitness of Houses 112 Overcrowding 112 Results of Survey 113 Unhealthy areas 115 New Houses 116 Appendices 117 9 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 Twenty-first 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 presentation of Annual Reports of Medical Officers of Health throughout the country. The chief vital statistics relating to the year are as follows : The population shows a diminution as compared with last year but it is to be remembered that the population for 1921 is an enumerated one, whereas that for 1920 was estimated. The Census figures for 1921 are 140,403, an increase of 16.9 per cent., compared with the figure for 1911. The birthrate,. 23.5, is somewhat lower than last year : the marriagerate, 14.2, shows a decrease compared with previous years; the death-rate, 11.7, and the infantile mortality rate, 62, compare with 10.5 and 61 in 1920. During the year three diseases were present in epidemic form, viz., scarlet fever, diphtheria, and zymotic enteritis. In consequence of these epidemics great pressure was put on the hospital accommodation of the Metropolitan Asylums Board, and in consequence it was necessary to isolate 135 B 9 10 cases of scarlet fever at home. These cases were, of course, selected cases, and in no case was there reason to suppose that the public safety was endangered through this. If these cases can be maintained at home during an epidemic period of scarlet fever, they can, with equal advantage, be retained during an epidemic period of measles, and by this means more use can be made of the hospital beds of the Metropolitan Asylums Board by providing hospital accommodation for the treatment of measles as opposed to the isolation of scarlet fever. Maternity and Child Welfare work has continued to grow during the year. The attendances at the Welfare Centres have increased from 2,249 in 1918, to 23,156 in 1921, a fact which speaks for itself. I have again to express my appreciation of the work of the staff of the Public Health Department and to thank the Public Health and Housing and the Maternity and Child Welfare 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, JOHN MACMILLAN. 11 Twenty-First Annual Report ON THE HEALTH OF THE METROPOLITAN BOROUGH OF WOOLWICH. Year ending 31st December 1921. NATURAL AND SOCIAL CONDITIONS OF THE DISTRICT. POPULATION. Census.—The population of Woolwich on the 19/20th June, 1921, consisted of 140,403 persons, of whom 69,GOG were males and 70,737 were females. The nett civilian figure, however, was 136,307. In 1911, the population of Woolwich was 121,376, so that there is a nett increase of 19,027 persons, the ratio between 1911 and 1921 being as 100 to 116. This is the largest relative and actual increase in any Metropolitan Borough. The density of population per acre was 17, but although this figure is the lowest in London, it loses value from the fact that over one-third of the Borough is not built on. The density figure per room is much more important, and here we find that the figure for Woolwich is 1.01, being the tenth lowest in London. The average number of persons per house was 5.28 as compared with a general London average of 6.06. The Census was taken in June instead of at the usual period 12 in April, and it is possible that the true increase in Woolwich may actually be greater owing to the fact that certain residents would be absent on holiday. Detailed figures for the various Wards and Parishes of the Borough are not yet available, but should be available by the time the next Annual Report is ready to be published. The estimated population for the different parishes of the Borough is as follows (non-civilians are excluded):— Parish Estimated population. Woolwich 31,267 West Plumstead 40,098 East Plumstead 36,680 Eltham 28,262 136,307 The above figures are those which have been used throughout the report for calculating the rates in the Borough and in different parishes. During the preceding five 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 THE DISTRICT. Tables showing the occupations of the inhabitants of the Borough, both at the time of the Census, 1911, and during the period of National Registration, were set out in detail in the Annual Report for 1920. 13 VITAL STATISTICS. The chief vital statistics of the Borough during 1921 and the preceding five years are shown in the next table. TABLE I. Vital Statistics of whole District during 1921 and six previous years. Year. Population estimated to middle of each Year. Births. Nett. Total Deaths Registered in the District. Transferable Deaths Nett deaths belonging to the District. of Non-residents registered in the D; strict. 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 1915 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 * 1919a 136,237 2737 19.3 1519 116 276 235 86 1679 12.3 b 141,918 * 1920 a 141,666 3658 24.7 1328 113 272 224 61 1487 10.5 b 147,827 1921 c 136,307 3197 23.5 1365 90 319 197 62 1594 11.7 d 140,403 *Estimate of Registrar-General. a Population for Death Rate. b Population for Birth Rate. c Civil population. d Including Military. Area of District in acres exclusive of area covered by water) 8239.7 Census, Total Population, all ages 140,403 1921.)Civilian Population, all ages 136,307 BIRTHS. The number of births was 3,197, and the birth-rate, calculated on the total population as disclosed at the Census was 23*5 as compared with 24.7 last year. 14 Notification of Births.—The 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, 3,011 births were notified. This is at the rate of 94% of the registered births and compares with 95% in 1920. 1,789 notifications were received from midwives, 377 from medical practitioners, 163 from the British Hospital for Mothers and Babies, 96 from the Military Families Hospital, 31 from the Woolwich Infirmary, and 555 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. 1, shows the number of births in each year since 1917, 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. 1. Y ear. Woolwich. London England & Wales Woolwich. Percentage of births notified No. of Births Birthrate Birth -rate No. of live births notified No. of Stillbirths 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 3463 112 95 1921 3197 23. 22.3 •) 22.4 3011 91 94 The natural increase of the population is the excess of 15 births over deaths. In 1918 it was 486; in 1919 it was 1,058 ; in 1920 it was 2,171; in 1921 it was 1,603. Table No. 2 shows the number of births in 1921 in each parish, and the respective birth-rates (after correction for outward and inward transfers) since 1917. TABLE No. 2. Period Woolwich West Plumstead East Plumstead Eltham The Borough 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 20.0 19.3 1920 30.4 21.9 24.1 23.2 24.7 1921 29.9 22.0 21.2 21.3 23.5 No. of Births 1921 935 884 776 602 3197 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 1917, and the illegitimate birth-rate per 1.000 births. TABLE No. 3. No. of illegitimate Illegitimate birth-rate TABLE No. 3. 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 1921 80 25.0 16 MARRIAGES. There were 1,000 marriages (1,240 in 1920). The marriage rate was 14-2 as compared with 19.7, 20.2, 19.8 and 17.5 in the four preceding years. DEATHS. Table I. shows the gross and nett deaths and death-rates in 1921 and each of the last six years, and shows how the nett death figure is obtained. The nett deaths were 1,594 and the nett death-rate 11.7. In 1920 it was 10.5. The following Table, No. 4, shows the death-rate of Woolwich as compared with certain other districts in 1919, 1920 and 1921. TABLE No. 4. 1919. 1920. 1921. England and Wales 13.8 12.4 12.1 96 Great Towns 13.8 12.5 12. 3 London 13.4 12.4 12.4 Greenwich 13.5 11.9 12.1 Lewisham 11.4 10.8 10.4 West Ham 13.3 12.7 9.7 East Ham 9.7 9.6 12.2 Erith 10.7 9.1 10.3 Woolwich 12-3 10.5 11.7 The following Table, No. 5, shows the death-rate in the Borough and each registration district since 1917. 17 TABLE No. 5. Period The Borough Woolwich Parish West Plumstead East Plumstead E It ham 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 1921 11.7 13.9 13.5 10.2 8.6 The death-rate in Woolwich in 1921 was the second lowest of all the Metropolitan Boroughs. With the exceptions of 1917 and 1920, it is the lowest death-rate recorded in the Borough. The next tables are self-explanatory. Table No. 6.—Birth-rate, Death-rate, and Analysis of Mortality during the Year 1921. (Provisional figures. Populations as enumerated in 1921 have been used for the purposes of this Table. The mortality rates refer to the whole population as regards England and Wales, but only to civilians as regards London and Woolwich. Birth rate per 1,000 Total Population. Annual Death-rate per 1,000 Population. Rate per 1,000 Births. Percentage of Total Deaths. All Causes. Enteric Fever. Small-pox. Measles. Scarlet Fever. Whooping cough. Diphtheria. Influenza. Violence. Diarrhoea and iEnferitls (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 22.4 12.1 0.02 0.00 0.06 0.03 0.12 0.12 0.23 0.44 15.5 83 25.5 92.5 6.4 1.1 96 Great Towns, including London (1911 Census Populations exceeding 50,000) 23.3 12.3 0.01 0.00 0.08 0.04 0.13 0.15 0.23 0.40 19.3 87 33.2 92.5 6.8 0.7 148 Smaller Towns (1911 Census Populations 20,000— 50,000) 22.1 11.3 0.01 0.00 0.05 0.03 0.11 0.11 0.26 0.35 15.6 84 17.7 93.5 5.1 1.4 London 22.3 12.4 0.01 — 0.05 0.06 0.12 0.25 0.23 0.42 21.3 80 49.2 91.6 8.2 0.2 WOOLWICH 23.5 11.7 0.01 — 0.04 0.07 0.12 0.29 0.27 0.22 18.8 62 40.2 93.9 6.1 0.0 18 TABLE II. Deaths of Woolw;ch Residents Registered during the Calendar Year 1921, classified by age and cause. Nett Deaths at the subjoined Ages of " Residentswhether occurring within or without the District. Causes of Death. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years 45 and under 65 years. 65 and under 75. 75 and upwards. All causes 1594 197 55 35 80 89 188 413 285 252 Enteric Fever 1.. .. .. .. .. 1 .. .. .. .. Small-pox .. .. .. .. .. .. .. .. .. .. Measles 4 1 1 1 1 .. .. .. .. .. Scarlet Fever 10 .. 1 2 5 2 .. .. .. .. Whooping Cough 16 9 5 1 1 .. .. .. .. .. Diphtheria 40 2 5 10 20 1 2 .. .. .. Influenza 37 1 1 .. 2 1 6 11 8 7 Encephalitis lethargica 4 .. . . .. .. 1 2 1 .. .. Meningococcal Meningitis 1 .. .. .. 1 .. .. .. .. .. Tuberculosis of Respiratory System 168 1 3 1 5 54 56 40 8 .. Other Tuberculous Diseases 39 3 8 5 9 6 2 5 1 .. Cancer, malignant disease 182 .. 1 1 • • 4 13 89 54 20 Rheumatic Fever 6 • • .. .. 1 3 1 .. .. 1 Diabetes 17 . . .. .. 1 2 3 4 5 2 Cerebral Haemorrhage, &c. 90 .. .. .. .. .. .. 32 31 27 19 TABLE II.—continued. Nett Deaths at the subjoined Ages of "Residents" whether occurring within or without the District. Causes of Death. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years 45 and under 65 years. 65 and under 75. 75 and upwards. Heart Disease 149 .. .. .. 6 3 12 57 42 29 Arterio-sclerosis 37 .. .. .. .. .. 1 10 11 15 Bronchitis 113 8 6 2 .. .. 3 26 39 29 Pneumonia (all forms) 98 16 11 4 8 2 16 21 13 7 Other Respiratory Diseases 21 2 1 1 .. .. 2 6 6 3 Ulcer of Stomach or Duodenum 14 .. .. .. 1 .. 3 8 1 1 Diarrhoea, &c. 72 56 4 4 2 .. .. 3 1 2 Appendicitis and Typhlitis 8 .. .. 2 1 2 1 2 .. .. Cirrhosis of Liver 12 .. .. .. .. .. .. 9 3 .. Acute and Chronic Nephritis 47 .. . . .. 1 .. 6 17 16 7 Puerperal Sepsis 5 .. .. .. .. .. 5 .. .. .. Other accidents and diseases of pregnancy and parturition 5 .. .. .. .. 2 3 .. .. .. Congenital debility and malformation, premature birth 70 69 1 .. .. .. .. .. .. .. Suicide 11 .. .. .. .. .. 5 5 1 .. Other deaths from violence 30 2 1 .. 4 1 6 6 3 7 Other defined diseases 286 27 5 1 11 4 40 61 42 95 Causes ill-defined or unknown 1 .. 1 .. .. .. .. .. .. .. 20 TABLE IIA. Showing 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 1921. Causes of Death. Male. Female. Woolwich. Plumstead. Eltham. Deaths in Public Institutions. West. East. In Borough. Residents. NonResidents. Outlying Institutions. All causes 806 788 435 542 374 243 332 66 308 Enteric Fever 1 .. 1 .. .. ..' .. .. 1 Small-pox .. .. .. .. .. .. .. .. .. Measles 2 2 3 .. 1 .. .. .. .. Scarlet Fever 6 4 3 2 1 4 .. .. 9 Whooping Cough 6 10 3 3 1 9 1 .. 2 Diphtheria 25 15 5 17 15 3 .. .. 37 Influenza 19 18 10 9 10 8 8 1 .. Encephalitis Lethargica 3 1 .. .. 1 3 .. .. 2 Meningococcal Meningitis 1 .. .. 1 .. .. .. 1 .. Tuberculosis of Respiratory System 85 83 49 59 42 18 32 5 35 Other Tuberculous Diseases 20 19 14 . 11 9 5 8 1 12 Cancer, Malignant disease 76 106 50 55 47 30 35 4 35 Rheumatic Fever 4 2 1 3 1 1 .. .. 1 Diabetes r-» / 10 4 5 3 5 3 1 1 Cerebral Haemorrhage, &c. 34 56 20 37 23 10 16 5 7 21 TABLE IIa.—continued. Causes of Death. Male. Female. Woolwich. Plums tead. Eltham. Deaths in Public Institutions. West. East. In Borough. Residents. NonResidents. Outlying Institutions. Heart Disease 62 87 39 50 30 21 21 1 11 Arteriosclerosis 25 12 12 11 8 6 18 2 9 Bronchitis 53 60 34 35 35 9 20 3 7 Pneumonia (all forms) 56 42 31 28 25 14 17 5 10 Other respiratory diseases 9 12 6 9 1 5 2 . . 3 Ulcer of Stomach or Duodenum 11 3 .. 3 6 5 .. .. 5 Diarrhoea, &c. 40 32 21 14 19 18 10 10 11 Appendicitis and Typhlitis 2 6 4 1 2 1 1 .. 8 Cirrhosis of Liver 9 3 3 5 2 2 6 .. 1 Acute and Chronic Nephritis 26 21 9 21 12 5 21 5 5 Puerperal Sepsis .. 5 1 2 2 .. 2 1 2 Other Accidents and Diseases of Pregnancy and Parturition .. 5 .. 3 1 1 3 1 1 Congenital Debility and Malformation, Premature Birth 44 26 23 21 13 13 10 3 7 Suicide 8 3 4 2 1 4 2 1 2 Other Deaths from Violence 20 10 8 11 9 o 15 4 3 Other Defined Diseases 151 135 76 115 54 41 81 12 81 Causes ill-defined or unknown 1 .. 1 .. .. .. .. .. .. 22 23 CAUSES OF DEATH. Table II. shows that 182 deaths were due to cancer, 168 to pulmonary tuberculosis, 149 to heart disease, 113 to bronchitis, 98 to pneumonia, 72 to cliarrhoeal diseases, and 70 to congenital debility, etc. There is a very marked increase in the deaths from diarrhoeal diseases and a very marked diminution in the deaths from congenital debility. Cancer and Malignant Disease. The number of deaths due to cancer or malignant disease (including sarcoma) each year since 1917 is shown in Table No. 7. TABLE No. 7. Year. Males. Females. Total. Death-rate. 1917 58 72 130 0.88 1918 81 84 165 1.10 1919 76 81 157 1.15 1920 60 95 155 1.09 1921 76 106 182 1.34 The next Table. No. 8, shows the site of the primary disease in all deaths from cancer (excluding other specified malignant tumours). 24 TABLE No. 8. Seat of Primary Disease. Males. Females. Total. Tongue 3 2 5 Tonsils 2 — 2 Pharynx 1 1 2 Œsophagus 9 — 9 Stomach 18 15 33 Liver and Gall Bladder 9 8 17 Intestines 9 15 24 Rectum 13 13 26 Uterus — 21 21 Ovary — 3 3 Breast — 15 15 Skin 3 — 3 Larynx 1 — 1 Lung 1 — I Pancreas — 2 2 Prostate 5 — 5 Bones — 1 1 Other specified organs 1 1 2 Abdominal Cavity (unspecified) - 3 3 Other and undefined - 1 1 75 101 176 The deaths from cancer each year continue to increase slowly and steadily, and cancer is playing a more important part in the mortality figures of the Borough. In 1921 the figures were the highest ever recorded, especially in the case of females, and the death-rate is the highest we have known in Woolwich. The cause of cancer is unknown, but research is being carried out in practically every country in the world, and sooner or later the cause of this disease will be discovered. We can say at present that it is not necessarily incurable and that even in incurable cases some degree of effective treatment can be carried out. In no disease, however, is an early diagnosis and prompt treatment so essential to success, and 25 early diagnosis and prompt treatment can only be obtained if early resort is made to a medical practitioner. It is therefore important that the public should appreciate the seriousness of delay in this disease, which is painless and insidious in its origin in individuals and is increasing equally insidiously amongst the population. Respiratory Diseases. 113 deaths were due to Bronchitis, 98 to pneumonia, and 21 to other respiratory diseases. The corresponding figures for 1920 were:—Bronchitis, 101; pneumonia, 97; other respiratory diseases, 16. The following Table, No. 9, shows the number of deaths each year since 1917 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. TABLE No. 9. Deaths from Respiratory Diseases. Year. Bronchitis. Pneumonia. Other Respiratory. Total. Death Rate. . No. under 5 years. Percentage under 5 years. 1917 113 142 17 272 2.1 i 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% 1921 113 98 21 232 1.7 51 22.0 % c 26 Diarrhœa. 72 deaths were due to diarrhœal diseases and of these, 60 occurred under two years of age. These deaths, in the main, were due to the epidemic of summer diarrhoea which occurred during the hot months of the year, and it is necessary to go back to the year 1911 to find figures comparable with those for 1921. In 1911 the number of deaths in children under one year of age was 87, compared with 56 in 1921. Expressed in terms of 1,000 births, this is 31 per 1,000 in 1911, compared with 18 per 1,000 in 1921. Violence and Suicide. 30 deaths—20 males and 10 females—occurred from violence, apart from suicide. 11 deaths were due to suicidal causes, 8 males and 3 females. Inquests. There were 102 inquests held on Woolwich residents during the year compared with 145, 135, 112, 131 and 181 in the preceding five years. INFANTILE MORTALITY. The deaths under one year were 197 as compared with 224 in 1920, 235 in 1919, and 268 in 1918. The infantile mortality rate (deaths under one year per 1,000 births) was 62. In 1920 the Infant mortality rate, 61, was the lowest ever recorded in the history of the Borough. In 1921, it was 62. 27 In West Pluinstead it was as low as 57. The rate for London was 80 ; in Lewisham it was 55; in Stoke Newington, 59. In 1920, Woolwich also occupied third place, the two Boroughs which were better being Hampstead and Chelsea. The following table, No. 10, gives the infantile mortality rate in each registration district of the Borough since 1917. TABLE No. 10. Year Borough Woolwich Parish West Plum stead East Plumstead Eltham 1917 79 97 70 84 67 1918 104 125 99 85 109 1919 86 96 82 68 92 1920 61 75 62 51 55 1921 62 59 57 64 70 Illegitimate Deaths. The number of deaths amongst illegitimate infants was 12. A comparison of the infantile mortality rates of legitimate and illegitimate children shows that the rate for legitimate was 59, and for illegitimate, 150. Causes of Death. The chief causes of death were; debility and premature birth, 57; diarrhoea, enteritis and gastritis, 56; pneumonia, 16. The following table, No. 11, 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. 28 TABLE No. 11. Year. No. of Births. Infantile Mortality Rate. Infant Deaths. Total Number Inlant Deaths under 4 weeks. Total Number under 4 weeks 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 1921 3197 62 197 72 23 Total 51249 87 4465 1707 34 As will be seen from the above Table, in 1920 the number of deaths under 4 weeks per 1,000 births was 28, in 1921 it was 23. These figures are low and are probably due in some measure to the increased care and attention to expectant and nursing mothers. Table No. III. shows the deaths under 1 year, classified by age and cause, for the year 1921. 29 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 Scarlet Fever .. .. .. .. .. .. .. .. .. .. Whooping-cough .. .. .. .. .. 3 4 2 • • 9 Diphtheria and Croup .. .. .. .. .. .. .. 1 .. 2 Erysipelas .. .. .. .. .. .. .. .. .. .. Tuberculous Meningitis .. .. .. .. .. .. .. 1 .. 1 Abdominal Tuberculosis .. .. .. .. .. .. .. .. .. .. Other Tuberculous Diseases .. .. .. .. .. 1 .. 1 1 3 Meningitis (not Tuberculosis) .. .. .. .. .. .. .. .. .. .. Convulsions 1 .. • • 1 2 2 1 1 .. 6 Laryngitis .. .. .. .. .. .. .. .. .. .. Bronchitis .. .. .. 1 1 2 2 2 1 8 Pneumonia (all forms) .. .. 1 1 2 4 5 3 2 16 Diarrhoea .. .. 2 .. 2 2 2 .. 3 9 Enteritis .. .. .. 3 3 9 13 14 7 46 Gastritis .. .. .. .. .. .. .. 1 .. 1 Syphilis .. .. .. .. .. 1 1 .. .. 2 Rickets .. .. .. .. .. .. .. 1 .. 1 Suffocation, overlying .. .. .. .. .. 1 .. .. .. 1 Injury at Birth 5 .. .. .. 5 .. .. .. .. 5 Atelectasis 3 .. .. .. 3 .. .. .. .. 3 Congenital Malformations 1 1 • • .. 2 6 3 1 .. 12 Premature Birth 28 7 1 .. 36 1 1 .. .. 38 Atrophy, Debility and Marasmus 5 • • 2 3 10 4 4 • • 1 19 Other causes 2 3 1 .. 6 3 3 1 1 14 45 11 7 9 72 39 39 29 18 197 Nett Births in the Year Legitimate 3117 Illegitimate 80 Nett Deaths in the year Legitimate 185 Illegitimate 12 30 HOSPITAL TREATMENT AND OTHER FORMS OF MEDICAL RELIEF. There is no general hospital in Woolwich, and in consequence considerable use is made of the London general hospitals, but no actual figures showing to what extent are available. It is proposed to erect a general hospital in Woolwich as a War Memorial, and plans for its erection are slowly maturing. Some information showing the extent to which hospitals are used may be obtained from the death returns, and the following table shows the number of cases which died in various institutions during the year. TABLE No. 12. No. of deaths. Infectious Disease Hospitals 55 Sanatoria and other Tuberculosis Institutions 47 Mental Hospitals 40 General Hospitals (including Maternity) 137 Cottage Hospitals 19 Poor Law Infirmaries 342 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. 31 SANITARY CIRCUMSTANCES OF THE DISTRICT. This part of the report, which has been largely prepared by your Chief Sanitary Inspector, deals statistically with the work (excepting food inspection) of the District Inspectors and the Lady Sanitary Inspector. Closet Accommodation. There are a few earth closets and 27 cesspools in the Borough. This is a slight increase in the number of cesspools, and is due to the erection of houses on the easterly slopes of Shooters Hill. Scavenging. (a) Removal of House Refuse. Loads removed in Woolwich 7,822 Do. Plumstead 15,214 Do. Eltham 4,866 Frequency Weekly Cost in Plumstead £6,074 15s. 3d. (b) Removal of Trade Refuse. Inoffensive— Loads removed in Woolwich 176 Do. Plumstead 126 Do. Eltham 52 Charge per load 5s. Offensive— Tradesmen on books 57 Receptacles removed 6,109 Charge per receptacle 6d. 32 The Annual Report for 1920 sets out the scheme whereby cesspools are emptied and house and trade refuse removed in the Borough, and little or no change has taken place during the year. Sanitary Inspection of the Borough. Staff.—Mr. C. W. Prance, temporary sanitary inspector, resigned in February, and Mr. C. V. W. Harris commenced duties as a temporary sanitary inspector in June. Complaints. The number of complaints received during the year, 2,064, compares with 1,691 in 1920, 719 in 1919, and 599 in 1918. 57 of these complaints related to the non-removal of dust, 38 being from Woolwich, 8 from Plumstead, and 11 from Eltham. Drainage. 33 combined drains were reported upon at the meetings of the Public Health and Housing Committee throughout the year. These related to 211 houses. The investigation in connection with the examination of these drains usually arises from stoppages, but where a stoppage is found on examination to be due to a temporary cause only, no further action is recommended. These circumstances existed in 28 instances. It was found necessary for 5 combined drains to be reconstructed. These were connected with 52 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 addition to the extensive repairs of combined drains, various small repairs are undertaken at the time of examination at the request of the owners, 33 and in this connection there have been 20 instances in which drains have been repaired on these lines at a total cost of £24 19s. 2d., which amount has been paid by the owners of the respective houses. Nuisances Abated. These are set out below. The total number of intimation notices served was 4,537, as compared with 4,259 in 1920 and 2,470 in 1919. It was found necessary to serve 1,403 statutory notices, as compared with 1,514 in 1920 and 846 in 1919. The number of cases reported to the Town Clerk for legal proceedings was 250. 24 summonses were taken out. Inspections. Tables 13 and 14 show in tabular form, for the whole district and for each ward, the various inspections made, and nuisances abated during the year. 34 TABLE No. 13. Premises Inspected. Dockyard. St. Mary's. River. St. George's. Burrage. Herbert. Glyndon. St. Margaret's. Central. St. Nicholas. Eltham. Total. Milkshops 10 8 17 7 8 13 18 12 4 23 28 148 Bakehouses 8 14 21 .. 17 5 14 4 8 12 39 142 Cowhouses 4 .. .. .. 5 5 .. 4 .. .. 39 57 Ice Cream Premises 16 13 23 4 20 4 31 7 6 43 28 195 Slaughterhouses .. 8 11 .. .. 10 .. .. 4 5 4 42 Fried Fish Shops 35 15 39 7 35 5 16 6 10 22 61 251 Premises where food is prepared (other than above) 25 21 84 4 4 11 12 4 3 10 48 226 Shops and Markets re Food (estimated) .. 17 599 50 55 56 70 78 98 115 161 1299 Factories, Workshops, Workplaces 76 47 310 29 66 69 34 14 82 112 132 971 Outworkers' Premises 70 3 27 3 40 15 69 90 64 81 62 524 Homes re Verminous Cases 8 50 163 .. 60 .. 44 18 16 48 20 427 Homes re Scabies Cases 35 25 33 30 65 27 55 8 65 115 88 546 Women's Lavatories 7 9 52 .. .. .. 11 8 1 6 9 103 Smoke Observations 3 2 1 3 7 2 7 .. .. .. .. 25 Tents and Vans .. .. .. .. .. .. .. 8 .. 6 20 34 Urinals accessible to Public 33 28 31 20 24 14 25 40 34 .. 48 297 35 TABLE No. 13—continued. Premises Inspected. Dockyard. St. Mary's. River. St. George's. Burrage. Herbert. Glyndon. St. Margaret's. Central. St. Nicholas. Eltham. Total. Animals so kept as to be a nuisance .. 3 12 10 8 5 6 .. .. 15 35 94 House to House .. .. .. .. .. .. .. .. .. .. 537 537 Housing Survey, Houses inspected 134 88 605 48 105 .. 419 525 116 701 59 2800 Do., number of following up primary inspections 231 88 570 296 22 87 310 306 67 618 225 2820 Complaints investigated 106 100 302 112 192 105 250 155 109 361 272 2064 Enquiries re Notified Infectious Disease 63 72 225 129 128 128 151 206 146 467 437 2152 School Reports 44 28 42 22 18 27 19 28 29 146 101 504 Special Inspections re Rats 76 13 23 24 24 7 18 7 11 6 11 220 Drains tested by Smoke Test 18 7 5 3 4 7 7 12 3 1 10 77 Do. Water Test 41 13 6 2 3 2 2 6 2 .. 7 84 New Houses Inspected—Water Certificates .. .. .. .. .. 1 .. .. .. .. 204 205 Registered Houses 105 11 93 90 30 12 39 16 1 34 .. 431 Miscellaneous (Unclassified) 249 158 450 88 74 8 37 370 113 771 707 3025 Re-inspections 1816 1752 2389 1327 384 357 1164 1108 776 2399 4444 17916 36 TABLE No. 14. Nuisances, etc., Abated. Dockyard. St. Mary's. Eltham. Burrage. Herbert. Glyndon. River. St. George's. St. Nicholas. Central. St. Margaret's. Total. Interiors cleansed 274 235 406 140 173 485 475 246 512 96 241 3283 Damp conditions in houses remedied 96 86 82 19 55 83 148 73 73 18 52 785 Defective guttering and rain water pipes 86 75 49 20 38 76 117 82 136 26 78 783 Improved ventilation 56 57 14 1 .. 3 2 .. 4 12 15 164 Defective roofs 129 139 63 43 53 117 170 100 156 42 50 1061 Deficient light, windows supplied or enlarged .. 1 5 .. .. .. 2 .. 2 .. .. 10 Paving in yards and wash-houses repaired 117 57 26 12 40 51 136 75 115 13 41 683 Underground rooms not in accordance with Acts 3 .. .. .. .. .. 3 7 .. .. .. 13 Waste pipes from baths, lavatories and wash-houses repaired or disconnected 41 11 22 12 14 31 34 21 37 3 12 238 Choked and defective drains 59 45 42 23 15 27 83 30 65 7 14 410 Defective traps .. .. 5 5 3 4 5 7 1 5 6 41 Defective or un ventilated soil pipe 1 .. 4 .. 1 1 10 1 .. 1 1 20 W.C.'s repaired; new traps or pans provided 18 14 30 27 27 68 30 23 59 13 50 359 Foul pans cleansed 12 9 10 5 5 16 13 13 26 1 5 114 37 TABLE No. 14—continued. Nuisances, etc., abated. Dockyard. St. Mary's. Eltham. Burrage. Herbert. Glyndon. River. St. George's. St. Nicholas. Central. St. Margaret's. Total. Flushing apparatus repaired or renewed 67 62 64 15 23 45 84 50 109 20 29 568 Additional w.c.'s provided to dwelling houses .. .. .. .. .. .. .. .. .. .. .. .. Do., factories and workshops .. .. 1 .. .. .. 6 .. .. .. .. 7 Wash-houses provided with sinks 2 .. 3 2 .. 1 2 1 .. .. .. 11 Defective and foul cisterns used for dietary purposes .. .. 4 .. 1 .. 4 .. .. .. 1 10 Defective and foul rain watertanks .. 1 .. 1 3 .. 1 .. .. .. 1 7 Insufficient supply of water or water cut off by M.W.B. 11 28 11 2 4 .. 1 .. 6 .. .. 63 Additional water supply .. .. .. .. .. .. .. .. .. .. .. .. Cases of overcrowding remedied 3 4 67 4 4 5 16 8 9 2 3 125 Dust bins supplied 116 118 130 30 74 114 169 78 200 31 48 1108 Verminous rooms cleansed 42 33 13 15 3 42 56 10 55 20 7 296 Accumulations of manure removed 11 10 7 5 4 7 4 2 23 .. 3 76 Dung pits provided .. 3 .. .. .. .. 1 1 .. .. .. 5 Smoke nuisances .. .. .. 3 2 .. 1 .. .. .. .. 6 Coppers repaired .. .. 27 4 13 35 .. .. 46 .. .. 125 Cooking stoves repaired .. .. 24 9 22 22 .. .. 65 .. .. 142 Sundry other nuisances 204 160 33 50 89 206 437 330 213 1 .. 1723 1348 1147 1141 447 666 1439 2010 1158 1912 311 657 12236 38 Prosecutions. The following table shows the number of summonses taken out during the year and the result of the proceedings in each case TABLE No. 15. Prosecutions under the Public Health, Housing, Town Planning, and London County Council (General Powers) Acts. No. Date of Hearing. Offence. Situation. Result. 1 1921. Feb. 22 Insufficient ashpit 8, Morris Street Dustbin supplied. £1 1s. costs. 2 Feb. 22 Non-provision of accommodation for cooking food on first floor 88, Eltham Road Work done. 10s. 6d. costs. 3 Feb. 22 Do. on 2nd floor Do. Work done. 10s. 6d. costs. 4 Feb. 22 Sanitary defects and dirty conditions 36, ames Street Order to abate in 21 days. Penalty, 5s. Costs, 10s. 5 Feb. 22 Defective yard paving Do. Work done. 10s. costs 6 Feb. 22 Sanitary defects and dirty conditions 37, James Street Order to abate in 21 days. Penalty, 5s. Costs, 10s. 7 Feb. 22 Defective yard paving Do. Work done. Costs, 10s. 8 Feb. 22 Sanitary defects and dirty conditions 38, James Street Order to abate in 21 days. Penalty, 5s. Costs, 10s. 9 Feb. 22 Do. 13, Eglinton Road Do. 10 Feb. 22 Do. Do. Do. 11 April 13 Dirty conditions and various nuisances 4, Sandbach Place Order to abate in 28 days 12 July 13 Insufficient ashpit 28, Siemens Road Supplied. Costs, 10s. 6d. 13 Aug. 31 Defective repair of a drain 80, Samuel Street Penalty, 1s. Costs, £1 1s. 14 Aug. 31 Defective yard paving 35, Belsom Road Work done. Costs, 10s. 6d. 15 Sept. 28 Insufficient ashpit 5, Glenalvon Street Supplied. Costs, 12s. 6d. 16 Sept. 28 Do. 8, Glenalvon Street Do. do. 2s. 39 TABLE No. 15—continued, No. Date of Hearing. Offence. Situation. Result. 17 1921 Sept. 28 Filthy bedding in 1st floor back room 38, Warwick Street Order to abate in 7 days. Penalty, 40s. Costs' £1 1s. 18 Oct. 26 Defective sink waste pipe 342, Albert Road Order to abate in 14 days. Penalty, £3. Costs, £2 2s. or 21 days' imprisonment. 19 Dec. 7 Defective yard paving 32, Frederick Place Penalty, 40s. Costs, £5 8s. 20 Dec. 7 No dustbin Do. Penalty, 10s. 21 Dee. 7 Defective sink waste and floor of passage Do. Order to abate in 14 days. Penalty, 10s. 22 Dec. 7 Dirty and damp conditions of house 87, Grangehill Road Order to abate in 28 days. Penalty, 5s. Costs, £1 10s. 23 Dec. 7 1922 Defective w.q. apparatus Do. Penalty, 5s. 24 Jan. 4 Defective yard paving 3, Walpole Place Penalty, £3 and Costs, £2 2s. Houses Let in Lodgings. Number on Register at beginning of year 449 Do. end of year 439 Number of Inspections made 431 Do. Notices served 130 Do. Prosecutions Cleansing of Verminous Persons. The station for cleansing verminous persons was opened in 1906. It is situated in White Hart Lane, Plumstead, in premises adjoining the Disinfection Station. The routine followed was described in 40 the Annual Report for 1919, and no change has taken place during the year. It will be noted from Table 16 however, that there is a decrease in the numbers as compared with 1920. This is due to the fact that the County Council are now treating slight verminous cases at one of their centres near Plumstead Station, with a consequent diminution of the number of cases that have been sent to White Hart Lane. The following table shows the extent to which the station has been used each year since 1917:— TABLE No. 16. Children. Adults. Grand Total. Year. Boys. Girls. Total. Males. Females. Total. 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 1921 1219 1112 2331 26 6 26 2357 Underground Sleeping Rooms. Action was taken under Section 17 of the Housing, Town Planning, etc., Act, 1909, with respect to an underground room that was illegally occupied. A closing order was made and served on the occupiers. In 12 other instances in which rooms were illegally occupied, the conditions were abated on service of intimation notices. Date of representation. Premises. Date of Closing Order. 27.5.21 19, Joseph Street 15.6.21 41 Offensive Trades. There are no offensive trades in Woolwich. Mortuaries. TABLE No. 17. Sun St. Sun St. Eltham. (Infectious) All Mortuaries. 1921. 1920. Number of bodies received— (a) for inquest 89 1 - 90 120 (b) for custody 25 - 17 42 11 Total number 114 1 17 132 131 Number of Post-Mortem Examinations 55 - - 55 74 Cemeteries. The following statistics have been supplied by the various Cemetery Superintendents and by the Vicar of Eltham.:— TABLE No. 18. Number of interments. 1919. 1920 1921 Woolwich Cemetery 606 617 647 Plumstead Cemetery 740 641 730 Eltham Cemetery 192 173 179 Plumstead Churchyard 37 41 24 1,575 1,472 1,580 During the year two copies of exhumation licences were received from the Home Office, and each disinterment was viewed. The arrangements made by the Cemeteries Department were very satisfactory. D 42 Inhabited House Duty.—No certificate under the Inland Revenue Act was issued during 1921, but 4 applications were refused. Rats.—During the year 220 complaints were received relating to rats and these were all investigated and dealt with under the Rata and Mice (Destruction) Act. A rat week was held during the last week in November and by arrangement with the Works Department, baits were laid in the sewer manholes in the areas where the sewers are old and likely to be infested with rats. Rag Flock Act. No samples were taken during the year. Increase of Rent and Mortgage Interest (Restrictions) Act, 1920. During the year 14 applications were made for certificates. In each case the owner was notified that a certificate had been applied for, and notices were served for the abatement of the nuisances existing. As a result, only 8 certificates were issued, a report (i.e., sufficient cause has not been made out for the issue of a certificate) being issued in the other instances. Factories, Workshops and Workplaces. The total number of factories, workshops and workplaces on the register at the end of the year was 195. The number of inspections, 971, compares with 310 for last year and 502 in 1919. It was found necessary to serve 54 notices, compared with 60 in 1920. With regard to outworkers, it may be said that the conditions under which outwork is carried out in Woolwich are 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:— 43 TABLE No. 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) 198 10 Workshops (Including Workshop Laundries) 573 30 Workplaces 200 14 Homeworkers' Premises 524 24 Total 1495 78 2.—Defects Found. Description. Number of Defects Found. Remedied. Nuisances under Public Health Act: Want of Cleanliness 49 49 Want of Ventilation 12 12 Overcrowding 4 4 Want of drainage of floors - - Other nuisances 32 32 Sanitary Accommodation insufficient 2 2 unsuitable or defective 21 21 not separate for sexes 1 1 Total 121 121 44 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) 2 Action taken in matters remediable under the Public Health Acts, but not under the Factory Act (S. 5) 'Notified by H.M. Inspector 3 Reports (of action taken) sent to H.M. Inspectors 3 Underground Bakehouses (S. 101):— In use during 1903 24 Certificates granted in 1906 1 in 1910 1 In use during 1921 9 Workshops on the Register (S. 131) at the end of 1921:— Workshop Laundries 3 „ Bakehouses 38 Other Workshops 104 Total number of Workshops on the Register 145 45 4.—Home Work. Nature of Work. Outworkers' Lists, Section 107. Number of Inspections of Outworkers' Premises. Outwork in Unwholesome Premises, Section 108. Outwork in Infected Premises, Sees. 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 50 227 .. .. 99 25 .. .. 157 .. .. .. .. .. .. Tennis Balls, etc. 6 427 .. .. 76 52 .. .. 367 .. .. .. 6 .. .. 56 654 .. .. 175 77 .. .. 524 .. .. .. 6 .. .. 46 FOOD. MILK. The bulk of the Woolwich milk supply is imported into the Borough, and is delivered at the various railway stations, but a small quantity is produced locally. There are in the Borough 13 cowsheds, in which there are 362 milch cows. The cowsheds are subject to annual licensing by the London County Council, and in consequence a standard of cleanliness of a fairly high level is maintained. During the year they were kept in such a condition as not to justify any objection being made to the Licensing Sessions of the County Council. During the period of food control, complete statistics were obtained with respect to the milk supply and the consumption of milk. It was then ascertained that approximately 33,000 gallons of milk were consumed each week, but this quantity varied somewhat from month to month. The Royal Arsenal Co-operative Society, Ltd., have a large dairy in Woolwich, where a large percentage of their milk for sale in S.E. London is prepared for distribution. The register of purveyors of milk has undergone a slight change during the year. There are now 72 milkshops on the register. During the year applications were received from 18 persons to be registered. 12 of these were with respect to the change of proprietorship and the incoming tenants were registered. Three applications for registration were refused because the premises were unsuitable and in two of these instances the applicants proposed to conduct their business from a stable in every-day use. 47 Three cows on three different occasions were purchased by a local butcher from a dairy farmer in the district and all were found to be affected with tuberculosis. The carcases were destroyed In consequence of these facts the London County Council were communicated with and one of their veterinary inspectors examined the whole of the cows in the various herds of the dairy farmer in question and reported that he found no trace of tuberculosis in any of them. In my report last year I gave details of the cost of milk during the year. The average cost during 1921, except during November and December when there was a considerable fall, was little or not at all below that of the previous year. The following are the figures for 1921:— Per quart. January 11d. February 11d. March 10d. April 9d. and 10d. May 8d. June 7d. and 8d. July 7d. and 8d. August 9d. September 8d. and 9d. October 8d. and 9d. November 9d. December 9d. TABLE No. 20. MILK AND CREAM REGULATIONS, 1912-1917. The following is a copy of the report already furnished to the Ministry of Health:— 48 REPORT ON ADMINISTRATION IN CONNECTION WITH THE PUBLIC HEALTH (MILK & CREAM) REGULATIONS, 1912. Report for the year ended 31st December, 1921. 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 223 (including 2 separated milk) Nil. - - Cream 8 5 .12% Explanation asked for and accepted .078% „ „ .33% „ „ .34% „ „ .4% „ „ 2.—Cream sold as "Preserved Cream." (a) Instances in which samples have been submitted to analysis to ascertain if the statements on the label as to preservative were correct:— (1) Correct statements made 2 (2) Statements incorrect — (3) Percentage of preservative found in each sample— Percentage as stated on statutory label— .4% "Not exceeding .4%" .4% Do. 49 (b) Determination of milk fat in creaan sold as Preserved Cream— (1) Above 35% 2 Below 35% — (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 Regulations have not been complied with, and the action taken Nil 3.—Thickening substances Nil 4.—Other observations, if any Nil MILK (MOTHERS AND CHILDREN) ORDER, 1919. On the 31st March, 1921, the Ministry of Health issued Circular 185, following upon the issue of Orders by the Food Controller and by the Ministry of Health whereby the Milk (Mothers and Children) Order, 1919, was revoked, in which attention was drawn to the fact that in future local authorities must obtain the sanction of the Ministry of Health, under the Maternity and Child Welfare Act, 1918, to schemes for the supply of milk to expectant aud nursing mothers and children under 5, and setting out the conditions under which milk could be given. The effect of Circular 185 was to limit, in ordinary circumstances, the supply of milk to nursing mothers, to expectant mothers in the last three months of pregnancy, and to children under 3 years of age, and to limit the quantity supplied to 1 pint per day. In exceptional cases, where a special medical certificate was given, 1½ pints per day might be given, and 50 children between 3 and 5 years of age might be supplied. The Circular also laid down that the financial circumstances of applicants were to be considered, and suggested the use of an economic circumstances scale. As far as Woolwich was concerned, the only change necessitated by this Circular, other than in the quantities of milk and age of recipients, was the appointment of a Special Committee consisting of the Chairman of the Maternity and Child Welfare Committee, the Medical Officer of Health and the Borough Treasurer, to deal with each application and authorise the issue of milk. Economic Circumstances Scale. In November, 1919, the Council adopted an economic circumstances scale for the supply of milk free of cost, and this scale was in operation up to and including October, 1921. On the 1st November the Council adopted the "Stepney" scale which is set out below. No. in family. Scale. s. d. One 16 0 Two 3 0 Three 10 6 Four 9 6 Five 8 6 Six (or more) 8 0 Deductions—Rent. No arrangements exist in the Borough for the supply of milk on a part payment basis. During the year no cases were discovered where people were obtaining milk who were not entitled to it under the Council's scheme, but the case discovered in 1920 in which the Council resolved to take proceedings was heard in January, 1921, and the following table No. 21 shows the result of the prosecution:— 51 TABLE No. 21. Offence. Result. Obtaining milk by 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 £19 6s. 7d. Dried Milk £2,458 0s. 0d. Dried milk has been sold at cost price at all of the Centres during the year to those who could not afford to pay the ordinary trade price. The Borough Council has made arrangements whereby dinners for expectant and nursing mothers are provided at eating houses to those recommended by the Medical Officer in charge of the Maternity Clinics. Experience has shown that this method of supplying food to expectant and nursing mothers, although likely to give them more physiological benefit than milk, is not popular, domestic difficulties in the main accounting for the unpopularity of these meals. During the year the cost of dinners was £99 0s. 6d. In connection with the supply of food and milk the grant of the Ministry of Health of 50 per cent. is available for approved expenditure. 52 FOOD INSPECTION, INCLUDING MEAT AND OTHER FOODS. 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 of the inspectors specially inspect the food exposed for sale in the market places and make regular inspections of the slaughterhouses in the Borough. Their is no public abattoir in the Borough. The number of carcases condemned on account of tuberculosis was four. On 65 occasions during the year unsound food was surrendered compared with 107 in 1920. Included in the food surrendered were 1 ton 8 cwt. 3 qrs. of fish, 3 tons 2 cwt. 3 qrs. of dried figs, 15 cwt. 20 lbs. of jam pulp, 2 cwt. 11 lbs. of bacon, 301 tins of fruit and other food stuff, 111 lbs. of pork, 7 cwt. 3 qrs. 16 lbs. of mutton, 114 lbs. of rabbits and smaller quantities of butter, fruit and offal. A small quantity of bacon was seized, but the Public Health Committee, taking into consideration the circumstances, resolved that the owner of the bacon should be cautioned that a recurrence of an offence of that kind would necessitate proceedings. No legal proceedings in connection with unsound food were taken during the year. During the year a considerable amount of unsound food was purchased by farmers in the district for the feeding of pigs. In these cases the Medical Officer of Health of the district releasing the unsound food sends a notification to the Public Health Department that he has done so, and frequent inspections have to be made to ensure that this unsound food is disposed of the way it was intended it should go. 53 TABLE No. 22. SLAUGHTER HOUSES. In 1914. In Jan.,1921. In Dec.,1921 Registered — — — Licensed 12 9 8 These premises have been systematically inspected during the year and the necessary notices served to remedy the insanitary defects discovered. At the annual licensing sessions of slaughterhouses of the London County Council it was not found necessary to oppose any of the existing licenses; The premises are maintained in a fairly satisfactory condition. Inspection of premises where food is prepared for sale or sold. 226 inspections of these premises were made during the year, compared with 129 in 1920. Vendors of Fried Fish. At the end of the year there were 65 premises where the business of a vendor of fried fish was carried on. These premises were specially inspected during the year by your Chief Sanitary Inspector and myself, the defects found by us being "followed up" by the district sanitary inspectors, and the necessary action taken by them. These businesses, in the nature of things, show many unsatisfactory features, and it is essential that scrupulous cleanliness should be observed by the workers in order to prevent accumulations of offensive material collecting in those parts of the premises likely to be soiled; that the premises used for this purpose should be properly constructed; that proper arrangements should be made for the disposal of offensive and decomposing material; and that the fact that food for the use of man is being prepared and sold is not lost 54 sight of. It was necessary to insist on sanitary improvements in many instances, and as a result it can now be said that a considerable improvement in the conditions and conduct of these businesses has been effected. In no case was it necessary to resort to legal proceedings. The collection of the offal by the Borough Council at a charge of 6d. per receptacle, is a great asset to this trade, and is of much value in preventing nuisances. In concise form is given below various statistics relating to premises where food is prepared. TABLE No. 23. On Register at end of 1921. Number of Proceedings. Inspections. Notices. Bakehouses 48 142 4 — Cowsheds 13 57 — — Milkshops 72 148 4 — Ice Cream Premises 100 195 2 — Slaughterhouses 8 42 — — Fried Fish Shops 65 251 26 - Premises where food is prepared (other than above) 87 226 17 — Food Poisoning. There has been no case of food poisoning in the Borough during 1921. SALE OF FOOD AND DRUGS. The following table No. 24 shows the number of the various analyses made during the year and the result of the analyses:— 55 TABLE No. 24. Article. Formal Samples. Informal Samples. Number Analysed. Number dulterated. Milk 212 9 221 15 Separated Milk 2 — 2 — Cream 5 3 8 6 Preserved Cream 2 — 2 — Butter 41 63 104 4 Lard — 14 14 — Cheese — 7 7 — Condensed Milk — 1 1 — Coffee — 17 17 — Cocoa — 16 16 — Pepper — 18 18 — Mustard — 4 4 — Malt Vinegar 4 — 4 — Vinegar 1 — 1 — Rice — 7 7 — Baking Powder — 6 . 6 — Ground Ginger — 6 6 — Honey — 4 4 — Flour 4 — 4 — Margarine 1 1 2 1 Olive Oil — 6 6 — Stout — 1 1 — Bread and Butter 8 — 8 4 Egg Substitute Powder - 6 6 - Dried Eggs — 2 2 — Borax — 6 6 — Camphorated Oil - 9 9 — 56 TABLE 24—continued. Article. Formal Samples. Informal Samples. Number Analysed. Number Adulterated Compound Liquorice Powder - 6 6 - Chocolate Colouring Powder - 1 1 - Sweet Spirit of Nitre White Precipitate 3 — 3 1 Ointment — 12 12 — Zinc Ointment - 8 8 — 283 233 516 31 The percentage of adulterated samples, 6, compares with 1.6 and 3.9 in the preceding two years. The number of samples taken on a Sunday was 18, none of which were adulterated. 10 of the informal samples were found to be adulterated. In the certificate furnished by the analyst in the case of milk, a fat percentage figure is given in the case of each sample. The following table shows the fat percentage figures for the year. The minimum legal standard is 3 per cent. TABLE No. 25. 4.5% and over 2 4% and under 4.5% 12 3.5% „ 4% 95 3% „ 3.5% 98 Below 3% 14 221 57 TABLE No. 26. Prosecutions under Sale of Food and Drugs Acts during 1921. No. Article. Nature of Offence. Name and Address of Vendor. Result of Proceedings. 1 Milk 67.6% deficient in fat E. A. Gill, 398, High Street, Plumstead Fine £5 and £2 2s. 0d. costs. 2 Milk 15% of added water and 5% deficient in fat. David Jones, 65, Maxey Road, Plumstead Fine £5 and £2 2s. 0d. costs. 3 Obstructing Inspector William Gill, 398, High Street, Plumstead Fine £15 and £1 1s. 0d. costs. 4 Milk 90.3% deficient in fat W. J. Brinkworth, 40, Garibaldi Street, Plumstead. Fine £3 and £2 2s. 0d. costs. 5 Milk 12.5% added water and 7.33% deficient in fat. A. Stanwell, 10, Chapel Street. Woolwich Fine £5 and £2 2s. 0d. costs. 6 Milk 35.6% deficient in fat E. Norris, 43, Burnt Ash Road, Lee Edwards & Sons, Ltd., 30, Burnt Ash Road, Lee. Fine £1 and £1 1s. 0d. costs. £2 2s. 0d. costs. 7 Milk 12.33% deficient in fat and 4.58% added water. C. F. Page, 21, Princes Road, Plumstead Fine £2 and £2 2s. costs. 8 Sweet Spirit of Nitre 41.4% deficient in Ethyl Nitrate. J. Neale, Ltd., 21, George Street, Woolwich £2 2s. 0d. costs. 9 Milk 10% deficient in fat A. G. Casselton, 72, Elibank Road, Eltham Fine £1 and £1 costs. 10 Milk 13.3% deficient in fat Eltham Dairies, 102, Westmount Road, Eltham. £3 3s. 0d. costs. 11 Butter 4.75% excess water and 10.37% of foreign fat. C. Ridewood, 116, High Street, Eltham Fine £1 and £2 2s. 0d. costs. 12 Bread and Butter Consisted of Bread and Margarine. F. Baker, 49, New Road, Woolwich Fine £1 and £1 18s. costs. 13 do. do. do. E. V. Rose, 4, Russell Place, Woolwich Fine 2s. and £1 18s. 0d. costs. E 58 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS DISEASES. NOTIFICATIONS. The total number of notifications (including duplicates) received during the year was 3,611, as compared with 2,743 in 1920. This increase is largely due to the fact that there were serious outbreaks of scarlet fever, diphtheria and zymotic enteritis. The outbreaks of scarlet fever and diphtheria are the largest known in the records of the Borough, and were general throughout the County of London. The scarlet fever epidemic was mild in character, but the mortality from diphtheria was above the average. The figures for zymotic enteritis are large, but compared with 1911, when 866 notifications were received, they show a distinct improvement. In 1911 the summer was hot and dry, and compares with the summer of the year under review, when 454 notifications were received. If we only consider children under 1 year, 265 notifications were received in 1911, compared with 155 in 1921. Table IV. shows notifications in detail for each disease and in the age groups. It also shows the numbers occurring in each parish of 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 No. 27 on page 60. 59 TABLE IV. Cases of Infectious Diseases notified during the Year 1921. Diseases. Number of Cases Notified. Total Cases Notified in each Locality. 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 05 05 and upwards West. East. Small-pox .. .. .. .. .. .. .. .. .. .. .. .. .. Anthrax .. .. .. .. .. .. .. .. .. .. .. .. .. Cholera, Plague .. .. .. .. .. .. .. .. .. .. .. .. .. Diphtheria (including Membranous Croup). 592 9 140 338 .69 34 2 .. 119 203 197 73 578 Erysipelas 59 1 1 3 9 13 29 3 15 18 14 12 9 Scarlet Fever 1351 5 270 919 101 50 6 316 362 359 314 1213 Typhus Fever .. .. .. .. .. .. .. .. .. .. .. .. .. Zymotic Enteritis 454 155 190 16 16 46 23 8 159 118 89 88 .. Enteric Fever 11 .. 1 4 2 3 1 .. 8 2 .. 1 10 Pneumonia 236 19 39 40 34 47 30 21 86 58 64 28 47 Puerperal Fever 14 .. .. .. 2 12 .. .. 3 7 3 1 9 Cerebro-Spinal Meningitis 1 .. .. 1 .. .. .. .. .. 1 .. .. .. Post-Basic Meningitis 1 1 .. .. .. .. .. .. .. 1 .. .. 1 Poliomyelitis .. .. .. .. .. .. .. .. .. .. .. .. .. Encephalitis Lethargica 9 .. .. .. 2 4 2 1 1 2 1 5 6 Ophthalmia Neonatorum 32 32 .. .. .. .. .. .. 7 7 11 7 9 Pulmonary Tuberculosis 276 .. 5 18 105 101 40 7 76 88 71 41 240 Other forms of Tuberculosis 80 2 15 34 15 9 5 .. 26 14 24 16 Measles 481 4 126 348 2 1 .. .. 230 56 93 102 .. Malaria 10 .. .. 2 2 4 2 .. 3 3 .. 4 .. Dysentery 4 .. .. .. .. 1 2 1 1 1 .. 2 1 Total 3611 228 787 1723 359 325 148 41 1050 941 926 694 2123 09 TABLE No. 27. Notification of Infectious Diseases, 1901 to 1921. Y ear. 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 .. .. .. .. .. .. .. .. .. .. 323 1902 228 233 267 50 98 11 189 1 .. .. .. .. .. .. .. .. .. .. 646 1903 6 186 389 42 58 2 165 3 .. .. .. .. .. .. .. .. .. .. 661 1904 6 163 472 25 74 5 186 1 .. .. .. .. .. .. .. .. .. .. 1240 1905 7 273 513 27 83 12 145 1 .. .. .. 212 .. .. .. .. .. .. 465 1906 .. 387 528 40 97 8 176 .. .. .. .. 366 .. .. .. .. .. .. 825 1907 .. 275 1023 27 110 6 150 .. 1 .. .. 93 .. .. .. .. .. .. 1453 1908 .. 362 596 19 90 6 154 .. l .. .. 173 .. .. .. .. .. .. 519 1909 .. 268 1027 13 113 9 206 .. .. .. .. 149 .. .. .. .. .. .. 768 1910 1 171 524 10 89 7 196 .. 1 .. .. 102 .. .. .. .. .. .. 396 1911 .. 239 518 16 82 16 375 .. 1 3 8 866 .. .. .. .. .. .. 801 1912 3 429 474 20 87 2 689 .. l 3 20 129 .. .. .. .. .. .. 775 1913 .. 321 626 14 70 8 675 .. .. 1 14 338 .. .. .. .. .. .. 387 1914 .. 416 714 18 107 7 498 .. 1 .. 18 199 .. .. .. .. .. .. 967 1915 .. 286 601 31 138 6 489 .. 50 2 19 173 .. .. .. .. .. .. 1179 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 1886 1920 1 427 538 6 82 13 428 .. 3 .. 29 31 3 .. 3 29 1 136 1013 1921 .. 592 1351 11 59 14 356 .. 1 .. 32 454 1 .. 9 10 4 236 481 *Voluntary Notification to 1910; partial to 1912; all cases thereafter. † Includes all forms of Pneumonia. ‡ Measles compulsorily Notifiable from 1/1/1916 to 31/12/1919. § Compulsory Notification of Zymotic Enteritis commenced 1913. 61 The following table No. 28 shows the number of deaths and the death-rates from various infectious diseases each year since 1917. TABLE No. 28. Year Small-pox. Diphtheria. Scarlet Fever. Enteric Fever. Puerperal Fever. Measles. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. 1917 .. .. 17 0.12 1 0.01 4 0.03 7 0.05 30 0.21 1918 . . .. 25 0.17 4 0.03 2 0.01 9 0.06 21 0.14 1919 2 0.01 28 0.21 3 0.02 5 0.04 5 0.04 7 0.05 1920 .. .. 25 0.18 4 0.03 2 0.01 5 0.04 21 0.14 1921 .. .. 40 0.29 10 0.07 1 0.01 5 0.04 4 0.03 TABLE No. 28—continued. Year. Erysipelas Diarrhoea and Enteritis. Pneumonia Cerebrospinal Fever and Post-basic Meningitis. Encephalitis Lethargica. Whooping Cough. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. 1917 4 0.03 43 0.29 142 0.98 6 0.04 .. .. 10 0.07 1918 1 0.01 40 0.27 208 1.42 7 005 .. .. 29 0.20 1919 2 0.01 32 0.24 125 0.92 2 001 3 0.02 11 0.08 1920 1 0.01 27 0.19 97 0.68 7 005 .. .. 14 0.10 1921 2 0.01 72 0.53 98 0.72 1 001 4 0.03 16 0.12 62 SMALL POX. No cases of small-pox were notified during the year. Contacts of small pox notified as such by 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. Notification Statistics. The number of notifications of measles received during the year was 481 as compared with 1,013 in 1920. Of these notifications 67 (62 Military) were by medical practitioners, 396 by school teachers, and 18 by parents. Removal to hospital. No case was removed to hospital during the year. Nursing. The Council made arrangements in 1916 for the home nursing of measles by voluntary nursing associations. During 1921 only 4 cases were nursed at home at a total cost to the Council of £2 10s. The number of visits paid by the nurses was 78, thus averaging 19 visits per case. Deaths. The number of deaths due to measles was 4, as compared with 21 in 1920 and 7 in 1919. 3 of these occurred in children under 5 years of age. School Closure. To prevent the spread of measles in school the London County Council have continued to close schools and departments (3 in 1921, as compared with 14 in 1920) and to exclude unprotected children from school. The period of exclusion or closure was usually for a few days only, but in some cases it was two weeks. 63 WHOOPING COUGH. During the year 386 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 of Health. The number of deaths was 16 as compared with 14 in 1920 and 11 in 1919. 15 deaths occurred in children under five years of age. ENTERIC FEVER. There were 11 cases of enteric fever notified during the year. The number of deaths was 1, giving a death-rate of 001. Bacteriological Diagnosis. Similar facilities as for diphtheria (q.v.) are provided at the Seamen's Hospital, Greenwich, and during the year 10 samples of blood were examined for Widals re-action. A positive result was obtained in two. The following Table, No. 29, shows the number of cases notified each year since 1917, in the various parishes and in the Borough and the percentage removed to hospital. TABLE No. 29. Year. The Borough. Woolwich. Plumstead Eltham. Percentage removed to Hospital. West. East. 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 1921 11 8 2 — 1 91 64 SCARLET FEVER. Notifications. During the year 1351 cases of scarlet fever were notified. This is the highest number ever recorded in the records of the Borough. The previous highest figures occurred in 1907 (1,023) and in 1909 (1,027). Table IV. shows the age distribution, the number in each parish, and the number removed to hospital. The following Table, No. 30, 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 each year since 1917. The term "case-rate" means the number of cases occurring per 1,000 population. TABLE No. 30. Year. The Borough. Woolwich. Plumstead Eltham. Percentage removed to Hospital. West. East. 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 1921 9.91 10.1 9.03 9.79 11.1 90 Return Cases. Below is shown in tabular form the number of return cases, the period elapsing between date of discharge from hospital of the primary case and the date of occurrence of the secondary case for the years 1920 and 1921: Period elapsing Under 1 month. 1-2 months. 2-3 months. Over 3 months. Total. 1920 No. of cases 24 1 2 1 28 1921 Do. 62 12 6 36 96 65 Home Isolation. 135 cases, or 10 per cent. of all cases, were isolated at home and in only one instance did a return case occur. All these cases were frequently visited at their homes by the Sanitary Inspectors as in previous years, and 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 Health of efficient home isolation, before their employees are allowed to return to work. During the year 33 such certificates were issued as compared with 18, 22 and 21 in the three preceding years. Multiple Cases. The following Table (No. 31) shows the house distribution of cases of scarlet fever in Wards:— TABLE No. 31. 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 24 89 48 52 58 53 72 69 166 163 821 821 2 cases occurred .. 6 12 17 10 12 6 14 6 24 44 151 302 3 „ „ .. 2 4 2 2 4 1 3 3 10 10 41 123 4 „ „ .. 1 3 2 1 .. .. 1 1 4 4 17 68 5 „ „ .. .. 1 1 .. .. .. 1 1 .. 2 6 30 6 „ „ .. .. .. .. .. .. .. .. .. .. .. .. .. 7 „ „ .. .. .. .. .. .. .. .. .. .. 1 1 7 27 33 109 70 65 74 60 91 80 204 224 1037 1351 Deaths. The number of deaths due to scarlet fever was 10. The deaths and death-rate from this disease since 1917 are shown in Table No. 28. 66 DIPHTHERIA. Notifications. During the year 592 cases of diphtheria were notified, as compared with 427 in 1920, 398 in 1919, and 208 in 1918. Table IV. shows the age distribution, the number in each parish, and the number removed to hospital. The following Table (No. 32) shows the case-rate in each parish and the percentage removed to hospital each year since 1917. The term "case-rate" means the mumber of cases occurring per 1,000 population. TABLE No. 32. Year. The Borough. Woolwich. Plumstead. Eltham. Percentage removed to Hospital. West. East. 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 1921 4.34 3.81 5.06 5.37 2.58 98 Return Cases. Below is shown in tabular form the number of return cases, the period elapsing between date of discharge from hospital of the primary case and the date of occurrence of the secondary case for the years 1920 and 1921:— Period elapsing Under 1 month. 1-2 months. 2-3 months. Over 3 months. Total. 1920 No. of cases 1 — - 1 2 1921 Do. 5 1 2 3 11 67 Home Isolation. 2 per cent. of all cases were isolated at home, and in connection therewith 1 certificate of home isolation was issued to enable Arsenal employees to resume work. Multiple cases. The following Table (No. 33) shows the house distribution of diphtheria, in Wards:— TABLE No. 33. 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 11 19 31 23 21 17 34 50 31 110 54 401 401 2 cases occurred 2 .. 4 4 6 2 9 10 .. 14 8 59 118 3 „ „ 2 .. 2 1 .. 1 .. 1 .. 4 1 13 39 4 „ „ .. .. .. .. .. .. 1 .. 1 1 .. 3 12 5 „ „ .. .. .. .. .. .. .. .. .. .. .. .. .. 6 „ „ .. .. .. .. .. .. .. 1 .. .. .. 1 6 7 „ „ .. .. .. .. .. .. .. .. .. .. .. .. .. 8 „ „ .. .. .. .. .. .. .. 1 .. 1 .. 2 16 15 19 37 28 27 20 45 63 32 130 63 479 592 Contacts. Contacts of cases were examined during the year as in previous years, and 15 cases, presenting no clinical symptoms, were discovered to be carriers. The usual steps were taken in each case. Bacteriological Examination. The Council's bacteriological work is done by the Bacteriological Department of the Seamen's Hospital, Greenwich. 966 swabs were examined during the year for diphtheria bacilli, and 122 were found positive. 68 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, or free where there is inability to pay. The amount supplied during the year was 88,000 units, at a total cost of £6 12s. Deaths. The number of deaths due to diphtheria was 40. The deaths and death rate of this disease each year since 1917 are shown in Table No. 28. OPHTHALMIA NEONATORUM, PUERPERAL FEVER AND EPIDEMIC DIARRHŒA. These diseases are dealt with under the Maternity and Child Welfare Section of the Report. PNEUMONIA, MALARIA, DYSENTERY AND TRENCH FEVER. During the year the following number of cases were notified:— Pneumonia 236 Malaria 10 Dysentery 4 Trench Fever — These diseases are compulsorily notifiable under the Public Health (Pneumonia, Malaria, Dysentery, etc.) Regulations, 1918. The deaths from Pneumonia during the past three years were:— 1919 1920 1921 125 97 98 69 It will be seen from Table No. 27 that there has been a steady increase each year in the number of notifications of Pneumonia. This increase is probably due in the main to the increased knowledge amongst medical practitioners that this disease is notifiable. I do not think it is due to the increased number of cases. It is desirable, however, to again draw attention to the fact that all forms of primary Pneumonia are notifiable and that the only secondary Pneumonia which is notifiable is Influenzal Pneumonia, Nursing Provision. 1 am informed by the Secretaries of the various voluntary Nursing Associations in the Borough that the following numbers of cases of pneumonia were nursed during the year:— Woolwich and Plumstead Nursing Association 68 St. Luke's Parish, Eltham: 23 Eltham Nursing Association: 4 Silvertown and North Woolwich Nursing Assoc. 2 No change has taken place with regard to the nursing situation in Eltham during the year. The following Table, No. 34, shows the number of notifications of Pneumonia received each month, classified according to the description of Pneumonia given on the certificate, and the sex incidence. It also shows the number of deaths occurring from all forms of Pneumonia during these months. In this connection, however, it must be remembered that Influenzal Pneumonia deaths are classified as due to Influenza. 70 TABLE No. 34. Monthly incidence of Pneumonia. Month. Male. Female. Total Type. No. of Deaths. Lobar Broncho Influenzal Primary January 18 16 34 16 15 1 2 10 February 17 13 30 8 11 8 3 14 March 16 12 28 12 6 6 4 15 April 5 6 11 5 2 1 3 6 May 8 8 16 5 8 3 4 June 4 4 8 5 1 1 1 5 July 9 1 10 4 2 1 3 1 August 3 2 5 3 2 5 September 11 3 14 4 5 5 5 October 8 2 10 4 2 3 1 3 November 19 8 27 10 6 1 10 11 December 25 18 43 7 8 19 9 19 Total 143 93 236 83 58 49 46 98 The following Table, No. 35, shows the distribution of the various forms of Pneumonia as set out in the medical certificates in each Ward of the Borough. TABLE No. 35. Notification of Pneumonia. Ward. Lobar. Broncho. Influenzal. Primary. Total. Dockyard 3 2 3 3 11 St. Mary's 8 10 2 2 22 River 16 13 8 2 39 St. George's 1 2 6 5 14 Burrage 8 4 — 4 16 Herbert 7 — — 3 10 Glyndon 4 6 4 5 19 St. Margaret's 5 1 4 3 13 Central 4 3 2 — 9 St. Nicholas 18 15 14 8 55 Eltham 9 2 6 11 28 83 58 49 46 236 71 The age distribution of notified cases of Pneumonia is contained in Table IV. ANTHRAX, GLANDERS AND HYDROPHOBIA. No cases of these diseases were notified during the year. ERYSIPELAS. There were 59 cases of Erysipelas notified during the year and 2 deaths occurred. The death-rates from this disease since 1917 are shown in Table No. 28. The following Table No. 36 shows the number of notifications received each year since 1917 (in Parishes) and the percentage of cases receiving hospital treatment:— TABLE No. 36. Year. The Borough. Woolwich. Plumstead. Eltham. Cases receiving Hospital Treatment. West. East. 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 1921 59 15 18 14 12 9 CEREBRO-SPINAL MENINGITIS, POST-BASIC MENINGITIS, POLIO-MYELITIS AND ENCEPHALITIS LETHARGICA. The following Table, No. 37, shows the age and sex distribution of all cases of these diseases occurring during the year:— 72 TABLE No. 37. Disease. All ages Under J 1-5 5-15 15- 25 2545 4565 65 and over M F M F M F M F M F M F M F M F Cerebro-spinal Meningitis 1 .. .. .. .. .. 1 .. .. .. .. .. .. .. .. .. Post-basic Meningitis 1 .. 1 .. .. .. .. .. .. .. .. .. .. .. .. .. Polio-myelitis .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Encephalitis Lethargica 3 6 .. .. .. .. .. .. 1 1 1 3 1 1 .. 1 The case of Post-basic Meningitis and 6 cases of Encephalitis Lethargica were removed to hospital. The number of deaths was— Cerebro-spinal meningitis — Post-basic meningitis — Encephalitis lethargica 4 73 TABLE No. 38. Tuberculosis. Summary of Notifications during the year ended 31st December, 1921. 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. 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. Poor Law Institutions. Sanatoria. Pulmonary Males .. 2 7 4 19 27 30 26 23 9 5 152 159 .. .. .. .. .. 39 81 ,, Females .. 3 .. 7 29 30 29 16 6 2 2 124 128 .. .. .. .. .. 29 64 Non-Pulmonary Males 1 6 13 8 3 2 2 .. 2 .. .. 37 39 .. .. .. .. .. 10 9 „ Females 1 9 8 5 4 6 5 2 .. 3 .. 43 44 .. .. .. .. .. 6 2 2 20 28 24 55 65 66 44 31 14 7 356 370 .. .. .. .. .. 84 156 f 74 TUBERCULOSIS. This part of the report, which has been in the main prepared by the Tuberculosis Officer, deals with the work of the Department under the Public Health (Tuberculosis) Regulations, 1912, and under the dispensary scheme approved by the Ministry of Health and by the London County Council. Notification Statistics. The total number of primary notifications, including 14 duplicates, received was 356. Notifications on forms C and D, i.e., notifications from institutions regarding admission and discharge, are not included in the above figures. It will be noted that the above figure, 356, compares very favourably with last year's total which was 428. The distribution of the various cases since 1918, was as follows:— TABLE No. 39. Y ear. Lungs. Meninges. Intestines and Peritoneum. Glands. Joints. Spine. Other Forms. All Causes. 1918 563 6 14 41 19 6 11 560 1919 394 4 3 35 19 5 14 474 1920 359 7 5 24 17 11 5 428 192! 285 14 5 17 17' 9 9 356 Cases of Tuberculosis in the District. It is difficult to estimate the number of cases of tuberculosis at present living in the district. The process of correcting the Tuberculosis Register which was started in 1920, has been going 75 on steadily during the year, and the work, as far as it goes, shows that the statistics for the rest of the Borough will have to be modified in a similar manner, as happened in the case of Eltham in 1920. On this basis it can be assumed that the number of cases of tuberculosis living at the end of the year does not exceed 2,300. This correction which was rendered possible by the amalgamation of all tuberculosis activities in the area is going on apace and by the summer of 1922 it is hoped that the correct figure will be obtained. Deaths. The following Table No. 40 shows the number of deaths from tuberculosis, the total deaths and death rates each year since 1917. It will be observed that the total number of deaths from tuberculosis was greater by 19 than in 1920, there being 7 more deaths from pulmonary forms and 12 from non-pulmonary forms. The rise in the death rate is due in some measure to these additional deaths and in some measure also to the fact that the population used for calculating the rates for 1921 was smaller than that used in 1920 TABLE No. 40. Year. Deaths. Death-rates. All Forms. Pulmonary. NonPulmonary. All Forms. Pulmonary. Non. Pulmonary. 1917 215 176 39 1.63 1.34 0.29 1918 222 190 32 1.65 1.41 0.24 1919 196 171 25 1.45 1 .26 0.19 1920 188 161 27 1.32 1.13 0.19 1921 207 168 39 1.52 1.23 0.29 76 The period which elapsed between notification and death is shown in the following Table :— TABLE No. 41. Pulmonary. Percentage. Non. Pulmonary. Percentage. Notified at death 29 17.3 19 48.7 0.1 months 10 6.0 10 25.6 1.3 24 14.3 2 5.1 3.6 29 17.3 .. .. 0.12 „ 27 16.1 1 2.6 1.2 years 21 12.3 3 7.7 2.5 20 11.9 4 10.3 Over 5 years. 8 4.8 .. .. 168 .. 39 .. This Table shows some slight improvement as compared with the similar Table published in the previous two years but it is far from satisfactory. The unsatisfactory part is probably due in the main to delay by persons suffering from this disease in seeking medical advice due in many cases no doubt to a want of appreciation of the condition from which they are suffering. Many adults and children have pulmonary tuberculosis without knowing it, and can give it to others, but these persons, if they are careful and clean, are not dangerous to those with whom they live. So long as this state of affairs, as shown in the Table, continues whereby over 37 per cent. of chest cases are notified 77 within three months of death, the success of any effort for the control of this disease must be materially diminished. Administrative Action.. The Dispensary which was established by the Central Fund in 1911 at Maxey Road, Plum. stead. was taken over by the Borough Council in April, 1921, This change was necessitated by the fact that the Central Fund found itself in financial difficulties and was unable to continue the grants it had previously made. Under its aegis the Voluntary Dispensary had carried out very good work in Woolwich ever since 1911, and the Council expressed its appreciation of this work in fitting terms in the Council's minutes. From April 1st, 1921, the Woolwich Borough Council took over the Dispensary en bloc. Staff. The staff at the close of the year consisted of— (a) 1 whole time Assistant Medical Officer of Health and Tuberculosis Officer ; Dr. F. J. C. Blackmore; (b) 1 whole time Deputy Tuberculosis Officer ; Dr. E. O'Connor; (c) 3 Tuberculosis Health Visitors; (d) 1 Dispenser and Tuberculosis Visitor ; (e) 1 Temporary Clerk. Under the present organisation all the Tuberculosis work in the Borough is done at the Tuberculosis Dispensary and by the Tuberculosis staff. Co.operation with Hospital and School Clinic. Agreements have been made with the Seamen's Hospital, Greenwich, for the diagnosis and X.ray examination of difficult cases and with the London Hospital for the treatment of Lupus, and at the close of the year, negotiations were being made whereby 78 cases requiring artificial pneumo.thorax could receive treatment at the Brompton Hospital. Tuberculous children who are of school age are referred to the School Clinic in Brewer Street for treatment for minor ailments and defective teeth. In a, similar manner arrangements exist whereby the School Medical Officers refer doubtful cases to the Dispensary and reports on all such cases are forwarded by the Tuberculosis Officer through the Divisional School Medical Officer to the doctors concerned. Co.operation with Medical Practitioners. Every effort is made to secure the co.operation with medical practitioners and the Tuberculosis Officer communicates with medical practitioners in connection with each case notified. The Tuberculosis Officer during the year saw 72 cases in consultation with medical practitioners at private houses, and in addition to this, 223 cases were referred to him at the Dispensary for the purpose of diagnosis. There is an increase in this work as compared with last year. Arrangements have been made for the following up of patients in cases where the diagnosis is doubtful, and every effort is made to secure the attendance of patients who are lax in keeping up the treatment prescribed. Home Contacts. Contacts are examined at the Tuberculosis Dispensary, but if they do not attend a revisit is made in order to persuade them to do so. Contacts are occasionally examined at home. Considerable difficulty is experienced in obtaining this attendance and failure to attend leads to a repeat visit by the Tuberculosis Visitor who urges the importance of examination. Treatment. The results of treatment of Tuberculosis are admittedly still far from satisfactory. There is an undoubted 79 tendency in certain quarters to regafd the results of sanatorium treatment as not commensurate with the cost, but in this connection two important factors must not be overlooked —(1) A period of three months in a sanatorium is much too short to yield really permanent results; and (2) Patients returning from a sanatorium are nearly always faced with the necessity of an immediate return to work owing to their financial circumstances. Most of these patients are really not fit to undertake a normal day's work, and as a result the benefit obtained at the sanatorium is speedily lost. Dispensary treatment is equally handicapped by the social circumstances of the patient and cannot yield its full results until the question of the employment of patients can be dealt with in a more satisfactory manner than at present. Dental Treatment. A scheme whereby tuberculous patients could obtain dental treatment was formulated during the year and submitted to the Council, but, unfortunately, the sanction of the Ministry of Health and the London County Council could not be obtained owing to financial stringency. Home Nursing. The nursing of patients confined to bed is carried out by the local Nursing Associations. Extra Nourishment. In May, 1921, the Council adopted the arrangement outlined by the Ministry of Health in Circular 194, whereby extra nourishment is available for certain selected cases of Tuberculosis. This scheme, however, was not put in force until October, 1921, and at the end of the year, 22 patients had received assistance of this kind at a total cost of £18 10s. 2d. 80 Non.pulmonary Tuberculosis. These patients are treated under the London County Council scheme, some being dealt with by the Invalid Children's Aid Association and a few in suitable homes through the Boards of Guardians. It is hoped that further beds will shortly be available and patients admitted more rapidly in consequence. After.care. The Council's scheme for the organisation of the treatment of tuberculosis in Woolwich included the appointment of a Lay Organiser one of whose principal duties would be the organisation of after.care. The sanction of the Ministry was obtained to this appointment in November, and immediately thereafter steps were taken to fill the vacancy. The appointment had not, however, been made at the end of the year. This is a very necessary branch of tuberculosis work and requires to be considerably developed here. In some measure during the year several patients have been assisted by means of a fund raised by the late Voluntary Dispensary, and the Council has authorised the acceptance of money from voluntary sources for this purpose. Shelters. 11 shelters are available for patients who are thus enabled to continue open.air treatment under better conditions than in some of the houses. During the year these shelters have been in use 360 weeks out of a possible 572. A small charge of 6d. to 1s. 6d. per week is made for the use of the shelters. Sanitary Defects. The Tuberculosis Visitors report all sanitary defects discovered in the homes of patients, and these reports are referred to the Public Health Department for the necessary action. 81 Bacteriological Examinations. During the year 714 specimens of sputum were examined at the Dispensary, 553 of which were negative and 161 positive. In addition to these, 206 specimens sent by medical practitioners, were examined at the Seamen's Hospital, of which 168 were negative and 38 positive. Institutional Treatment. The following Table shows the number of cases admitted to hospitals and sanatoria and Poor Law institutions and Training Colonies during the year:— TABLE No. 42. Hospitals. Sanatoria. Infirmary. Training Colonies. Insured 130 83 38 2 Uninsured 41 20 29 .. Children 17 31 4 .. Totals 188 134 71 2 These 395 admissions represent a total of 297 individual patients and the monthly admissions from June to December are as follows:— TABLE No. 43. January 29 July 33 February 31 August 27 March 36 September 36 April 40 October 39 May 37 November 35 June 23 December 29 82 TABLE No. 44. Return as to work carried out in connection with the Tuberculosis Dispensary for the period from 1st January to 31st December, 1921. Insured. Uninsured. Males. Females. Children, under 16. Adults. Males. Females. 1. (a) Number of persons examined for the first time during the above period at or in connection with the Dispensary 264 121 530 39 242 (6) Number included under 1 (a) who were found to be suffering from pulmonary tuberculosis 69 30 9 8 35 (c) Number included under 1 (a) who were found to be suffering from non.pulmdhary tuberculosis 3 4 8 2 4 (d) Number included under I (a) who were found to be non.tuberculous. . 84 41 300 18 105 (e) Number included under 1 (a) in whom the diagnosis was found to be doubtful 108 46 213 11 98 Insured. Uninsured 2. (a) Total attendances at the Dispensary (including attendances at the Dispensary of persons included under 1 (a) 3,946 4,849 (b) Number of the above attendances at which systematic physical examinations and records were made 1,341 1,896 3. Number of visits to patients at their own homes by the Dispensary medical officers in connection with the supervision of home conditions 623 257 4. Number of visits to patients at their own homes by the Dispensary nurses in connection with the supervision of home conditions and " following up " 2,087 3,392 5. Number of persons suffering from or suspected to be suffering from tuberculosis referred to the Hospital to which the Dispensary is affiliated 5 .. 6. Number of consultations with the— (a) Medical Adviser of the Insurance Committee .. .. (6) Consulting Physicians at the Hospital to which the Dispensary is affiliated .. .. (c) Practitioners at the homes of patients 55 17 7. Number of written reports concerning individual patients made to— (a) Public authorities 1,234 706 (b) Practitioners 411 125 8. Number of specimens of sputum examined 445 269 83 GENERAL ADMINISTRATION WITH REGARD TO INFECTIOUS DISEASE. This general action was described in detail in the Annual Report for 1919, and little change in the procedure has taken place since that date. Disinfection. The following Table shows the various rooms and articles disinfected during the year:— TABLE No. 45. No. of rooms disinfected after ordinary fevers 1,825 do. do. Tuberculosis 216 do. do. Verminous cases 39 Total number of articles disinfected 48.384 84 MATERNITY AND CHILD WELFARE WORK. Staff. No change occurred in the Maternity and Child Welfare staff during the year, so that at the end of 1921 the staff consisted of:— (a) One whole time Assistant Medical Officer of Health— Dr. Rachael Mackenzie. (b) A part time Medical Officer (in charge of cases at the Council's Home for Ailing Babies), Dr. F. 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. 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. 85 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. At the end of the year, 3 Ante.natal Sessions and 11 Infant Consultations were being held each week. 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 5s. for each case so referred. During the year 47 cases were sent there for treatment. No arrangements, however, have been made for the treatment of children suffering from enlarged tonsils and adenoids. VOLUNTARY WORK. 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 134, and the total number of attendances (including mothers) was 988. 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. 86 Through the courtesy of the Matron, I am able to report that during the year the number of nursing mothers in residence was 49 and their length of stay was about 3 to 4 weeks. The number of children was 36. The charges are 25s. per week for a nursing mother and baby, and £1 Is. per week for nursery children. The cases are medically examined weekly. British Hospital for Mothers and Babies. This institution, which comprises a School for Midwives and a Maternity Hospital provides accommodation for 14 indoor cases. At the end of 1921, a new building in Samuel Street (to replace the, existing one in Wood Street) had almost been completed. The new Hospital provides accommodation for 40 indoor cases and negotiations have been in progress for some time whereby sufficient accommodation will be reserved for 144 Borough Council cases per annum. I am informed by the Secretary, Miss Alice Gregory, that the number of cases admitted during the year was 202, the number of births, 201, the number of outdoor cases, 281. There is an ante.natal and post.natal clinic at this Institution at which 902 cases attended during the year. 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 8 babies. Number of mothers admitted during the year 13 87 Number of mothers with babies admitted during the year 0 Number of births in the Home 13 Number of deaths Average duration of stay of each completed case 6 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. The duration of stay has increased to six months as compared with 4½ months in 1920. 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. The following Table, No. 46, shows certain statistical information regarding the Home for the year 1921:— TABLE No. 46. (1) (a) No. of cases in hospital on the 1st January, 1921 13 (b) do. admitted during the year 107 (c) do. remaining in on the 31st Dec., 1921 9 (2) Average duration of stay 38 days 88 (3) Reasons for admission— Malnutrition, Marasmus and Debility 35 Bronchitis and Pneumonia 7 Zymotic enteritis, Diarrhœa and Colitis 26 Vomiting, Dyspepsia and Constipation 20 Congenital Heart Disease 2 Rickets 1 For observation (ultimately diagnosed Tuberculosis) 3 Miscellaneous—Skin conditions, etc. 13 107 (4) Number of cases discharged— (a) in good health 66 (b) improved 24 (c) no improvement 10 100 (5) Number of cases of infectious disease— (a) Measles Nil (b) Whooping cough 2 (c) Epidemic diarrhœa 24 (d) Other infectious disease Nil (6) Number of deaths 11 The Work of the Health Visitors. The number of Health Visitors is 7, two of whom hold the combined appointment of Sanitary Inspector and Health Visitor. They have continued to do good work during the year. Their duties are as follows:—The visiting and supervision of all children under school age needing this attention; the visiting of 89 expectant mothers who have attended at an Ante.natal Clinic or for whom visits are desirable: inquiry into stillbirths and the deaths of young children, and attendance at the Centre to which women and children come for medical and hygienic advice. Table No. 47 gives a classification of the number of visits paid by the Health Visitors during 1920 and 1921, and from that Table it will be seen that there has been an extensive increase in the variety and amount of work done. 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 tenth and fourteenth day. The necessity for subsequent visits is gauged by what is discovered at the first, but, as a general rule, an endeavour is 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 for 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. Investigation into Still.births. During the year investigation was made into 80 cases of still.birth. In 21 cases the cause of still.birth was due to natal trouble, and in 3 others the child was born macerated. 15 cases of prematurity G 90 occurred, in 2 instances the other twin was born dead, and in 1 case both twins were born dead. In the remaining cases the enquiry was negative. Other Work. In addition to these visits the Health Visitors have made certain investigations into the cause of infant deaths and have visited notified cases of ophthalmia neonatorum, puerperal fever, and pneumonia in children under 5 years of age. During the early part of the year they also made visits to notified cases of tuberculosis, but when the Borough Council took over the Tuberculosis Dispensary in April, 1921, this work was transferred to the Tuberculosis Visitors. The number of visits made to expectant mothers was 263, compared with 201 in 1920 and 38 in 1918. Co.operation with Sanitary Inspectors. Any sanitary defects discovered by the Health Visitors in the course of their duty have been referred to the Sanitary Inspectors for remedial action. The number of instances in which defects were Teported by them during the year was 195. The following Table shows the classification of visits paid by the Health Visitors during the year 1920 and 1921. TABLE No. 47. 1920 1921 Births—1st visits 2,856 2,800 Re.Visits 3,456 8,904 Infant deaths investigated 99 163 Still births investigated 50 80 Expectant mothers—Home visits to 201 263 Infectious diseases— Ophthalmia Neonatorum—1st Visits 28 31 Re.Visits 44 30 91 Measles—1st Visits 256 153 Re.Visits 36 79 Puerperal fever—1st Visits 12 10 Re.Visits 3 6 Zymotic enteritis—1st Visits 31 319 Re.Visits 8 264 Tuberculosis—Visits 250 92 Pneumonia (all forms) under 5 12 115 years—Visits Visits unclassified 561 713 Visits unsuccessful—no admission 1,731 2,814 Totals 9,634 16,836 The Work of the Centres. The work of the Centres has continued to increase during the year and the following Table shows the detailed statistics for the year 1921, and the consolidated statistics for 1919 and 1920. TABLE No. 48. No. on Roll of Centre. No. of Attendances. Mothers. Children. Mothers. Children. Expectant. Nursing. Expectant. Nursing. Town Hall 239 262 1,800 453 431 9,415 Eltham 115 137 914 220 316 5,601 Plumstead 133 178 1,172 268 276 5,924 North Woolwich 2 0 139 2 8 1,055 New Eltham . 6 125 — 15 1,161 Totals 1921 489 588 4,150 943 1,046 23,156 1920 309 445 3,122 789 1,047 21,613 1919 178 54 1,263 436 101 7,450 92 As will be seen from the Table there has again been an increase in the attendances at the Centres, and in consequence of this increase opportunities for observation of special cases have been diminished and so it has been found necessary to continue the consultations instituted last year at which the Assistant Medical Officer sees special cases each morning by appointment. At the Centres advice is given to nursing and expectant mothers and to children under 5 years of age, but the treatment has been limited to the use of such simple remedies as grey powder and sodium citrate. No mothercraft classes have been held during the year. More children have been in attendance at the Centres during the year, but the average number of attendances per year made by each child has diminished. In tabular form is shown below in Table No. 49 the number of children on the roll of the Centres during the year 1921. classified according to their year of birth, and it will be seen that in the overcrowded Centres, namely, Town Hall and Plumstead, the number of attendances per year compares very unfavourably with the smaller Centres like New Eltham and North Woolwich. 93 TABLE No. 49. Children in Attendance at each Centre. Year of Birth. Woolwich. Plums tead. Eltham. New Eltham. North Woolwich. Voluntary (Beresford Street) Total. 1921 1336 389 252 30 61 35 1,403 1920 701 451 321 48 46 52 1,619 1919 242 179 145 27 15 21 629 1918 100 75 85 7 7 15 289 1917 63 45 68 9 9 6 200 1916 57 33 42 4 1 5 142 1915 1 .. 1 .. .. .. 2 Total 1,800 1,172 914 125 139 134 4,284 Attendances of Children at each Centre. 1921 3,281 2,364 1,744 380 403 205 8,377 1920 4,467 2,587 2,462 545 494 415 10,970 1919 1,101 610 692 176 94 94 2,767 1918 265 207 347 25 28 38 910 1917 175 102 238 22 31 16 584 1916 125 54 111 13 5 4 312 1915 1 .. 7 .. .. .. 8 Total 9,415 5,924 5,601 1,161 1,055 772 23,928 94 The Needs of the Borough. During the year negotiations have been in progress with the British Hospital for Mothers and Babies for the provision of maternity assistance to necessitous expectant mothers; with the local branch of the British Medical Association for the provision of dental treatment for children under school age and for expectant and nursing mothers, and with the Ministry of Health for the establishment of an additional Centre to serve the Slade area. Feeding of Infants in Woolwich. An enquiry was made towards the end of the year into the type of feeding adopted in the case of infants in Woolwich. The method adopted was as follows:— (a) On the card of every child under 1 year of age attending a Welfare Centre between the 15th November and the 31st December, was inserted once, and once only, the terms "Breast," or "Breast and Hand," or "Hand fed. (b) The child's age was taken on the day on which this note was made; (c) At the end of the period the results were summarised for the whole Borough and the appropriate percentages were worked out. The number of infants in Woolwich at that time may be taken as 3,100; the feeding of 833 was recorded, so that the sample consists of over 25 per cent. of all Woolwich infants. These infants of course, were all Centre children, and it may be that these figures are not true for the Borough 95 as a whole, but they must be approximately true amongst the class who attend the Centres. This Table is very interesting and shows a much higher percentage of breast feeding amongst children between the age of 6 and 9 months than one would have expected, and if so it is cause for congratulation. It is not altogether free from objection owing to the fact that it was taken in December when young children would not be attending, but it is worth while placing on record for comparative purposes when maternity and child welfare work will have been longer in progress. In 1904, Dr. Sidney Davies in a report on Summer Diarrhœa, published the following statement:—(From the context it appears that the term "breast fed" includes partially breast fed): "To discover what proportion of children were normally fed at the breast an enquiry was made. At 174 houses where babies under one year were found in the course of house to house inspection, it appeared that 82 per cent. of children under one year were breast fed, and 91 per cent, of those under 3 months." These figures are higher than those of the present day, but in view of the smaller numbers concerned the probable error is greater. The Table set out below shews the method of feeding, age in months and the appropriate percentages. 96 TABLE No. 50. Feeding of Children attending Centres, December, 1921. Method of Feeding. Age in Months. Grand Total. 0.1 1.2. 2.3. 3.4. 4.5. 5.6. . 6.7. 7.8. 8.9. Total. 0.9. 9.10. 10.11. 11.12. Breast 30 71 48 38 34 46 23 29 19 338 8 7 1 354 Breast and Hand 3 5 10 5 16 13 9 11 18 96 12 11 5 124 Hand 6 15 22 21 29 43 30 38 34 238 42 44 31 355 39 91 86 64 79 102 62 78 71 672 62 62 37 833 Percentages. Breast 77.0 78.0 55.8 59.4 43.0 45.1 37.1 37.2 26.8 50.3 12.9 11.3 2.7 42.5 Breast and hand 7.6 5.5 18.6 7.8 20.3 12.7 14.5 14.1 25.4 14.3 19.4 17.7 13.5 14.9 Hand 15.4 16.5 25.6 32.8 36.7 42.2 48.4 48.7 47.8 35.4 67.7 71.0 83.8 42.6 97 INFECTIOUS DISEASES IN RELATION TO THIS WORK. Puerperal Fever. During the year 14 cases of Puerperal Fever were notified compared with 13 in 1920. The case. rate per 1,000 births was 4.38, as compared with 5.43, 2.55 3 55 in the three preceding years. 9 cases received hospital treatment. There were 5 deaths giving a mortality rate of 0 04. Ophthalmia Neonatorum. During the year 32 cases were notified. The following Table No. 51, shows the eye conditions in each case and the permanent results. TABLE No. 51. Date of Notification. Condition of Right eye. Result. Condition of Left eye. Result. Remarks. Jan. 20 Infected Cured Not infected Died in hos. tal, 15/2/21 28 do. — Infected — Feb. 14 do. Cured Not infected — Left Borough 14 do. do. Infected Cured 14 do. do. do. do. 23 do. — Not infected — 27 do. Cured Infected Cured Mar. 4 do. do. do. do. 4 do. do. do. do. 15 do. do. Not infected — 19 Not infected — Infected Cured 26 Infected Cured do. do. 31 do. do. do. do. April 11 do. do. do. do. 13 do. do. do. do. 28 do. do. do. do. May 7 do. do. do. do. 7 do. do. do. do. June 14 do. do. do. do. July 18 do. do. do. do. 25 Left Borough after notification 98 TABLE No. 51—continued. Date of Notification. Condition of Right eye. Result. Condition of Left eye. Result. Remarks. August 3 Infected Cured Infected . . Cured 14 Not infected do. do. 29 Infected .. Cured Not infected — Sept. 4 do. do. Infected Cured 7 do. do. . . do. do. 17 Not infected — do. No information Oct. 21 Infected Cured do. Cured Left Borough 18/1/22 Nov. 11 do. Improved do. Improved 14 do. Cured do. Cured Dec. 17 do. do. do. do. 24 clo. do. do. do. 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 12 cases were nursed at a cost of £11 15s, 235 visits were made, the average number of visits paid to each case being 20. Measles, Whooping.cough and Polio.myelitis. These diseases are dealt with in the Infectious Diseases section of the report (see pages 62, 63 and 71). Epidemie Diarrhœa. It has long been known that epidemic diarrhoea is a disease associated with warm summers, and 1921 proved no exception to this rule. In a report of the Local Government Board published in 1885, Dr. Ballard stated that when the underground temperature at a depth of 4 ft. rises to 56 degrees F., summer diarrhoea begins. This temperature was reached by July 16th and immediately thereafter there was a sharp rise in the number of notifications. 99 I give below a composite Table (No. 52) showing certain meteorological observations taken at Greenwich; the number of cases of summer diarrhœa, and the number of death occurring in the five months, June, July, August, September and October. TABLE 52. Weeks ending 1921. Meteorological Observations. Zymotic Enteritis. Average temperature 4 feet below ground. Departure from average mean air temperature for 65 years. Number of days on which rain fell. Rainfall in inches. Number of cases notified under 2 years of age. Total Notifications. Number of deaths under 2 years of age. Total deaths. June 4 51.5 — 0.2 3 0.33 .. .. .. .. 11 52.4 — 0.8 1 001 .. .. .. .. 18 53.4 + 1.9 .. 0.00 1 1 .. .. 25 54.2 + 0.5 2 0.03 2 2 .. .. July 2 551 — 2.3 1 0.23 .. .. .. 1 9 55.9 + 21 .. 000 2 3 2 2 16 57.3 + 7.8 .. 000 8 9 1 1 23 58.5 + 8.1 1 0.08 9 19 2 3 30 59.6 + 4.7 3 0.07 40 50 2 4 August 6 599 + 2.5 3 017 43 69 4 4 13 59.6 — 0.2 3 014 50 71 4 6 20 59.3 + 2.4 2 0.34 43 64 3 5 27 59.3 + 10 2 003 23 54 7 8 Sept. 3 59.2 + 10 .. 0.00 16 26 7 7 10 590 + 4.5 1 001 17 23 4 4 17 58.8 + 1.4 4 1.81 13 21 4 4 24 58.2 + 4.8 .. 0.00 6 10 .. .. Oct. 1 57.9 + 0.2 .. 0.00 2 8 3 3 8 57.4 + 13.6 1 0.01 4 8 1 1 15 57.7 + 8.9 2 0.40 6 6 .. .. 22 56.7 + 7.3 4 0.36 3 4 .. .. 29 55.4 + 0.4 1 0.02 .. .. 2 4 288 451 46 57 100 Incidence. The following Table shows the age and sex incidence of cases of zymotic enteritis notified in Woolwich during the year. This Table bears out the well.established observation that summer diarrhoea is more apt to attack males than females at all ages. No statistics are available showing the similar incidence of this disease in other London Boroughs because it is notifiable only in Deptford, Fulham, Greenwich and Woolwich. The number of cases under 1 year notified in these Boroughs was as follows :—Deptford, 65; Fulham, 100; Greenwich, 105; Woolwich 155. TABLE No. 53. Zymotic Enteritis—Notifications. Age and Sex Incidence in various months. Months. Sex. 0.1. 1.2. 2.5. 5.15. 15.45 Total. Grand Total. M. F. To end of June M. 2 3 .. .. .. 5 .. .. F. 1 .. .. .. .. .. 1 6 July M. 15 24 3 1 6 49 .. .. F. 18 9 3 .. 9 .. 39 88 August M. 48 44 18 6 23 139 .. .. F. 37 31 17 6 32 .. 123 262 September M. 17 9 3 1 10 40 .. .. F. 9 11 6 1 10 .. 37 77 To end of December M. 6 6 1 0 0 13 .. .. F. 2 2 0 1 3 8 21 Totals M. 88 86 25 8 39 246 F. 67 53 26 8 54 208 454 The following Table shows the age incidence in Wards:— 101 TABLE No. 54. Zymotic Enteritis—Notifications. Age Incidence in Wards. Age Periods. Dockyard. St. Mary's. River. St. George's. Burrage. Herbert.. St. Margaret's. Glyndon. Central. St. Nicholas. Eltham. Total. 0.1 a 4 19 8 13 5 12 14 6 39 24 155 ] .2 9 8 26 6 14 1 5 22 10 18 20 139 2.5 2 3 10 .. 4 1 5 9 2 10 5 51 5.15 1 .. 2 1 1 1 4 .. .. 1 5 16 15. 6 17 24 2 2 1 3 1 1 2 34 93 29 32 81 17 34 9 29 46 19 70 88 | 454 From the above Table and from Table No. 2, we find that the number of children under 2 years, attacked per 1,000 births was 92 in the Borough, 97 in Woolwich, 97 in West Plumstead, 94 in East Plumstead and 73 in Eltham. Density of population would appear, therefore, to be a factor in increasing the tendency to diarrhoea, and probably also low.lying areas. Deaths. During 1921, 72 deaths were certified as due to diarrhceal diseases. Of these, 56 occurred in children under 1 year, 4 in children between 1—2 years, 6 in children from 2—15 years and 6 amongst adults, 45 years and upwards. Out of the 56 deaths under 1 year in 24 instances the first intimation received by me of the presence of the disease was the death certificate, and in 14 other instances, 102 death took place within 24 hours of notification. The death. rate under 2 per 1,000 births was 18.8; in Woolwich it was 17.1, in West Plumstead, 14.7; in East Plumstead 20.6; and in Eltham, 24.9. The following Table, No. 55, shows the deaths from diarrhœa and enteritis at various ages under 2 each year since 1911 and the mortality rate under 2 years per 1,000 births. TABLE No. 55. Diarrhœa, Enteritis, etc. Nett Deaths at various ages under two years of age. Year. 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. Total Deaths under 2 years. Rate per 1,000 Births. 1911 .. •• •• 1 1 19 28 24 15 87 101 35.9 1912 .. .. .. .. .. 1 6 3 .. 10 10 3.6 1913 .. .. .. 2 2 12 11 13 3 41 48 16.9 1914 .. .. .. 1 1 7 7 4 4 23 30 10.6 1915 .. .. .. .. .. 6 11 5 5 27 32 11.3 1916 .. 1 3 .. 4 6 6 3 3 22 22 7.2 1917 .. 1 1 1 3 7 8 4 .. 22 26 9.6 1918 .. .. .. .. .. 4 19 6 2 31 33 13.0 1919 .. 2 1 .. 3 5 4 4 2 18 18 6.6 1920 .. .. .. .. 1 6 7 4 .. 18 20 5.5 1921 .. .. 2 3 5 11 15 15 10 56 60 18.8 103 As in previous years, careful enquiry was made into the method of feeding adopted in the case of children under 1 because it is now generally agreed that diarrhœal diseaes are more frequent amongst hand.fed infants than amongst those who are breast.fed. It was found that out of the 155 infants affected, 17 were breast.fed, 15 were breast and hand. fed, and 114 were hand.fed, while in 9 cases no information was available. Taking notified and non.notified cases together, 56 deaths occurred, 3 of whom were breast.fed, 4 were breast and hand, and 39 were hand.fed, while no information was obtained in 10 cases. Enquiries were made into 167 cases in all, 18 of which were breast.fed, 16 breast and hand.fed and 124 hand.fed. Amongst these children 34 per cent. of those fed on cows' milk died, 24 per cent. of those fed on dried milk died, and 39 per cent. of those fed on various other foods died. If we assume—and it is not an unreasonable assumption—that the distribution of breast and hand.fed children in the Borough approaches somewhat to that Table given a little earlier on on the work of the Centres, we find that the incidence of summer diarrhoea amongst breast.fed children was 1.25 per cent., amongst breast and hand 3.32 per cent. and amongst hand.fed, 8.91 per cent. In the case of notified cases between one and two years, namely 139, the number of cases where, in addition to solid feeding breast milk was used, was 15, cows' milk 67, dried milk 15, and condensed milk 13. Summer diarrhoea has been a notifiable infectious disease in Woolwich, without limitation of age and sex, since 1913; since 1905 it has been partially notifiable. In consequence of this notification we have been able to accumulate a large 104 amount of information regarding the incidenoe of this disease, information which is more complete than would have been ascertained from the death returns. It must not be assumed that the number of notifications indicates the prevalence of the disease, and I have little doubt from personal observation and from the experience of the Health Visitors, that many cases of zymotic enteritis were not notified. Summer diarrhœa attacks persons at all ages, but it is amongst young children that most of the deaths occur. As compared with previous epidemics, notably 1911, the incidence of the disease was lessened and the mortality rate was diminished, in both cases these figures being about 50 per cent. of those in 1911. The infantile mortality death.rate from diarrhœa is high as can be seen from the Table on page 108 giving the death.rates amongst infants under 2 years in London boroughs. In Woolwich only 4 deaths occurred between 1—2 years of age, the remainder occurring under 1 year. Diarrhœal diseases were the chief cause of infant deaths during the past year or it may be said that the proportion of diarrhœa deaths was much higher in Woolwich than in London as a whole. In July it was recognised that it was likely we should be visited with a severe epidemic of summer diarrhœa, and steps were taken to warn all medical practitioners that this disease was notifiable. At the same time a simple handbill of advice to parents was printed and circulated by means of the Welfare Centres. The local press very kindly printed excerpts of the handbill. Special rapid inspections were made by the Sanitary Inspectors in the affected areas to secure the rapid abatement of acute nuisances. The Home for Ailing Babies was reserved for cases of summer diarrhœa during August and September. 105 The epidemic started in July and reached the maximum in the second week of August and gradually declined during September and October. It appeared first mainly in two parts of the Borough, namely, High Street area, Woolwich, and the Reidhaven Road area, Plumstead, and reached, its maximum in the third week of July. Its course in Plumstead was as follows: in children under 5 years of age it reached its maximum in St. Nicholas Ward in the third week of July; in the Central Ward in the second week of August; Glyndon Ward also in the second week of August, while in St. Margaret's Ward sporadic cases only occurred more or less evenly throughout the whole period. As St. Nicholas Ward is the most easterly Ward in the Borough, Central being next and Glyndon furthest West, it looks as if this disease travelled from East to West. In the High Street area in Woolwich, which is included in the River and Burrage Wards, it reached its maximum in the first week of August; in the Dockyard and St. Mary's Wards in the second week, and in St. George's in the third week. It can be assumed that the temperature was more or less uniform for these separate areas all the time except possibly in the in the high area of St. Margaret's and St. George's, so that it looks as if the high temperature was not the main factor in the spread of the disease, but there must have been some other factor at work as well. The following Table shows the house distribution of notified epidemic diarrhœa cases. TABLE No. 56. No. of houses in which occurred— 1 case. 2 cases. 3 cases. 4 cases. Institutions. Totals. Houses 380 26 4 1 — 411 Cases 380 52 12 4 6 454 106 Summary. 1. The year was marked by the highest epidemic of summer diarrhœa since 1911, but compared with that year the incidence and the death rates were approximately halved. The proportion of infant deaths due to diarrhœal diseases was in excess of that due to them in London as a whole. In spite of this the infant mortality rate in Woolwich was 62, the third lowest in London. 2. Only 18 deaths occurred amongst those cases (under 1) which were notified more than 24 hours before death, compared with 38 deaths amongst those not notified or notified within 24 hours of death. This discounts somewhat the value of compulsory notification in the control of these diseases. 3. The case mortality in children under 1 year was 36 per cent.; in children from 1 to 5 years, 4.2 per cent. In 1911 the corresponding figures were 32 per cent. and 49 per cent respectively. 4. The incidence of disease was 125 per cent. amongst breast.fed infants; 3.32 per cent. amongst breast and hand fed infants, and 8.91 per cent. amongst hand.fed infants. Dried milk does not appear to diminish the case rate of summer diarrhœa, but it appears to have some influence in diminishing the case.mortality rate. 5. It is very important that parents should appreciate more that diarrhœa in the summer months means danger, and should obtain medical and nursing assistance and advice before it is too late. 107 Tables showing the age and sex incidence of all notifications received since 1905 and the incidence of deaths from diarrhœa in all Metropolitan Boroughs for each quarter of 1921 and during the whole year are given below. It should be borne in mind, however, that diarrhœal deaths is a more comprehensive term than zymotic enteritis. TABLE No. 57. Notification of Zymotic Enteritis. Year. Male. Female. Total. Under 1 year. Total under 1 year. 1.2 years. 2.5 years. Over 5 years. Under 3 months. 3.6 months. 6.9 months. 9.12 months. 1905 112 100 212 18 39 34 29 120 56 25 11 1900 187 179 366 31 52 52 59 194 99 39 34 1907 48 45 93 6 18 14 11 49 23 3 18 1908 96 77 173 11 28 25 27 91 55 12 15 1909 79 70 149 12 10 20 22 64 35 18 32 1910 54 48 102 5 10 12 13 40 31 17 14 1911 434 432 866 28 69 79 89 265 240 171 190 1912 61 68 129 4 4 16 6 30 26 22 51 1913 181 157 338 16 30 41 28 115 84 54 85 1914 102 97 199 9 29 24 33 95 56 32 16 1915 108 65 173 10 26 23 27 86 52 21 14 1916 42 38 80 7 13 4 12 36 20 17 7 1917 59 42 101 9 10 10 8 37 38 14 12 1918 50 68 118 11 26 14 12 63 35 15 5 1919 61 62 123 6 18 19 12 55 29 15 24 1920 19 12 31 3 5 4 7 19 8 4 . 1921 246 208 454 22 35 59 39 155 139 51 109 1,939 1,768 3,707 208 422 450 434 1,514 1,026 530 637 108 TABLE No. 58. Deaths from Diarrhœa and Enteritis (under 2 years). Metropolitan Boroughs—Rate per 1,000 births. Boroughs. Year 1921. First Quarter. Second Quarter. Third Quarter. Fourth Quarter. Bethnal Green 38.6 25.1 8.8 103.1 47.1 Shoreditch 38.2 13.2 9.5 113.8 35.8 Kensington 29.5 21.7 8.7 60.0 35.2 Stepney 28.9 113 6.6 73.1 17.9 Paddington 27.7 20.3 191 54.4 28.3 Southwark 25.8 12.9 5.4 78.0 24.1 Hammersmith 23.4 10.8 11.3 51.7 28.5 Poplar 21.9 8.8 6.3 69.6 14.9 Lambeth 21.9 3.1 3.9 42.8 16.1 Bermondsey 21.3 9.5 5.9 48.6 25.4 Islington 20.5 8.8 6.7 49.9 25.6 Hackney 20.3 4.3 3.4 51.2 17.6 Deptford 20.2 8.0 11.8 55.4 7.0 Fulham 20.1 11.0 3.3 48.4 17.6 Finsbury 19.1 5.9 2.4 22.7 14.7 Woolwich 18.4 7.0 1.3 54.7 12.1 Westminster 18.2 10.6 7.8 47.9 36.7 St. Panceras 17.5 10.6 3.8 37.2 14.7 Camberwell 16.7 8.6 5.1 40.8 17.7 Battersea 16.6 13.2 3.4 34.3 14.1 Chelsea 16.4 10.8 3.8 35.0 15.6 Lewisham 15.3 8.3 3.3 41.8 7.6 City of London 15.1 .. 29.4 — Wandsworth 14.4 7.7 3.8 35.1 13.4 Greenwich 13.7 3.3 .. 31.2 21.1 St. Mary.lebone 13.1 4.6 .. 12.8 10.2 Holborn 12.3 .. 25.2 24.4 18.5 Stoke Newington 12.1 4.0 11.6 27.8 9.7 Hampstead 11.9 2.8 10.3 16.4 13.2 London 21.3 9.4 5.9 50.1 19.3 Administrative Measures. Cases of Puerperal fever, Ophthalmia Neonatorum, Epidemic Diarrhoea and Pneumonia (under 5 years of age) are visited by the Health Visitors. In many cases nursing assistance has been provided, and hospital accommodation found where the home conditions were 109 totally unsuited for the needs of the patient. Any insanitary conditions noted by them are reported to the Sanitary Inspectors for the action necessary, 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. 110 SANITARY ADMINISTRATION. SANITARY STAFF. The staff of the Public Health Department is shown in detail on pages 3 and 4. 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. BACTERIOLOGICAL EXAMINATIONS. Bacteriological examinations are carried out at the Dreadnought Hospital, Greenwich, by Dr. Arthur Davies. Each examination cost 4s. The number and nature of the various examinations made during the year is shown below for comparative purposes; the total number in 1920 is also given. TABLE No. 59. Associated disease Positive result Negative result Total. Total. 1920 Diphtheria 122 844 966 845 Enteric Fever 2 8 10 6 Tuberculosis 38 168 206 202 162 1,020 1,182 1,053 1ll HOUSING GENERAL HOUSING CONDITIONS. The condition of housing in the country has not yet reached normal, and in a district such as Woolwich the difficulties to which I drew attention last year in this connection still remain. It has, therefore, been impossible to effect all that is desirable in connection with the older houses in the Borough. The survey of the district, commenced in February, 1920, and has continued. The procedure laid down in the Manual of Unfit Houses and Unhealthy Areas issued by the Ministry of Health in 1919 was followed out again throughout the year. Shortage of Houses. The housing problem is not quite so acute as it was in 1920, but there is still evidence of a shortage of houses in spite of the number erected under the Council's Housing Scheme. This scheme has been proceeding during the year, and the following Table shows the position up to the 31st December, 1921: — TABLE No. 60. Number of houses in occupation on 31 Dec., 1920 Nil do. do. 31 Dec., 1921 192 do. in. course of construction, 31 Dec., 1921 108 Number of additional houses approved, subject to satisfactory tenders 98 112 Population. This is referred to in detail in the general section of the report. Government Houses and Hutments. These hutments were originally erected as a purely temporary expedient, but it is obvious that they must continue for some time as permanent residences. In view of the temporary nature of the structures deterioration has reached the stage that in many of them a considerable amount of work must be done to keep them in a reasonably satisfactory condition. The Government Officials in charge of the hutments act in cordial co.operation with the Council's Officers in an endeavour to maintain these premises in a satisfactory and sanitary condition. Housing Survey. The housing survey has continued to occupy mainly the whole time of two inspectors. The survey is associated with two aspects:— (a) Fitness of houses. (b) Overcrowding. The worst areas in the district were inspected in 1920, so that the houses inspected during this year have been of a slightly better kind, and therefore the results differ from those of the previous year. The records have again been made on cards and the details of the survey recorded in the following eight separate headings :— 1. Arrangements for preventing contamination of water supply. 2. Water closet accommodation. 3. Condition of house in regard to lighting and free circulation of air. 4. Drainage. 113 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, as set out in Chap. V. in the Manual, and they record all defects that exist in the houses under any of the above eight provisions. When the cards of one street are completed, they are transferred to the district inspector who then separates the cards relating to the houses where nuisances have been recorded, inspects these houses and serves the necessary notices in order to obtain the abatement of the nuisances. A record is then made by the district inspector on the card showing the results of his work, and the card is then filed for future reference. The number of nuisances abated and the amount of work that has been effected during the year have considerably increased. This has been possible in consequence of the slightly diminished cost of labour and materials. The subsequent action by the district inspectors is causing the arrears that accumulated during the war to be gradually overtaken, but there is much that still remains to be done. The housing conditions at present are such as to make it impossible for any active steps to be taken with respect to the issue of closing orders. Results of Survey. During the year a total of 2,800 houses were surveyed by the inspectors specially engaged 114 in this work. These were periodically reported upon 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 impossibility 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 4 Grade 2, Unfit for human habitation by reason of extensive dilapidations and dirty conditions, but subjective to effective remedy under a Closing order 16 Grade 3. Generally dilapidated, damp, dark, and dirty, but subject to remedy either under Sec. 28 of the Housing, Town Planning, etc., Act, 1919, or the Public Health (London) Act, 1891 479 Grade 4. Few defects, capable of being remedied under the Public Health (London) Act, 1891 1,231 Grade 5. Satisfactory 1,070 Total 2,800 The above conditions have been recorded by the survey inspectors, but it is always difficult to draw a hard and fast line in such an analysis, and the conclusions therefore must only be regarded as approximate. It must, however, be appreciated that in connection with the inspection of the 115 older houses no finality can be reached, and that the older the house the more rapid the deterioration. As time goes on the number of houses that will come under the category for consideration for demolition must of necessity increase, and it is in consequence of this that there is necessity sometimes, in the older and more dilapidated house where the only satisfactory method would be reconstruction, to modify the requirements in consequence of the consciousness that ultimately more serious steps will have to be taken. The records that are made of the inspections include the number of persons occupying the house, 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 again been adopted this year. It is therefore possible to compare the conditions in 1920 with those now recorded for 1921. The following are the details with respect to the 2,800 houses inspected:— 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. 2,145 298 357 364 697 15,289 persons in 2,800 houses containing 13,378 rooms; = 5.5 persons per house, and just over 11 persons per room. Unhealthy Areas, No areas have been represented under Part I. of the Housing Act, 1890, and no complaints that areas were unhealthy have been made. 116 New Houses. Water Certificates were granted during the year for the following new houses erected in the Borough: Council's Housing Scheme, Eltham. Date. 20 Houses 15th April. 19 ,, 15th June. 9 „ 27th July. 57 „ 16th September. 20 ,, 14th October. 26 ,, 12th November. 41 ,, 9th December. Private enterprise. Trevorna, Glenlea Road 18th February. Addison House do. 14th April. Melrose do. 30th April. 3, Glenlyon Road 16th September. 3, Glenlea Road do. Pumping Sta. House, Shooters Hill do. Glenmerrin, Glenlea Road 14th October. 13, Glenlea Road 12th November. 5, Glenlyon Road 9th December. 15, Glenlea Road 9th December. 117 APPENDICES. HOUSING CONDITIONS. STATISTICS. Year ending 31st December, 1921. 1.—General. Estimated Population 136,307 General Death Rate 11.7 Death Rate from Tuberculosis 1.52 Infantile Mortality 62 Number of dwelling.houses of all classes 26,428 Number of working.class dwelling.houses 22,289 Number of new working.class houses erected 202 2.—Unfit Dwelling.houses. 1.—Inspection. Total number of dwelling.houses inspected for housing defects (under Public Health or Housing Acts) 7,649 Number of dwelling.houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 2,800 Number of dwelling.houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 20 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 1,047 118 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 3,427 * Includes Intimation Notices. 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 (b) By Local Authority in default of Owners nil Number of dwelling.houses in respect of which closing orders become 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 1,514 Number of dwelling.houses in which defects were remedied— (a) By Owners *1,544 (b) By Local Authority in default of Owners nil * Includes those carried over from 1920. (c) Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc, Act, 1909. Number of representations made with a view to to making of Closing Orders 1 119 Number of dwelling.houses is respect of which Closing Orders were made *1 Number of dwelling.houses in respect of which Closing Orders were determined, the dwelling. houses 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. 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 bye.laws 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.