Woo 23 AC 4372 Metropolitan Borough of Woolwich. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR WOOLWICH. 1923. BY J. MACMILLAN, D.S.O., M.C., M.B., D.P.H., Medical Officer of Health. Woolwicb: Pryce & Bon, Ltd. (T.U. Federation), 31-35 Powib Street. 1924. Metropolitan Borough of Woolwich. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR WOOLWICH. 1923. BY J. MACMILLAN, D.S.O., M.C., M.B., D.P.H., Medical Officer of Health. Woolioicl): Pryce & Son, Ltd. (T.U. Federation), 31-35 Powis Street. 1924. 2 Public Health and Housing Committee— (At 31st December, 1923) His Worship the Mayor (Councillor J. Newman, J.P.). Councillor Miss G. E. Walters (Chairman). Councillor Miss M. Crout, J.P. (Vice-Chairman). Alderman— Mrs. Dormer. Counciillors— R. M. W. Allen P. Chinnery. H. A. Hart. J. Lee. Rev. J. F. Matthews. W. C. Montano. W. E. H. Narborough. S. H. Reed. H. C. E. Saville. Mrs. M. E. T. Smith. J. A. Turnbull. Miss S. Turnbull. 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 Miss M. Crout, J.P. (Vice-Chairman). Alderman Mrs. E. Dormer. Councillor P. Chinnery. Councillor Rev. J. F. Matthews. Councillor Mrs. M. E. T. Smith. 3 TABLE OF CONTENTS. page Public Health and Housing Committee 2 Maternity and Child Welfare Committee 2 do. do. Visiting Sub-Committee 2 Preface 6 I.—General Statistics. Population 9 Social Conditions of the District 10 Census, 1921—Occupations 14 II.—Vital Statistics. Summary of Statistics 15 Births 16 Marriages 19 Deaths 19 Infantile Mortality, 1923 29 Do. 1904-1923 31 III.—Notifiable Diseases. Notifications 39 Deaths of Notified Cases 44 Notifications each year since 1901 45 Measles 46 Scarlet Fever 46 Diphtheria 49 Do. —Three yearly incidence 50 Enteric Fever 53 Pneumonia. Malaria, Dysentery and Trench Fever 54 Ophthalmia Neonatorum 8 Puerperal Fever 59 Zymotic Enteritis 59 Acute Poliomyelitis 59 Other Notifiable Infectious Disease 60 Tuberculosis 62 a 2 4 IV.—Causes of Sickness. page Reports of Medical Practitioners 73 V.—Nursing Arrangements, Hospitals and Other Institutions. Professional Nursing in the Home 74 Midwives 75 Clinics and Treatment Centres 76 Hospitals 77 Institutional Provision for Unmarried Mothers 81 Ambulance Facilities 82 Maternity and Child Welfare. Administrative Action 83 Work of the Centres 84 Treatment—Dental Scheme 86 Work of the Health Visitors 86 Supply of Milk to Necessitous, Expectant and Nursing Mothers, and Young Children 88 Feeding of Infants in Woolwich 89 Rate of Growth of Woolwich Infants 91 VI.—Laboratory Work. Public Analyst 100 Bacteriological Examinations 100 Supply of Antitoxin 100 VII.—Sanitary Administration. Adoptive Acts, By-laws and Regulations in force in the District 101 Closet Accommodation 104 Scavenging 104 Complaints 104 Drainage 104 Increase of Rent and Mortgage Interest (Restrictions) Acts 105 Inhabited House Duty 106 Houses Let in Lodgings 106 5 page Underground Sleeping Rooms 106 Destruction of Rats 107 Rag Flock Act 107 Offensive Trades 107 Sanitary Inspection of the Borough 108 Mortuaries 114 Cemeteries 114 Outworkers 114 Factories, Workshops and Workplaces 115 Inspection of Premises where Food is Prepared 119 Unsound Food 121 Food Poisoning 121 Slaughterhouses 121 Disinfection and Disinfestation 122 Dairies, Cowsheds and Milkshopa 123 Sale of Food and Drugs 124 Milk and Cream Regulations, 1912-1917 124 Smoke Abatement 129 Mosquitoes 129 VIII.—Staff. Staff 131 IX.—Housing. General Housing Conditions 134 Housing Survey—Fitness of Houses 136 Do. Overcrowding 138 Unhealthy Areas 138 Action taken under Housing Acts 138 New Houses 139 Meteorology. 6 PREFACE. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Woolwich. Mb. Mayor, Ladies and Gentlemen, I have the honour to submit the Twenty-third Annual Report on the health of the Metropolitan Borough of Woolwich. As in previous years, and in accordance with the instructions of the Council, the report follows the outline indicated by the Ministry of Health, in order to secure uniformity in the presentation of Annual Reports of Medical Officers of Health throughout the Countiy. The chief Vital Statistics relating to the year are as follows. The population has increased compared with last year, being now estimated by the Registrar General to be 140,000. The birth rate, 20'5, is lower than last year. The marriage rate, 169, compares with 165 in 1922. The death rate, 9'9, is the lowest in the metropolitan area and the in. fantile mortality rate, 43, is the second lowest in the Metropolitan Boroughs, and both these rates are the lowest in the records of the Borough. Excluding cases of measles and tuberculosis, 876 notifications of infectious disease were received during the year, compared with 1,427 in the previous year. 194 cases of measles came to the knowledge of the Department through information given mainly by school teachers. In 1922 the 7 corresponding figure was 2,698. There were very few cases of diphtheria (152) notified, and the number of cases of scarlet fever (334) was much below the average of the last twenty years. 381 notifications of tuberculosis were received, 311 of which related to new cases. This figure is practically the same as the corresponding figure of last year. It is estimated that there are 2,289 notified cases of tuberculosis living in the district, and that 929 of these persons are suffering from active tuberculosis. An essential element in dealing with this disease is the formation of a Care Committee whose function is to deal with the social and economic side of the family, while the sanitary authority is looking after the preventive and medical side. In April the Council resolved to form such a Committee, and this Committee, having received the approval of the Ministry of Health and the London County Council, started work in November. A development of an organised scheme of care work can confidently be looked forward to in 1924. Maternity and Child Welfare work continues to develop, and the Council can look with pleasure and satisfaction on the great fall which has taken place in infant mortality within the past twenty years. Twenty years ago an infantile mortality rate of 43 did not appear to be within the realm of practicability, but the solid advance in this work during the last decade leads one to look forward to an even lower infantile mortality rate in the future, and particularly so in the first month of life. The attendance at the centres, 26,706, constitutes a record, and shews an increase of 2,765 over that of the previous year. There is some evidence that children aged 1-5 years are being brought to the centres in increasing numbers year by year. The result of an enquiry into the rate of growth of Woolwich children in the 8 first year of life is included in the Maternity and Child Welfare section of the report. The reports of the Sanitary Inspectors shew that a considerable amount of work has been carried out in the improvement of the sanitary condition of houses, but improvement in existing houses cannot be satisfactorily maintained until more are built. Details of the work of supervision of the food supplies, a matter of great importance, are given in that section of the report dealing with Sanitary Administration. The staff have carried out their duties during the year in a thorough and conscientious manner and personally I owe much to them for the zeal they have shewn in their work. I take this opportunity of expressing my thanks to the Members of the Council, especially to those serving on the Public Health and Housing, and Maternity and Child Welfare Committees, for the support and sympathetic consideration they have given to the work of the Department during the year. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, JOHN MACMILLAN. , 9 Twenty-third Annual Report on the HEALTH OF THE METROPOLITAN BOROUGH OF WOOLWICH, Year ending 31st December, 1923. SECTION I.—GENERAL STATISTICS. Area (acres) 8,282 Population, 1921 140,389 Number of Inhabited Houses, 1921 26,048 Number of Families or Separate Occupiers, 1921 33,647 Rateable Value, October, 1923 £954,085 Sum represented by a penny rate, October, 1923 £3,975 Population. The population of the Borough at the time of the Census, 1921, consisted of 140,389 persons, but the nett civilian population consisted of only 136,307 persons. For 1923, the civilian population is estimated by the Registrar General to be 140,000. This estimate is based on the 1921 figures after allowance for the varying rate of natural increase, as evidenced by the births and deaths, and for migration as indicated from other sources. In estimating the population in the various registration districts, I have followed a similar method and have made use of the information available in the Housing Department as to movement from other parts of the Borough to Eltham. 10 The estimated figures are as follows:— Estimated Population. Woolwich 32,620 West Plumstead 41,249 East Plumstead 35,552 Eltham 30,579 140,000 The above figures have been used throughout the Report for calculating the rates in the Borough and in the various registration districts. SOCIAL CONDITIONS OF THE DISTRICT. At the beginning of 1923 the Registrar General published a further report on the 1921 Census dealing with the workplaces of occupied persons in England and Wales. In this report the population of the country was classified by reference to the day distribution of the occupied population. The figures, so far as they apply to Woolwich, are shown below and they show that the day population of the Borough exceeded by 6,685 the enumerated night population. This excess of the day population is a feature of central London Boroughs and is not, as a rule, noted in the peripheral Boroughs. There are many large works on the borders of Woolwich and in the influx of workers to these places lies the explanation of this fact. It will be seen from Table No. 1 that 16,397 Woolwich residents work outside Woolwich, and 23,082 people living outside the Borough work in the Borough. Expressed in percentage figures, 24.3 per cent, of the occupied male population and 30 per cent, of the occupied female population work outside the Borough. 11 The Table given below shows the night residence of workers in Woolwich who live outside the Borough and the day workplaces of Woolwich residents who spend their working day away from Woolwich:— TABLE No. 1. Enumerated in Woolwich but working elsewhere. Working in Woolwich but enumerated elsewhere. Area. (16,397) (23,082). viz. in viz. in London 11,098 12,603 City of London . 2,729 — Battersea 31 129 Bermondsey 336 276 Bethnal Green — 103 Camberwell 258 1,154 Chelsea 67 38 Deptford 266 1,133 Finsbury 282 49 Fulham 36 69 Greenwich 2,016 5,338 Hackney 38 150 Hammersmith 61 57 Hampstead 30 29 Holborn 414 28 Islington 98 210 Kensington 107 64 Lambeth 241 579 Lewisham 375 1,514 Paddington 43 67 Poplar 303 338 St. Marylebone 437 39 St. Pancras 195 128 Shoreditch 104 75 12 Enumerated in Woolwich but working elsewhere. Working in Woolwich but enumerated elsewhere. Area. (16,397). (23,082). viz. in viz. in London—continued. Southwark 364 390 Stepney 218 207 Stoke Newington — 27 Wandsworth 79 315 Westminster 1,905 . . 93 London (Undefined) 39 — Essex 2,341 5,575 Barking 21 147 East Ham — 1,785 Lford 28 170 Leyton — 401 Romford 77 — Southend-on-Sea — 77 West Ham 2,132 2,663 Walthamstow — 115 Wanstead — 29 Woodford — 24 Hertfordshire 26 36 Kent 2,164 3,859 Beckenham — 68 Bezley 318 1,566 Bromley M.B. 27 113 Bromley R.D. 41 161 Chislehurst 31 132 Crayford 226 92 Dartford U.D. 141 114 Dartford R.D. 68 38 Erith 1,125 1,009 13 Enumerated in Woolwich but working elsewhere. Working in Woolwich but enumerated elsewhere. Area. (16,397). (23,082). viz. in viz. in Kent—continued. Gillingham — 22 Gravesend — 28 Margate — 45 Penge — 65 Ramsgate — 30 Sidcup 53 177 Middlesex 223 571 Acton 29 20 Ealing — 27 Edmonton — 61 Enfield — 28 Hendon — 25 Hornsey — 49 Tottenham 24 142 Willesden 52 50 Wood Green — 34 Surrey 121 438 Croydon 37 213 Richmond 26 — Mitcham — 24 Sutton — 24 Wimbledon — 39 Other Parts of England and Wales 341 — Outside England and Wales 83 — 14 The following Table sets out under generalised headings the total number of males and females engaged in occupations at ages of 12 years and upwards. (Census, 1921):— TABLE No. 2. Occupations of Woolwich Inhabitants (over 12 years). Males Females I Fishermen 2 — II Agricultural occupations 414 30 III Mining and quarrying occupations 15 — IV Makers of coke, lime, cement, etc. 12 4 V Makers of bricks, pottery, glass, etc 106 18 VI Workers in chemicals, paints, etc. 1,223 66 VII Metal workers 8,525 214 VIII Workers in precious metals 80 11 IX Electrical apparatus makers, fitters, etc. 1,894 923 X Makers of watches, clocks, etc. 187 14 XI Workers in skins; leather goods makers 219 28 XII Textile workers 46 62 XIII Makers of textile goods and articles of dress 645 1,823 XIV Makers of foods, drinks and tobacco.. 528 189 XV Workers in wood and furniture 1,586 51 XVI Paper workers ; printers, etc. 416 140 XVII Builders, bricklayers, etc. 1,488 3 XVIII Painters and Decorators 1,032 9 XIX Workers in other materials 157 35 XX Workers in mixed or undefined materials (not elsewhere enumerated) 183 328 XXI Workers in gas, water and electricity supply. 138 — XXII Transport workers.. 4,583 307 XXIII Commercial and financial occupations 3,241 1,822 XXIV Public administration and defence 7,080 629 XXV Professional occupations 1,358 1,605 XXVI Persons employed in entertainments, etc. 210 118 XXVII Persons employed in personal service ., 1,344 4,451 XXVIII Clerks and Draughtsmen 2,249 2,438 XXIX Warehousemen, Storekeepers and Packers 1,198 217 XXX Stationary engine drivers, Dynamo and Motor Attendants 738 — XXXI Other and undefined 6,822 178 Total occupied 47,719 15,763 XXXII Total unoccupied 6,417 39,868 Total occupied and unoccupied 54,136 55,631 15 SECTION II.—VITAL STATISTICS. In accordance with the requirements of the Ministry of Health, the following extracts from the Vital Statistics of the year are shewn below:— TABLE No.. 3. Births—Legitimate 2,973 „ Illegitimate 74 2,867 Birth Rate 205 Deaths 1,387 Death Rate 9'9 Number of women dying in, or in consequence of child birth 5 (a) From Sepsis 3 (b) From other causes 2 Deaths of Infants under 1 year 123 (a) Legitimate 113 (b) Illegitimate 10 Infantile Mortality Rate 43 Deaths from Measles (all ages) Nil „ Whooping Cough (all ages) 4 „ Diarrhoea (under 2 years) 10 The chief Vital Statistics of the Borough during the quinquennial period 1919 to 1923 are shewn in Table No. 4. 16 TABLE No. 4. Year. Population estimated to middle of each Year. Births. Total Deaths Registered in the District. Transferable Deaths. Nett Deaths belonging to the District. Nett. of Non-residents registered in the District. of Residents not registered in the District. Under 1 Yr. of Age. At all Ages. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 1919 a 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 140,389 1922 c 138,254 2941 21.3 1354 98 347 184 62 1603 11.6 d 142,350 1923 c 140,000 2867 20.5 1198 64 253 123 43 1387 9.9 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) .. 8,282 Census, 1921. Total Population, all ages 140,389 Civilian Population, all ages 136,307 BIRTHS. During the year 2,939 births were registered in Woolwich, 1,510 being boys and 1,429 girls. Corrected by outward and inward transfers these numbers become 2,867, 1,457 and 1,410, respectively. The corrected figures for the different registration districts were as shewn in Table No. 5 which follows:— 17 TABLE No. 5. Registration Districts. Males. Females. Total Births. Woolwich 402 121 823 West Plumstead 398 354 752 East Plumstead 339 320 669 Eltham 318 315 633 The Borodgh 1457 1410 2867 The birth rate, calculated on the civilian population, was 20'5 compared with 21'3 in 1922. Notification of Births. During the year, 2,864 live births were notified. This is at the rate of 97 per cent, of the registered births and compares with 98 per cent, last year. 1,628 notifications were received from midwives, 305 from doctors, 528 from the British Hospital for Mothers and Babies, 132 from the Military Families' Hospital, 40 from the Woolwich Infirmary and 231 from other persons. The following Table No. 6 shews the number of births in each year since 1919, the birth rate for the same period for Woolwich, London, England and Wales, the number of live and still births notified each year and the percentage of notified births. B 18 TABLE No. 6. Year Woolwich. London England & Wales Woolwich. Percentage of births notified No. of births Birthrate Birth- rate No. of live births notified No. of Stillbirths 1919 2737 19.3 18.3 18.5 2645 67 97 1920 3658 24.7 26.5 25.4 3463 112 95 1921 3197 23.5 22.3 22.4 3011 91 94 1922 2941 21 3 21.0 20'6 2884 72 98 1923 2867 20.5 20.2 19.7 2864 93 97 Natural Increase of Population. The natural increase of population is the excess of births over deaths. In 1920 it was 2,171 ; in 1921 it was 1,603 ; in 1922 it was 1,338, and in 1923 it was 1,480. Table No. 7 shews the birth rates in each registration district (after correction for outward and inward transfers) each year since 1919. TABLE No. 7. Period. Woolwich West Plumstead East Plumstead Eltham The Borough 1919 21.4 16.9 19.1 20'6 19.3 1920 30.4 21.9 241 23.2 24.7 1921 29.9 22.0 21.2 21.3 23.5 1922 26.1 18.9 20.1 20.8 21.3 1923 25.2 18.2 18.5 20.7 20.5 19 Illegitimate Births. The following Table shews the number of illegitimate births each year since 1919 and the illegitimate birth rate per 1,000 births. In 1923, 60 were registered in Woolwich and 22 inward transfers and 8 outward transfers were made by the Registrar General. The nett figure for the Borough is therefore 74. TABLE No. 8. Year. Number of Illegitimate births. Illegitimate birth rate per 1,000 births. 1919 151 55.2 1920 141 38.5 1921 80 25.0 1922 106 36.0 1923 74 25.8 MARRIAGES. There were 1,181 marriages (1,138 in 1922). The marriage rate was 16.9 as compared with 19'8, 17'5, 172 and 165 in the four preceding years. DEATHS. Table No. 4 shews the gross and nett deaths and death rates each year since 1919 and shews how the nett death figure is obtained. The nett deaths were 1,387 and the nett death rate 9.9. In 1922 it was 11.6. The death rate 9.9 is the lowest amongst the Metropolitan Boroughs. In 1923 the death rate for England and Wales was 11.6, for London 11.2 and the mean death rate for the 105 Great Towns was 11.6. b 2 20 The death rates for each registration district each year since 1919 are shewn in the following Table No. 9. TABLE No. 9. Period. Woolwich West Plumstead East Plumstead Eltham The Borough 1919 16.2 12.7 10.3 10.1 12.3 1920 13.4 10 4 10.1 7.8 10.5 1921 13.9 . 13.5 10.2 8.6 11.7 1922 13.9 11.7 10 5 10.1 11.6 1923 12.1 10.5 9.7 6.9 9.9 The seasonal mortality in the four quarters of the year was as follows:—First quarter, 10.8; second quarter, 10.2; third quarter, 8.6; fourth quarter, 10.1. DEATHS IN PUBLIC INSTITUTIONS. In tabular form is shewn below the number of deaths of Woolwich residents which took place in various Institutions during the year. TABLE No. 10. Hospital or Institution. Number of Deaths. Poor Law Institutions 399 London General Hospitals 69 Special Hospitals 33 Mental Hospitals 30 Cottage Hospitals and Nursing Homes 20 Sanatoria and Tuberculosis Institutions 18 Infectious Diseases Hospitals 6 575 21 TABLE No. 11.—Birth-rate, Death-rate, and Analysis of Mortality during the Year 1923. The following three Tables are self-explanatory. 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. j Small-pox. Measles. Scarlet Fever. Whoopingcough. Diphtheria. Influenza. Violence. J Diarrhœa and Enteritis (under 2 Years) Total Deaths under One Year. Causes of Death Certified by Registered Medical Practitioners Inquest Cases. Uncertified Causes of Death. England and Wales 19.7 11.6 001 0.00 0.14 0.03 0.10 0.07 0.22 0.44 7.7 69 920 6.9 1.1 105 County Boroughs and Great Towns, including London 20.4 11.6 0.01 0.00 0.15 0.03 0.12 0.09 0.22 0.40 9.9 72 92.2 7.2 0.6 157 Smaller Towns (1921 adjusted Populations 20,000— 50,000) 19.8 10.6 0.01 — 0.19 0.02 9 0.10 0.06 0.21 0.38 6.4 69 92.6 6.1 1.3 London 20.2 11.2 0.01 0.00 0.08 0.02 0.09 0.13 0.17 0.45 10.2 60 90.8 9.1 0.1 WOOLWICH 20.5 9.9 — — — 0.03 0.03 0.01 0.17 0.29 0.07 43 90.8 9.2 — 22 TABLE No. 12. Deaths of Woolwich Residents Registered during the Calendar Year 1923, classified by age and cause Causes of Death. Nett Deaths at the subjoined Ages of " Residents " whether occurring within or without the District. All Ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and under 75 75 and upwards. All causes 1387 123 12 20 44 72 173 397 266 280 Enteric Fever .. .. .. .. .. .. .. .. .. .. Small-pox .. .. .. .. .. .. .. .. .. .. Measles .. .. .. .. .. .. .. .. .. .. Scarlet Fever 4 .. .. .. 33 .. .. 1 .. .. Whooping Cough 4 4 .. .. .. .. .. .. .. .. Diphtheria 2 .. .. 2 .. .. .. .. .. .. Influenza 24 .. .. .. 3 3 2 8 4 4 Encephalitis lethargica .. .. .. .. .. .. .. .. .. .. Meningococcal meningitis 2 .. 2 .. .. .. .. .. .. .. Tuberculosis of respiratory system. 172 .. .. .. 8 38 75 48 3 .. Other Tuberculous Diseases 19 1 1 4 5 3 2 3 .. .. Cancer, malignant disease 175 .. .. .. .. 1 13 97 46 18 Rheumatic Fever 7 .. .. .. 2 3 2 .. .. Diabetes 10 .. .. .. .. 1 1 4 2 2 Cerebral haemorrhage, &c. 102 .. .. .. .. .. 1 31 38 32 23 TABLE No. 12—continued. Nett Deaths at the subjoined Ages of " Residents," whether occurring within or without the District. Causes ot 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 166 .. .. .. .. 3 13 65 49 36 Arterio-sclerosis 39 .. .. .. .. .. 1 6 18 14 Bronchitis 93 2 1 .. .. .. 5 20 26 39 Pneumonia (all forms) 65 13 2 .. 3 2 9 18 7 7 Other Respiratory Diseases 10 .. .. .. .. 1 1 4 1 3 Ulcer of Stomach or Duodenum 11 .. .. .. .. .. 3 5 3 .. Diarrhoea, &c. 17 8 2 .. 2 1 .. .. 1 .. Appendicitis and Typhlitis 6 .. .. .. 1 1 3 .. .. .. Cirrhosis of Liver 9 .. .. .. .. .. 1 3 3 2 Acute and Chronic Nephritis 35 .. .. .. 2 2 4 13 10 4 Puerperal Sepsis 3 .. .. .. .. 2 1 . . . . Other accidents and diseases of pregnancy and parturition 2 .. .. .. .. 2 .. .. .. .. Congenital debility and malformation, ture birth 63 63 .. .. .. .. .. .. .. .. Suicide 15 .. .. .. .. 1 2 10 2 .. Other deaths from violence 41 2 .. 3 5 5 8 10 5 3 Other defined diseases 291 30 4 3 10 5 25 50 48 116 Causes ill-defined or unknown .. .. .. .. .. .. .. .. .. .. 24 TABLE No. 13. Shewing the nett deaths of Woolwich residents, all deaths occurring in Institutions in the Borough, and deaths of Woolwich residents occurring in Institutions outside the Borough, during the year 1923. [##]Causes of Death. Male. Female. Woolwich. Plumstead. Eltham. Deaths in Public Institutions. West. East. In Borough. Outlying Institutions. Residents. NonResidents. All causes 720 667 397 433 345 212 353 51 222 Enteric Fever .. .. .. .. .. .. .. .. .. Small-pox .. .. .. .. .. .. .. .. .. Measles .. .. .. .. .. .. .. .. .. Scarlet Fever 2 2 .. 2 2 .. .. .. 3 Whooping Cough 1 8 1 1 1 1 .. .. 1 Diphtheria.. .. 2 1 .. 1 .. .. .. 2 Influenza 8 16 3 16 3 2 2 1 .. Encephalitis Lethargica .. .. .. .. .. .. .. .. .. Meningococcal Meningitis 2 .. 1 1 .. .. .. 1 .. Tuberculosis of Respiratory System 93 79 54 52 49 11 38 4 28 Other Tuberculous Diseases 9 10 1 6 10 1 11 1 3 Cancer, malignant disease 91 84 46 60 39 30 44 6 27 Rheumatic Fever 3 4 2 2 1 2 .. .. 2 Diabetes 3 7 2 2 2 4 2 .. 3 Cerebral Hsemorrhage, &c. 49 53 22 40 32 8 44 5 7 25 TABLE No. 13—continued. Plumstead. Deaths in Public Institutions. Causes of Death. Male. Female. Woolwich. West. East. Eltham. In Borough. Outlying Institutions. Residents. NonResidents. Heart Disease 70 96 40 51 46 29 31 3 14 Arterio-sclerosis 24 15 12 11 8 8 10 2 7 Bronchitis 47 46 38 25 18 12 16 2 8 Pneumonia (all forms) 40 25 28 13 9 15 7 2 13 Other respiratory diseases 7 3 5 2 1 2 3 1 2 Ulcer of Stomach or Duodenum 8 3 2 6 1 2 .. 1 6 Diarrhcea, &c. 11 6 8 4 3 2 3 2 3 Appendicitis and Typhlitis 5 1 1 1 4 .. 2 .. 3 Cirrhosis of Liver 7 2 1 3 4 1 5 1 1 Acute and Chronic Nephritis 18 17 8 10 12 5 15 3 3 Puerperal Sepsis .. 3 2 .. .. 1 1 .. 1 Other Accidents and Diseases of Pregnancy and Parturition .. 2 .. 1 1 .. 1 .. .. Congenital Debility and Malformation, Premature Birth 30 33 23 12 16 12 15 3 3 3uicide 11 4 7 4 3 1 4 1 1 Other Deaths from Violence 28 13 17 9 8 7 9 2 7 Other Defined Diseases 153 138 71 99 71 50 90 10 74 Causes ill-defined or unknown .. .. .. .. .. .. .. .. .. 26 CAUSES OF DEATH. Table No. 12 shews that 175 deaths were due to Cancer, 172 to Pulmonary Tuberculosis, 166 to Heart Disease, 102 to Cerebral Haemorrhage, 93 to Bronchitis, 65 to Pneumonia and 63 to Congenital Debility. Only 24 deaths were due to Influenza as compared with 66 last year. Cancer and Malignant Disease. The deaths ascribed to Cancer or Malignant Disease each year since 1919 are shown in Table No. 14. TABLE No. 14. Year. Males. Females. Total. Rate. Percentage of Total Deaths. 1919 76 81 157 1.15 9.35 1920 60 95 155 1.9 10.42 1921 76 106 182 1.84 11.42 1922 72 94 166 1.20 10.36 1923 91 84 175 1.25 12.62 The incidence of Cancer does not decline. This is not surprising because we do little or nothing to prevent the spread of this disease. We do not know how it originates and until we do so very little preventive work can be carried out. Until more is known of the factors which give rise to Cancer there does not appear to be anything which a local authority can do except to educate the general public to the fact that the earlier the case is seen by a medical man the better the chance of recovery. A number of theories have been put forward—theories as to infection, theories as to cancer houses and cancer districts, theories connected with diet, theories as to heredity and theories as to irritation— 27 but they are only theories and do not explain all the facts. Cancer, except in one instance, in its early stages does not give rise to pain and this is what makes it so dangerous. It gives rise to other signs, however, and it is important that the attention of the general public should be drawn to these signs, not in any alarmist fashion but as part of their general education. Swelling in the breast of a woman over 40 years, irregular bleeding at the change of life, bleeding from the bowels after 45 years, sores or swellings inside the mouth or on the tongue over 45 years, are all signs pointing to the necessity for a medical examination. The following Table shews the seat of primary disease in all deaths from Cancer (excluding other specified malignant tumours). TABLE No. 15. Seat of Primary Disease. Males. Females Total. Deaths in Hospital. Tongue 5 5 4 Mouth and Jaw 5 5 3 Pharynx 1 1 . . (Esophagus 12 2 14 8 Stomach 18 10 28 8 Liver and Gall Bladder 4 4 8 1 Intestines 7 14 21 6 Rectum 16 4 20 9 Uterus .. 13 13 6 Ovary .. 2 2 1 Breast .. 24 24 9 Vagina and Vulva .. 1 1 .. Skin .. .. .. .. Larynx 3 1 4 2 Lung 3 2 5 1 Pancreas 1 .. 1 .. Kidneys and Suprarenals * .. .. .. .. Bladder 6 1 7 .. Other specified Organs 3 2 5 4 Abdominal cavity (unspecified) 1 .. 1 .. Other and undefined .. 1 1 2 85 81 166 64 28 RESPIRATORY DISEASES. 93 deaths were due to Bronchitis, 65 to Pneumonia and 10 to other respiratory diseases. The corresponding figures for 1922 were:—Bronchitis, 123, Pneumonia 116, and other respiratory diseases, 5. The following Table No. 16 shews the number of deaths each year since 1919 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. 16. Deaths from Respiratory Diseases. Year. Bronchitis. Pneumonia. Other Respiratory. Total. Death Rate. No. under 5 years. Percentage under 5 years. 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% 1922 123 116 S 244 1.8 64 26.2 % 1923 93 65 10 168 1.2 22 13.1 % DIARRHOEA. 17 deaths were certified to be due to diarrhœal diseases during the year, 10 of these occurring in children under 2 years of age. The corresponding figures for 1922 were 9 and 7 respectively. 29 VIOLENCE AND SUICIDE. 41 deaths—28 males and 13 females—occurred from violence apart from suicide. 15 deaths were due to suicidal causes—11 males and 4 females. TUBERCULOSIS AND THE INFECTIOUS FEVERS. These are dealt with in the section dealing with the notifiable infectious diseases. INQUESTS. There were 128 inquests held on Woolwich residents during the year, compared with 144 in 1922, 102 in 1921, 145 in 1920 and 135 in 1919. INFANTILE MORTALITY. The number of deaths under one year was 123, compared with 184 in 1922, 197 in 1921 and 224 in 1920. The infantile mortality rate (deaths under one year per 1,000 births) was 43. The following Table No. 17 gives the infantile mortality rate in each registration district and it will be noted that the rate is highest in Woolwich and lowest in West Plumstead, the West Plumstead figure being 37. This is the lowest rate which has ever been recorded in any year, in any registration district in the Borough. 30 TABLE No. 17. Year. The Borough Woolwich Parish. West Plumstead East Plumstead Eltham. 1919 86 96 82 63 92 1920 61 75 62 51 55 1921 62 59 57 64 70 1922 62 65 57 80 45 1923 43 51 37 42 39 Illegitimate Deaths. The number of deaths amongst illegitimate infants was 10. A comparison of the infantile mortality rates of legitimate and illegitimate infants shows that the rate for legitimate was 40 and for illegitimate, 135. Causes of Death. The chief causes of death were:—Premature Birth and Debility, 53; Pneumonia, 13 and Diarrhoea, 8. Four deaths occurred from whooping-cough. The premature birth and debility figures are approximately the same as last year but the others are considerably lower. The following Table No. 18 shews the infantile mortality rate, the number of infant deaths, the number of deaths under 4 weeks per 1,000 births each year since 1905. 31 TABLE No. 18. Year. No. of Births. Infantile Mortality Rate. Infant Deaths. Total Number Infant 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 1922 2941 62 184 87 29 1923 2867 43 123 72 25 Total .. 57057 84 4772 1926 34 The above Table shews that the number of deaths under 4 weeks per 1,000 births was 25, and that although the general average rate is 34, within the last four years this figure has been under 30. The improvement which was noted last year in the first four weeks has continued. The chief causes of death in this period were premature birth, 36, marasmus, 9, atelectasis, 7, and congenital malformation, 7. Table No. 19 shews the number of deaths under one year classified by age and cause for the year 1923, and Tables Nos. 20 and 21 which follow, shews the causes of all infant deaths in the past five years, classified by parishes and sex, and in two age groups. 32 TABLE No. 19. INFANT MORTALITY, 1923. Nett Deaths from stated Causes at various Ages under One Year of Age. Causes of Death. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 1 month 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 .. .. .. .. .. .. .. .. .. .. Scarlet Fever .. .. .. .. .. .. .. .. .. .. Whooping-cough .. .. .. .. .. .. 1 1 2 4 Diphtheria and Croup .. .. .. .. .. .. .. .. .. .. Erysipelas .. .. .. .. .. .. .. .. .. .. Tuberculous Meningitis .. .. .. .. .. .. .. .. .. .. Abdominal Tuberculosis .. .. .. .. .. .. .. .. .. .. Other Tuberculous Diseases .. .. .. .. .. .. .. .. 1 1 Meningitis (not Tuberculous) .. .. .. .. .. .. 2 .. .... 2 Convulsions 2 1 .. .. 3 1 2 2 .. 8 Laryngitis .. .. .. .. .. .. .. .. .. .. Bronchitis .. .. .. .. .. .. 1 .. 1 2 Pneumonia (all forms) .. .. .. 1 1 4 2 .. 3 13 Diarrhœa. .. .. .. .. .. 1 1 .. .. 2 Enteritis .. .. .. .. .. .. 2 2 1 5 Gastritis .. .. .. .. .. 1 .. .. .. 1 Syphilis .. .. .. 1 1 .. .. .. .. 1 Rickets .. .. .. .. .. .. .. .. .. .. Suffocation, overlying .. 1 .. .. 1 .. 1 .. .. 2 Injury at Birth 5 .. .. 5 .. .. .. .. 5 Atelectasis 5 2 .. .. 7 .. .. .. .. 7 Congenital Malformation 5 2 .. .. 7 1 1 .. .. 10 Premature Birth 26 4 5 1 36 4 1 .. .. 41 Atrophy, Debility, and Marasmus 1 3 4 1 9 2 .. .. .. 12 Other causes .. 1 1 .. 2 1 1 .. 3 7 44 14 10 4 72 15 15 10 11 123 Nett Births registered during the calendar year Legitimate 2793. Illegitimate 74. Nett Deaths registered during the calendar year Legitimate 113. Illegitimate 10. 33 TABLE No. 20. INFANT DEATHS, 1919—1923. Cause of Death. The Borough. Woolwich. West Plumstead. East Plumstead. Eltham. M. F. M. F. M. F. M. F. M. F. Small-pox • • • • • • • • • • • • • • • • • • • • Chicken-pox • • • • • • • • • • • • • • • • • • • • Measles 5 3 1 1 2 1 2 1 • • Scarlet Fever • • • • • • • • • • • • • • • • • • • • Whooping Cough 15 17 3 3 3 3 3 6 6 5 Diphtheria 4 • • 1 • • 1 • • 1 • • 1 • • Erysipelas • • • • • • • • • • • • • • • • • • • • Tuberculous Meningitis 4 1 2 • • • • • • 1 1 1 • • Other Tuberculous diseases 7 3 2 1 3 • • 2 2 • • • • Meningitis (not Tuberculous) 7 3 3 • • • • 2 1 • • 3 1 Convulsions 17 17 5 2 3 5 6 3 3 7 Laryngitis 1 1 • • • • • • 1 1 • • • • • • Bronchitis 31 21 5 9 8 4 15 6 3 2 Pneumonia 68 44 30 19 11 8 14 10 13 7 Diarrhœa 9 6 6 2 3 1 • • 3 • • • • Enteritis 47 37 14 13 12 5 11 11 10 8 Gastritis 7 1 3 • • 2 1 • • • • 2 • • Syphilis 5 9 2 4 • • 2 1 1 2 2 Rickets 1 3 • • • • 1 • • • • 2 • • 1 Suffocation 3 10 • • 3 2 6 1 1 • • • • Injury at Birth 10 8 3 1 1 1 2 1 4 5 Atelectasis 17 13 6 3 3 5 4 3 4 2 Congenital Malformation 31 22 6 5 13 9 1 2 11 6 Premature Birth 130 116 45 40 26 33 34 23 25 20 Atrophy, Debility & Marasmus 82 40 22 10 19 15 27 9 14 6 Other causes 51 36 20 4 8 13 12 12 11 7 552 411 179 120 121 115 139 97 113 79 963 299 236 236 192 34 TABLE No. 21. INFANT DEATHS, 1919-1923. The Borough. Woolwich. West Plumstead. East Plumstead. Eltham. Cause of Death. Under 4 weeks 4 weeks1 year Under 4 weeks 4 weeks1 year Under 4 weeks 4 weeks1 year Under 4 weeks 4 weeks1 year Under 4 weeks 4 weeks1 year Small-pox .. .. .. .. .. .. .. .. .. .. Chicken-pox .. .. .. .. .. .. .. .. .. .. Measles .. 8 .. 2 .. 3 .. 3 .. .. Scarlet Fever .. .. .. .. .. .. .. .. .. .. Whooping Cough .. 32 .. 6 .. 6 .. 9 .. 11 Diphtheria .. 4 .. 1 .. 1 .. 1 .. 1 Erysipelas .. .. .. .. .. .. .. .. .. .. Tuberculous Meningitis .. 5 .. 2 .. .. .. 2 .. 1 Other Tuberculous diseases.. .. 10 .. 3 .. 3 .. 4 .. .. Meningitis (not Tuberculous) .. 10 .. 3 .. 2 .. 1 .. 4 Convulsions 11 23 .. 7 5 3 3 6 3 7 Laryngitis .. 2 .. .. .. 1 .. 1 .. .. Bronchitis 4 48 1 13 12 21 3 2 Pneumonia 11 101 4 45 1 18 2 22 4 16 Diarrhoea 3 12 1 7 2 2 3 .. .. Enteritis 7 77 2 25 2 15 2 20 1 17 Gastritis .. 8 .. 3 .. 3 .. .. .. 2 Syphilis 3 11 1 5 .. 2 1 1 1 3 Rickets .. 4 .. .. .. 1 .. 2 .. l Suffocation 6 7 2 1 3 5 1 1 .. .. Injury at birth 18 .. 4 .. 2 .. 3 .. 9 .. Atelectasis 29 1 9 .. 7 1 7 .. 6 .. Congenital malformation .. 31 22 6 5 15 7 1 2 9 8 Premature birth 228 18 81 4 51 8 52 5 44 1 Atrophy,Debility & Marasmus 69 53 19 13 19 15 22 14 9 11 Other causes 29 58 9 15 5 16 8 16 7 11 449 514 139 160 112 124 102 134 96 96 963 299 236 236 192 35 In view of the phenomenally low infantile mortality figure, I have investigated the records of the Borough since 1904 and present herewith in tabular form, a Table, No. 22, shewing the rates during the four quinquennial periods, 1904-1908, 1909-13, 1914-18, and 1919-23. In this Table, rates per 1,000 births have been calculated for groups of diseases. These groups are as follows :— (a) Infectious Diseases:— Smallpox, Chicken-pox, Measles, Scarlet Fever, Whooping Cough, Diphtheria and Erysipelas. (b) Tuberculous diseases. (c) Diseases of the nervous system:— Convulsions, Meningitis. (d) Diseases of the respiratory system:— Laryngitis, Bronchitis, Pneumonia. (e) Diseases of the digestive system:— Diarrhoea, Enteritis and Gastritis. (f) Syphilis. (g) Diseases of development. (h) All other diseases. For comparative purposes the figures for 1923 are shewn separately. The great improvement in the infantile mortality rate of 1923 compared with that of the quinquennium 1904-1908 is largely due to the diminution in the incidence of digestive diseases, respiratory diseases and debility and marasmus. It will be noted from Table 22 that the improvement which has taken place is not so marked in the first month of life as in the remaining eleven months. c 2 36 Infant health depends in the main on single domestic hygienic precautions, and the improvement which has taken place must be attributed to the spread of education amongst mothers, as to the best methods to be adopted to secure the care and comfort of infants, and to the general improvement which has taken place in sanitation during the period. These remarks particularly apply to the age period, two to twelve months. The rates given above shew that further improvement must take place in the first month of life—a more difficult matter because it involves ante-natal and natal care. If I read this Table correctly, there is evidence that this improvement is now beginning. Table No. 23 which follows, gives in similar detail corresponding information for the different registration districts for the quinquennium 1919-1923. 37 TABLE No. 22. INFANT MORTALITY, 1904-1923, Rates for stated Groups of Diseases and for stated Age Periods in Quinquennial Periods and for the year 1923. Quinquennial Periods. Groups. Totaxs. Sub-Divisions of Group " G." DeathRates. Congenital defects. Prematurity. Debility. Under 4 weeks. Over 4 weeks A B C D E F G H 1904-1908 6.89 3.77 7.19 18.90 23.73 1.36 41.39 8.83 11206 5.41 21.55 14.43 39.55 72.51 1909-1913 5.13 2.53 5.56 1399 12.66 1.27 32.42 9.71 83.27 4.71 16.60 1111 32.70 50.57 1914-1918 6.28 1.78 3.50 19.84 9.21 1.36 33.83 9.92 85.72 3.21 20.42 10.20 34.26 51.46 1919-1923 2.86 •98 2.86 10.78 6.95 •90 27.33 9.87 62.53 344 15.97 7.92 29.16 33.37 1923 1.39 •35 3.49 5.23 2.79 •35 21.97 7.33 42.90 3.48 14.30 4.19 25.11 17.79 The rates in each case are per 1,000 births. 38 TABLE No. 23. INFANT MORTALITY, 1919-1923. Rates for stated Groups of Diseases and for stated Age Periods Classified by Registration Districts. District. Groups. Totals. Sub-Divisions of Group "G," Death-rates. A B C D E F G H Congenital defects. Prematurity. Debility. Under 4 weeks. Over 4 weeks. Woolwich 2.08 1.15 2.31 14.53 8.76 1.38 29.53 9.23 68.97 2.52 19.62 7.39 32 06 36.91 West Plumstead 2.45 .73 2.45 7.84 5.88 •49 28.17 9.80 57.81 5.39 14.45 8.33 27.44 30.37 East Plumstead 3.39 1.57 2.61 11.99 6.51 •52 25.03 9.91 61.53 78 14.86 9.39 26.60 34.93 Eltham 3.82 •31 4.45 7.94 6.35 1.27 26.05 10.80 60.99 5.40 14.30 6.35 30.49 30.49 The Borough 2.86 •98 2.86 10.78 6.95 .90 27.33 9.87 62.53 3.44 15.97 7.92 29.16 33.37 The rates in each case are per 1,000 births. 39 SECTION III.—NOTIFIABLE DISEASES. NOTIFICATIONS. The total number of notifications, excluding duplicates, was 1,381, compared with 4,430 in 1922 and 3,611 in 1921. The decrease is due chiefly to the absence of measles, but there has been a diminution in the incidence of diphtheria, scarlet fever and pneumonia. Table 26 shews the notifications in detail for each Parish, and Table No. 24 shews the number of cases removed to hospital or sanatorium. The incidence of tuberculosis shews a slight increase this year, there being 311 cases notified compared with 305 in the previous year, but against this must be set the fact that in 1922, 32 deaths of non-notified tuberculosis occurred, whereas in 1923 only 17 occurred. The ratio between non-notified and the total tuberculosis deaths in 1922 was as 1 is to 6, and in 1923 was, as 1 is to 11. The following diseases are notifiable in the Borough:— (1) Pubhc Health (London) Act, 1891 (Section 55):— Cholera Puerperal fever Continued fever Relapsing fever Diphtheria Scarlatina or Scarlet Enteric fever Smallpox (fever Erysipelas Typhoid fever Membranous croup Typhus fever. 40 (2) Local Government Board Regulations:— Disease. Date. Dysentery 7/1/1919 Malaria 7/1/1919 Ophthalmia Neonatorum 5/2/1914 Plague 19/9/1900 Pneumonia—Acute primary 7/1/1910 Pneumonia—Acute influenzal 7/1/1919 Trench fever 7/1/1919 Tuberculosis 19/12/1912 (3) Ministry of Health Regulations:— Encephalitis Lethargica (acute) .. 31/12/1919 (4) By resolution of the London County Council:— Anthrax (human) 26/4/1909 Cerebro-spinal fever 13/3/1912 Glanders (human) 26/4/1909 Hydrophobia (human) 26/4/1909 Poliomyelitis (acute) and Polio-encephalitis 13/3/1912 (5) By resolution of the Woolwich Borough Council:— Zymotic enteritis 25/8/1913 The following four tables are published in accordance with the requirements of the Ministry of Health, and shew the total number of cases of infectious disease notified during the year ; the total number of deaths occurring amongst these cases, and the distribution and case-rate per 1,000 population in the various registration districts of the Borough. Table No. 28, which follows, shews the incidence of infectious disease in the Borough each year since 1901. 41 TABLE No. 24. INFECTIOUS DISEASES. Diseases. Total cases notified Cases admitted to Hospital. Total Deaths Diphtheria 152 147 2 Scarlet Fever 334 322 4 Enteric Fever (including Para-typhoid) 16 12 — Puerperal Fever 8 5 3 Pneumonia 242 50 |65 Erysipelas 40 10 1 Cerebro-spinal Meningitis 5 3 2 Poliomyelitis 6 4 — Encephalitis Lethargica 1 1 — Malaria 4 1 1 Dysentery 1 1 — Ophthalmia Neonatorum 18 8 — Zymotic Enteritis 49 7 17 Tuberculosis Pulmonary Males 128 139 93 Females 117 97 79 Total 245 236 172 Tuberculosis Non-pulmonary Males 30 24 9 Females 36 22 10 Total 66 46 19 Measles 194 5 — 1381 858 286 *. Not Notifiable—information obtained from voluntary sources. † Deaths from Influenzal Pneumonia not included. No cases of Smallpox, Typhus fever, Cholera, Continued fever, Relapsing fever, Plague, Trench fever, Anthrax, Glanders, Hydrophobia, or Acute Polio-encephalitis were notified during the year. 42 TABLE No. 25. CASES OP INFECTIOUS DISEASES NOTIFIED—1923. Diseases. Number of Cases Notified. Age Groups. All Ages. Under 1 year. 1 and under 2 years. 2 and under 3 years. 3 and under 4 years. 4 and under 5 years. 5 and under 10 years. 10 and under 15 years. 15 and under 20 years. 20 and under 35 years. 35 and under 45 years. 45 and under 65 years. 65 and over. Diphtheria 152 .. 6 12 12 10 51 12 23 21 5 .. .. Scarlet Fever 334 3 11 20 28 32 150 45 21 18 6 .. .. Enteric Fever 16 .. 1 1 1 2 3 1 4 2 1 .. Puerperal Fever 8 .. .. .. .. .. .. .. .. 6 2 .. . Erysipelas 40 .. 1 .. .. 1 2 l 2 7 4 15 6 Pneumonia 242 12 15 8 16 7 29 8 11 47 27 43 19 Malaria 4 .. .. .. .. .. .. .. 1 2 1 .. .. Ophthalmia Neonatorum 18 18 .. .. .. .. .. .. .. .. .. .. .. Dysentery 1 .. .. .. .. .. .. .. .. 1 .. .. .. Encephalitis lethargica 1 .. .. .. .. .. .. .. .. .. .. 1 Cerebro-spinal meningitis 5 .. 2 .. .. .. 1 1 1 .. .. .. .. Poliomyelitis 6 1 .. 2 3 .. .. .. .. .. .. .. .. Zymotic enteritis 49 20 1 8 2 .. 5 l 1 1 .. .. .. Tuberculosis Pulmonary Males 128 1 .. .. .. .. 3 .. 24 42 26 30 2 Females. 117 .. .. 1 .. .. 5 8 23 48 19 12 1 Total 245 1 1 . . 8 8 47 90 45 42 3 Tuberculosis Non-pulmonary Males 30 1 4 1 2 8 2 3 7 2 3 3 .. Females. 36 .. 4 2 3 7 7 4 4 2 3 .. Total 66 1 8 3 2 5 9 10 11 6 5 6 .. Measles (including German 194 .. 1 1 6 25 156 4 .. 1 .. .. .. Measles) 1381 56 56 56 70 80 413 94 119 204 97 108 28 43 TABLE No. 26. Cases of Infectious Diseases Notified in the Borough and Parishes during the Year 1923, showing the Case Kate per 1 ,000 Population. Diseases. Borough. Total Cases notified in each locality. Case Rates per 1,000 Population. Woolwich. Plumstead. Eltham. Borough. Woolwich. Plumstead. Eltham. West. East. West. East. Diphtheria 152 29 44 44 35 1.09 0.89 1.07 1.24 1.14 Scarlet Fever 334 101 91 74 68 2.39 3.10 2.21 2.08 2.22 Enteric Fever 16 5 7 2 2 0.11 0.15 0.17 0.06 0.06 Puerperal Fever 8 4 1 2 1 0.06 0.12 0.02 0.06 0.03 Erysipelas 40 10 10 13 7 0.29 0.31 0.24 0.37 0.23 Pneumonia 242 96 58 48 40 1.73 2.94 1.41 1.35 1.31 Malaria 4 2 1 1 0.03 .. 0.05 0.03 0.03 Ophthalmia neonatorum 18 7 3 5 3 0.13 0.21 0.07 0.14 0.10 Dysentery 1 .. .. 1 .. 0.01 .. .. 0.03 .. Encephalitis lethargica 1 .. 1 .. .. 0.01 0.02 .. .. Cerebro.spinal meningitis 5 2 1 .. 1 0.04 0.06 0.02 0 03 0.03 Poliomyelitis 6 2 3 1 0.04 0.06 0.07 .. 0.03 Zymotic Enteritis 49 26 13 8 2 0.35 0.80 0.31 0.22 0.06 Pulmonary Tuberculosis 245 81 66 60 38 1.75 2.48 1.60 1.69 1.24 Tuberculosis (other forms) 66 14 14 28 10 0.47 0.42 0.34 0.79 0.33 Measles (including German Measles) 194 10 7 26 151 1.39 0.31 0.17 0.73 4.94 1381 387 321 313 360 9.86 11.86 7.78 8.80 11.77 44 TABLE 27. DEATHS OP NOTIFIED CASES OF INFECTIOUS DISEASES (INCLUDING MEASLES), 1923. Diseases. Number of Deaths. All ages. Age groups. Under 1 1- 2- 3- 4- 5-10 10-15 15-20 20-35 35-45 45-65 65- Diphtheria 2 .. .. 1 .. 1 .. .. .. .. .. .. .. Scarlet Fever 4 .. .. .. .. .. 3 .. .. .. .. 1 Enteric Fever .. .. .. .. .. .. .. .. .. .. .. .. Puerperal Fever 3 .. .. .. .. .. .. .. .. 2 .. 1 .. Erysipelas 1 .. .. .. .. .. .. .. .. .. .. 1 .. Pneumonia 65 13 2 2 1 1 2 1 1 4 6 18 14 Malaria 1 .. .. .. .. .. .. .. .. .. .. 1 .. Ophthalmia Neonatorum .. .. .. .. .. .. .. .. .. .. .. .. .. Dysentery .. .. .. .. .. .. .. .. .. .. .. .. .. Encephalitis Lethargica .. .. .. .. .. .. .. .. .. .. .. .. .. Cerebro-spinal Meningitis 2 .. 2 .. .. .. .. .. .. .. .. .. .. Poliomyelitis .. .. .. .. .. .. .. .. .. .. .. .. .. Zymotic Enteritis 17 8 2 2 1 .. 1 1 .. 1 .. .. 1 Tuberculosis—pulmonary Males 93 .. .. .. .. .. 6 30 20 35 2 Females 79 .. .. .. .. .. 2 6 8 38 11 13 1 Total 172 .. .. .. .. .. 2 6 14 68 31 48 3 Tuberculosis—Non-pulmonary Males 9 1 .. 2 l .. .. 1 1 1 .. 2 .. Females 10 .. 1 .. 1 4 .. 1 2 .. 1 .. Total 19 1 1 2 l 1 1 1 2 3 .. 3 .. Measles .. .. .. .. .. .. .. .. .. .. .. .. .. 286 22 7 7 3 3 12 9 17 78 37 73 18 45 TABLE No. 28. Notification of Infectious Diseases, 1901 to 1923. Year. Small-pox Diphtheria and Mem. Croup. Scarlet Fever. Enteric Fever. Erysipelas. Puerperal Fever. Tuberculosis.* Continued Fever. Cerebro-Spinal Fever. Anterior Poliomyelitis Encephalitis lethargica. Ophthalmia Neonatorum. Zymotic Enteritis.§ Anthrax. 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 .. l .. .. .. 102 .. .. .. .. 396 1911 .. 239 518 16 82 16 375 .. l 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 .. l .. .. 18 199 .. .. .. .. 967 1915 .. 286 601 31 138 6 489 .. 50 2 .. 19 173 .. .. .. .. 1179 1916 1 271 222 9 95 16 469 .. 17 .. .. 33 80 .. .. .. .. 1590 1917 .. 277 147 12 79 12 543 .. 22 1 .. 41 101 .. .. .. .. 1710 1918 .. 240 222 12 61 14 660 .. 11 3 .. 23 118 .. .. .. .. 800 1919 4 398 243 26 63 7 474 .. 7 1 3 34 123 1 61 7 123 1886 1920 1 427 538 6 82 13 428 .. 6 .. 3 29 31 .. 29 1 136 1013 1921 .. 592 1351 11 59 14 356 .. 2 .. 9 32 454 .. 10 4 236 481 1922 .. 437 511 8 37 11 305 1 2 4 3 26 31 .. 11 .. 345 2698 1923 .. 152 334 16 40 8 311 .. 5 6 1 18 49 .. 4 1 242 194 * 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. 46 MEASLES. Notification Statistics. The number of cases coming to the knowledge of the Department during the year was 194, as compared with 2,698 in 1922. This disease is not notifiable and we depend upon notifications received from the school medical service and cases discovered by Health Visitors as an index to its prevalence. Nursing. The Council made arrangements in 1916 for the home nursing of Measles by the voluntary Nursing Associations. During 1923, three cases were nursed at home at a total cost to the Council of £1 1s. 0d. The number of visits paid by nurses was 42, thus averaging 14 visits per case. School Closure. No departments in Schools were closed by the London County Council during the year. Removal to Hospital. Cases of measles are received into the hospitals of the Metropolitan Asylums Board on the certificate of the Medical Officer of Health. During the year, 5 cases were removed. SCARLET FEVER. Notification. During the year 334 cases of scarlet fever were notified, compared with 511 in 1922 and 1,351 in 1921. The case rate is shewn in Table No. 26. The number of notifications received each quarter was as follows:— First quarter, 104. Third quarter, 55. Second quarter, 67. Fourth quarter, 108. Return Cases. The following Table shews the number of return cases, the dates of notification, the dates of discharge from hospital and some observations on the condition of the primary cases on discharge. 47 TABLE No. 29. No. in register. Date admitted to hospital. Date discharged. Total days in hospital. Onset of secondary case. Remarks on primary case. 43 5/ 2/23 12/ 4/23 67 17/ 4/23 78 3/ 3/23 28/ 4/23 57 3/ 5/23 4/ 5/23 22 27/ 1/23 17/ 4/23 80 13/ 5/23 8/ 6/23 Eight otorrhcea 12 19/ 1/23 21/ 4/23 93 15/ 5/23 15 22/ 1/23 28/ 4/23 97 11/ 6/23 Nasal discharge: slight otorrhoea 101 27/ 3/23 1/ 5/23 36 18/ 6/23 86 10/ 3/23 26/ 4/23 48 18/ 6/23 Nasal discharge: had otorrhcea in hospital Sore throat 166 27/ 6/23 26/ 7/23 30 3/ 8/23 7/ 8/23 159 14/ 6/23 1/ 8/23 49 8/ 8/23 160 16/ 6/23 1/ 8/23 47 1/ 9/23 135 19/ 5/23 5/ 7/23 48 10/ 8/23 Nasal discharge 184 30/ 7/23 20/ 9/23 53 26/ 9/23 1/10/23 169 29/ 6/23 9/ 8/23 42 19/10/23 24/10/23 History of ear trouble 225 30/ 9/23 20/11/23 52 15/12/23 142 16/10/23 18/12/23 64 22/12/23 Home Isolation. 12 cases, or 3.6 per cent. of cases, were isolated at home and in no instance did a return case occur. Regular inspections were made by the Sanitary Inspectors in order to ascertain that proper precautions for preventing the spread of disease were being taken, and in no instance has there been any ground for supposing that the public safety is endangered by home isolation in suitable cases. 48 The Royal Arsenal authorities require cases to be removed to hospital, or a certificate from the Medical Officer of Health of efficient home isolation, before their employees are allowed to return to work. During the year three certificates were issued. Multiple Cases. The following Table No. 30, shews the house distribution by wards of cases of scarlet fever occurring during the year. The term “house” in this Table is synonymous with the term “family” except in two instances where two families are involved. TABLE No. 30. 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 12 13 20 32 10 13 16 17 10 40 46 229 229 2 cases occurred .. 1 3 .. 2 1 5 .. 2 5 8 27 54 3 ,, ,, .. 2 .. 2 .. 1 .. 4 1 1 2 13 39 4 ,, ,, .. .. 1 .. .. .. .. 1 .. 1 .. 3 12 Total houses 12 16 24 34 12 15 21 22 13 47 56 272 334 This year the Ministry of Health have asked for information regarding the attack rate per 1,000 persons under 15 not known to have had a previous attack of the disease in question, according as they are housed under different conditions—for example, less than 1 person per room; 1-2 persons per room; more than 2 persons per room. The records do not give this information, and so the Table has been calculated shewing the case rate according to the total population living under these conditions at the time of the Census, 1921. 49 TABLE No. 31. Population in private families. Attack rates per 1,000. Less than 1 person per room 67,239 .79 1-2 persons per room 54,447 3.76 More than 2 persons per room 10,270 3.69 DIPHTHERIA. Notification. During the year 152 cases of diphtheria were notified, compared with 437 in 1922. The case rate is shewn in Table No. 26. The number of notifications received each quarter was as follows:— First quarter, 44. Third quarter, 28. Second quarter, 49. Fourth quarter, 31. Return Cases. All the return cases occurred in one family and the particulars are shewn in the following Table. TABLE No. 32. No. in Register Date admitted to Hospital. Date Discharged. Total days in Hospital. Onset of Secondary Cases. Remarks on primary case. 1922 436 26-12-1922 7-3-1923 72 14-3-1923 17-3-1923 22-3-1223 24-3-1923 26-3-1923 — Home Isolation. Five cases, or 3.3 per cent. of all cases were isolated at home, and in no instance did a return case occur. Multiple Cases. The following Table No. 33 shews the house distribution in wards of cases of diphtheria occurring during d 50 the year. The term “house” in this Table is synonymous with the term “family.” 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 3 5 12 3 18 2 5 8 10 29 21 116 116 2 cases occurred .. 1 2 .. .. 1 3 .. .. 1 2 10 20 3 „ ,, .. .. .. .. 1 .. .. .. .. 1 .. 2 6 4 „ ,, .. .. .. .. .. .. .. .. .. .. .. .. .. 5 ,, ,, .. .. .. .. .. .. .. .. .. .. 2 2 10 Total houses 3 6 14 3 19 3 8 8 10 31 25 130 152 Similar information with regard to the attack rate with reference to housing conditions has been asked for by the Ministry of Health in the case of diphtheria as with scarlet fever, and the corresponding Table is given below. TABLE No. 34. Population in private families. Attack rates per 1,000. Less than 1 person per room 67,239 .40 1-2 persons per room 54,447 1.53 More than 2 persons per room 10,270 3.31 Incidence of Diphtheria in Woolwich Families during the three years ending 31st March, 1923. During this period, 1,371 cases of diphtheria were notified, and the records regarding 1,318 cases occurring in ordinary dwelling houses 51 have been examined. The balance of 53 is accounted for by military cases, cases occurring in institutions and by lost record cards. All notifications of diphtheria were regarded for this purpose as notifications including bacteriological cases and those notified more than once in successive years. There were eleven such cases of secondary notifications in the series, one case being notified three times, and ten others twice. The following Table shews the number of families attacked and the number of cases occurring in each family. It will be noted that in 84 per cent. of the families attacked, only one case occurred over a period of three years:— TABLE No. 35. No. of Cases in family. No. of Families. Total No. of Cases. Excluding Cases Notified more than once. No. of Families. No. of Cases. 1 896 896 902 902 2 123 245 122 244 3 33 99 29 87 4 8 32 7 28 5 2 10 2 10 6 or more 5 35 5 35 1,067 1,318 1,067 1,306 Table No. 36 shews in detail the number of days elapsing between the first case and the subsequent cases in the family, and the number of instances in which this sequence of events occurred. In constructing this table, regard has been given to the fact that if a third case occurs in the family, a second must have occurred previously, and so, interpreted in this light, Table No. 35 reads as follows:—In 1,067 families, at least one case occurred; in 171, two cases; in 48, three eases; in 15, four cases; in 7, five cases; in 5, six cases; in 3, seven cases, and in 2, eight cases. d 2 52 TABLE No. 36. Period elapsing between first and subsequent cases. Number of Families : Total subsequent cases. Serial Number of Case. 2 3 4 5 6 7 8 Days .. 0— 2 30 1 1 — 32 — 4 26 7 1 — — — — 34 — 6 20 3 — 1 1 — — 25 — 8 13 6 1 — — — — 20 —10 8 6 4 — — — — 18 —20 23 9 3 3 2 2 1 43 —30 6 3 1 1 1 — — 12 Months.. — 3 19 6 3 1 — — 1 30 — 6 5 2 — 1 1 1 — 10 Years .. — 1 8 1 9 — 2 10 3 1 — — — — 14 — 3 3 1 — — — — — 4 Totals 171 48 15 7 5 3 2 251 It should be noted that this Table refers every case to the first case in the family, and takes no cognisance of the time between the second and third or between the fourth or fifth case, and it should read as follows:—32 subsequent cases occurred within 48 hours, involving 30 families in 29 of which there were only two cases, and in one of which there were four cases in all. It shews 251 secondary cases and 185 of these, or 73.7 per cent. occurred after four days from the initial outbreak in the family. Table No. 37 which follows, compares the incidence of diphtheria amongst different sized families and for purposes of comparison the total families, as enumerated at the Census, has been used. In the comparison in the second half of the table it will be noted that simultaneous attacks, i.e., occurring within 48 hours, have been excluded, simultaneous cases 53 being regarded as one attack. This table would seem to shew that the larger the family (up to families of 6 persons) the greater the liability to attack and the greater the incidence of multiple attacks. TABLE No. 37. Census, 1921. Families attacked. % of total families. Families with multiple attacks. All families. No. of simultaneous cases. Excluding simultaneous attacks. Size of Families. No. of Families. No. % per family attacked. No. % per family attacked. 1 2289 3 0.13 •• •• •• •• •• 2 6443 35 0.54 1 2.82 •• •• •• 3 7713 153 1.99 15 10.00 i 14 9.15 4 6318 239 3.78 27 11.29 4 23 9.62 5 4390 236 5.37 41 17.37 4 37 17.37 6 2784 154 6.47 29 18.83 6 23 14.93 7 1714 111 5.61 22 19.82 1 21 18.92 8 963 54 5.39 18 33.33 2 16 29.63 9 & over 1033 55 5.32 16 29.09 3 13 23.64 Not stated •• 27 •• 2 •• •• •• •• ENTERIC FEVER. Sixteen cases of enteric fever were notified during the year. In 3 cases the diagnosis was not confirmed. In the following Table the details of each case are shewn:— 54 TABLE No. 38. No. Date. Sex. Age. Diagnosis. Final Diagnosis. Result. 1923 1 Jan. 2 F. 10 Para Typhoid B. Para Typhoid B. Cured 2 Mar. 21 M. 14 Typhoid Lobar Pneumonia Cured 3 May 9 F. 26 Typhoid Para Typhoid B. Cured 4 May 29 F. 20 Para Typhoid Para Typhoid Cured 5 June 12 F. 9 Typhoid Para Typhoid B. Cured 6 June 18 M. 5 Enteric Enteric Cured 7 July 6 F. 44 Enteric Para Typhoid B. Cured 8 July 30 M. 3 Enteric Lobar Pneumonia Cured 9 Sept. 9 F. 2 Enteric Typhoid Cured 10 Sept. 26 F. 26 Typhoid Para Typhoid B. Cured 11 Oct. 7 F. 51 Para Typhoid Not Typhoid Fever Cured 12 Oct. 11 F. 25 Typhoid Typhoid Cured 13 Oct. 16 F. 14 Typhoid Para Typhoid A. Cured 14 Oct. 27 M. 38 Para Typhoid Para Typhoid Cured 15 Nov. 15 F. 1 Para Typhoid Para Typhoid B. Cured 16 Nov. 22 M. 18 Enteric Typhoid Cured PNEUMONIA, MALARIA, DYSENTERY AND TRENCH FEVER. These diseases are compulsorily notifiable under the Public Health (Pneumonia, Malaria, Dysentery, etc.) Regulations, 1919. During the year the following number of cases was notified:— Pneumonia 242 Malaria 4 Dysentery 1 Trench Fever 0 55 Pneumonia. The notifications and deaths from pneumonia during the past five years have been as follows:— Notifications. Deaths. 1919 123 125 1920 136 97 1921 236 98 1922 345 116 1923 242 65 It is perfectly clear that medical practitioners do not understand what forms of pneumonia are notifiable, and the common mistake seems to be in assuming that the description in the Regulations “Acute Primary Pneumonia” means Acute Lobar Pneumonia. It is true that it means Acute Primary Lobar Pneumonia, but it also means Acute Primary Broncho Pneumonia and any other acute primary pneumonia. The following quotation from a Memorandum issued by the Local Government Board in 1919 defines exactly what was the intention of the Board when Regulations were made for the notification of pneumonia:— " Acute pneumonia may be defined as a febrile disease characterised by inflammation of the lungs and due to one or more specific micro-organisms. Two forms of the disease are generally recognised :— (a) Acute lobar or croupous pneumonia ; and (b) Acute lobular or broncho-pneumonia. Either of these may be either primary or secondary to some other recognised disease." One of the chief objects of notification of pneumonia was to obtain statistical evidence of the extent to which the disease or diseases existed, and until notification is more thorough this object cannot be achieved. Another very important reason for making these diseases notifiable was to 56 enable local authorities to provide nursing assistance where this was necessary, and, when one remembers that pneumonia is the fourth highest cause of death in this Country at the present time, any measure which assists its cure and treatment is of the greatest importance. Nursing Provision. I am informed by the Secretaries of the various voluntary Nursing Associations in the Borough that the following number of cases of pneumonia were nursed during the year:— Woolwich and Plumstead Nursing Association 77 Eltham District Nursing Association 5 Silvertown and North Woolwich Nursing Association 4 St. Luke's Parish Nursing Association 1 87 On the assumption that one death is equivalent to three cases of pneumonia, 60 cases were treated in hospitals. It is known that 50 notified cases were so treated. The following Table No. 39 shews the number of notifications of pneumonia received each month, classified according to type and to the sex incidence. It also shews the number of deaths occurring from all forms of pneumonia during the year. 57 TABLE No. 39. Month. Male, Female. Total. Type No. of Deaths. Lobar. Broncho. Influenzal Acute Primary, (not specified) Acute primary pneumonia Influenzal pneumonia January 10 6 16 6 6 — 4 9 1 February 13 4 17 8 4 2 3 6 2 March 12 5 17 3 2 5 7 5 — April 19 9 28 5 — 9 14 9 4 May 16 10 26 7 5 10 4 3 2 June 16 7 23 3 6 6 8 6 July 12 9 21 8 4 — 9 2 August 11 5 16 8 7 — 1 2 — September 8 6 14 11 — 1 2 3 — October 9 1 10 4 2 1 3 3 — November 19 10 29 6 10 6 7 6 1 December 15 10 25 7 4 6 8 12 2 160 82 242 76 50 46 70 65 12 The next Table, No. 40, shews the distribution of pneumonia in each Ward in the Borough, classified according to the type of pneumonia given on the notification certificate:— TABLE No. 40. NOTIFICATION OF PNEUMONIA. Ward. Lobar. Broncho. Influenzal. Acute Primary. Total. Dockyard 5 3 2 6 16 St. Mary's 1 5 3 2 11 River 10 26 14 3 53 St. George’s 9 1 1 5 16 Burrage 6 . . 7 . . 13 Herbert 4 1 3 . . 8 Glyndon 3 . . 8 7 18 St. Margaret's 11 1 . . 7 19 Central . . 2 2 3 7 St. Nicholas 16 7 2 16 41 Eltham 11 4 4 21 40 76 50 46 70 242 58 Malaria. The Regulations provide that it is the duty of the Medical Officer of Health to take all practical steps to ensure that persons suffering from Malaria are supplied with sufficient mosquito netting ; receive the necessary quinine treatment; receive proper advice as to the continuation of quinine treatment in order to prevent relapses, and receive proper advice as to the precautions to be taken to prevent the spread of infection. Four cases of malaria were notified but in only one of them was it necessary to take the action contemplated under the Regulations of 1918. On becoming acquainted with the facts of this case, I sent the patient to the Seamen's Hospital to receive the necessary treatment and advice in order to prevent a relapse and the spread of infection. He was admitted as an in-patient there. A subsequent examination of his blood failed to show the presence of the malaria parasite. OPHTHALMIA NEONATORUM. Eighteen cases of ophthalmia neonatorum were notified during the year and eight cases were treated in hospital. In tabular form is shewn below, as required by the Ministry of Health, the result of each case :— TABLE No. 41. OPHTHALMIA NEONATORUM. No. notified. Treated: Vision unimpaired. Vision impaired. Total blindness. Deaths. At home. In hospital 18 10 8 18 •• •• •• 59 Nursing. The Council made arrangements in 1920 for the home nursing of patients suffering from this disease. During 1923, six cases were nursed at home at a total cost to the Council of £6 9s. Od. The number of visits paid by nurses was 129. PUERPERAL FEVER. Eight cases of Puerperal fever were notified during the year and five were treated in hospital, four being in hospitals of the Metropolitan Asylums Board and one in a Poor Law Institution. Three deaths occurred. ZYMOTIC ENTERITIS. 49 cases of zymotic enteritis were notified, compared with 31 in 1922. The number of cases and the number of deaths 31 in 1922. The number of cases and the number of deaths occurring in each quarter are shewn below:— Quarter. Cases. Deaths. First 0 4 Second 5 3 Third 36 8 Fourth 8 2 49 17 ACUTE POLIOMYELITIS. Six cases of this disease were notified during the year. The following Table shews in detail the condition of each patient at the end of the year:— 60 TABLE No. 42. Date notified. Sex. Age. Condition on 31st December, 1923. Treatment obtained. 1923. March 18 F. 2½ Bight leg affected. Now recovering under massage and electrical treatment. Able to walk. Out-patient, Miller Hospital May 25 F. 3 Hight leg affected. Now receiving electrical treatment and massage. Able to stand, but not able to walk. Guy's Hospital July 7 F. ½ Left arm affected. Improvement gradual. Out-patient, Miller Hospital July 27 F. 2½ In good health Out-patient, Miller Hospital August 16 F. 3 Progress satisfactory under mild massage. Propose to transfer to Queen Mary's Hospital, Carshalton. In-patient, Woolwich Infirmary August 31 F. 3 Progress satisfactory under mild massage. Propose to transfer to Queen Mary's Hospital, Carshalton. In-patient, Woolwich Infirmary OTHER NOTIFIABLE INFECTIOUS DISEASES. No cases of Smallpox occurred and no special comment is required on the incidence of Whooping-cough, Erysipelas, or Cerebro-spinal Meningitis. The number of cases of these diseases is shewn in Table No. 28 and is below the average of preceding years. 61 TABLE No. 43. TUBERCULOSIS. Summary of Notifications received during year ended 31st December, 1923. Age-periods— Notifications on Form A. Notifications on Form B. Number of Notifications on Form C. Number of Primary Notifications. Total Notifications on Form A. Number of Primary Notifications. Total Notifications on Form B. Poor Law Institutions. Sanatoria. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 .... 45 to 55 55 to 65 65 & upwards Total Primary Notifications. Under 5 5 to 10 10 to 15 Total Primary Notifications. Pulmonary Males 1 .. 3 .. 24 22 20 26 18 12 2 128 167 .. .. .. .. 2 14 111 ,, Females .. 1 5 8 23 21 27 19 12 .. 1 117 141 .. .. .. .. .. 28 56 Non-Pulmonary Males 1 9 2 2 7 1 1 3 1 2 .. 29 32 . . .. 1 1 1 3 17 „ Females .. 9 6 5 4 1 3 2 1 2 .. 33 34 .. 1 2 3 4 2 16 Total 2 19 16 15 58 45 51 50 32 16 3 307 374 .. 1 3 4 7 47 200 New Cases not Notified. Pulmonary Males .. .. .. .. .. 1 .. 1 1 3 1 7 .. .. .. .. .. .. .. .. „ Females .. .. 2 .. 1 1 .. .. 1 .. 1 6 .. .. .. .. .. .. .. .. Non-Pulmonary Males .. 1 .. .. .. .. 1 .. 1 .. .. 3 .. .. .. .. .. .. .. .. ,, Females .. .. 1 .. .. .. .. .. .. .. .. 1 .. .. .. .. •• .. .. .. Grand Total 2 20 19 15 59 47 52 51 35 19 5 324 •• .. .. .. •• .. •• •• 62 TUBERCULOSIS. This part of the report, which has been 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 the London County Council who contribute 50 per cent. and 25 per cent. respectively, of the nett expenditure. Staff. At the end of the year the staff consisted of one whole-time and one part-time Tuberculosis Officer, three Tuberculosis Visitors, one Clerk-Dispenser, and one Lay Organiser. Two changes have taken place during the year— one whole-time Medical Officer being replaced by one halftime Medical Officer, and one Nurse-Dispenser being replaced by one Clerk-Dispenser. The half-time Medical Officer devotes the other half of his time to work under the Council's Maternity and Child Welfare scheme. Notifications. The total number of notifications received was 381, but 70 of these related to cases which had been previously notified so that the total number of new notifications was 311. The corresponding number for 1922 was 305. 17 cases of tuberculosis died before notification, compared with 32 in 1922. The total cases coming under notice for the first time during the year were 328, compared with 337 in the previous year. In August, 1923, all medical practitioners were circularised by the Ministry of Health on their obligations under the Tuberculosis Regulations, and it is clear, from the increased number of duplicate notifications, and from the small number of unnotified deaths, that increased attention is being given by practitioners to notification. Notifications received on forms “C” and “D,” i.e., notifications from institutions regarding admissions and discharges, are not included in the above figures. 63 The distribution of the various cases notified since 1919 is as follows:— TABLE No. 44. Year. Lungs. Meninges. Intestines and Peritoneum. Glands. Joints. Spine. Other Forms. All Causes. 1919 394 4 3 35 19 5 14 474 1920 359 7 5 24 17 11 5 428 1921 285 14 5 17 17 9 9 356 1922 245 8 5 16 20 5 6 305 1923 245 9 6 31 8 10 12 311 Cases of Tuberculosis in the District. The Public Health (Tuberculosis) Regulations, 1921, impose on the Medical Officer of Health the duty of keeping the Tuberculosis Register up to date. This work has been carried out throughout the year and the cases on the register at the end of the year can be classified as follows—the corresponding figures for 1922 being given for purposes of comparison :— 1923 1922 Number of cases reported to be well 1,360 1,278 Number of cases presumably suffering from active tuberculosis 929 933 Total number of cases in the Borough 2,289 2,211 It will be noted from these figures that they do not agree with what may be described as the natural increase of notifications over deaths. The discrepancy is due to the cases transferred to other districts, and to those untraced during the year. 64 Cases classified as “well” are those which are found to be well and working and not in need of medical treatment at the time of the visit of the Tuberculosis Visitor. The following Table shews the number of deaths from . tuberculosis and the total deaths and death rates since 1919. TABLE No. 45. Year. Deaths. Death-rates. All Forms. Pulmonary. NonPulmonary. All Forms. Pulmonary. NonPulmonary. 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 1922 190 163 27 1.37 1.18 0.19 1923 191 172 19 1.36 1.22 0.14 It will be seen from the above Table that 191 deaths were certified as due to tuberculosis during the year, but, in addition to these, 13 persons, who had been notified as cases of tuberculosis, died during the year. The following Table shews information relating to these cases. 65 TABLE No. 46. Case No. Date notified as Tuberculosis Cause of Death. Remarks of Tuberculosis Officer. 1 24- 8-23 Zymotic Enteritis 2 21-12-11 Cerebral Hæmorrhage Was an arrested case of [Tuberculosis 3 23- 4-23 Sarcoma of Ileum 4 27- 9-19 Bronchiectasis 5 14- 9-22 Aortic Aneurysm 6 23- 3-23 Cancer of Lung 7 1- 3-21 Bronchitis 8 16- 9-22 Bronchitis T.B. + (29-9-22) 9 30- 9-21 Bronchitis T.B. + + + 10 19- 5-21 Bronchitis T.B. — (4 tests) 11 29-11-20 Pernicious Anaemia 12 30-10-19 Bronchitis T.B. + 13 31- 1-23 Specific disease of Lung The period which elapsed between notification and death was as shewn below :— TABLE No. 47. Pulmonary. Percentage. Non-Pulmonary. Percentage. Not Notified 13 7.6 4 21.0 0—1 Months 24 13.9 10 52.6 1—3 21 12.2 — — 3—6 12 7.0 2 10.5 6—12 ,, 24 13.9 1 5.3 1—2 years 24 13.9 1 5.3 2—5 33 19.2 1 5.3 Over 5 years 21 12.2 — — 172 19 The ratio between non-notified and the total tuberculosis deaths, as will be seen from the Table shewn above, is therefore as one is to eleven. e 66 Co-operation with Hospitals and Invalid Children's Aid Association. Arrangements which were made in previous years for special hospital examination or treatment were continued during the year. These arrangements were with the Seamen's Hospital for X-Ray examination of difficult cases ; with the London Hospital for the treatment of lupus, and with the Brompton Hospital for the provision of artificial pneumo-thorax refills. 42 cases were referred to the Seamen's Hospital; 2 cases (involving 52 attendances) were referred to the London Hospital, and 4 cases (involving 41 attendances) to the Brompton Hospital. 32 children, who were in need of convalescent treatment, and who, on examination at the Dispensary were found to be non-tuberculous, were referred to the Woolwich branch of the Invalid Children's Aid Association, and were given suitable treatment. Co-operation with the School Medical Service. In this branch of the work children may be referred by the Tuberculosis Officer to the District School Medical Officer or by him to the Tuberculosis Officer. During the year this cooperation was improved by the introduction of a system under which all children so referred are reviewed once a year by these two officers in consultation, and such further measures as seem necessary are decided upon. Many children were referred direct to the School Clinic in Brewer Street for treatment for minor ailments and dental caries. Co-operation with Medical Practitioners. Happy relations continue to exist between the Dispensary and the medical practitioners in the Borough. New regulations made by the Ministry of Health, which will come into operation in 1924, will improve the co-operation with medical practitioners who have charge of insured patients. During the year the Tuberculosis Officer saw 45 cases in consultation at the homes of 67 patients, and 239 cases were referrred to him at the Dispensary by medical practitioners. Home Contacts. The number of contacts examined at the Dispensary shews a gratifying increase, the figures being 525 compared with 362 for the year 1922. This figure will steadily increase as soon as patients realise the importance of the examination of those in the same house for the detection of early cases of the disease. Home Nursing. The various local Nursing Associations have continued to render very valuable assistance in the nursing of patients who are confined to bed. Extra Nourishment. Under the scheme sanctioned by the Ministry of Health, extra nourishment was supplied to certain selected cases of tuberculosis. Extra nourishment is only sanctioned for one month at a time. Each case is recommended by the Tuberculosis Officer and is then subject to review by a Committee, which, in the early part of the year, was a Sub-Committee of the Council, but is now a Sub-Committee of the Care Committee. The total number of applications (affecting 82 persons) approved was 230, the total cost to the Council being £241 15s. 2d. Dental Treatment. This service was sanctioned by the Ministry of Health in 1922. During the year, 49 patients received treatment, the total number of attendances being 142. Patients receive dental treatment free, but when articial teeth are necessary, patients are assessed according to their means, each case being treated on its merits. Dentures were supplied in ten cases at a total cost of £39 10s. 0d., and during the year the income received under this head was £18 12s. 6d. e 2 68 Shelters. The Council have provided, in accordance with their powers under the Tuberculosis Regulations, eleven shelters for the use of patients. These were used to the fullest extent during the year. Additional shelters are required. Bacteriological Examinations. During the year 607 specimens of sputum were examined at the Dispensary of which 495 were negative and 112 positive. These were in addition to the specimens of sputum sent by individual general practitioners to the Seamen's Hospital, Greenwich, for examination, of which 172 were negative and 48 positive. Institutional Treatment. The following Table shews the number of patients admitted to hospitals, sanatoria, Poor Law institutions, and training colonies during the year:— TABLE No. 48. Hospitals. Sanatoria. Infirmary. ing Colonies. Insured 71 94 40 3 Uninsured 34 35 21 — Children 25 19 8 — 130 148 69 3 These numbers refer to 282 persons, and the monthly admissions from January to December were as follows:— January 31 July 26 February 25 August 36 March 33 September 34 April 32 October 37 May 24 November 26 June 30 December 16 69 Care Work. The Council's Tuberculosis Care Scheme was formulated during the year and the Tuberculosis Care Committee came into being in the autumn. The Committee at the end of the year was constituted as follows:— Bodies. Representatives. Woolwich Borough Council Councillors Miss G. E. Walters, R. M. W. Allen, H. Harvey, J. A. Turnbull, J.P. Woolwich Board of Guardians Captain W. T. Cusheon, Mrs. E. M. Newman Lewisham Board of Guardians Miss E. P. Goody London County Council Miss E. F. Faulkner, Dr. H. R. Kidner Trade Unions Mr. T. R. Goy, Mr. T. S. Sills, Mr. G. Wordley Employers Mr. S. J. Clothier, Miss Fletcher, Mr. R. A. E. Welford Friendly Societies Mr. W. Cherry, Mr. W. A. Lyon, Mr. F. D. Smyth London Insurance Committee Mr. W. Edwards Panel Committee for County of London Dr. J. J. O'Mullane War Pensions Committee Miss N. Budd Woolwich Invalid Children's Aid Association Mrs. J. B. Great Rex Late Tuberculosis Dispensary Committee Mr. E. G. Dixon, J.P. Ex-officio Members:— Voluntary Visitors Miss R. C. Wild, Miss L. P. Bloxam, Miss M. Shaw, Mr. A. Dennis Tuberculosis Officer Dr. F. J. C. Blackmore Medical Officer of Health Dr. J. MacMillan The first meeting of the Care Committee was held in October. Three Sub-Committees were formed in order to deal with the varied aspects of care work. These Committees were constituted as follows:— 94 TABLE No. 58. MALES. Ages in weeks. No. of Infants weighed. Weight in lbs. Increase in period. Average gain per week In lbs. Ounces (approx.) 3 585 8.25 .. .. 8 896 10.23 1.98 .39 6¼ 13 846 11.98 1.75 .35 5¾ 18 770 13.69 1.71 .34 5½ 23 694 14.93 1.24 .25 4 28 651 16.15 1.22 .24 4 33 607 17.36 1.21 .24 4 38 532 18.56 1.20 .24 4 43 455 19.75 1.19 .24 4 49 525 20.63 .88 .15 2½ 70 Sub-Committee. Meetings held Genera] Purposes and Assessment Weekly Finance Monthly Employment Periodically The Committee, during the last two months of the year, organised the machinery for care work and took over the responsibility of advising the London County Council as to the assessment of patients for hospital treatment, and the Borough Council with regard to the provision of additional nourishment and artificial teeth. These are described officially as subsidiary work on the part of the Care Committee, but, in actual fact, they take up a large amount of time to the exclusion of the proper work of the Committee which is to look after the social and economic side of the family of the tuberculous, while the sanitary authority is looking after the preventive and curative side. The Committee is enthusiastic and the development of an organised scheme of Care work can confidently be looked forward to in 1924. Form " R " (a return as to work carried out in connection with the Dispensary during the year) is appended. 71 TABLE No. 49. Return as to work carried out in connection with the Maxey Road Tuberculosis Dispensary for the year 1923. (Form " R " (revised)). Number of Under observation at the Dispensary on Jan. 1st pending diagnosis. Examined for the first time during the year, Total. Found to be Under observation at the Dispensary on Dec. 31st pending diagnosis. Ceased attendance before completion of diagnosis. Suffering from Tuberculosis. Not suffering from Tuberculosis. Pulmonary. NonPulmonary. (a) All persons (including " Contacts." Adults. M. 12 288 300 64 2 218 15 1 F. 9 367 376 61 5 296 11 3 Cliildren under 15 M. 13 285 298 10 272 7 3 F. 12 260 272 7 4 249 8 4 Total 46 1,200 1,246 138 21 1,035 41 11 (B) " Contacts " (included in (a;. Adults. M. 1 106 107 19 1 78 8 1 F. 3 149 152 14 2 126 7 3 Children under 15 M. 1 143 144 .. 2 138 4 .. F. 1 127 128 .. .. 118 10 .. (c) Insured persons included in (a). M. 8 250 258 56 1 188 13 .. F. 1 111 112 29 3 75 4 1 72 TABLE No. 49 (continued). 1. Number of patients under treatment or supervision (excluding persons under observation or domiciliary treatment) on the 31st December 649 2. Total number of attendances of patients at the Dispensary during the year— Insured 3,435 Uninsured 4,178 3. Number of persons placed during the year under observation at the Dispensary for the purpose of diagnosis 301 4. Number of cases in which the period of observation at the Dispensary exceeded two months 38 5. Number of insured patients under domiciliary treatment on December 31st 280 6. Number of reports received from Insurance Practitioners in respect of insured patients under domiciliary treatment during the year 191 7. Number of persons referred to affiliated hospitals for consultation 8. Number of consultations with medical practitioners at the homes of patients— Insured 42 Uninsured 3 9. Number of other visits paid by Tuberculosis Officers to the homes of patients 627 10. Number of visits paid by Nurses or Health Visitors to the homes of patients for dispensary purposes 3,909 11. Number of specimens of sputum examined in connection with the work of the Dispensary 607 73 SECTION IV—CAUSES OF SICKNESS. Specify any causes of sickness and invalidity which have been specially noteworthy in the district during the year. (This should include information obtained from local general practitioners). Unfortunately, no definite information is available on this subject, but it can be safely said that there was a phenomenally low incidence of sickness during the year amongst the inhabitants of Woolwich. Generally the death rate throws some light on the sickness rate, and when it is noted that 68 per cent, of the deaths occurring in 1923 were of persons over 45 years of age, and that at no time in the history of the Borough has the proportion of deaths amongst persons under 45 years of age been so low, the statement set out above can be safely made. I have been in personal communication with the medical practitioners in the Borough during the year, and have gathered in general conversation that they have had very little sickness to deal with. At the end of the year I wrote to several of them on this question, and their replies were so uniform that they might have been prepared in this office in advance and cyclostyled. The following is typical:— " In reply to your letter, there is nothing noteworthy to report as regards health conditions during the year." What is written above is true up to, and including November. In December there was a rise in the sickness rate and there was some increase in the number of cases of bronchitis and other catarrhal diseases. There was very little infectious disease, the notifications of diphtheria being lower than they have ever been in the records of the Borough. 74 SECTION V.—SUMMARY (for reference) of Nursing Arrangements, Hospitals, and other Institutions available for the District (including Report on Maternity and Child Welfare Work). In tabular form is set out a summary of the nursing arrangements, hospitals and other institutions available for the district:— Professional Nursing in the Home. There are four Nursing Associations in the district, as follows :— The Woolwich and Plumstead Nursing Association, 22 Nightingale Place, Woolwich, S.E. 18. The Silvertown and North Woolwich District Nursing Association, Saville Road, Silvertown, E. 16. The Eltham District Nursing Association, (Nurse), Miss M. Alexander, 13 The Broadway, Eltham. St. Luke's Parish, Eltham, (Nurse), Miss Bloomfield, 83 Congreve Road, Eltham. The areas in which these Nursing Associations work are sufficiently well-defined by their names. The Woolwich and Plumstead District Nursing Association, in addition to doing general nursing in the district, provide nurses for the London County Council School Clinics and for the Garrison. When an allowance is made for this, it is estimated that the whole time of seven to eight nurses is devoted to general nursing in the district. 75 All these Nursing Associations will nurse cases of measles, whooping-cough, ophthalmia neonatorum and tuberculosis, but they do not, and it is not desirable that they should, provide nursing assistance for cases of scarlet fever, diphtheria or enteric fever. Nursing assistance is given for a limited number of cases of acute primary and acute influenzal pneumonia. The Borough Council have entered into agreements with all these Nursing Associations, whereby nursing assistance in necessitous cases is paid for by the Borough Council for patients requiring such assistance if suffering from measles or ophthalmia neonatorum. The rates paid are as follows : Is. Od. per visit; two or more cases in one home, 6d. per case, per visit. There is an urgent necessity for the extension of these arrangements for the nursing of pneumonia, and, at the time this report is being prepared, negotiations are in progress with the various Nursing Associations to enable the Council (as is done by many other Boroughs in London) to provide a skilled nursing service for persons suffering from the pneumonias. Midwives. Through the courtesy of Sir William Hamer, the Comity Medical Officer of Health, 1 have been able to ascertain that 47 midwives gave notice during the year of their intention to practise as midwives in the Borough of Woolwich. The Council do not employ or subsidise practising midwives. 76 TABLE No. 50. CLINICS AND TREATMENT CENTRES. Situation. Nature of Accommodation. By whom provided. Sessions weekly. Maternity and Child Welfare Centres. Town Hall, Woolwich Doctor's room, Weighing room, Waiting rooms, etc. Woolwich Borough Council 6 289 High Street, Plumstead Do. Do. 6 179 Well Hall Road, Eltham Do. Do. 4 Wesley Hall, Timbercroft Lane, Plumstead Doctor's room, Weighing room, Do. 1 Church Army Hut, New Eltham Doctor's room, Weighing room. Woolwich Borough Council 1 St. John's Hall, North Woolwich Do. Do. 1 Victory Club, Beresford Street Doctor's room, Weighing room. Waiting room. Voluntary Organisation 1 Day Nurseries. Nil School Clinics. Brewer Street, Woolwich Doctor's rooms, Treatment rooms, Waiting rooms. Local Medical Association Daily Plumstead Road, Plumstead Do. Do. Daily Cyril Henry Treatment Centre, St, Mary Street, Woolwich Accommodation for operating on, and detention of, cases of enlarged tonsils and adenoids London County Council Daily 77 TABLE No. 50—continued. Situation. Nature of Accommodation. By whom provided. Sessions weekly. Borough Disinfecting Station, White Hart Road, Plumstead Accommodation for cleansing of verminous children Woolwich Borough Council Daily Tuberculosis Dispen sary. Maxey Road. Plumstead Doctor's rooms, Waiting rooms, Dressing rooms, Dispensary, etc. Woolwich Borough Council Daily Venereal Diseases. Nil. Hospitals Provided or Subsidised by the Local Authority, or by the County Council. (1) Tuberculosis. The County Council is responsible for the institutional treatment of tuberculosis in London and they maintain no institution in Woolwich. (2) Maternity. The British Hospital for Mothers and Babies, Samuel Street, Woolwich (40 beds). This Hospital was opened in March, 1922, and provides accommodation for 40 cases. This includes the isolation block. The scheme for the construction of the Hospital was a more ambitious one than was actually carried out, but the building has been constructed in such a way as to allow for further extensions. The new buildings do not provide accommodation for an ante-natal or post-natal clinic and so, in the meantime, it has been necessary to retain for this purpose the old Hospital in Wood Street. 78 I am indebted to Miss Gregory, the Secretary of the Hospital, for the following information which shews, statistically, the number of cases dealt with during the year :— Mothers admitted during the year 565 Children born 566 Maternal Death 1 Outdoor Cases 219 Ante-Natal and Post-Natal Clinics :— Mothers attending clinics 1,016 Attendances of Mothers 3,230 Infants attending clinics 311 Attendances of Infants 982 The Council have entered into an agreement with the Hospital authorities whereby sufficient accommodation for 144 confinements per annum is reserved at a cost of £1,500 per annum. In addition, the Hospital has undertaken to provide ante-natal accommodation for such cases as require ante-natal treatment. This is the first complete year in which this agreement has been in operation and during the year 144 cases were admitted. Each patient admitted is required to pay fees according to the earnings of her husband, and the minimum fee has been fixed at £3 per confinement in the case of multiparae, and £4 per confinement in the case of primiparae. This charge is based on a nominal residence of 14 days but an additional fee of 3s. Od. per day is charged if this period is exceeded. The am omit recovered in patients' fees during the year was £483 18s. 6d., making a net cost of £1,016 Is. 6d., 50 per cent, of which is recoverable from the Ministry of Health. (3) Children. The Home for Ailing Babies, Eglinton Road, Plumstead. Provided by the Borough Council (21 beds). The following Table shews certain statistical information for the Home for the year 1923 :— 79 TABLE No. 51. (a) Number of cases in hospital on the 1st January, 1923 5 Number of cases admitted during the year 87 Number remaining in on the 31st December 9 (b) Average duration of stay 47 days (c) Reasons for admission :— Malnutrition, Marasmus and Debility 39 Vomiting, Dyspepsia and Constipation 25 Rickets 6 Observation 6 Diarrhoea 5 Bronchitis 2 Miscellaneous 4 87 (d) Number of cases discharged :— (i) In good health 55 (ii) Improved 14 (iii) No improvement 7 76 (c) Number of cases of infectious diseases :— (i) Measles - (ii) Whooping cough - (iii) Epidemic diarrhoea - (iv) Chicken pox 1 (/) Number of deaths 7 (4) Fever. Nil. (5) Smallpox. Nil. (6) Other. 80 There are no other hospitals in the Borough subsided by the Local Authority or by the London County Council. The following institutions are available for general treatment:— Eltham Cottage Hospital Beds 22 Woolwich and Plumstead Cottage Hospital ,, 13 Military Families' Hospital ,, 24 There is no information available as to the extent the London general hospitals are used by the inhabitants of this Borough, but some information can be obtained from the death returns, and the following Table shews the number of deaths of Woolwich residents occurring in London general hospitals during the year :— TABLE No. 52. Hospitals. Number of Deaths. Miller 18 Guy's 16 Seamen's 13 King's College 5 London 4 St. Bartholomew's 4 St. Thomas's 2 University College Hospital 2 South London 1 Charing Cross 1 Royal Free Hospital 1 French 1 Freemasons' 1 69 81 A general hospital is urgently required in Woolwich, not only for the purposes of this Borough but to serve that large extra-metropolitan area east of Woolwich where no general hospital exists. Money for this purpose has been collected each year since 1919 and in 1923 the Council, as work for the relief of unemployment, levelled the site, made the approach roads and constructed the foundations: It is important in the public interests that the remainder of the work should be expedited. The number of deaths of Woolwich residents which occurred in the local Infirmaries was as follows :—Woolwich Infirmary, 323 ; Lewisham Infirmary, 67. Institutional Provision for Unmarried Mothers. Woolwich and Plumstead Maternity Home. There is a small home for unmarried mothers, situated at 23 Vicarage Park, Plumstead, which provides accommodation for eight mothers and babies. The numbers admitted to this Home are not so large as in previous years. This is due to the fact that the Home had to be temporarily closed in July owing to the illness of the Superintendent. Through the courtesy of the Superintendent t I am able to give the following information :— Number Mothers in the Home on 1st January, 1923 3 Babies in the Home on 1st Januar.y, 1923 3 Mothers admitted during 1923 8 Babies do. do. 3 Births 4 Deaths(Child) 1 Average duration of stay of each completed case 6 months Mothers who attended ante-natal clinics of the Borough Council 5 f 82 The function of this Home is to give illegitimate children a chance of survival and the mothers are kept in the Home doing the light work of the Home for six or seven months. When they leave, situations are found for them, if possible, where the child can be taken. A grant of £50 was made by the Council towards the funds of the Home. Ambulance Facilities, (a) Infectious cases. Under the Public Health (London) Act, persons in London suffering from certain notifiable diseases may be conveyed to hospital and treated in a hospital of the Metropolitan Asylums Board and persons suffering from any dangerous infectious disease may be conveyed by ambulance to other places on payment. (b) For Non-Infectious and Accident Cases. The Medical Officer of Health in his Annual Report for 1922, drew attention to the fact that the ambulance service available for Woolwich was inadequate and in particular referred to the service of the London County Council. It is pleasing to record that during 1923 the London County Council resolved to establish an ambulance station in Woolwich and all the services for which their ambulances are available will no doubt then be extended to Woolwich. The ambulance service of the London County Council was established in 1915 in order to deal at all times with persons suffering from accidents in the street and in public places, and subsequently it was extended to include the removal, in certain circumstances, of maternity cases, to hospital, but it is not in ordinary circumstances available, or intended for the removal of persons suffering from illness in a private house. At the present time the nearest ambulance station to Woolwich is in Lee High Road, Lewisham, nearly four miles away from the thickly populated part of the Borough. It was found during a test period by the London County Council that an average call time of 8.7 minutes was obtained for the whole of London, whereas the average call time for Woolwich was 14.5 minutes, the 83 highest average in London. With regard to the maternity services, I am informed that these services are available for all Metropolitan Boroughs with the exception of a few on the periphery of the County. There appears to be little doubt that, when the ambulance station is open in Woolwich (it is hoped in 1924), these services will be extended to this Borough also. Ambulances can be obtained, on payment, from the Metropolitan Asylums Board for the removal of non-infectious cases, and the ambulances of the Guardians are available for admission to their institutions. MATERNITY AND CHILD WELFARE. It will be convenient to deal here with the work of the Council in connection with Maternity and Child Welfare during the year. Staff. The staff at the end of the year is shewn in detail in Section VIII. During the year, the Council, with the approval of the Ministry of Health, appointed an additional Assistant Medical Officer who devotes half of his time to Maternity and Child Welfare work and half to Tuberculosis. By this arrangement it was possible to increase the number of sessions at which medical consultations were given. Administrative Action in Connection with the Notification of Births. As a matter of routine, as soon as a notification of a birth is received, suitable literature is sent to the mother by post and the first visit is made by the Health Visitor between the tenth and fourteenth day in all cases where such visits are considered necessary or desirable. The necessity for second visits is gauged by what is discovered at the first visit, but as a general rule it has been found possible to work up to the following standard :—three visits during the first year and one visit in each subsequent year up to the age of five. f 2 84 Welfare Centres. These are set out in detail in Table No. 50. At the end of the year 3 ante-natal and 17 infant consultations were being held each week. Voluntary Centre. Excellent work has been done at the Voluntary Centre at the Victory Club, Beresford Street, Woolwich. These voluntary workers are engaged in one of the worst areas in Woolwich and their duties are so difficult that great credit is due to them. The number of children attending the centre during the year was 124 and the total number of attendances, including mothers, was 899. The Work of the Centres. The following Table, No. 53, gives detailed statistics for the year 1923 and consolidated statistics for the year 1922. The large increase in the number of attendances at the Slade Centre, held at the Wesley Hall, Timbercroft Lane, Plumstead, has shewn that the necessity for this Centre has been more than justified. TABLE No. 53. No. on Roll of Centre. No. of Attendances at Centre. Mothers : Children. Mothers : Children. Expectant. Nursing. Expectant. Nursing. Town Hall 269 374 1,515 399 753 3,641 Plumstead 118 164 1,025 219 285 5,403 Eltham 117 136 1,007 194 247 5,583 Slade .. 2 300 .. 6 2,431 North Woolwich 1 .. 117 3 .. 801 New Eltham 1 116 1 841 Beresford Street (Voluntary) 8 24 124 12 76 811 Totals 1923 513 701 4,204 827 1,368 24,511 „ 1922 520 590 4,240 860 1,123 21,968 85 If the Table which follows (Table No. 54) is compared with similar Tables published in previous years, it will be noticed that a gradual increase is taking place in the number of attendances made by children over a year old, and that some progress is being made in securing complete supervision of 'young children until this duty falls on the Education Authority. The Table shews the number of children, classified by year of birth, attending each Centre, and the number of attendances made by them during the year. TABLE No. 54. Children in attendance at each Centre. Year of Birth. Town Hall. Plumstead. Eltham. The Slade. New Eltham. N. Woolwich. Beresford Street (Voluntary). Total. 1923 424 327 314 96 27 40 31 1,259 1922 548 323 235 103 38 43 42 1,332 1921 288 194 167 49 24 21 25 768 1920 182 127 173 41 16 11 21 571 1919 65 47 84 7 8 2 4 217 1918 a 7 34 4 3 — 1 57 1,515 1,025 1,007 300 116 117 124 4,204 Attendances of Children at each Centre. 1923 2,467 1,892 2,374 971 286 225 212 8,427 1922 4,081 2,188 1,544 1,046 385 423 357 10,024 1921 1,210 776 675 205 83 120 147 3,216 1920 692 418 677 169 57 28 73 2,114 1919 177 99 234 20 21 5 21 577 1918 14 30 79 20 9 — 1 153 8,641 5,403 5,583 2,431 841 801 811 24,511 86 Treatment. Children requiring medical or surgical treatment are referred to the School Clinic, Brewer Street, and the Borough Council pays 5s. Od. for each case so referred. During the year 22 cases were sent there for treatment. Dental Scheme. The dental work is carried out under the aegis of a local association of medical practitioners at their Clinic at Brewer Street, and the following Table shews the number of cases attending and the number of attendances during the year. The number of dentures authorised to be supplied was 14. TABLE No. 55. Number. Attendances. Expectant Mothers 15 115 Nursing Mothers 24 35 Children under 5 69 82 108 232 The Work of Health Visitors. No change has taken place in the Health Visiting Staff during the present year, at the end of which they numbered eight, two of whom hold the combined appointment of Sanitary Inspector and Health Visitor. It is no longer necessary to detail the work of the Health Visitors but the extensive nature of it can been seen from a study of Table No. 56 which shews in detail the number of visits paid by them during the year. In addition to this they attend centres at which women and children come for medical and hygenic advice and arrangements have been made whereby the Health Visitor is in attendance at the centres serving the district in which she works. Their visits are welcomed by the mothers and the phenomenally low infantile mortality rate, namely, 43, the lowest which has 87 ever been recorded in the Borough, must be attributed in great part to the spread of education in child nurture which has been disseminated in every home in the Borough where such information is needed. In 1923, the Council, with the approval of the Ministry of Health, paid the class fees of two Health Visitors attending a refresher course for Health Visitors. Other Work. In addition to birth visits, they have made investigations into the cause of infant deaths and still-births and have visited notified cases of ophthalmia neonatorum, puerperal fever, and pneumonia in children under five years. Very little of their time indeed has been taken up with the distribution of free milk under the Council's assisted milk scheme, other arrangements having been made for the verification of income of applicants for assisted milk. This work, which, in the first instance, was placed on Health Visitors, is not essentially Health Visitors' work and it was found that it interfered with their normal work. The increase of, approximately, 3,000 visits this year is due in the main to this arrangement. The following Table No. 56 shews the classification of visits paid by the Health Visitors in 1922 and 1923 :— TABLE No. 56. 1922. 1923. Births—First Visits 2,677 2,672 ,, Re-visits 9,271 14,024 Infant deaths investigated 175 117 Still-births investigated 55 81 Expectant mothers—home visits to 330 440 88 1922. 1923. Infectious diseases :— Ophthalmia Neonatorum—First visits 26 18 ,, ,, Re-visits 40 33 Measles—First visits 2,080 19 „ Re-visits 741 9 Puerperal fever—First visits 7 5 ,, „ Re-visits 2 1 Zymotic Enteritis—First visits 25 41 ,, ,, Re-visits 27 37 Tuberculosis Visits 57 70 Pneumonia (all forms) under 5 years 204 104 Visits unclassified 562 666 Visits unsuccessful—No admission 1,873 2,736 18,152 21,073 Supply of Milk, etc., to Necessitous, Expectant and Nursing Mothers and to Young Children. The approximate cost of milk and dinners supplied to expectant and nursing mothers during the year, was as follows :—Dried milk, £1,582 ; Fresh milk, £5 13s. 8d. ; Dinners, £1 7s. 6d. In February, 1923, the Council considered the terms of a letter from the Ministry of Health and resolved that new scales of income as a test of necessity should be introduced, and the following scales were adopted :— No. in Family. Free. Half-cost. s d. s. d. One 13 0 .. 15 0 Two 10 6 .. 12 6 Three 8 6 .. 10 0 Four 7 6 .. 8 6 Five 7 0 .. 8 0 Six 6 6 .. 7 6 Per head after deduction of rent. 89 The adoption of these scales is the chief explanation of the fall in the cost of these services. No cases were found during the year where milk was obtained by false pretences. Feeding of Infants in Woolwich. The usual enquiry was carried out in the month of December and the results are very similar to those obtained in the two previous years. In the Table which follows, all the observations made in 1921, 1922 and 1923 are consolidated. I think it can be safely assumed that if a curve were constructed from the figures given in this Table it would shew the normal diminution each month in the percentage of children breast fed so far as Woolwich is concerned. These figures do not materially differ from similar figures published by other Medical Officers of Health. 90 TABLE No. 57. Feeding of Infants attending Centres. Consolidated Return of Observations, 1921-1923. 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 144 292 187 156 138 146 108 81 57 1309 31 20 5 1365 Breast and Hand 11 35 39 46 50 38 41 44 51 355 60 54 60 529 Hand 13 63 86 92 123 139 129 126 116 887 136 134 172 1329 168 390 312 294 311 323 278 251 224 2551 227 208 237 3223 Percentages. Breast 85.7 74.9 59.9 53.1 44.4 45.2 38.8 32.3 25.4 51.3 13.7 9.6 2.1 42.4 Breast and Hand 6.6 9.0 12.5 15.6 16.1 11.8 14.8 17.5 22.8 13 9 26.4 26 0 25.3 16.4 Hand 7.7 16.1 27.6 31.3 39.5 43.0 46.4 50 2 51.8 34.8 59.9 64.4 72.6 41.2 91 Enquiry into Rate of Growth (weight) of Woolwich Infants born in 1921. In the routine work of infant welfare centres a large amount of material is accumulated year by year, and this should be placed on record so that it can be available for statisticians or other persons interested who can make full use of it. If one considers such an every-day subject as the rate of change which takes place week by week in the weight of a baby, great difficulty will be found in obtaining the authority on which the usual published weight chart is based. Observations of weight have been made in various countries by different observers at different times, and by different methods, but when the results are compared it is found that considerable differences exist at the various age periods. The usual weight chart, as published, is for both sexes, whereas, as is well known, growth is different in boys and girls, the boys developing much more rapidly from the start. Every day, in our welfare centres, babies are weighed. These weights are recorded and are useful to shew the progress of an individual baby from week to week. In the mass, little attempt has been made to formulate the rate of growth in particular localities, although it is now generally believed that it is unsound to use a standard weight chart for the whole of Great Britain and that separate charts should be constructed for each locality. Babies vary in size and rate of growth in different areas and a standard chart is apt to be misleading, being too flattering or disappointing, as the case may be, to intelligent mothers. It was considered desirable to make an investigation on these lines in Woolwich and during the last twelve months such an invesitgation has been carried out, the idea underlying the enquiry being to find the weight of the average Woolwich infant at each week in the first year of its life. 92 Method of Enquiry. The enquiry was limited to children born in the year 1921 who had attended the centres in 1921 and 1922. The total number of male infants whose weights were tabulated was 801 and the number of female infants was 732 ; the total weighings for males being 6,379 and for females, 5,454. The weight was recorded at the centres to the nearest ounce, and the age was recorded to the nearest week, the practice being to ignore three or less days and to count four or over as a full week. Subsequently, in order to complete the figures for the birth weights and the first two weeks, I asked Mrs. Parnell, the Matron of the British Hospital for Mothers and Babies for this information and she very kindly gave me, from her 1921 records, detailed weights of 92 male and 96 female children—at birth, at the end of the first week and at the end of the second week. These figures have been incorporated with the Centre figures in all the tables except Table No. 60. Type of Case. Many of the standards in use have been based on specially selected infants, e.g., some observers have only included what they describe as normal babies and have excluded premature infants, twins, and sickly children, and have even excluded healthy, normal children who have had an attack of some disease. I think it is perfectly obvious that by this process of selection, bias cannot entirely be overcome, and consequently the results probably over-state the true position with regard to infants. The personal equation is likely to make us careful to select, in any process of selection, only infants above the normal. As has been pointed out above, this enquiry was to ascertain the weight of the average Woolwich infant and so no differentiation whatever was made. Every child, although its weight was abnormal, was included and it was hoped that, by dealing with fairly large numbers, a fair average standard of weight could be 93 lated. No differentiation was made between breast and handfed infants. It may be that, by adopting this method, the weight of a normal child is understated, but it appears to me that it is likely to be as near the truth as is any process of selection of so-called normal babies. In any event, the older the baby becomes the more likely is the average weight obtained to be accurate, because a certain number of weaklings are removed by death in the early months. The following short tables shew the result for the boys and girls, respectively, during the first year of post-natal growth, at intervals of five weeks. In constructing these tables a five-weekly period was grouped, the middle of the period being regarded as the age, i.e., in calculating the weights of children at eight weeks, all weights were used which were tabulated in the sixth to the tenth week period. In this connection, however, it should be noted that in Table No. (30, the weight of infants of three weeks is over-stated, for the reason that the number of observations of children of one and two weeks is very small compared with those of four and five weeks. In these short tables the same baby may appear more than once in each five-weekly period and to this extent the results are vitiated. The weights given in these tables do not quite agree with those given in Tables No. 61 and No. 62, as is to be expected, but they approximate very closely fo each other. In the diagrams the short table weights are represented by lines, the full table weights by dots. 94 TABLE No. 58. MALES. Ages in weeks. No. of Infants weighed. Weight in lbs. Increase in period. Average gain per week In lbs. Ounces (approx.) 3 585 8.25 .. .. 8 896 10.23 1.98 .39 6¼ 13 846 11.98 1.75 .35 5¾ 18 770 13.69 1.71 .34 5½ 23 694 14.93 1.24 .25 4 28 651 16.15 1.22 .24 4 33 607 17.36 1.21 .24 4 38 532 18.56 1.20 .24 4 43 455 19.75 1.19 .24 4 49 525 20.63 .88 .15 2½ TABLE No. 59. FEMALES, Ages in weeks. No. of Infants weighed. Weight in lbs. Increase in period. Average gain per week In lbs. Ounces (approx.) 3 532 7.75 .. .. .. 8 727 9.56 1.81 .36 5¾ 13 731 11.17 1.61 .32 5¼ 18 643 12.84 1.67 .33 5¼ 23 576 1413 1.29 .26 4 28 554 15.41 1.28 .26 4 33 510 16.36 .95 .19 3 38 458 17.28 .92 .18 3 43 408 18.13 .85 .17 2¾ 49 502 18.92 .79 .13 2¼ The following Table No. 60 shews in comparative form how the infant weights (both sexes) differ in the various registration districts. The British Hospital figures have not been included because the necessary information was not available. 95 TABLE No. 60. INFANT WEIGHTS (in lbs.). Age in weeks.- The Borough. Woolwich. West Plu instead. East Plumstead. Elthum. 3 8.49 8.39 8.62 8.44 8.54 8 9.93 10.04 1006 9.79 9.85 13 11.61 11.79 11.50 11.55 11.58 18 13.30 13.38 13.23 13.41 13.18 23 14.57 14.71 14.46 14.94 14.17 28 15.81 16.01 15.68 16.05 15.51 33 16.90 17.09 17.00 17.00 16.59 38 17.97 17.86 18.15 18.15 17.77 43 18.98 19.08 18.86 18.90 19.05 49 19.79 19.92 19.72 19.92 19.61 The following two tables No. 61 and No. 62 give the age in weeks, the number of observations (weighings) made at each week, the mean weight in lbs., the standard deviation and the co-efficient of variation for each set of observations. The standard deviation is a statistical method of expressing how closely the weights of different babies at the same age approximate to each other and the co-efficient of variation is one hundred times the standard deviation divided by the mean weight. In reading these mean (average) weights, the co-efficient of variation will enable one to express the extent of variation which can occur at any given age, e.g., at 25 weeks it can be said that 68.27 per cent. of all Woolwich male babies will be within the following limits of weight:—15.72 lbs. plus 12.7 per cent. and 15.721bs., minus 12.7 per cent. 96 TABLE No. 61. MALE BABIES.—THE BOROUGH. Age in Weeks. No. of Observations. Weight in lbs. Standard deviation. Co-efficient of variation. Birth. 92 753 1.17 15.5 1 95 * 7.16 1.07 14.9 2 112 7.31 1.04 14.2 3 79 8.11 1.40 12.8 4 135 8.70 1.50 17.2 5 164 9.23 1.57 17.0 6 163 9.49 1.78 18.7 7 176 9.80 1.72 17.5 8 192 10.24 1.79 17.5 9 177 10.63 1.96 18.4 10 188 10.88 1.94 17.9 11 175 11.13 2.01 18.1 12 171 11.90 2.19 18.5 13 164 11.91 2.08 17.5 14 150 12.45 217 17.4 15 186 12.63 2.14 16.9 16 159 13.08 2.15 16.4 17 158 13.38 2.21 16.5 18 143 13.80 2.25 16.3 19 155 14.15 2.49 17.6 20 155 14.07 2.28 16.2 21 135 14.27 2.22 15.7 22 145 14.63 2.30 15.7 23 145 14.87 2.39 16.0 24 121 15.16 1.93 12.7 25 148 15.72 2.00 12.7 26 126 15.39 2.26 14.7 27 137 16.05 2.27 14.2 28 141 1601 2.44 15.2 29 125 16.52 2.22 13.4 30 122 16.81 2.45 14.6 31 118 16.84 2 57 15.3 32 126 17.02 2.49 14.6 33 127 17.68 2.42 13.7 34 114 17.53 2.24 12.8 35 122 17.74 2.64 14 8 36 108 18 02 2.34 13.0 37 113 18.52 2 63 14.2 38 105 18.63 2.47 13.2 39 106 18.74 2.35 12.6 40 100 18.94 2.26 11.9 41 90 19.27 2.55 13.2 42 90 19.34 2.44 12.6 43 98 20.09 2.40 11.9 44 85 20.03 2.53 12.6 45 92 2000 2.72 13.6 46 89 20.02 2.73 13.7 47 76 20.33 2.42 11'9 48 75 20.82 2.65 12.7 49 77 20.88 2.47 11.8 50 79 20.78 2.61 12.5 51 49 20.93 2.87 13.7 52 80 20.84 2.98 14.3 6653 97 g 98 TABLE No. 62. FEMALE BABIES.—THE BOROUGH. Age in weeks. No. of Observations. Weight in lbs. Standard deviation. Co.efficient of variation. Birth 96 7.36 1.15 15 6 1 99 703 117 16.6 2 128 7.16 1.13 15.8 3 79 7.88 1.32 16.7 4 105 8.20 1.25 15.2 5 121 8.58 1.38 16.1 6 148 8.78 1.53 17.4 7 131 9.19 1.75 19.0 8 148 9.66 1.58 16.3 9 158 9.83 1.73 17.6 10 142 10.32 1.74 16 8 11 146 10.51 1.80 17.1 12 151 10.94 2.00 18.3 13 155 11.12 2.02 18.2 14 142 11.45 1.90 16.6 15 137 11.88 1.82 15.3 16 141 12.30 1.92 15.6 17 121 12.41 1.84 14.8 18 141 12.92 2.02 15.6 19 108 13.20 2 03 15.4 20 132 13.41 1.96 14.6 21 114 13.86 209 15.1 22 119 13.88 2.09 15.1 23 120 14.03 2.05 14.6 24 110 14.33 2.30 16.1 25 113 14.56 2.04 14.0 26 125 1517 2.19 14.4 27 116 15.20 2.13 14 0 28 105 15.42 2.17 14.1 29 104 15.63 1.93 12.4 30 104 15 71 1.93 12.3 31 111 1608 2.18 13.5 32 116 16.40 2.21 13.5 33 87 16.35 1.88 11 5 34 87 16.43 2.15 13.1 35 109 16.57 2.49 15 0 36 86 17.28 2.10 12.2 37 95 17.29 2.44 14.1 38 79 16.78 2.27 13.5 39 95 1713 2.72 15.9 40 103 17.81 2.49 13.9 41 86 17.45 2.59 14.8 42 81 18.11 2.67 14.7 43 84 17.93 2.56 14.3 44 82 18.27 2.29 12.5 45 75 18.99 2.76 14.5 46 70 18.44 2.58 13.9 47 73 18.64 2.19 11.8 48 75 18.89 2.34 12.4 49 75 18.79 2.69 14.3 50 73 1910 2.40 12.5 51 59 1916 2.32 121 52 77 19.39 2.31 11.9 5737 99 g 2 100 SECTION VI.—LABORATORY WORK. Analysis of Food and Drugs. The Public Analyst is Sir William R. Smith, and the laboratory work in connection therewith is carried out at the Royal Institute of Public Health. The detailed results of analyses made will be found in the section dealing with the Food and Drugs Acts. Bacteriological Examinations. Bacteriological examinations are carried out at the Seamen's Hospital, Greenwich. In tabular form is shewn below the number and result of the various examinations made during the year. For comparative purposes the figures for the year 1922 are also given. TABLE No. 63. Associated Disease. Positive Result. Negative Result. Total 1923. Total 1922. Diphtheria 58 493 551 874 Enteric Fever 6 20 26 9 Tuberculosis 48 172 220 187 Dysentery — 2 2 — 112 687 799 1,070 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 32,000 units at a total cost of £2 8s. 0d., all of which was recovered. 101 SECTION VII.—SANITARY ADMINISTRATION. This section of the report deals statistically with the work of the Sanitary Inspectors and Sanitary Administration, and has been prepared by the Chief Sanitary Inspector. ADOPTIVE ACTS, BY-LAWS AND REGULATIONS RELATING TO PUBLIC HEALTH IN FORCE IN THE DISTRICT. There are no adoptive Acts in force in the district. The following is a list of By-laws and Regulations made under the various Acts, with the date of adoption:— By-laws made under:— Public Health (London) Act, 1891. Section. Date of adoption. 16(1) Prevention of nuisances arising from matter thrown in any street; offensive matter running into an uncovered place; keeping of animals; paving of yards and open spaces. 15th May, 1903 16 (2) Closing of cesspools and privies: removal and disposal of refuse. 28th June, 1893 16 (2) Removal of faecal and offensive matter. 26th Nov., 1901 39 (1) Construction of closets, privies, ashpits, cesspools and dung receptacles. 28th June, 1893 14th June, 1901 3rd Jan., 1905 39 (2) Keeping water closets supplied with sufficient water. 24th June, 1903 102 Section. Date of adoption. 45 Decent conduct of persons using public lavatories, etc. 24th June, 1903 50 Securing cleanliness and freedom from pollution of tanks, cisterns and other receptacles used for storing water. 24th June, 1903 88 Management of Mortuaries 24th June, 1903 94 Houses let in lodgings (Woolwich and Plumstead Parishes only). 13th Aug., 1895 95 Tents, Vans, Sheds 24th June, 1903 19 Bone boiler, Manure manufacturer or Tallow melter. 25th Nov., 1907 19 Gut scraper and Catgut maker or Catgut manufacturer. 25th Nov., 1907 19 Fat Melter or Fat Extractor 25th Nov., 1907 19 Fellmonger 25th Nov., 1907 19 Dresser of Fish Skins 25th Nov., 1907 19 Dresser of Fur Skins 22nd March, 1922 19 Glue and Size Manufacturer 25th Nov., 1907 19 Knacker 25th Nov., 1907 19 Slaughterer of Poultry 22nd Dec., 1923 19 Soap boiler 25th Nov., 1907 19 Tripe Boiler 25th Nov., 1907 London County Council (General Powers) Act, 1908:— 9 Rag and Bone dealer 18th Sept., 1923 9 Fish Curer 28th Feb., 1914 9 Vendor of Fried Fish 28th Feb., 1914 London County Council (General Powers) Act, 1902:— 53 Common Lodging Houses 14th Aug., 1903 London County Council (General Powers) Act, 1903:— 54 Conveyance of carcases of dead horses through public streets. 21st Feb., 1905 103 Section. Date of adoption. Metropolis Management Act, 1855:— 202 Drains, regulating dimensions of, keeping, cleansing and repairing of. 14th June, 1901 Metropolis Management Act, 1855 (Section 202) and Metropolis Management Acts (Amendment (By-laws) Act, 1899:— Plans to be deposited. Construction, reconstruction, or alteration of pipes, drains, traps and other apparatus. 20th Aug., 1903 Slaughterhouse, Etc. (Metropolis) Act, 1874 and the Local Government Act, 1888:— Slaughterer of Cattle 27th Oct., 1891 Baths and Washhouses Act, 1846:— 34 Management, Use and Regulations of Public Baths. 24th June, 1903 Public Health Act, 1875:— 167 Regulating the use of the Market place. 24th June, 1903 Regulations made under:— Factories and Workshops Acts and Public Health (London) Act, 1891:— Bakehouses 31st Jan., 1902 Dairies, Cowsheds and Milkshops Order, 1885:— 13 Dairies, Cowsheds and Milkshops 3rd July, 1885 Housing, Town Planning, etc. Act, 1909:— 17 (7) Underground Rooms 9th Feb., 1911 Section 55 of the Public Health (London) Act, 1891, has been applied to Zymotic Enteritis. 104 Closet Accommodation. There are a few earth closets in the Borough. These are inspected periodically but no action has been taken with regard to their abolition during the year as they are situated in the rural parts of the district where there are no sewers available. The number of cesspools is 31. Scavenging. (a) Removal of House Refuse:— Loads removed. Woolwich 6,878 Plumstead 12,422 Eltham 5,763 Frequency Weekly Cost in Plumstead £5,431 12s. 5d. (b) Removal of Trade Refuse:— Inoffensive:— Woolwich 966 Plumstead 9 Eltham 145 Charge per load 5s. 0d. Offensive:— Tradesmen on Books 59 Receptacles removed 5,964 Charge per receptacle 6d. Complaints. The number of complaints entered in the complaint book during the year was 1,718, compared with 1,865 last year. 31 of these complaints related to the nonremoval of household refuse—3 in Woolwich, 25 in Plumstead and 3 in Eltham. Combined Drains. 36 combined drains, relating to 208 houses, were reported on at various times throughout the 105 year. Reconstruction was necessary in five cases (involving connections to 29 houses) and the usual notices for reconstruction were served and complied with. At the request of the owners various small repairs to drains were undertaken at the time of the examination and the total cost of this (£6 7s. 6d.) was recovered from the owners concerned. Increase of Rent and Mortgage Interest (Restrictions) Acts, 1920-1923. During the year 13 applications were made by the occupiers of 12 houses for certificates that the houses they occupied were not in a reasonable state of repair. In one case the house was let in two parts and both occupiers made application. Four certificates were granted; in two cases the applications were withdrawn before they were considered by the Public Health Committee, and in seven cases a report only was ordered to be issued. The Rent Restrictions (Notices of Increase) Act, 1923, and the Increase of Rent and Mortgage Interest (Restrictions) Act, 1923, came into force during the year, and require that the certificate of the sanitary authority shall specify what works require to be executed in order to put the house in a reasonable state of repair, and one of them provides that it shall be a good defence to any claim for the payment of rent or arrears that the house is not in a reasonable state of repair, if the tenant has served a copy of the certificate on the owner. When an application is received for a certificate the house is inspected and notices are served on the owner to remedy the defects that exist. It is interesting to note that the Act of 1923 differs from the original Act in that a certificate can only be issued for a house when it is not in a reasonable state of repair, whereas in the original Act, it could be issued if a house was not in a reasonable state of repair or was not in all respects reasonably fit for human habitation. 106 Inhabited House Duty. There have been no applications for certificates under the Customs and Inland Revenue Acts 1890 and 1903. HOUSES LET IN LODGINGS. On Register at beginning of year 422 ,, end of year 425 Inspections made 285 Notices served 193 Prosecutions — Underground Sleeping Rooms. The County Medical Officer of Health on the 17th October, 1923, asked by letter for the following information in connection with a report he is preparing on this subject for the County Council:— (a) Number of basements in the Borough used for dwelling purposes. (ib) Number of basement dwellings in the Borough with ceilings at or below street level. (c) Number of basement dwellings in which the width of area in street does not exceed 3 feet. (d) Number of basement dwellings in which the width of area in street does not exceed 4 feet. In order to obtain these details and to make them representative of the circumstances existing in the Borough, arrangements were made for a complete inspection of all basement rooms and the following Table furnishes the particulars. 107 TABLE No. 64. BASEMENT ROOMS. Ward. No. of basements used for dwelling purposes. No. of basement dwellings with ceilings at or below street level. No. of basement dwellings in which the width of area does not exceed— 3 feet. 4 feet. 1 2 3 4 5 Dockyard 273 38 196 268 St. Mary's 155 16 107 125 River 114 8 83 102 St. George's 166 44 132 167 Burrage 78 7 22 33 Herbert 68 40 54 54 Glyndon 62 35 9 37 Central 75 12 40 87 St. Nicholas, S. 65 8 41 101 St. Nicholas, N. 97 11 23 46 Eltham 64 1 62 64 St. Margaret's 167 46 77 99 1,384 266 846 1,183 * Includes those contained in column 4. Rats. During the year 58 investigations were made under the Rats and Mice (Destruction) Act. A "Rat Week" was held in November and by arrangement with the Works Department, 5.074 baits were laid in 101 old sewers likely to be infested with rats. Rag Flock Act. No samples have been taken during the year. Offensive Trades. There are no offensive trades in Woolwich. 108 Action taken under Public Health Acts or By-laws. Statistical tables are set out on the following two pages shewing the number of inspections made by the sanitary inspectors and the number of nuisances abated. 3,446 intimation notices and 1,262 statutory notices were served during the year. These compare with 4,191 and 1,294, respectively, in 1922. There were 165 cases in which the owners neglected to comply with the statutory notices and these were reported to the Town Clerk for legal proceedings. The Town Clerk followed his usual procedure of writing a letter reminding the owner that he was in default in not complying with the notices and requesting his attention forthwith and that in the event of his continued neglect a summons would be issued. It was found necessary to issue 39 summons (compared with 6 in 1922) the details of which are set out in Table No. 67. TABLE No. 65. Premises Inspected. Total Milkshops 239 Bakehouses 192 Cowhouses 40 Ice Cream Premises 557 Slaughterhouses 29 Fried Fish Shops 320 Premises where Food is Prepared (other than above) 531 Shops and Markets re Food (estimated) 1,934 Factories, Workshops and Workplaces 881 Outworkers' Premises 887 Houses re Verminous Cases 222 Homes re Scabies Cases 116 Women's Lavatories 107 Smoke Observations 37 Tents and Vans 15 109 TABLE No. 65—continued. Premises Inspected. Total. Urinals accessible to Public 205 Animals so kept as to be a Nuisance 33 Housing Survey—Houses inspected 3,192 Do. Number of following up primary visits 1,853 Complaints Investigated 1,718 Enquiries re Notified Infectious Diseases 740 School Reports 243 Special Inspections re Rats 58 Drains Tested by Smoke Test 59 do. Water Test 20 New Houses Inspected—Water Certificates 166 Registered Houses 285 Theatres, Cinemas, etc. 23 Basements Inspected 1,384 Miscellaneous (unclassified) 1,898 Re-inspections 10,792 TABLE No. 66. Nuisances, etc., Abated. Total Interiors Cleansed 2,101 Damp conditions in houses remedied 674 Defective guttering and rain water pipes 625 Improved ventilation 281 Defective roofs 801 Deficient light—windows supplied or enlarged 12 Paving in yards and washhouses repaired 632 Underground rooms not in accordance with Acts 13 Waste-pipes from baths, lavatories and washhouses repaired or disconnected 153 Choked and defective drains 295 Defective traps 24 110 TABLE No. 66—continued. Nuisances, etc.. Abated. Total. Defective or unventilated soil pipe 10 W.C.'s repaired, new traps or pans provided 231 Foul pans cleansed 120 Flushing apparatus repaired or renewed 388 Additional w.c.'s provided to dwelling houses I Additional w.c.'s provided to factories and workshops 1 Washhouses provided with sinks 11 Defective and foul cisterns used for dietary purposes 5 Defective and foul rain water tanks 10 Insufficient supply of water or water cut off by M.W.B. 40 Additional water supply — Cases of overcrowding remedied 31 Dust bins supplied 492 Verminous rooms cleansed 221 Accumulations of manure removed 40 Dung pits provided 2 Smoke nuisances 3 Cooking stoves repaired 213 Coppers repaired 160 Miscellaneous 1,213 TABLE No. 67. Prosecutions under Public Health and kindred Acts. No. Date of Hearing. Offence. Situation. Result. 1 Jan. 23 Yard not properly paved 74 Cordite Street Work done. Withdrawn. 12/6 costs 2 do. Defective scullery roof; damp condition ground floor front room; choked front eaves gutters; defective ceiling of scullery 33 Pendrell Street Order to abate in 21 days 111 No. Date o£ Hearing. Offence. Situation. Result. 3 do. Insufficient and unsuitable accommodation for the cooking of food Do. Fined 5/- 4 do. Damp walls of the ground floor front room 22 Kirkham Street Costs £1 Is. Order to to abate in 21 days 5 do. Dirty ceiling of first floor front room; deficient means of ventilation of back room ground floor; defeotive sash cords 109 Southport Road Order to abate in 10 days. 21/- costs 6 do. Defective rain water gutter to main roof at back of house causing dampness 111 Southport Road Work done. Withdrawn. 21/- costs 7 do. Defective rain water gutter and w.c. apartment ventilating into washhouse 15 Earl Street .. Order to abate in 14 days. 21/- costs 8 March 8 Defective yard paving 35 Winifred Street Work done. Withdrawn. 12/6 costs 9 do. Insufficient ashpit 33 Winifred Street Work done. Withdrawn. 3/- costs 10 April 5 Dirty conditions and defective guttering 14 Bastion Road Order to abate in 21 days. 10/6 costs 11 do. Dirty conditions and defective sashcords 8 Bastion Road .. Work done. Withdrawn. 10/6 costs 12 do. Dirty conditions 6 Bastion Road .. Work done. Withdrawn. 10/6 costs 13 do. Defective yard paving 16 Bastion Road Pined 20/- 14 April 12 Defective yard paving 103 Kidd Street Work done. Withdrawn, 15/- costs 15 do. Defective yard paving 107 Kidd Street Work done. Withdrawn. 15/- costs 16 do. Chickens and rabbits so kept as to be a nuisance 9 Hargor Road Order to abate in 14 days. 5/- costs 112 No. Date of Hearing. Offence. Situation. Result. 17 May 2 Room in a dirty state. Accumulation of filthy clothing and bedding 7 Marshall's grove Premises vacated. Summons withdrawn 18 do. 3 Damp site of house 196 Albert Road.. Work done. Withdrawn. 5/- costs 19 do. 31 Non-compliance with a Nuisance Order 9 Hargor Road .. Fined 20/- or 14 days' imprisonment. 10/costs 20 June 14 Occupied house without an efficient supply of water 9 Tewson Road .. Adjourned. Closing Order in 28 days. 8/- costs 21 do. 28 Non-compliance with a Nuisance Order 9 Hargor Road .. Pined 43/- and £1 Is. costs 22 Oct. 10 Defective yard paving . 22 Plumstead High Street Work done. 8/- costs 23 do. Defective roofs of house and back addition ; defective eaves gutter to back addition roof; defective plaster to bedroom Do. Order to abate in two weeks. 2/- costs 24 do. Dirty walls and ceiling of scullery; defective manhole cover 91 Robert Street Work done. 2/- costs 25 do. Leaky roof of bouse 87 Robert Street Work done. 2/- costs 26 do. Dirty and defective conditions 75 Robert Street Work done. 2/- costs 27 do. Defective yard paving Do. Work done. 2/- costs 28 do. Defective w.c. pan Do. Work done. 2/- costs 29 do. Dirty walls and ceilings of passage and scullery; defective skirting of back room ground floor 21 Spearman Street Order to abate in two weeks. 3/- costs. 113 No. Date of Hearing. Offence. Situation. Result. 30 do. Dirty and defective conditions 23 Spearman Street Order to abate in two weeks. 3/- costs 31 do. Do. 31 Spearman Street Order to abate in two weeks. 3/- costs 32 do. Do. 33 Spearman Street Withdrawn. Change of owner 33 do. Leaky roof of house 35 Spearman Street Withdrawn. Change of owner 34 do. Dirty and defective conditions 37 Spearman Street Withdrawn. Change of owner 35 do. • Various defects 39 Spearman Street Withdrawn. Change of owner 36 Nov. 21 Non-compliance with a Nuisance Order 22 Plumstead High Street Fined 20/- and £1 Is. costs 37 do. Defective back gutters causing dampness 17 Earl Street .. Work done. Withdrawn. Costs 10/6 38 Deo. 5 Dirty and defective conditions 89 Robert Street Work done. Costs paid £1 Is. 39 do. Defective main roof of house 14 Arthur Street Withdrawn. Work done. Costs 10/6 H 114 MORTUARIES. TABLE No. 68. Sun Street. Sun Street Infectious). Eltham. All Mortuaries. Number of bodies received: 1923 1922 (a) for inquest 70 — — 70 104 (b) for custody 6 1 3 10 20 76 1 3 80 124 Number of Post-Mortem Examinations 47 — — 47 68 CEMETERIES. TABLE No. 69. Number of Interments. 1921 1922 1923 Woolwich Cemetery 647 612 515 Plumstead Cemetery 730 720 599 Eltham Churchyard 179 199 153 Plumstead Churchyard 24 33 23 1,580 1,564 1,290 Number of Exhumations carried out during year 4 Outworkers. In April your Medical Officer had occasion to report to the Council that the sorting of peppercorns was being carried out by outworkers in the Borough and that the circumstances under which the work was being carried out 115 were such as to make it necessary that this class of homework should be subject to suitable inspection. It was found, however, that the provisions of Section 107, Factory and Workshops Act, did not apply to this class of work, although employers employing outworkers to pick peas were required to send lists to the Medical Officer of Health half-yearly. As a result of your Medical Officer's representation the Council were of opinion that it would be desirable that persons engaged in the trade of sorting peppercorns should be included in the scheduled trades as provided by Section 107, and representations were made to the Secretary of State accordingly. On 9th October, 1923, the Secretary of State intimated that investigations had been made up and down the country, and that this neighbourhood was apparentJy the only one where this business was being carried out, and that in these circumstances it was not considered necessary to schedule this trade under the provisions of Section 107. The employers in question undertook to submit voluntarily a list of all persons employed in this trade. Factories, Workshops and Workplaces. The Medical Officer of Health is required under Section 132 of the Factory and Workshops Act, 1901, to include in his Annual Report details of the administration of this Act in his district. The total number of factories, workshops, and workplaces on the register at the end of the year was 325. This was an increase of 97 over the previous year. The number of inspections of these premises was 881 which compares with 512 for 1922. Sanitary defects were found in 38 instances. The following tables are in the form adopted by the Home Office in order to ensure uniformity in the presentation of statistics:— h 2 116 TABLE 70. 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) 320 12 Workshops (Including Workshop Laundries) 513 23 Workplaces 48 3 Homey orkers' Premises 887 18 Total 1768 56 2.—Defects Found. Description. Number of Defects. Found. Remedied. Nuisances under Public Health Act: Want of Cleanliness 30 30 Want of Ventilation 3 3 Overcrowding O *J 2 Want of Drainage of floors — — Other nuisances 11 11 Sanitary Accommodation insufficient 2 1 unsuitable or defective 6 6 not separate for sexes — - Total 54 53 117 TABLE 70—continued. 3.—Other Matters. Class. Number. Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshops Act. (S. 133) 1 Action taken in matters remediable under the Public Health Acts, but not under the Factory Act (S. 5). Notified by H.M. Inspector 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 1923 11 Workshops on the Register (S. 131) at end of 1923:— Workshop Laundries 10 ,, Bakehouses 24 Other Workshops 133 Total number of Workshops on the Register 167 118 TABLE 70—continued. 4.—Home Work. Out Workers' Lists, Section 107. Number of Inspections of Outworkers' premises. Outwork in Unwholesome Premises, Section 108. Outwork in Infected Premises, Sections 109,110. Nature of Work. 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 (See. 109). Prosecutions (Sees. 109, 110). Twice in the year. Once in the year. Failing to keep or permit inspection of Lists. Failing to Bend lists. Lists. Outworkers. Lists. Outworkers. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Wearing Apparel 46 140 2 4 83 14 .. .. 296 7 7 .. .. .. Tennis Balls, etc. 6 521 .. .. 62 74 .. .. 586 11 11 .. 6 .. .. Artificial Flowers .. .. .. .. 1 .. .. .. 5 .. .. .. .. .. .. 52 667 2 4 146 88 .. •• 887 18 18 .. 6 •• •• 119 Work of Sanitary Inspectors under Article 19 of the Sanitary Officers Order, 1922. The routine and special work of the Sanitary Inspectors under the Order has been shown in Tables Nos. 65 and 66, and the figures given in these tables include the work in connection with special Acts such as the Rats and Mice (Destruction) Act, 1919. The Public Health Department supervises the removal of house refuse in Plumstead where this work is carried out by a firm of contractors. In Eltham and Woolwich, removal of house refuse is done by direct labour by the Borough Council and is under the supervision of the Works Department. The sanitary staff consists of one Chief Inspector, seven District Inspectors, one Food and Drugs Inspector, one Woman Inspector, two part-time Health Visitors and Sanitary Inspectors, and one Inspector who is entirely engaged on the housing survey work and on special investigations. Inspection of Premises where Food is prepared. Three Sanitary Inspectors regularly inspect the market places where food is exposed for sale at all periods of the day, and maintain a systematic supervision of the slaughter-houses. The District Inspectors keep under observation food exposed for sale in the district, and include in this supervision the inspection of fried fish shops, bakehouses and premises where ice-cream is made or sold. 192 inspections of bakehouses were made compared with 171 for 1922. Reference is made in subsequent paragraphs to the condition under which fried fish is sold and ice-cream made and sold. There are 104 premises other than those already mentioned where food is prepared and/or sold, and 531 inspections of these were made during the year. Vendors of Fried Fish. At the end of the year there were 71 premises where the frying of fish was carried out. This is an 120 increase of two on the previous year. The popular demand for fried fish appears to be increasing, and it is important that conditions under which trade of this description is carried out should be adequately inspected. It is difficult to understand why many persons handling this commodity should be indifferent to cleanliness, personal and environmental. 320 inspections were made and 47 notices served. Ice-Cream Vendors. There was a reduction in the number of persons selling ice-cream in the Borough. During the summer it was found that there were 188 vendors of this commodity compared with 224 in 1922. The mild summer may account for the diminution of this number. The number of inspections made was 557. In concise form is given below statistics relating to premises where food is prepared or sold. TABLE No. 71. On Register, Dec., 31st. Inspections. Notices. Prosecutions Bakehouses 46 102 28 - Cowsheds 11 40 - - Milkshops 80 239 19 - Ice Cream Premises 188 557 7 - Slaughter-houses 8 29 1 - Fried Fish Shops 71 320 47 - Premises where food is prepared (other than above) 104 531 14 - 121 Unsound Food. On 54 occasions during the year unsound food was surrendered, compared with 59 in 1922. Included in the food surrendered were 14 cwt. of Beef; 6 cwt. of Mutton; ¾ cwt. of Pork; 133 stone Fish; 40 tins of Fish; 75 tins of condensed milk; 6 stone of Dates; 7 cwt. of Potatoes; 108 lbs. of Plums; 100 lbs. of Onions; 35 lbs. of jellied sweets. The number of carcases condemned on account of tuberculosis was three—one pig and two bullocks. No intimation was received during the year that farmers in the district had purchased unsound food for the food of cattle. One seizure was made consisting of 2½ lbs. of tomatoes. The Public Health Committee, having regard to all the circumstances, resolved that a caution be sent to the vendor intimating that in the event of a repetition of the offence proceedings would be instituted. Food Poisoning. There were no cases of food poisoning brought to the notice of the Department during the year. Number and Condition of Slaughterhouses, Registered or Licensed. In tabular form below is shewn the number of slaughterhouses licensed in 1914 and in January and December, 1923. These premises have been regularly inspected. There is no public abattoir in the Borough. TABLE No. 72. SLAUGHTERHOUSES. In 1914. In January, 1923. In December, 1923. Registered - - - Licensed 12 8 8 122 Arrangements for Disinfection and Disinfestation and the extent of their use. Disinfection. The Council's Disinfecting Station is situated in White Hart Road and two steam disinfectors are provided. The disinfecting staff numbers three. The following Table shews the various rooms and articles disinfected during the year. TABLE No. 73. Rooms disinfected after ordinary fevers 469 „ „ tuberculosis 308 „ „ verminous cases 28 „ „ for other reasons 103 Total articles disinfected 15,727 Applications for special disinfection, not associated with notifiable infectious diseases, are considered and carried out at the expense of the applicant. The total amount received from this source was £14 1s. 0d., 52 disinfections being carried out. Disinfestation. The number of children attending the Cleansing Station is for practical purposes the same as 1922, the decrease from previous years being due to the policy of the London County Council in treating slight verminous cases at their Minor Ailment Centres. It would, however, be more gratifying to be able to report a consistent and permanent diminution in the number of children attending the Station by reason of the parents being more active in keeping their children clean and wholesome. The following Table shews the extent to which the Station has been used each year since 1919:— 123 TABLE No. 74. Children. Adults. Grand Total. Year. Boys. Girls. Total. Males. Females Total. 1919 1919 1816 3735 13 8 21 3756 1920 1955 1678 3633 23 6 29 3662 1921 1219 1112 2331 26 6 32 2363 1922 394 1493 1887 9 7 16 1903 1923 280 1731 2011 18 1 19 2030 Action taken with regard to Dairies, Cowsheds and Milkshops. In accordance with the provisions of the Milk and Dairies (Amendment) Act, 1922, two registers of purveyors of milk are maintained, one restricted to retail purveyors and the other to wholesale purveyors and producers who do not sell milk by retail. In tabular from below is shewn the alterations which took place in the registers during the year:— Retail. Wholesale. Total. On registers on 1st January 81 8 89 Removed during the year 20 - 20 Added during the year 20 1 21 On registers on 31st December 81 9 90 During the year your Medical Officer inspected the premises of all persons on the registers, and only in one case did he report a vendor for removal from the register, oh the ground that the premises were unsuitable, and that the public health was likely to be endangered. In this case formal notice was 124 served on the vendor who attended at a meeting of the Health Committee and undertook to cease selling milk. He has carried out this undertaking. The other cases shewn in the Table relate mainly to transfers or persons voluntarily ceasing to sell milk. There were three applications under the Milk (Special Designations) Order, 1922, two being from one firm who desired to be licensed for the sale of Certified and Grade "A" milk. These applications were granted. All the dairies and milkshops in the Borough have been regularly inspected during the year. There are 11 cowsheds in the Borough (compared with 12 in the previous year), in which there are 401 milch cows. These cowsheds are subject to annual licensing by the London County Council. Action taken under the Sale of Food and Drugs Acts and the Milk and Cream Regulations, 1912-17. Table No. 75 shews the number of the various analyses made during the year and the result of the analyses. The precentage of adulterated samples, 5.3 per cent. compares with 6 per cent. and 3.9 per cent. in the preceding two years. The number of samples taken on Sundays was 24, none of which were adulterated. 125 TABLE No. 75. Article. Formal Samples. Informal Samples. Number Analysed. Number Adulterated Milk 184 - 184 3 Cream 2 4 6 5 Preserved Cream 1 1 2 - Condensed Milk 8 - 8 - Butter 15 52 67 - Lard - 6 6 - Coffee 3 6 9 - Cocoa - 14 14 - Essence of Coffee with Chicory 1 10 11 2 Dripping - 6 6 - Cheese - 6 6 - Jam - 2 2 - Beef Sausage - 6 6 - Tinned Sardines - 3 3 2 Tinned Tomatoes 1 8 9 2 Canned Herrings - 4 4 - Tinned Fish 1 9 10 1 Baking Powder 7 - 7 - Tinned Peas 4 6 10 10 Mustard - 1 1 - Vinegar - 6 6 - Pepper - 6 6 - Self Raising Flour - 5 5 - Sponge Cakes - 4 4 - Olive Oil - 11 11 - Golden Syrup - 5 5 - Borax - 6 6 - Magnesia - 6 6 - Camphorated Cil - 10 10 - 126 TABLE No. 75—continued. Article. Formal Samples. Informal Samples. Number Analysed. Number Analysed Compound Liquorice Powder - 6 6 - Cream of Tartar - 14 14 - Prescriptions 6 10 16 - 233 233 466 25 In the certificate furnished by the Public Analyst in the case of milk, a fat percentage figure is given for each sample. The following table shews the fat percentage figures for 1921, 1922 and 1923. The minimum legal standard is 3 per cent. TABLE No. 76. 1921. 1922. 1923. 4.5% and over 2 1 1 4% and under 4.5% 12 31 12 3.5% and under 4% 95 104 84 3% and under 3.5% 98 113 85 Below 3% 14 9 2 221 258 184 The following table shews the number of formal adulterated samples and the action taken in each case. 127 TABLE No. 77. ADULTERATED SAMPLES—ACTION TAKEN. Sample No. Sample of Particulars of Adulteration. Action Taken. 155 Tinned Peas 3.36 grains of copper Sulphate per lb. Pined £20 and £10 10s. 0d. costs 204 Do. 5.6 grains of copper sulphate per lb. Pined £5 and £ 1 1s. 0d. costs 206 Do. 2.04 grains of copper sulphate per lb. Case dismissed 207 Do. 2 grains of copper sulphate per lb. No Proceedings 208 Do. 2'28 grains of copper sulphate per lb. Case withdrawn 241 Milk Coloured with annatto Explanation asked for and accepted. Vendor cautioned 245 Cream Contained .49% boric acid Do. 273 Tinned Sardines Contained .114% of tin Vendor cautioned. Stock surrendered 317 Small Pish in Oil Contained .075% of tin Do. 348 Tinned Tomatoes Contained .0818% of tin Vendor cautioned 390 Essence of Coffee Contained .08% salicylic acid Do. 418 Milk Deficient in fat to the extent of 8.66% Dismissed under the Probation of Offenders' Act. Costs 17s. 0d. 537 Cream Contained .24% of boric acid Explanation asked for and accepted 616 Milk Deficient in fat to the extent of 3.66% Vendor cautioned 128 TABLE No. 78. REPORT ON ADMINISTRATION IN CONNECTION WITH THE PUBLIC HEALTH (MILK & CREAM) REGULATIONS, 1912-1917. Report for the year ended 31st December, 1923. 1.—Milk and Cream not sold as "Preserved Cream." Number of samples examined for presence of a preservative. Number in which preservative was reported to be present. Percentage and Nature of preservative found in each sample. Action taken. Milk 184 Nil - - Cream 6 5 .3% boric acid Informal sample .54% „ „ .49% „ „ Explanation asked for and accepted Informal .18% „ „ .24% „ „ Explanation asked for and accepted 2.—Cream sold as Preserved Cream: (a) Instances in which samples have been submitted to analyst to ascertain if the statements on the label as to preservatives were correct 2 (i) Correct statements made 2 (ii) Incorrect statements made - (iii) Percentage of Preservative found in each sample: .22% .3% Percentage stated on statutory label: In each case "Not exceeding 0.4%. 129 (6) Determinations made of milk fat in cream sold as Preserved Cream:— (i) About 35 per cent 2 (ii) Below 35 per cent - (c) Instances where (apart from analysis) the quirements as to labelling or declaration of Preserved Cream in Article V (1) and the proviso in Article V (2) of the Regulations have not been observed Nil (d) Particulars of each case in which the lations have not been complied with, and action taken Nil 3. Thickening substances Nil 4. Other observations (if any) Nil Action taken with regard to Smoke Abatement. During the year 10 complaints were received from persons other than Sanitary Inspectors. 37 observations of smoke nuisances were made by the various District Inspectors during the year. Mosquitoes. During May many complaints were received from persons living in Abbey Wood that they were being troubled by swarms of mosquitoes, that children were being bitten and that the health of the inhabitants of the districts was endangered thereby. Investigations were made and it was found that the mosquito causing the trouble was of the culicine variety. No specimens of the malaria mosquito (anopheline) were discovered. The area in which the complaints were received is near the Plumstead Marshes and also in the vicinity of a large allotment area. On many of the allotments an improvised type of well had been sunk I 130 at depths varying from 9 to 15 feet. On other allotments open tanks were used for the temporary deposit of water. The area therefore was eminently suitable for the breeding of mosquitoes. When investigations were made it was found that many of these wells, and many of the stagnant pools of water were teeming with mosquito larvae, in addition to which a number of barrels were found containing a quantity of water and full of larvae. I immediately communicated with the allotment associations and with the owner of the barrels, and allocated two Inspectors to supervise the area. Leaflets were prepared and circulated through the agency of the schools, setting forth the best methods of dealing with breeding places of mosquitoes. I also communicated with the Borough Engineer with respect to the ditches on the marshes that were under his control. Everybody who could help in this matter did so, and as a result conditions considerably improved. It was found that the use of paraffin sprayed over ditches was only effective for about a week and it was necessary therefore to see that the spraying was renewed. 131 SECTION VIII.—PUBLIC HEALTH STAFF. The names, qualifications, and year of appointment of members of the Health Staff at the 31st December, 1923, are shewn below in the form requested by the Ministry of Health. The nursing and domestic staff of the Home for Ailing Babies is not included. Year appointed. Name. Qualifications. Appointment. 1918 Mackenzie, R. M.B., Ch.B., D.P.H. Assistant Medical Officer of Health for Maternity and Child Welfare 1921 Blackmore, F. J. C. M.R.C.S., L.R.C.P. Assistant Medical Officer of Health and Tuberculosis Officer tl923 Topping, A. M.A., M.D., D.P.H. Assistant Medical Officer (General Purposes) 1891 Smith, Sir W. R. M.D., D.Sc., D.P.H., L.L.D., F.R.S. (Edin.) Public Analyst (Part time) *1890 Duck, A. G. F.S.I.A., Cert. Royal San. Inst., Cert. Meat and other foods Chief Sanitary Inspector *1896 Little, W. Cert. Royal San. Inst., Cert. Meat and other foods Sanitary Inspector *1897 Wood, W. Cert. Royal San. Inst. Sanitary Inspector *1898 Potter, A. G. Cert. Royal San. Inst. Sanitary Inspector *1901 Tedham, W. Cert. Royal San. Inst., Cert. Meat and other foods Sanitary Inspector *1904 Powell, T. Cert. Royal San. Inst., Cert. Meat and other foods Sanitary Inspector I 2 132 Year appointed. Name. Qualifications. Appointment. *1909 Shaw, H. Cert. Royal San. Inst., Cert. San. Insp. Exam. Board, Cert. San. Insp. Assocn., Cert. Meatand other foods Sanitary Inspector *1920 Pendrill, H. W. Cert. San. Insp. Exam. Board, Cert. Meat and other foods Sanitary Inspector *1921 Harris, C. V. Cert. San. Insp. Exam. Board, Cert. Royal San. Inst., Cert. Meat and other foods Sanitary Inspector *1922 Couch, C. Cert. San. Insp. Exam. Board, Cert. Royal San. Inst., Cert. Meat and other foods Sanitary Inspector *1904 Farrugia, Mrs. A. Cert. San. Insp. Exam. Board, Cert. Royal San. Inst. Woman Sanitary Inspector †1917 Latham, Miss K. Cert. San. Insp. Exam. Board., Cert. Royal San. Inst., C.MB. Health Visitors' Cert., Cert. approved by Board of Education Health Visitor *†1918 Garside, Mrs. M. Cert. San. Insp. Exam. Board, Health Visitors' Certificate Health Visitor and Sanitary Inspector †1919 Burnett, Miss W. Cert. San. Insp. Exam. Board, C.M.B. Health Visitors' Diploma, Cert. approved by Board of Education Health Visitor †1919 Tibbits, Miss E. Cert. San. Insp. Exam. Board, Health Visi tors' Diploma, Cert. approved by Board of Education Health Visitor *†1919 Ware, Miss C. Cert. San. Insp. Exam. Board., C.M.B., Cert. approved by Board of Education Health Visitor and Sanitary Inspector †1920 Campbell, Miss M. Cert. General Hospital Training, C. M. B., Cert. San. Insp. Exam Board Health Visitor 133 Year appointed. Name. Qualifications. Appointment. 11920 Morgan, Miss F. Cert. General Hospital Training, C. M. B., Health Visitors' Cert. Maternity and Child Welfare Cert. Health Visitor †1922 Seccombe, Miss W. Cert. General Hospital Training, C. M. B., Health Visitors' Cert. Health Visitor †1921 Castledine, Mrs. L. Cert. General Hospital Training Tuberculosis Visitor †1921 Hunter, Miss M. Cert. San. Insp. Exam. Board. C.M.B., Health Visitors' Diploma Tuberculosis Visitor †1921 Mahony, Miss N. Cert. General Hospital Training, Health Visitors' Cert. Tuberculosis Visitor †1923 Luffman, Miss M. Dispensing Certificate Clerk-Dispenser †1922 Morrison, Mrs. L. - Lay Organiser †1921 Cross, Miss S. Cert. General Hospital Training, C.M.B. Matron, Home for Ailing Babies Clerks: Britter, A. Smith, H. S. Collyer, H. M. Prescott, H. T. Taylor, S. G. †Stephenson, Miss D. †Edwards, Mrs. E. (temporary). Pike, L. (temporary). Mortuary Keeper: P. Leason. The Medical Officer of Health* is Administrative Tuberculosis Officer and Executive Officer under the Council's Maternity and Child Welfare Scheme. *Salary contributions made under Public Health Acts. †Salary contributions made by Exchequer Grants. 134 SECTION IX.—HOUSING. In accordance with the instructions of the Ministry of Health, the following tabular statement is shewn:— TABLE No. 79. Number of new houses erected during the year:— (a) Total 172 (b) With State assistance under the Housing Acts, 1919 or 1923:— (i) By the Local Authority 110 (ii) By other bodies or persons — 1.—Unfit Dwelling Houses. Inspection. (1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 7,229 (2) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 3,192 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 10 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 716 2.—Remedy of Defects without Service of Formal Notices.* Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their officers 2,412 * Includes intimation notices. 135 3.—Action under Statutory Powers. (a) Proceedings under Section 28 of the Housing, Town Planning, etc. Act, 1919:— (1) Number of dwelling houses in respect of which notices were served requiring repairs 3 (2) Number of dwelling houses which were rendered fit:— (a) By Owners 4 . (6) By Local Authority in default of Owners 0 (3) Number of dwelling houses in respect of which closing orders became operative in pursuance of declarations by owners of intention to close 0 (b) Proceedings under Public Health Acts:— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 1,053 (2) Number of dwelling houses in which defects were remedied:— (a) By Owners 1,033 (b) By Local Authority in default of owners 0 (c) Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc. Act, 1909:— (1) Number of representations made with a view to the making of closing orders *13 (2) Number of dwelling houses in respect of which closing orders were made 0 (3) Number of dwelling houses in respect of which closing orders were determined, the dwelling houses having been rendered fit 0 (4) Number of dwelling houses in respect of which demolition orders were made 0 * Underground rooms. 136 (5) Number of dwelling houses demolished in pursuance of demolition orders 0 Housing in the Borough. The housing conditions are still far from satisfactory, and the number of families requiring houses does not appear to diminish, but rather increase, as the building of new houses does not keep pace with the normal annual demand, irrespective of making up the arrears that have accumulated in late years. The average number of persons per house in Woolwich at the time of the Census was 5'066. Since that date the nett number of additional houses to June, 1923, was 427, equivalent to 2,163 persons. The increase in the population is given by the Registrar General as 3,693. The Council's new housing scheme progresses slowly. At the end of 1923, 410 houses had been built and occupied and an additional 38 were in course of erection. It is proposed to erect an additional 160, but the necessary approval has not yet been obtained. Houses are again being built in increasing numbers in Eltham by private enterprise and 62 were completed during the year as compared with 30 in 1922 and 10 in 1921. The number of houses demolished was 30. Housing Survey. The house-to-house inspection has continued on the same lines that were instituted in 1920 and occupies the whole time of one inspector and half the time of another. This work is known as the housing survey. The worst areas in the Borough have now been surveyed and the record cards passed on to the district inspectors. These records have received attention, and the necessary notices served for the abatement of the nuisances. The details 137 recorded are set out under the headings given in the Housing (Inspection of District) Regulations, 1910. During the year a total of 3,192 houses was surveyed and recorded by the Inspectors engaged in this work compared with 3,987 in 1922. The results of the survey were periodically reported to the Public Health Committee. The summarised results for the year are 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 14 Grade 2.—Unfit for human habitation by reason of extensive dilapidations and dirty conditions, but subjective to effective remedy under a Closing Order 10 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 477 Grade 4.—Few defects, capable of being remedied under the Public Health (London) Act, 1891 1,248 Grade 5.—Satisfactory 1,443 Total 3,192 In addition to the details required to be recorded by the above-mentioned Regulations, a record is made of the number of persons occupying the houses. This distribution of the population is shewn below and similar figures from previous reports are given for comparative purposes. 138 TABLE No. 80. Year. 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. Persons per House. Rooms per person. With less than two persons per room. With two persons per room. With more than two persons per room. 1920 2075 333 272 437 604 5.6 .83 1921 2145 298 357 364 697 5.5 .87 1922 3384 371 232 390 1309 5.3 .94 1923 2708 280 204 325 773 5.4 .96 Unhealthy Areas. No areas have been represented under Part I of the Housing Act, 1890, and no complaints that areas are unhealthy have been made. ACTION TAKEN UNDER THE HOUSING ACTS, 1909 and 1919. As far as houses were concerned, no action was taken under the Housing Act, 1909, during the year, but five houses were dealt with in accordance with the provisions of Section 28 of the Housing, Town Planning, etc. Act, 1919. At the end of the year the necessary repairs had been satisfactorily completed in four cases. In the other case the work had been started. In December, your Medical Officer drew the attention of the Committee to 13 cases where underground rooms were illegally occupied. Having regard to the present housing difficulties and to the sanitary conditions of these rooms, it was resolved to take no action in seven cases. With regard to the other six cases, as the Council meeting was in January, 1924, the action taken must, for the purposes of this report, be shewn as pending at the end of the year. 139 TABLE No. 81. Date of representation. Premises. Date of Closing Order. Remarks. 1923. 1923. Feb. 9 14 Milward Street - House rendered fit July 23 21 Morris Street - Do. Sept. 21 63 Earl Street - Repairs commenced Oct. 19 90 Maxey Road - House rendered fit Dee. 14 102 Wickham Lane - Do. Dec. 14 5 Nelson Street - Underground room Action pending at end of year Dec. 14 97 Sand Street — Do. Dec. 14 107 Parkdale Road.. — Do. Dec. 14 "Melladew," High Street, Eltham — Do. Dec. 14 12 Fenwick Street — Do. Dec. 14 28 Sladedale Road — Do. New Houses. Water certificates were granted during the year for the following new houses erected in the Borough:— Council's Housing Scheme. Eltham 44 March 9th. 54 April 13th. 8 June 15th. Private Enterprise. Woolwich Nil — Plumstead, West— The Grange, Brent Road April 13th. The Bungalow, Waldstock Road September 31st. 140 82a Plumstead Common Road October 19th. Yardman's Cottage, rear of 1 Conduit Rd. October 19th. House over Garage in Shrewsbury Park November 16th. Plumstead, East— The Rise, Bostall Hill September 21st. Argyle Villa, Southland Road November 16th. 56, 58, 60 and 62 Howarth Road November 16th. 50, 52 and 54 Howarth Road December 14th. Eltham— 55 Westmount Road January 12th. Claremont, Westmount Road do. 18 Glenesk Road do. 20 Glenesk Road do. 14 Glenlyon Road do. Kashmir, Glenesk Road do. Orchard Corner, Westmount Road do. Budleigh, Westmount Road February 9th. Glendover, Westmount Road do. 114 Westmount Road March 5th. 116 Westmount Road do. Temperley, Glenesk Road do. Beaucourt, Westmount Road do. 61 Westmount Road April 13th. 118 Westmount Road do. 120 Westmount Road do. 20 Glenesk Road do. Le Nid, Glenlea Road May 11th. Avilion, Glenlea Road do. 79 Westmount Road do. 154 Westmount Road do. Sobroad, Glenlea Road do. Sidlands, Glenlea Road June 15th. 141 Electra House, Westmount Road June 15th. The Bield, Glenlea Road do. Minerva, Glenlea Road July 6th. The Shanty, Glenlea Road do. 152 Westmount Road do. Tenby, Glenlea Road September 21st. The Chalet, Glenlea Road do. The Dene, Glenlea Road do. 83 Westmount Road do. 67 Gourock Road do. 69 Gourock Road do. 80 Dun vegan Gardens do. 132 Westmount Road do. Springfield, Glenlea Road October 19th. Saltwood, Glenlea Road do. Braemont, Glenlea Road do. 63 Gourock Road November 16th. 65 Gourock Road do. 69 Glenesk Road do. 6 Glenesk Road do. 82 Dunvegan Gardens do. 1 Brickhill Villas, Footscray Road December 14th. 2 Brickhill Villas, Footscray Road do. 73 Glenesk Road do. 43 Winn Road do. 142 METEOROLOGY. Meteorological Observations taken at the Royal Observatory, Greenwich, during the year 1923. Week ending 1923. Temperature of the Air. Departure from average mean air temp. of 65 years. Average Temperature 4 feet below ground. Number of days on which rain fell. Rainfall in inches. Highest during Week. Lowest during Week. Mean Temperature. Jan. 6 51.8 28.2 40.8 + 2.4 44.0 3 0.84 13 53.0 27.3 40.6 + 2.7 43.5 5 0.38 20 51.7 25.0 39.5 + 1.1 42.9 3 0.22 27 50.1 29.3 41.5 + 2.5 42.4 — 0.00 Feb. 3 54.9 40.7 49.7 + 10.0 42.7 3 0.14 10 51.1 25.9 42.3 + 3.0 13.7 4 0.82 17 51.6 34.9 42.3 + 3.1 43.8 6 0.71 24 48.3 31.9 38.9 — 0.7 43.1 6 0.74 March 3 57.2 35.1 45.8 + 5.5 43.1 5 0.52 10 52.8 33.2 41.7 + 0.7 43.4 5 0.55 17 50.1 27.2 40.5 — 1.0 43.2 3 0.95 24 57.6 31.7 43.6 + 1.5 43.3 3 0.24 31 70.6 37.8 51.5 + 7.8 44.3 6 0.28 April 7 63.2 35 2 47.7 + 1.7 45.6 2 0.09 14 68.0 31.2 46.9 + 0.8 45.9 6 0.75 21 58.0 35.3 45.9 — 20 46.7 — 000 28 59.9 50.7 45.8 — 2.8 46.7 3 0.46 May 5 80.6 41.7 58.4 + 8.8 47.5 2 012 12 71.8 34.1 50.7 — 0.6 49.6 4 0.33 19 60.5 37.9 46.0 — 6.9 49.4 3 0.36 26 66.8 36.8 51.0 — 3.9 49.6 3 0.44 June 2 62.7 42.3 49.0 — 7.8 49.9 2 0.75 9 71.0 35.4 52.7 — 5.5 50.1 3 0.18 16 72.0 44.6 55.3 — 3.2 51.0 2 0.18 23 79.2 38.2 56.4 — 3.5 51.7 3 0.04 30 78.3 43.4 58.8 — 2.6 52.6 1 0.08 143 METEOROLOGY—continued. Week ending 1923. Temperature of the Air. Departure from average mean air temp. of 65 years. Average Temperature 4 feet below ground. Number of days on which rain fell. Rainfall in inches. Highest during Week. Lowest during Week. Mean Temperature. July 7 90.1 49.9 65.4 + 3.3 53.6 - 0.00 14 92.2 52.2 73.9 + 11.2 56.0 2 1.88 21 83.9 49.9 66.2 + 2.9 57.8 3 0.07 28 80.4 48.2 63.0 + 0.3 58.2 3 0.23 Aug. 4 78.1 49.8 61.8 — 0.3 58.1 3 0.39 11 90.7 45.9 68.5 + 6.2 58.5 — 0.00 18 88.2 48.1 64.0 + 1.7 59.1 3 0.44 25 71.3 49.7 59.7 — 1.5 58.9 3 0.92 Sept. 1 72.6 43.3 56.4 — 3.9 58.3 4 0.56 8 71.4 40.3 55.4 — 3.9 57.2 1 0.10 15 77.4 42.9 60.0 + 2.0 57 0 2 0.34 22 63.3 390 52.5 — 4.1 56.6 5 0.48 29 73.4 42.9 58.0 + 2.9 55.9 3 0.24 Oct. 6 75.1 33.5 51.8 — 1.6 55.8 4 1.04 13 67.8 41.9 53.3 + 2.1 54.9 6 1.73 20 66.6 34.3 49.8 + 0.3 53.9 4 0.85 27 59.3 43.6 51.5 + 3.6 53.1 7 1.29 Nov. 3 59.9 36.9 49.8 + 2.7 52.3 4 0.32 10 52.6 23.4 40.2 — 5.2 51.5 4 0.78 17 54.8 26.0 42.5 — 0.7 48.9 4 0.56 24 44.1 29.9 36.5 — 5.7 47.3 1 0.02 Deo. 1 45.4 22.7 32.7 — 8.7 45.8 1 0.08 8 48.0 27.3 38.2 — 3.0 44.7 4 0.27 15 48.2 25.3 40.7 — 0.2 44.1 1 0.02 22 49.8 28.5 40.1 + 0.5 44.1 4 0.32 29 49.9 24.3 37.7 — 0.8 43.4 6 0.90