WOO 32 Metropolitan Borough of Woolwich ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR WOOLWICH 1932 BY J. MACMILLAN, D.S.O., M.C., M.B., D.P.H. Medical Officer of Health LONDON: E. G. BERRYMAN & SONS, LTD. Blackheath Road, S.E.10. PUBLIC HEALTH AND HOUSING COMMITTEE. At 31st December, 1932. His Worship the Mayor (Councillor R. A. M. Walters, J.P.). Councillor H. Vaughan (Chairman). Councillor F. J. Bloomfield (Vice-Chairman). Alderman S. G. Turner. Councillors: B. A. G. Beaten W. W. Burr P. Chinnery Miss M. Crout, J.P. Mrs. L. E. Driver A. H. Gilder Miss C. K. Lambeth Mrs. E. L. Reeves Rev. H. Stebbings Miss S. Turnbull H. J. Turner Miss G. E. Walters, J.P. MATERNITY AND CHILD WELFARE COMMITTEE. Comprising the Members of the Public Health and Housing Committee. Councillor H. Vaughan (Chairman). Councillor Miss C. K. Lambeth (Vice-Chairman). 3 TABLE OF CONTENTS. PAGE Public Health and Housing Committee 2 Maternity and Child Welfare Committee 2 Preface 6 I.— GENERAL STATISTICS. Census, 1931 10 Population, 1932 15 Sickness and Invalidity 16 Physical Features of the Area 16 II.— VITAL STATISTICS. Annual Statistics (including those of Wards) 17 Births 19 Marriages 21 Deaths 21 Deaths from Cancer 25 Maternal Mortality 27 Child Mortality 28 Infantile Mortality 29 III— GENERAL PROVISION OF HEALTH SERVICES. Public Health Officers 32 Professional Nursing in the Home 35 Midwives 35 Laboratory Facilities 35 Adoptive Acts, By-laws and Regulations in Force in the District 35 Institutional Treatment for Unmarried Mothers 36 Ambulance Facilities 36 Vaccination 36 Supply of Insulin 38 Maternal Mortality 38 Health Visiting 39 Clinics and Treatment Centres 39 Hospitals 40 IV.— HEALTH PROPAGANDA. Health Week, 1932 43 Health Demonstrations at Eltham 43 Health Lectures to Adults 44 Health Talks to School Children 44 Informal Talks 44 "Better Health" 44 Health Services Booklet 45 Central Council for Health Education 45 v.— SANITARY ADMINISTRATION. Staff 46 Water Supply 46 Removal and Disposal of Refuse 46 Drainage 48 Smoke Abatement 48 Complaints 48 4 page Sanitary Inspection of the Area 48 Factory and Workshops Act 50 Rats 52 Offensive Trades 52 Rag Flock Act 52 Mortuaries 52 Cemeteries 53 Removal of Infirm and Diseased Persons 53 Legal Proceedings 53 Public Baths and Washhouses 54 VI.— INSPECTION AND SUPERVISION OF FOOD. General Reference 56 Milk Supply 57 Agricultural Produce (Grading and Marking) Acts 58 Merchandise Marks Act 59 Meat Inspection 60 Other Food Premises 61 Unsound Food 61 Sophistication of Food 63 Adulterated Samples—Action Taken 66 Food Poisoning 66 Chemical and Bacteriological Examination of Food 68 Nutrition 68 Food By-laws 68 VII.— HOUSING. Statistics 69 Inspection of Houses 71 Rent Restrictions Acts 72 Tents and Vans 72 Houses Let in Lodgings 72 New Houses 72 Council's Housing Scheme 73 Common Lodging Houses 73 Census, 1931 73 Bug Infestation 78 VIII.— INFECTIOUS DISEASES. Notifications 82 Diphtheria 88 Scarlet Fever 89 Smallpox 91 Erysipelas, Malaria and Dysentery 91 Enteric Fever 91 Anterior Poliomyelitis 91 Cerebro-Spinal Meningitis 91 Encephalitis Lethargica 92 Puerperal Fever and Puerperal Pyrexia 92 Ophthalmia Neonatorum 93 Zymotic Enteritis 93 Whooping Cough 93 Measles 93 Pneumonia 95 Tuberculosis 96 IX.— MATERNITY AND CHILD WELFARE. General Reference 106 Staff 107 Notification of Births Acts 108 The Work of the Health Visitors 108 5 page The Work of the Welfare Centres 109 Feeding of Infants 110 Artificial Sunlight Clinic 112 Toddlers' Clinic 113 Maternity Outfits 117 Compensation for Midwives 117 Public Health (Puerperal Fever and Puerperal Pyrexia) Regulations, 1926 117 Obstetric Complications in Private Practice 117 Home Helps 118 Treatment of Minor Ailments 118 Dental Treatment 118 Orthopædic Treatment 119 Provision of Nursing Assistance 119 Day Ambulance Service for Maternity Cases 119 Hospital Treatment for Children 120 Institutional Midwifery 120 Ante-Natal and Emergency Hospital Treatment 120 Convalescent Home Treatment for Children 120 Convalescent Home Treatment for Mothers 121 Assisted Milk Scheme 121 Collective Teaching to Mothers 121 Blind Persons Act, 1920 121 Widows', Orphans', and Old Age Contributory Pensions Act, 1925 121 APPENDICES. I. Report on a case of Cow-pox 122 II. Special Report on Medical Inspection of Toddlers 128 III. Meteorological Tables 139 6 PREFACE. To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Woolwich. Mr. Mayor, Ladies and Gentlemen, I have the honour to submit the Thirty-Second Annual Report on the Health of the Metropolitan Borough of Woolwich. In accordance with the instructions of the Council the report follows the outline indicated by the Ministry of Health in order to ensure uniformity in the presentation of Annual Reports of Medical Officers of Health throughout the country. The vital statistics for the year are as follows:—The birth rate was 14.0, compared with 15.1 in 1931; the death rate was 11.1 as compared with 11.6; the infantile mortality rate was 60 as compared with 59; the neo-natal mortality rate (deaths under four weeks, per 1,000 births) was 24.82 as compared with 28.77. Maternal deaths numbered 6—two less than in 1931—the rate for the year being 2.92. The population of the Borough is estimated by the Registrar General at the middle of the year to be 146,900. This is the total population and includes the military. It marks a return to the pre-war practice of the Registrar General who has now discontinued the system inaugurated during the war of differentiating between the civil and military populations. It is on this figure that the rates of the Borough are calculated and so, when any comparison of figures in this report is made with those of the past 17 years, this change of practice must be allowed for. During the year a volume of the 1931 Census Reports showing the tables relating to the Administrative County of London was published. From this the figures in so far as they relate to Woolwich have been extracted and comparisons are made with the figures for 1921. This report shows that the population of Woolwich has increased during the last decade by 4.6 per cent, compared with an increase of 15.67 per cent in the previous inter-censal period. The increase is, however, practically confined to Avery Hill and Sherard Wards. The detailed figures, so far as they relate to population, will be found in the first part of the report, and so far as they relate to dwellings, rooms and families, in the Housing Section of the report. Compared with 1931, the incidence of notifiable infectious diseases showed little change. There were fewer cases of diphtheria (233 against 281) and more scarlet fever (544 against 387). The number of cases of pneumonia notified fell from 371 to 247, while the number of notifications of puerperal fever and puerperal pyrexia 7 received was 40, compared with 49. There were 7 cases of smallpox. Measles, which is not a notifiable disease, was present in epidemic form and 3,135 cases were discovered. The number of primary cases of Tuberculosis coming to the knowledge of the Department during the year was 294 (305 in 1931). At the end of the year there were 813 cases of pulmonary and 217 cases of non-pulmonary tuberculosis, making a total of 1,030 (1,208 cases in 1931) known to be living in the Borough. The deaths from tuberculosis numbered 154 (168 in 1931). How carefully and conscientiously the work of the Sanitary Inspectors has been carried out can be realised by perusing those parts of the report which deal with sanitary inspection of the area, infectious diseases, inspection and supervision of the food supplies, and housing. It is pleasing to record once again that during the year additional professional qualifications were obtained by the following Inspectors:— Laboratory Technique of Meat Inspection, Smithfeld— F. A. Andrew, F. Hemingway. Meat Certificate of the Royal Sanitary Institute— F. J. Hoines. The problem of bug-infested houses has received much attention during the year and the disinfection section of the Department has been reorganised to deal with it. A scheme for providing for more co-operation between owners of bug-infested houses and the Council has also been put into operation. The scheme is fully described in the Housing Section of the report. Disinfestation is a public health problem of the greatest importance at the present day in view of the widespread prevalence of the pest and its effect upon the health and comfort of the individual. There is no actual proof that it spreads disease, at any rate in this country, but it irritates individuals in greater or less degree, it feeds on them, it disturbs their rest and sleep, it gives rise to an offensive odour and disfigures the walls and ceilings of their dwellings. Its effects on individuals are more serious in the case of children. The powers of local authorities in the Metropolis in dealing with the supervision of food supplies and food premises were strengthened by two clauses in the London County Council (General Powers) Act, 1932. The first enables Metropolitan Boroughs to register, refuse to register, or to remove from the register, premises where preserved, pickled, potted and pressed meat and fish are prepared, and where ice-cream is made, stored or sold. The second empowers the County Council to make bye-laws for dealing with the handling and transport of food. The Council during the year acquired land measuring about 27 acres for a burial ground for Eltham. The land is situated on the southern slopes of Shooters Hill and includes about seven acres of woodland, where it will be possible to provide facilities for cremation. The history of the growth of cremation in this country is 8 extremely interesting. In 1874 sixteen pioneers formed the Cremation Society of England and four years later built the Woking Crematorium. The first cremation, however, took place at a private crematorium in Dorset in 1883. In 1884 a Welsh doctor cremated his son by a crude method on the top of a Welsh hill. He was arrested and tried at Cardiff Assizes but was acquitted, the judge holding that cremation was legal if carried out without nuisance to others. In 1885 the Cremation Society permitted cremation at Woking and from that time cremation has steadily grown in this country. There are now 24 crematoria, 14 of which belong to municipalities. In the period 1885-1932, 64,467 cremations have taken place. The number last year was 6,315; five years ago it was 3,265; ten years ago, 2,009, and fifteen years ago 1,509. From these figures it is evident that the movement in favour of cremation is steadily advancing in this country. A cremation is conducted with all the solemnity and reverence with which earth burial is associated. It takes place, however, under cover. Instead of the committal to the open grave, the coffin, at the appropriate part of the service, moves quietly on rollers through doors (which open and close noiselessly) while the service proceeds. In a little over an hour cremation has accomplished what earth burial takes years to do. The ashes may be placed in an urn and disposed of by burial, by depositing in the appropriate part of the crematorium—the columbarium—or taken away for disposal elsewhere. In all the English crematoria there is, however, a Garden of Rest where the ashes may be scattered—a practice which is growing in favour. Cremation is controlled by regulations made by the Home Secretary under the Cremation Act. Application must be made by the nearest relative or by an executor, who has to make a statutory declaration, and two medical certificates as to death have to be completed by independent medical practitioners. The written authority of the medical referee appointed by the Cremation Authority to the cremation has then to be obtained. These precautions provide a much more effective safeguard against secret crime than earth burial. Cremation is easily arranged for; it is not expensive; it prejudices in no way public health, and it avoids the necessity of purchasing expensive sites for cemeteries. In the woodlands of this new cemetery site at Eltham it will be possible to arrange for the disposal of the dead in a manner—solemn, reverent, aesthetic and hygienic—amidst surroundings which will appeal to every hallowed sentiment of our race. In 1931 a Health Centre at Eltham was opened in which provision was made, not only for Maternity and Child Welfare services but also for the School Medical Treatment services, thus ensuring definite co-ordination between these two services. This scheme received the whole-hearted approval of the Ministry and of the County Council. At the end of the year, when it was found necessary to consider plans for the enlargement of Plumstead Welfare Centre owing to the great increase in the amount of work done there, consideration was being given to the 9 possibility of making this Centre a combined one. At the same time an opportunity arose for establishing a permanent Centre in North Woolwich by adapting one of the Council's buildings there. The scheme for the medical supervision of toddlers continues to grow in usefulness. It is a very valuable method of filling in the gap between the infant and the school entrant and particularly so in areas where day nurseries are unnecessary and nursery schools have not been established by the Education authorities. The report of the year's working will be found in Section IX, and in the Appendix will be found a very full report of the incidence of anæmia, heart conditions and rheumatism amongst toddlers, which has been prepared by Dr. Margaret Emslie, the Medical Officer of the Clinic. The attendances at all Centres continue in increase, the total number being 54,629, compared with 53,115 in 1931. I regret to report the death of Sir William Robert Smith, Public Analyst, which occurred on March 17th at the age of 83 years. A native of Woolwich, his official connection began on 29th October, 1889, when he became Medical Officer of Health and Public Analyst for the Woolwich Local Board of Health. In 1890 he became Public Analyst to the Plumstead District Board of Works, and subsequently to the Plumstead Vestry. In 1901, when the Metropolitan Boroughs were formed, he ceased to be Medical Officer of Health, but was appointed Public Analyst for the whole Borough. His record of public service, however, extends beyond Woolwich. He was the first Medical Officer of the old School Board for London and was the founder and Principal of the British, now the Royal, Institute of Public Health. In addition he had a long record of service as a member of local authorities having been Mayor of Holborn, Vice-Chairman of the Metropolitan Asylums Board and Chairman of the Holborn Guardians. In 1918 he was a Sheriff of the City of London. During the war he served as a specialist Sanitary Officer with the rank of Colonel R.A.M.C. (T.). His reputation, however, extended beyond this country and he received many decorations and degrees from foreign governments and universities. A man of courage and great personality with a wide knowledge of men and human affairs, he has left behind him a great record in public service. I am very conscious of the help and consideration given to me by the Chairman and Members of the Health Committees, and indeed by the Council generally, in dealing with the many health problems which required attention during the year, and I am glad of this opportunity of expressing my indebtedness to them. My sincere thanks are also given to the staff of the department for their co-operation and assistance during the year. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, J. MACMILLAN, Medical Officer of Health. 10 THIRTY-SECOND ANNUAL REPORT of the HEALTH OF THE METROPOLITAN BOROUGH OF WOOLWICH. Year ending 31st December, 1932. SECTION I.— GENERAL STATISTICS. TABLE No. 1. Area (acres) 8,282 Population, estimated to middle of 1932 146,900 Population, Census 1931:— Total (including Military) 146,881 Civilians 141,504 Number of inhabited houses, 1931 29,870 Number of families or separate occupiers, 1931 38,176 Rateable value (April, 1932) £1,043,941 Sum represented by a penny rate (April, 1932) £4,349 Census. The Registrar General in the month of June issued a volume relating to the County of London and giving information regarding the Census which was taken on the night of April 26th/27th, 1931. The volume deals with population; with dwellings, rooms and families; with sex, age and marital conditions. The population of the County of London has declined during the decade and the decline is more marked than it was in the period 1911-1921. In 21 of the metropolitan boroughs, compared with 14 in that decade, the population has decreased. Increases have taken place in Greenwich, Hammersmith, Hampstead, Kensington, Lewisham, Paddington, Wandsworth and Woolwich. The increase in Lewisham was 26.3%, and in Wandsworth 7.5% It was 4.6% in Woolwich, and less in the other boroughs mentioned. Even in these boroughs there is evidence of loss of population by outward movement as in most of them the actual increase is less than it should have been by calculating the excess of births over deaths. The following Table, No. 2, shows the number of persons and the sex groupings in the various wards in 1921 and the corresponding numbers in 1931, the increase or decrease, the acreage, and the number of persons per acre in 1931. 11 Table 2 Ward. Acreage. Persons. Males. Females. Persons per Acre. 1921 1931 Increase or Decrease. 1921 1931 Increase or Decrease. 1921 1931 Increase or Decrease. Dockyard 139 7,646 7,093 -553 3,843 3,474 -369 3,803 3,619 -184 51.0 St. Mary's 99 6,783 6,344 -439 3,760 3,426 -334 3,023 2,918 -105 64.1 River 572 13,001 12,036 -965 6,689 6,385 -304 6,312 5,651 -661 21.0 St. George's 325 8,749 8,863 +114 5,243 5,577 +334 3,606 3,286 -220 27.3 Burrage 184 8,763 8,100 -663 4,329 3,951 -378 4,434 4,149 -285 44.0 Herbert 245 9,084 8,451 -633 4,052 3,873 -179 5,032 4,578 -454 34.5 Glyndon 302 9,563 8,769 -794 4,751 4,347 -404 4,812 4,422 -390 29.0 St. Margaret's 552 13,545 12,541 -1,004 6,578 6,069 -509 6,967 6,472 -495 22.7 Central 115 8,769 8,028 -741 4,214 3,845 -369 4,555 4,183 -372 69.8 St. Nicholas 1,207 15,452 13,904 -1,548 13,066 6,935 -884 13,112 6,969 -661 11.5 Abbey Wood 782 10,726 10,729 +3 5,247 5,482 13.7 Well Hall 687 14,009 13,122 -887 13,136 6,300 +6,926 15,172 6,822 +6,789 19.1 Avery Hill 1,824 8,131 11,603 +3,472 5,250 6,353 6.4 Sherard 1,249 6,168 17,298 +11,130 8,512 8,786 13.8 8,282 140,389 146,881 +6,492 69,661 73,191 +3,530 70,728 73,690 +2,962 17.7 12 The population in North Woolwich was 4,409 in 1911, 3,970 in 1921, and 3,579 in 1931, a decrease of 391 persons in the last decade. It will be noted from Table 2 that in only two Eltham wards— Avery Hill and Sherard— is there any substantial increase in the population. There are slight increases in St. George's and Abbey Wood wards but in all the others there are decreases. A population increases when there is excess of births over deaths and where there is an excess of immigration over emigration, and diminishes where there is an excess of deaths over births and an excess of emigration. During the past thirty years, in each of the three parishes which originally composed this borough, the number of births has invariably exceeded the number of deaths, i.e., what is known as a natural increase in the population has taken place. In all the parishes, however, migration has been an important factor as well, as the successive Censal populations do not approximate in any of them to the natural increase. The extent of migration in the last decade is shown in Table No. 3, below, which gives for each of the old parishes the percentage figures for natural increase, gain or loss by migration and the nett gain or loss. It shows that in the borough outward movement to the extent of 2.2% took place during the past ten years. The table should be read thus—in the decade 1921-31 the population of the borough should have increased by natural growth 6.8%; in actual fact it only increased by 4.6%, and therefore there was a loss of 2.2% by migration. TABLE No. 3 Percentage Gains or Losses. Natural Increase. Migration. Nett Increase or decrease. Woolwich +7.8 -12.9 -5.1 Plumstead +5.0 -12.1 -7.1 Eltham +10.8 +37.6 +48.4 The Borough +6.8 -2.2 +4.6 The number of persons per acre in the Administrative County of London was 58.7 and in the metropolitan boroughs this figure varied from 151.7 in Southwark to 17.7 in Woolwich. The following Table, No. 4, shows the age and sex groupings (quinquennial groups) of the population at the time of the Census. For comparative purposes the number of persons in 1921 is also shown and the percentage increase or decrease at each age period. 13 TABLE No. 4. Age Groups (Age last Birthday). Persons. Males. Females. Persons. 1921 1931 1931 1931 Increase or Decrease. Percentage Increase or Decrease. 0—4 13,021 10,391 5,301 5,090 -2,630 -20.20 6—9 12,508 12,181 6,180 6,001 -327 -2.61 10—14 12,960 12,164 6,130 6,034 -796 -6.14 15—19 13,551 13,528 7,606 5,922 -23 -.17 20—24 12,343 13,300 7,011 6,289 +957 +7.75 25—29 11,571 12,555 6,172 6,383 +984 +8.50 30—34 10,403 11,485 5,556 5,929 +1,082 +10.40 35—39 10,065 10,740 5,009 5,731 +675 +6.71 40—44 9,814 9,649 4,587 5,062 -165 -1.68 45—49 9,274 8,995 4,349 4,646 -279 -3.01 50—54 7,745 8,543 4,187 4,356 +798 +10.30 65—59 5,806 7,505 3,761 3,744 +1,699 +29.26 60—64 4,262 6,032 2,995 3,037 +1,770 +41.53 65—74 5,077 7,239 3,315 3,924 +2,162 +42.58 75—95 1,989 2,574 1,032 1,542 +585 +29.41 140,389 146,881 73,191 73,690 +6,492 +4.62 Sub-Groups (included in above). 0-1 3,133 2,084 1,070 1,014 -1,049 -33.48 1—2 3,194 2,066 1,029 1,037 -1,128 -35.32 2—3 2,145 2,074 1,076 998 -71 -3.31 3—4 2,171 2,069 1,065 1,004 -102 -4.70 4—5 2,378 2,098 1,061 1,037 -280 -11.77 It will be noted from the Table that the distribution of the different age groups indicates that the population of Woolwich is an older population than it was in 1921, and this observation is borne out by the fact that in that year the average age of males was 29.6 years, and females 30.4 years, whereas in 1931 it was 31.5 and 32.9 respectively. 14 The following Table has been prepared in order to show in what respects the Woolwich population differs in age grouping from the population of London as a whole and it will be noted that, compared with London generally, there is a relative excess number of persons under 19 years of age and between 30 and 39 years. In all other ages there are relatively fewer people in Woolwich. TABLE No. 5 Age last Birthday Woolwich. London. Persons. Males. Females. 0—4 105 99 110 100 5—9 111 105 111 100 10—14 113 105 120 100 15—19 102 111 91 100 20—24 91 96 86 100 25—29 94 92 97 100 30—34 102 101 102 100 35—39 105 104 107 100 40—44 99 98 99 100 45—49 94 95 95 100 50—54 97 97 97 100 55—59 99 99 98 100 60—64 99 101 98 100 65—69 95 95 95 100 70—74 91 92 93 100 75—95 86 90 85 100 At the time of the Census 1,025 males and 1,088 females were enumerated in the area but normally resident elsewhere in England and Wales, and 1,305 males and 1,602 females who normally are resident in Woolwich were enumerated elsewhere in England and Wales. The number of private families and housing conditions generally will be found in the Housing section of the report, q.v. 15 The following Table shows the population living in institutions and other special premises. TABLE No. 6. Total Population. Inmates Only. Persons. Males. Females. Persons. Males. Females. Workhouses 438 277 161 419 273 146 Other Poor Law Institutions 63 55 8 57 53 4 Hospitals (not Military, etc.) 988 351 637 713 342 371 Convalescent and Nursing Homes 15 5 10 2 1 1 Other Places of Detention 31 26 5 — — — Military Hospitals 4 4 — 1 1 — Military Barracks 5,372 4,401 971 — — — Ships 344 341 3 — — — Inland Barges and Boats 32 31 1 — — — Age, Sex and Marital Condition.— The Number of females per 1,000 males was 1,007, the figure for the County being 1,151. The following Table shows the marital conditions of Woolwich residents in age and sex groups: TABLE No. 7. Age. Sex. Single. Married. Widowed. Divorced. 0—15 Males 17,611 — — — Females 17,125 — — — 15—45 Males 18,840 16,836 240 25 Females 15,456 19,190 634 36 Over 45 Males 1,639 15,764 2,206 30 Females 2,115 13,596 5,512 26 Population. The population at the middle of 1932 was estimated by the Registrar General to be 146,900. As from the 1st January, 1932, he has decided to discontinue the exclusion of deaths of non-civilians from local statistics and to revert to the pre-war practice of assigning these deaths in accordance with the general rules. Accordingly 16 no separate estimate of the local civil population is included this year. As a result the figures upon which the vital statistics of three wards of the old parish of Woolwich are calculated are substantially increased with a corresponding fall in the birth and death rates. The estimated population in each of the Wards of the Borough at the middle of 1932, is shown in the following Table. TABLE No. 8 Wards Population Dockyard 7,032 St. Mary's 6,210 River 11,842 St. George's 8,426 Burrage 8,046 Herbert 8,429 Glyndon 8,694 St. Margaret's 12,487 Central 7,915 St. Nicholas 13,825 Abbey Wood 10,804 Well Hall 13,085 Avery Hill 12,255 Sherard 17,850 In the old parishes the estimated populations are therefore:— Woolwich 33,510 Plumstead 70,200 Eltham 43,190 Sickness and Invalidity. There was no unusual or excessive mortality during the year which calls for any comment under this head. Physical Features and General Characteristics of the Area. In the physical configuration of the Borough the outstanding feature is Shooters Hill, which rises over 400 feet above sea level. At a little lower level, on the Woolwich and Plumstead side, there is a well-marked plateau of Woolwich and Plumstead Commons, due to the erosion of local clay from off the pebble beds. Lower down still is the level plain of the Thames. Southward, in Eltham and Lee, the land, after sloping downward from Shooters Hill, rises slightly again in Eltham and then falls away towards New Eltham and Lee, but rises again as it approaches Chislehurst. In the main this area is composed of London clay although there is a considerable amount of sand and gravel in Avery Hill Ward. 17 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. 9. Births—Legitimate 1,980 „ —Illegitimate 74 2,054 Still-births 64 „ Rate per 1,000 total births 31.1 Birth Rate 14.0 Deaths 1,635 Death Rate 11.1 Percentage of total deaths occurring in public institutions 55.9 Number of women dying in, or in consequence of, Child Birth:— (a) From Sepsis 4 (b) From other causes 2 Deaths of Infants under one year:— (a) Legitimate 111 (b) Illegitimate 12 Infantile Mortality Rate 60 Deaths from Measles (all ages) 25 „ „ Whooping Cough (all ages) 8 „ „ Diarrhœa (under 2 years of age) 8 18 The chief Vital Statistics since 1901 are given in the following Table:— TABLE No. 10 Year. Population estimated to middle of each Year. Births. Nett Deaths belonging to the District. Nett. Under 1 year. At all Ages. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate. (1) (2) (3) (4) (5) (6) (7) (8) 1901 117,652 3536 30.1 457 129 1709 14.6 1902 119,285 3734 31.3 467 125 1837 15.4 1903 117,842 3684 31.3 398 108 1638 13.9 1904 118,456 3535 29.8 477 135 1763 14.9 1905 118,589 3546 29.9 362 102 1604 13.5 1906 119,143 3549 29.8 388 109 1668 14.0 1907 119,704 3330 27.8 373 112 1616 13.5 1908 122,258 3176 26.0 300 94 1516 12.4 1909 120,227 2947 24.5 242 82 1587 13.2 1910 121,197 2842 23.6 242 85 1418 11.7 1911 121,487 2810 23.1 272 97 1566 12.9 1912 121,932 2776 22.8 208 75 1456 11.9 1913 122,382 2833 23.1 228 80 1549 12.7 1914 122,431 2838 23.2 241 85 1706 13.9 1915 a 138,200 2839 21.9 268 94 1837 14.2 b 129,505 1916 a 141,783 3068 23.5 213 69 1704 13.1 b 130,313 1917 a 147,078 2718 20.6 216 79 1566 11.9 b 131,942 1918 a 150,650 2548 19.0 270 106 2100 15.6 b 134,453 1919 a 141,918 2737 20.1 235 86 1679 12.3 b 136,237 1920 a 140,000 3658 26.9 224 61 1487 10.9 b 135,904 1921 a 141,700 3197 23.2 197 62 1594 11.6 b 137,604 1922 a 142,350 2941 21.3 184 63 1603 11.6 b 138,254 1923 a 143,530 2867 20.5 123 43 1387 9.9 b 140,000 1924 a 144,400 2590 18.5 168 65 1543 11.0 b 139,980 1925 a 145,440 2582 18.3 141 55 1519 10.8 b 140,740 1926 a 146,200 2463 17.4 107 43 1450 10.2 b 141,900 1927 a 144,770 2242 15.9 95 42 1491 10.6 b 140,770 1928 a 146,600 2269 16.1 114 50 1554 11.0 b 141,100 1929 a 146,800 2312 16.3 144 62 1780 12.6 b 141,600 1930 a 146,800 2188 15.5 91 42 1547 10.9 b 141,600 1931 a 147,400 2155 15.1 128 59 1654 11.6 b 142,600 1932 a 146,900 2054 14.0 123 60 1635 11.1 a Total Population. b Civil Population. 19 The chief Vital Statistics for 1932, for the Wards of the Borough, are given in the following Table:— TABLE No. 11. Wards. Population. Births Deaths under 1 Deaths at all A ges Number Rate. Number Rate. Number Rate Dockyard 7,032 115 16.4 13 113 79 11.2 St. Mary's 6,210 112 18.0 7 62 83 13.4 River 11,842 181 15.3 15 83 166 14.0 St. George's 8,426 144 17.1 7 49 85 10.1 Woolwich 33,510 552 16 5 42 76 413 12.3 Burrage 8,046 110 13.7 8 73 108 13.4 Herbert 8,429 128 15.2 5 39 87 10.3 Glyndon 8,694 138 15.9 10 72 137 15.8 St. Margaret's 12,487 175 14.0 9 51 139 11.1 Central 7,915 94 11.9 4 43 108 13.6 St. Nicholas 13,825 184 13.3 12 65 172 12.4 Abbey Wood 10,804 117 10.8 6 51 113 10.5 Plumstead 70,200 946 13.5 54 57 864 12.3 Well Hall 13,085 136 10.5 9 66 119 9.1 Avery Hill 12,255 159 13.0 7 44 120 9.8 Sherard 17,850 261 14.6 11 42 119 6.7 Eltham 43,190 556 12.9 27 49 358 8.3 BOROUGH 146,900 2,054 14.0 123 60 1,635 11.1 If the rates in St. Mary's, River and St. George's Wards and in Woolwich parish are compared with those of previous years it must be borne in mind that for the first time since 1914 these rates are calculated on the total population and not on the civilian population. Births. During the year 2,265 births were registered in the Borough, 1,179 being males and 1,086 females. Corrected by outward (212 males and 180 females) and inward (98 males and 83 females) transfers, these numbers become 2,054, 1,065 and 989 respectively. The birth rate was 14.0 compared with 15.1 in 1931, and 15.5 in 1930. 20 Illegitimate Births. The number of illegitimate births registered was 67. There were 16 inward transfers and 9 outward transfers, making a nett figure of 74, equivalent to 36 per 1,000 births. Natural Increase of Population— This term means the excess of births over deaths. In 1928 it was 715; in 1929, 532; in 1930, 641; in 1931, 501, and in 1932, 419. Notification of Births.— During the year 2,209 live births were notified. This is at the rate of 97.5 per cent of the registered births and compares with 98.7 per cent last year. The births were notified as shown in the following Table:— TABLE No. 12. British Hospital for Mothers and Babies 709 Midwives 686 St. Nicholas Hospital 264 Military Families' Hospital . 199 War Memorial Hospital 136 Medical Practitioners 77 Parents 55 Eltham Cottage Hospital 34 Midwives' Homes 14 Other Persons 35 In addition to these, 32 notifications were received from the Medical Officer of Health, Greenwich, 74 from the Medical Officer of Health, Lewisham, and 29 from other Medical Officers of Health. 78 still-births were notified. It is known that 1,145 Woolwich births took place in institutions either within or without the Borough, so that the percentage of institutional midwifery for the Borough as a whole was 57.54. The following Table, No. 13, shows the number of corrected births each year since 1928; the number of live and still-births notified; the percentage of notified births, and the birth rates for the same period for Woolwich, London, and England and Wales:— TABLE No. 13. Year. No. of Births. No. of Live Births. Notified. No. of Still Births. Percentage of Births Notified. Birth Rate. Woolwich. London. England and Wales. 1928 2269 2336 80 98 16.1 15.9 16.7 1929 2312 2300 92 96 16.3 15.7 16.3 1930 2188 2272 74 98 15.5 16.3 15.7 1931 2155 2303 84 99 15.1 15.0 15.8 1932 2054 2209 78 98 14.0 14.3 15.3 21 Marriages. There was 1,160 marriages (1,250 in 1931). The marriage rate was 15.79, as compared with 17.7, 14.1, 15.3 and 17.05 in the four preceding years. Deaths. The total deaths registered in the Borough was 1,446. This figure includes 193 non-residents who died in the district, but does not include 382 residents who died outside the Borough. When allowance is made for inward and outward transfers the nett figure of 1,635 is obtained. The death rate for the year was 11.1, compared with 11.6 in 1931, and 10.9 in 1930. Only in one of the Metropolitan boroughs, namely, Lewisham, was a lower death rate (10.2) recorded. In 1932 the death rate for England and Wales was 12.0, for London 12.3, and the mean death rate for 118 County Boroughs and Great Towns (including London) was 12.2. The seasonal mortality in the four quarters of the year was as follows:— First Quarter, 15.1; Second Quarter, 9.5; Third Quarter, 8.6; Fourth Quarter, 10.5. Deaths in Public Institutions.— In tabular form is shown below the number of deaths of Woolwich residents which took place in various institutions during the year:— TABLE No. 14. Hospital or Institution Number of Deaths Public General Hospitals 626 Voluntary General Hospitals 113 Mental Hospitals 52 Special Hospitals 47 Infectious Diseases Hospitals 36 Sanatoria and Tuberculosis Institutions 12 Cottage Hospitals and Nursing Homes 28 914 The following Tables are self explanatory:— 22 TABLE No. 15 Birth Rates, Death Rates and Analysis of Mortality in the year 1932. Rate per 1,000 Population. Annual Death-rate per 1,000 Population. Rate per 1,000 Live Births. Percentage of Total Deaths. All Causes Typhoid and Paratyphoid Fevers. Smallpox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Violence. Diarrhœa and Enteritis (under 2 yrs.) Total Deaths under 1 year. Certified by Registered Medical Practitioners. Inquest Cases. Certified by Coroner after P.M. No Inquest. Uncertified Causes of Death. Live Births Still Births England and Wales 15.3 0.66 12.0 0.01 0.00 0.08 0.01 0.07 0.06 0.33 0.54 6.6 65 91.1 6.2 1.8 0.9 118 County Boroughs and Great Towns, including London. 15.4 0.64 12.2 0.00 0.00 0.12 0.01 0.08 0.07 0.28 0.54 8.6 70 91.3 5.9 2.3 0.5 126 Smaller Towns (Estimated Resident Populations, 25,000 to 50,000 at Census 1931). 15.2 0.68 11.4 0.01 – 0.07 0.01 0.07 0.04 0.31 0.53 5.3 61 91.9 5.8 1.3 1.0 London 14.3 0.46 12.3 0.00 0.00 0.19 0.02 0.08 0.07 0.28 0.57 12.5 67 89.4 6.2 4.4 0.0 WOOLWICH 14.0 0.41 11.1 0.01 0.00 0.17 0.02 0.05 0.05 0.33 0.37 3.9 60 90.1 7.0 2.9 0.0 23 TABLE No. 16 Deaths registered during the calendar year 1932, including non-residents in institutions in the Borough. Causes of Death. Nett Deaths at the subjoined ages of "Residents," whether occurring within or without the District. Deaths in Public Institutions. 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 35 years. 35 and under 45 years. 45 and under 55 years. 55 and under 65 years. 65 and under 75 years. 75 and upwards. In Borough. Outlying Institutions. Residents. NonResi dents. All Causes 1635 123 23 22 38 74 66 98 152 256 397 386 552 175 362 Typhoid and Paratyphoid Fevers 2 — — — — 1 — — — 1 — — — — 1 Measles 25 5 8 3 8 1 — — — — — — 1 — 15 Scarlet Fever 3 — 2 — 1 — — — — — — — — — 3 Whooping Cough 8 5 1 — 2 — — — — — — 1 — 5 Diphtheria 8 — — 2 6 — — — — — — — — — 8 Influenza 49 — 1 1 1 1 3 5 4 5 11 17 25 7 6 Encephalitis Lethargica 1 — — — — — — — — 1 — — — — 1 Cerebro-Spinal Fever 4 1 2 — — 1 — — — — — — — — 3 Tuberculosis of Respiratory System 139 — — 1 1 28 27 34 23 20 4 1 55 20 33 Other Tuberculous Diseases 15 1 — 2 3 3 1 1 — 1 1 2 6 4 5 Syphilis 4 1 — — — — — 1 — 2 — — 2 — 2 General Paralysis of the Insane, Tabes Dorsalis 9 — — — — — 3 2 2 2 — — 4 1 5 Cancer, Malignant Disease 210 — — — 1 1 4 8 29 56 69 42 57 23 57 Diabetes 19 — — — — — 2 1 3 3 6 4 11 1 2 Cerebral Hæmorrhage, etc. 71 — — — — — — 2 3 13 34 19 22 7 10 Heart Disease 365 — — 2 2 7 4 16 26 67 111 130 110 26 47 Aneurysm 7 — — — — — — 1 1 2 3 — 2 1 3 Other Circulatory Diseases 68 — — — — — — — — 13 29 26 12 3 22 Bronchitis 67 4 — — — — 1 1 5 7 21 28 9 — 6 Pneumonia (all forms) 81 25 4 5 2 5 1 2 4 7 15 11 35 15 14 Other Respiratory Diseases 21 2 — — 2 — — — 4 5 3 5 4 1 4 Peptic Ulcer 26 — — — — — — 4 8 6 6 2 9 1 10 Diarrhœa, etc. 12 7 1 — — — — — 2 — 2 — 4 4 4 Appendicitis 3 — — 1 — 3 2 1 1 2 3 — 10 2 2 Cirrhosis of Liver 7 — — — — — — — 2 5 — — 3 — 1 Other Diseases of Liver, etc. 8 — — — — — 1 3 1 — 1 2 4 4 1 Other Digestive Diseases 30 5 — — — — 1 — 5 6 5 8 16 1 4 Acute and Chronic Nephritis 54 — — — 1 2 3 2 5 7 20 14 6 7 13 Puerperal Sepsis 4 — — — — 1 3 — — — — — 4 — — Other Puerperal Causes 2 — — — — — 1 1 — — — — 2 2 — Congenital Debility, Premature Birth, Malformations, etc. 55 55 — — — — — — — — — — 30 6 8 Senility 42 — — — — — — — — 1 6 35 22 6 13 Suicide 17 — — — — 1 2 3 4 4 3 — 5 1 1 Other Violence 55 6 1 2 5 9 3 3 4 4 7 11 27 12 12 Other Defined Diseases 134 6 3 3 3 10 4 7 16 16 37 29 54 20 41 Causes ill-defined or unknown — — — — — — — — — — — — — — — 24 TABLE No. 17 Nett Deaths registered during 1932, classified by sex and wards. Causes of Death. The Borough. Woolwich. Plumstead. Eltham. Males Females Dockyard St. Mary's River St. George's Burrage Herbert Glyndon St. Margaret's Central St. Nicholas Abbey Wood Well Hall Sherard Avery Hill All Causes 873 762 79 83 166 85 108 87 137 139 108 172 113 119 119 120 Typhoid & Paratyphoid Fevers 2 — — — — — 1 — — — — — — — — 1 Measles 13 12 1 2 2 6 1 — 2 2 — 5 1 2 1 — Scarlet Fever — 3 — — — — — — — 1 — — 2 — — — Whooping Cough 3 5 2 — — 1 — — — — — 1 1 2 1 — Diphtheria 5 3 — — 2 1 — — — 1 — — 1 — 3 — Influenza 22 27 1 4 5 2 3 1 3 7 4 7 3 5 1 3 Encephalitis Lethargica 1 — — — — 1 — — — — — — — — — — Cerebro-Spinal Fever 3 1 — — — 1 1 — 1 — — 1 — — — — Tuberculosis of Respiratory System 83 56 5 7 22 9 7 12 17 3 6 21 7 9 14 — Other Tuberculous Diseases 8 7 1 2 2 2 1 2 — — — — 2 — 2 1 Syphilis 3 1 — — 1 — — — 2 — — — — 1 — — General Paralysis of the Insane, Tabes Dorsalis 9 — — — 1 — — — 1 — — 4 — 2 1 — Cancer, Malignant Disease 108 102 10 11 25 5 14 12 16 14 16 20 16 16 14 21 Diabetes 11 8 — — — 1 1 1 2 4 2 1 1 2 — 4 Cerebral Hæmorrhage, etc. 33 38 6 1 9 — 6 2 6 8 6 6 5 6 6 4 Heart Disease 173 192 22 23 31 22 29 16 34 29 20 38 27 21 17 36 Aneurysm 6 1 — 1 1 — — — 1 — 1 1 — — 2 — Other Circulatory Diseases 40 28 1 2 6 2 2 4 5 5 6 10 3 4 8 10 Bronchitis 33 34 4 2 7 3 2 2 4 5 10 12 7 2 2 5 Pneumonia (all forms) 51 30 4 3 11 3 5 4 6 6 6 10 4 7 9 3 Other Respiratory Diseases 11 10 1 2 2 — — — — 3 3 2 2 2 3 1 Peptic Ulcer 17 9 1 1 1 3 — 2 3 4 1 — 3 3 2 2 Diarrhœa, etc. 5 7 1 — 3 — — 2 2 1 — 1 1 — 1 — Appendicitis 10 3 — — 1 1 2 1 1 1 3 1 1 — — 1 Cirrhosis of Liver 3 4 — 1 1 1 — 1 1 1 — 1 — — — — Other Diseases of Liver, etc. 3 5 — — 1 — — — 2 1 3 — 1 — — — Other Digestive Diseases 12 18 4 1 4 — 5 4 — 3 1 1 — 1 1 5 Acute and Chronic Nephritis 32 22 2 4 3 4 4 3 3 6 4 1 5 5 4 6 Puerperal Sepsis — 4 1 — — — 1 — — — — — 1 1 — — Other Puerperal Causes — 2 1 1 — — — — — — — — — — — — Congenital Debility, Premature Birth, Malformations, etc. 33 22 3 4 — 4 5 1 5 7 1 5 3 4 7 6 Senility 16 26 1 2 4 — 4 1 5 3 3 5 5 5 2 2 Suicide 10 7 — 1 3 — 1 1 1 2 — 5 1 1 — 1 Other Violence 36 19 4 2 7 4 4 4 4 4 — 3 4 7 6 2 Other defined Diseases 78 56 3 6 11 9 9 11 10 18 12 10 6 11 12 6 Causes ill-defined or known — — — — — — — — — — — — — — — — 25 Causes of Death.— Table No. 16 shows that 365 deaths were due to Heart Disease, 210 to Cancer, 154 to Tuberculosis, 81 to Pneumonia, 71 to Cerebral Hæmorrhage, etc., and 75 to diseases of circulation. There were 55 deaths from Congenital Debility and Prematurity. In every instance these figures are lower than those of 1931. There were 49 deaths from Influenza compared with 34 in 1931. The number of deaths from Measles was 25, as against 1 in 1931, and 15 in 1930. Seventy-three per cent of all deaths occurred in persons over 45 years of age. Respiratory Disease.— The following Table, No. 18, shows the number of deaths each year since 1928 from respiratory diseases, the annual death rate, the number of deaths under five years of age, and the percentage of deaths occurring in children under five years of age. TABLE No. 18 Year. Bronchitis. Pneumonia. Other Respiratory. Total. Death Rate. Number under 5 years. Percentage under 5 years. 1928 113 71 18 202 1.4 32 15.8 1929 121 119 15 255 1.8 51 20.0 1930 61 101 19 181 1.3 35 19.3 1931 91 126 20 237 1.7 54 22.8 1932 67 81 21 169 1.2 40 23.6 Cancer.— The total number of deaths was 210, of which 108 occurred in males and 102 in females. In the following Table, No. 19, is shown the number of deaths certified as due to Cancer and Malignant Disease, each year since 1928:— TABLE No. 19 Deaths from Cancer and Malignant Disease. Year. Males. Females. Total. Rate. Percentage of Total Deaths. 1928 100 109 209 1.48 13.45 1929 93 120 213 1.50 11.97 1930 107 94 201 1.42 12.99 1931 125 95 220 1.54 13.30 1932 108 102 210 1.43 12.84 26 The following Table, No. 20, shows the seat of primary disease in all deaths from Cancer (including all other specified malignant tumours):— TABLE No. 20. Seat of Primary Disease. Males. Females. Total. Deaths in Hospital. Lip 1 — 1 1 Tongue 8 — 8 5 Mouth and Tonsil 4 1 5 4 Jaw 2 — 2 1 Pharynx 2 — 2 2 Œsophagus 3 6 8 4 Stomach 16 16 32 15 Liver and Gall Bladder 6 8 13 2 Intestines 13 15 28 14 Rectum 13 4 17 11 Ovary — 10 10 7 Uterus — 11 11 3 Breast — 17 17 11 Skin 4 3 7 4 Larynx 6 1 7 6 Lung 7 1 8 5 Pancreas 1 4 5 3 Bladder 4 2 6 3 Prostate 10 — 10 6 Thyroid 1 — 1 1 Abdominal Cavity 1 — 1 1 Sarcoma 4 2 6 2 Other Organs and undefined 3 2 5 3 108 102 210 114 27 Maternal Mortality.— The number of deaths from Puerperal Sepsis was 4, and from other accidents and diseases of pregnancy, 2, making a total of 6 maternal deaths; 2 less than in 1931. The maternal death rate per 1,000 births was 2.92 as against 3.71 in 1931. The following Table shows the causes of death each year since 1912:— TABLE No. 21. Maternal Mortality, Woolwich, 1912-1932. Year. Abortion. Ectopic Gestation Placenta Prævia. Other Puerperal Hæmorrhage. Other Accidents of Child Birth. Child Birth with Secondary Causes. Puerperal Eclampsia Puerperal Phlebitis and Embolism Puerperal Fever. Totals. 1912 1 - - - - - 1 1 1 4 1913 1 - - - 1 - 1 - 2 5 1914 1 - 1 2 - 1 1 1 4 11 1915 1 1 - - 1 - 2 - 3 8 1916 — 1 1 1 4 - 1 - 7 15 1917 — 1 - 2 - 1 2 1 7 14 1918 1 - - 2 1 - 1 1 9 15 1919 — 2 1 2 - - 2 1 5 13 1920 — 1 - - 1 - 1 3 5 11 1921 — - - - - - 3 2 5 10 1922 — - - 1 - - 2 - 3 6 1923 — - - - 1 - 1 - 3 5 1924 — - 2 1 1 - 3 1 2 10 1925 — - 1 2 1 1 1 - 3 9 1926 - 1 - 2 - - - 1 2 6 1927 - 1 - - - - 1 1 3 6 1928 - 2 1 - 1 - 1 - 8 13 1929 2 2 _ - 2 1 3 1 3 14 1930 1 - _ - - 1 2 - 4 8 1931 - - _ - 1 - 1 - 6 8 1932 — - - 1 - - 1 - 4 6 Total 8 12 7 16 15 5 31 14 89 197 28 Inquests.— There were 155 inquests held on Woolwich residents during the year, compared with 103 in 1931. Deaths of Children, 1—5 Years of Age.— The number of deaths of children between 1 and 2 years of age was 23, and between 2 and 5 years, 22. In 1931 these figures were 29 and 30. The causes of death are given in detail in Table No. 16. The following Tables show the variation in rates of mortality in these ages in the last five years. These rates have been calculated on the estimated populations living at these ages and in stated groups of diseases:— TABLE No. 22. Child Mortality (1—2 years). Death Rates per 1,000 estimated age population from stated Groups of Diseases Period. Estimated mean Population. Infectious Fevers. Tuberculosis. Respiratory Diseases. Diarrhœal Diseases. All other causes. Total Deaths. 1928 2,129 4.70 .94 2.82 .94 1.88 11.27 1929 2,141 4.20 .47 2.80 1.40 4.20 13.07 1930 2,190 5.48 .91 4.11 1.37 1.37 13.24 1931 2,071 1.45 1.45 6.76 .48 3.86 14.0 1932 2,016 6.45 — 1.99 .49 2.48 11.41 TABLE No. 23. Child Mortality (2—5 years). Death Rates per 1,000 estimated age population from stated Groups of Diseases Period. Estimated mean Population. Infectious Fevers. Tuberculosis. Respiratory Diseases. Diarrhœal Diseases. All other causes. Total Deaths. 1928 7,121 1.83 .42 .42 .14 .98 3.79 1929 6,822 1.91 .44 1.02 .14 1.91 5.42 1930 6,534 1.39 .46 .92 .00 .76 3.53 1931 6,373 .78 .62 .94 .16 2.20 4.70 1932 6,294 .79 .48 .79 — 1.43 3.49 29 Infantile Mortality. The number of deaths of infants under one year of age was 123, compared with 128 in 1931, and 91 in 1930. The rate of infant mortality resulting from these deaths (deaths under 1 year per 1,000 births) was 60, compared with 59 in 1931, and 42 in 1930. The rates for the different Wards in the Borough are shown in Table No. 11. According to a return of the Registrar General for the year 1932, lower rates were recorded in ten of the Metropolitan Cities and Boroughs as follows:—The City, 46; Chelsea, 52; Hackney, Hampstead and Stoke Newington, 54; Lewisham, 55; Lambeth, 56; Bermondsey, 57, and Battersea and Fulham, 58. The rate for the Administrative County of London was 67, and for England and Wales, 65. The following Table, No. 24, shows the distribution of infantile mortality throughout the year, calculated on a varying year basis:— TABLE No. 24. Births. Deaths under 1 Year. Rate. First Quarter 512 49 96 Second Quarter 575 28 54 Third Quarter 488 24 45 Fourth Quarter 479 22 42 Causes of Death.— The causes of infantile mortality are set forth in Tables Nos. 26 and 27, which show the incidence of mortality from each cause for infants, distinguished by age, sex and wards. It will be noted from these Tables that the chief causes of death were:—Premature Birth, 38; Pneumonia, 25; Congenital Malformation, 13; Debility, 4; Diarrhœal Diseases, 7, and Measles, 5. The neonatal mortality rate (deaths under 4 weeks) was 24.82, compared with 28.77 in 1931, and 20.11 in 1930. Of the 51 neo-natal deaths, 36 were certified to be due to Premature Birth, 5 to Congenital Malformation and 4 to Injury at Birth. Deaths of Illegitimate Children.— Twelve illegitimate children died, compared with 8 in 1931, and 1 in 1930. The infantile mortality rate figure for illegitimate children was 162, compared with 56 for legitimate children. Institutional Deaths.— In tabular form is shown below the number of deaths of Woolwich infants which took place in various institutions during the year. These figures are included in those shown in Table No. 14:— TABLE No. 25. Hospital or Institution Number of Deaths Public General Hospitals 43 Voluntary General Hospitals 7 Fever Hospitals 8 Special Hospitals 14 72 Tables are set out in the following pages which classify in various ways the causes of infant death in 1932. 30 TABLE No. 26. Infant Mortality, 1932. 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. Smallpox - - - - - - - - - - Chicken Pox - - - - - - - - - - Measles - - - - - - 1 1 3 5 Scarlet Fever - - - - - - - - - - Whooping Cough - - - - - 1 - 2 2 5 Diphtheria and Croup - - - - - - - - - - Erysipelas - - - - - - - 1 - 1 Tuberculous Meningitis - - - - - - - - 1 1 Abdominal Tuberculosis - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - Meningitis (not Tuberculous) - - - - - - 1 - - 1 Convulsions - - - - - - - - 1 1 Laryngitis - - - - - - - - - - Bronchitis - 1 - - 1 1 1 1 - 4 Pneumonia - - 1 1 2 7 8 1 7 25 Diarrhœa - - - - - - - - 1 1 Enteritis - - - - - 2 - 4 - 6 Gastritis - - - - - - - - - - Syphilis - - - - - 1 - - - 1 Rickets - - - - - - - - 1 1 Suffocation, Overlying - - - - - - - - - - Injury at Birth 4 - - - 4 - - - - 4 Atelectasis - - - - - - - - - - Congenital Malformation 5 - - - 5 4 2 - 2 13 Premature Birth 30 6 - - 36 1 1 - - 38 Atrophy, Debility and Marasmus 1 - - - 1 3 - - - 4 Other Causes 2 - - - 2 5 2 1 2 12 42 7 1 1 51 25 16 11 20 123 Nett Births registered during the calendar year Legitimate, 1,980; Illegitimate, 74. Nett Deaths registered during the calendar year Legitimate 111; Illegitimate, 12 31 TABLE No. 27. Nett Infant Deaths, classified by sex and wards. Causes of Death. The Borough. Woolwich. Plumstead. Eltham. Males. Females. Dockyard. St. Mary's. River. St. George's. Burrage. Herbert. Glyndon. St. Margaret's. Central. St. Nicholas. Abbey Wood. Well Hall. Sherard. Avery Hill. Smallpox — — — — — — — — — — — — — — — — Chicken Pox - - - - - - - - - - — — — — — — Measles 3 2 1 — 1 1 — - - 1 - - - 1 - — Scarlet Fever — — — — — — — — — — — — — — — — Whooping Cough — 5 2 — — 1 — — — — — — 1 1 — — Diphtheria and Croup - — — — — — — — — — — — — — — — Erysipelas - 1 - - 1 — — — — — — — — — — — Tuberculous Meningitis 1 - - 1 — - - - - — — — — — — — Abdominal Tuberculosis — — — — - — — — — — — - — — — — Other Tuberculous Diseases — - — — - - - - - - - - - - - — Meningitis (not Tuberculosis) 1 — — — — — — — 1 — — — — - - - Convulsions 1 — — — — - — — — — 1 — — — — — Laryngitis — — - — — - — - - - - — - - - - Bronchitis 3 1 1 — 2 - — — — 1 — — — — — — Pneumonia 21 4 1 2 6 1 1 2 3 - 1 4 — 2 2 — Diarrhœa 1 — — — 1 — — — — — — — — — — — Enteritis 2 4 - - 2 - — 2 — — — 1 1 — — — Gastritis — - - - - - - - - — — — — — — — Syphilis 1 — — — — — — — — — — — — 1 — — Rickets 1 - - - - - - - - — — 1 — — — — Suffocation, Overlying - — - - — — — - - — — — — — — — Injury at Birth 2 2 2 - 1 - — - - - - - 1 — — — Atelectasis — - — - — - - - — — — — — — — — Congenital Malformation 7 6 1 1 - 3 1 - 1 1 - 1 3 - — 1 Premature Birth 22 16 2 3 — 1 2 1 3 6 1 4 — 4 6 5 Atrophy, Debility & Marasmus 4 - - - — - 2 — 1 — — — — — 1 — Other Causes 4 8 3 — 1 - 2 - 1 - 1 1 - - 2 1 74 49 13 7 15 7 8 5 10 9 4 12 6 9 11 7 32 SECTION III. GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. i. Public Health Officers of the Authority. (a) In tabular form are shown below the names, qualifications and appointments of all Medical Officers employed by, or discharging duties for the Council, either whole or part time, or in a consultative capacity, at the 31st December. TABLE No. 28. Year appointed. Name. Qualifications. Appointment. 1918 Mackenzie, R. E. W. M 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. 1931 Proudfoot, M. E. M.B., Ch.B. Assistant Medical Officer (General Purposes). 1931 Saunders-Jacobs, E. V. M.A., M.B., B.S., M.R.C.S., L.R.C.P., B.Sc., D.P.H. do. do. 1927 Lynham, J. E. A. B.A., M.D., D.M.R.E. Consultant, Artificial Sunlight. 1927 Taylor, H. G. F.R.C.S. Consultant under Puerperal Fever Regulations, 1926. Obstetric Consultant (1931). 1930 Emslie, M. M.B., Ch.B. Medical Officer, Toddlers Clinics (part time). 1930 Brews, R. V. L.R.C.P.I. and L.M., L.R.C.S.I. and L.M. Public Vaccinator (part time). 1930 Cowie, W. M.A., M.B., C.M. do. 1930 Clarke. C. F. M.R.C.S., L.S.A. do. 1930 Wise, H. M. M.B., M.R.C.S., L.R.C.P. do. 1930 Milton, E. F. M.D., B.S. do. 1930 Blackall, G. M.B., B.A.O., D.P.H. do. 1930 Power, F. J. L.R.C.P.I. and L.M., L.R.C.S.I. and L.M. do. The deputies for the above Public Vaccinators are respectively:— Dr. N. E. Sampey, Dr. D. Wilson, Dr. H. M. Wise, Dr. E. C. Wise, Dr. W. T. Milton, Dr. R. W. Wood, Dr. R. Lewys-Lloyd. 33 (b) In tabular form are shown below the dates of appointments, names, and qualifications of the Public Analyst, the Sanitary Inspectors, Health Visitors, the Vaccination Officer, the Tuberculosis Staff and the Clerical Staff employed by the Council. Sir W. R. Smith, who had been Public Analyst since 1891, died in March, 1932. The Council made arrangements with Dr. A. Stewart, the Public Analyst for the Metropolitan Borough of Islington, to act as Public Analyst pending the appointment of a successor. TABLE No. 29. Year appointed. Name. Qualifications. Appointment. 1909 Shaw, H. Cert. Royal San. Inst.; Cert. San. Insp., Exam. Board; Cert. San. Insp., Assocn.; Cert. Meat and other foods. Chief Sanitary Inspector. (1928) 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. 1920 Pendrill, H. W. Cert. San. Insp., Exam. Board; Cert. Advanced Inspectors' R.S.I.; Cert. Meat and other foods; Cert. Smoke Insp., R.S.I. 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; Cert. Smoke Insp., R.S.I. Sanitary Inspector. 1925 Pindar, E. B. Cert. San. Insp., Exam. Board; Cert. Royal San. Inst.; Cert. Meat and other foods. Sanitary Inspector. 1928 Andrew, F. A. Cert. San. Insp., Exam. Joint Board; Cert. Meat and other foods. Sanitary Inspector. 1929 Hemingway, F. Cert. San. Insp., Exam. Joint Board; Cert. Meat and other foods. Sanitary Inspector. 1930 Kersey, H. M. Cert. San. Insp., Exam. Joint Board; Cert. Meat and other foods; Cert. Smoke Insp., R.S.I. Sanitary Inspector. 1931 Hoines, F. J. Cert. San. Insp., Exam. Joint Board; Cert. Meat and other foods. Sanitary Inspector. 1904 Farrugia, Mrs. A. Cert. San. Insp., Exam. Board; Cert. Royal San. Inst. Woman Sanitary Inspector. 34 TABLE No. 29—continued. Year, appointed. Name. Qualifications. Appointment. 1917 Latham, Miss K. Cert. San. Insp., Exam. Board; Cert. Royal San. Inst.; C.M.B.; Health Visitors' Cert., Board of Education Health Visitor. 1918 Garside, Mrs. M. Cert. San. Insp., Exam. Board; C.M.B.; Health Visitors' Cert. Health Visitor and Sanitary Inspector. 1919 Burnett, Miss W. Cert. San. Insp., Exam. Board; C.M.B.; Health Visitors' Cert., Board of Education. Health Visitor. 1919 Tibbits, Miss E. Cert. San. Insp., Exam. Board; Health Visitors' Cert., Board of Education. Health Visitor. 1919 Ware, Miss C. Cert. San. Insp., Exam. Board; C.M.B.; Health Visitors' Cert., 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 Visitors' Cert., Royal San. Inst. Health Visitor. 1920 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. 1927 Farrell, Miss E. V. Cert. General Hospital Training; C.M.B.; Heliotherapy Cert.; Health Visitors' Cert., Board of Education. Health Visitor and Artificial Sunlight Nurse. 1930 Frederick, Miss F. E Cert. General Hospital Training; C.M.B.; Health Visitors' Cert. Health Visitor. 1931 Taylor, S. G. – Vaccination Officer (part time). 1921 Castledine, Mrs. L. Cert. General Hospital Training Tuberculosis Visitor. 1921 Prestige, Mrs. M. Cert. San. Insp., Exam. Board; C.M.B.; Health Visitors' Cert., Board of Education. Tuberculosis Visitor. 1921 Mahony, Miss N. Cert. General Hospital Training; Health Visitors' Cert. Tuberculosis Visitor. 1923 Smith, Mrs. M. Dispensing Certificate Clerk-Dispenser. 1922 Morrison, Mrs. M. L. – Lay Organiser. CLERKS: Allen, L. Britter, A. Collyer, H. M. Crawford, Miss I. Edwards, Mrs. N. Pike, L. Prescott, H. T. Smith, H. S. Stephenson, Miss D. Taylor, S. G. (part time). The Medical Officer of Health is Administrative Tuberculosis Officer and Executive Officer under the Council's Maternity and Child Welfare Scheme. 35 ii. Professional Nursing in the Home. The arrangements for providing nursing assistance in the home were set out fully in my annual report for 1930. No change has taken place in the constitution of the various Associations or of the areas in which they work. They are all under agreement with the Council to provide nursing assistance at the cost of the Council for cases of measles, whooping cough, zymotic enteritis, ophthalmia neonatorum, pneumonia, anterior poliomyelitis, puerperal fever, puerperal pyrexia and tuberculosis. The rates of payment vary from 6d. to 1s. 3d. per visit. iii. Midwives. There are no whole-time midwives employed by the Council. By the courtesy of the County Medical Officer of Health, I have been able to ascertain that 59 midwives gave notice during the year of their intention to practise in the Borough. iv. Laboratory Facilities. The bacteriological work of the Council rendered necessary by investigations into infectious diseases and food poisoning is carried out at the War Memorial Hospital. The bacteriological examination of milk samples is carried out partly at the Woolwich War Memorial Hospital and partly at the Clinical Research Laboratory. A minimum of 500 samples are purchased annually in accordance with the provisions of the Food and Drugs (Adulteration) Act, 1928, and the various Regulations and Orders in which are laid down the standards for food. They are submitted for chemical analysis to the Public Analyst. During the year the work was carried out at the Royal Institute of Public Health. v. Adoptive Acts, By-Laws and Regulations Relating to Public Health in Force in the District. Adoptive Acts.— The Small Dwellings Acquisition Acts, 1899-1923, have been adopted by the Council. During the year, the Borough Treasurer tells me, the Council made 252 advances to purchasers of houses in accordance with the provisions of these Acts. By-laws and Regulations.— A complete list of the various by-laws and regulations in force in the Borough was given in the Annual Report for 1930. New Legislation.— The London County Council (General Powers) Act, 1932, contains provisions dealing with:— (a) Registration of premises for sale, etc., of Ice Cream and Preserved Food. 36 (b) The notification of Food Poisoning. (c) Extending Section 47 of the Public Health (London) Act, 1891, which deals with unsound food, to include any article, solid or liquid, offered as a prize or reward in connection with an entertainment or for the purpose of advertisement. (d) Empowering the London County Council to make by-laws for promoting sanitary and cleanly conditions in the manufacture, preparation, storage, transport or exposure for sale of any article intended to be sold as food. At the end of the year the London County Council had not formulated the by-laws referred to above. vi. Institutional Treatment for Unmarried Mothers, Illegitimate Infants and Homeless Children. There are no special provisions for any of these classes in the Borough. vii. Ambulance Facilities. The London County Council's ambulance service is available:— (a) For the removal to hospital, free of charge, of persons suffering from infectious disease; (b) For the removal, on payment, of persons suffering from non-infectious disease to hospitals or other places; (c) For the removal, free of charge, of cases of accident and sudden illness arising in the streets or public buildings, to hospitals or home. (d) For the removal, free of charge, of ordinary maternity cases between the hours of 11 p.m. and 8 a.m., and urgent maternity cases during the daytime, when accompanied by a doctor or nurse. In addition to these services the Council hire the ambulances of the London County Council for the conveyance of non-urgent maternity cases, between 8 a.m. and 11 p.m., to hospitals in the London area. A note on the use of this service will be found in the Maternity and Child Welfare Section. viii. Vaccination. I submit a return by the Vaccination Officer on the work carried out under the Vaccination Acts for the year 1931. 37 TABLE No. 30. RETURN to be made on or before the 9th of February, 1933, by Mr. S. G. Taylor, Vaccination Officer of all Sub-Districts of the Metropolitan Borough of Woolwich Registration District, respecting the Vaccination of Children whose Births were registered from 1st January to 31st December, 1931, inclusive:— Registration Sub-Districts comprised in Vaccination Officer's District. Number of Births returned in the "Birth List Sheets" as registered from 1st January to 31st December 1931. Number of these Births duly entered by 31st January, 1933, in Columns I., II., IV. and V. of the "Vaccination Register" (Birth List Sheets), viz.:— Col. I. Col. II. Col. IV Number in respect of whom Statutory Declaration of Conscientious Objection has been received. Col. V. Died Unvaccinated. Successfully Vaccinated. Insusceptible of Vaccination. Had Small Pox. 1. 2. 3. 4. 5. 6. 7. 1. Plumstead 551 231 2 — 240 30 2. Woolwich† 1,268 665 7 — 475 52 3. Eltham 513 256 4 — 200 22 Total 2,332 1,152 13 — 915 104 Number of these Births which on 31st January, 1933, remained unentered in the "Vaccination Register" on account (as shown by "Report Book") of:— Number of these Births remaining on 31st January, 1933, neither duly entered in the "Vaccination Register" (Columns 3, 4, 5, 6 and 7 of this Return) nor temporarily accounted for in the "Report Book" (columns 8, 9 and 10 of this Return). *Total Number of Certificates of Successful Primary Vaccination of Children under 14 received during the Calendar Year 1932. Number of Statutory Declarations of Conscientious Objection actually received by the Vaccination Officer irrespective of the dates of birth of the children to which they relate, during the Calendar Year 1932. Postponement by Medical Certificate. Removal to Districts the Vaccination Officers of which have been duly apprised. Removal to places unknown or which cannot be reached; and cases not having been found. 8. 9. 10. 11. 12. 13. 5 10 27 6 These figures are to be obtained from columns 2 and 6 of the Summary (Form N. 13 31 20 5 6 12 8 5 24 53 55 16 1,230* 879 For notes on Table 30 see page 38. 38 Notes on Table No. 30. NOTE.—(a) The total of the figures in columns 3 to 11 should agree with the figure in column 2. Any cases of children successfully vaccinated after the declaration of conscientious objection had been made should be included in column 6 above and not in column 3. The number of such cases should be inserted here:— 5. (b) The figures in columns 2 to 11 should not include re-registered births or cases of children born in other districts. *The total in this column should be the number of Certificates of successful primary vaccination of children under 14, actually received during the year, including any relating to births registered in previous years. The total thus given should include the Certificates of successful primary vaccination of which copies have been sent to the Vaccination Officers of other Districts. The total number of Certificates for the year 1932 sent to other Vaccination Officers should be stated here:— 84. †Includes the Burrage and Herbert Wards in Plumstead Parish. (Signature) S. G. TAYLOR, Date—10th February, 1933. Vaccination Officer. ix. Supply of Insulin to Persons Suffering from Diabetes. In May, 1930, the Council agreed to supply Insulin to diabetic patients who were necessitous and unable to obtain it under the National Health Insurance Acts, and obtained the Ministry's approval. A continuing approval was obtained in May, 1931. A supply of Insulin was given under this scheme to four patients during the year, the total cost being £13 6s. 4d. Insulin is supplied to medical practitioners under the following conditions:— (1) The application must state the name, age, address and sex of the patient for whom it is required. (2) A quarterly report must be furnished in respect of each patient treated, giving the following information:— (a) The number of doses of Insulin administered. (b) Stating whether any tests were made of the urine or of the blood of the patient, and, if so, by whom and with what results. (c) A report on the progress of the patient. x. Maternal Mortality. In accordance with the terms of the Ministry of Health Circular 888, confidential enquiries are made by the Council's medical officers into every maternal death and reports are furnished to the Ministry of Health. The services of a Consultant Surgeon are now available for cases of obstetric emergencies and difficulties occurring at home and for consultation and treatment in cases of puerperal fever or puerperal pyrexia. Arrangements have also been made for the home nursing of such cases and for such bacteriological investigations as are necessary. 39 xi. Health Visiting. The arrangements made for the visiting of children between the ages of one and five years and the general working of the Council's maternity and child welfare scheme are described in Section IX. xii. Clinics and Treatment Centres. In tabular form below is shown a list of clinics and treatment centres in the Borough. It does not differ from the one published last year. Persons requiring treatment for venereal diseases can obtain it at certain London hospitals. TABLE No. 31. Clinics and Treatment Centres. Situation. Nature of Accommodation. By Whom Provided. Sessions Weekly. Maternity and Child Welfare Centres. Old Town Hall, Woolwich Doctor's Room Woolwich Borough Council. 8 Weighing Rooms Waiting Rooms, etc. 236, Plumstead High Street do. do. 6 Westhorne Avenue, Eltham Doctor's Room, Ante - Natal Room, Ante-Room, Weighing Room, Waiting Room, Lecture Hall. do. 6 Wesley Hall, Timbercroft Lane, Plumstead Doctor's Room do. 2 Weighing Room All Saints' Church Hall, New Eltham Doctor's Room do. 2 Weighing Room St. John's Hall, North Woolwich do. do. 1 Holy Trinity Church Hall, Beresford Street Doctor's Room do. 1 Weighing Room Waiting Room St. Luke's Hall, Westmount Road Doctor's Room do. 1 Weighing Room Sunlight Clinic. Old Town Hall, Woolwich Treatment and Weighing Rooms, etc. do. 9 Day Nurseries. Nil. 40 TABLE No. 31—continued. Situation. Nature of Accommodation. By Whom Provided. Sessions Weekly. School Clinics. Brewer Street, Woolwich Doctors' Rooms, Treatment Rooms, Waiting Rooms. Local Medical Association. Daily. 236, Plumstead High Street do. do. do. 4 Plumstead High Street do. do. do. Daily. Westhorne Avenue, Eltham Doctor's Room, Dentist's Room, Recovery Room, Minor Ailments Room, Waiting Room. do. Daily. Cyril Henry Treatment Centre, St. Mary's Street, Woolwich Accommodation for operating on, and detention of, cases of enlarged tonsils and adenoids London County Council. Daily. Borough Disinfecting Station, White Hart Road, Plumstead Accommodation for cleansing of verminous children. Woolwich Borough Council. Daily. Tuberculosis Dispensaries. Maxey Road, Plumstead Doctors' Rooms do. Daily Waiting Rooms Dressing Rooms Dispensary, etc. 179, Well Hall Road Doctor's Room do. 3 Waiting Room Venereal Diseases. Nil. Orthopaedic Clinic. 8, Thomas Street, Woolwich Clinic Woolwich Invalid Children's Aid Assocn. Daily. Waiting Room Dressing Room xiii. Hospitals. The Medical Officer of Health is asked to report under this heading on the hospitals belonging to the local authority and hospitals with which the local authority has made arrangements for the admission of patients. There are no hospitals belonging to this local authority, but arrangements for the admission of patients have been made with two local hospitals:— (a) War Memorial Hospital; (b) British Hospital for Mothers and Babies. The Council's arrangements with these hospitals were fully reported on in the Annual Report for 1930, but it may be convenient to refer to them briefly here. 41 At the War Memorial Hospital the Council reserve twelve beds for children under five years, and sufficient accommodation as may be necessary for 66 maternity cases per annum. In addition, the hospital authorities are under contract to provide emergency treatment as occasion arises for such cases of midwifery as require it. At the British Hospital for Mothers and Babies, such accommodation as may be necessary for 144 confinements per annum, and for their ante-natal treatment, is reserved for cases sent by the Borough Council. The following figures, taken from the joint survey of the medical and surgical services in London, prepared partly by the London Voluntary Hospitals Committee and partly by the County Medical Officer, show where Woolwich residents requiring institutional treatment during the year 1931 obtained it in London and in institutions outside London, belonging to the London County Council. Voluntary Hospitals. London Teaching Hospitals:— Guy's, 156; St. Thomas's, 51; St. Bartholomew's, 41; Charing Cross, 33; Westminster, 33; London, 30; King's College, 26; University College, 24; St. George's, 18; Royal Free, 6; Middlesex, 3; St. Mary's, 3. London General Hospitals (over 100 beds):— Woolwich War Memorial, 1,192; Miller, 585; St. John's (Lewisham), 102; Homœopathic, 25; Jewish, 1. London General Hospitals (under 100 beds):— Eltham, 538; Blackheath, 12; Mildmay Mission, 4; Mildmay Memorial, 3; French, 2; Italian, 2. Special Hospitals:— British, for Mothers (Maternity), 511; Hospital for Consumption, 77; Hospital for Sick Children, 46; Cancer (Free), The, 36; Royal Westminster Ophthalmic, 32; Royal London Ophthalmic, 30; Evelina (Children), 28; South London (Women), 24; Golden Square, Throat, Nose and Ear, 23; Royal Eye, 22; Royal Waterloo (Children and Women), 16; National, Queen Square (Nervous), 15; East London (Children), 12; Gordon (Fistula, etc.), 12; West End (Nervous), 11; Elizabeth Garrett Anderson (Women), 10; Royal National Orthopædic, 10; St. Peter's (Stone), 9; Children's, Hampstead, 8; Grosvenor (Women), 8; Royal Dental, 7; St. Mark's (Fistula, etc.), 7; City of London (Heart and Lungs), 6; East End, Maternity, 6; Marie Curie (Radium), 6; Central London, Throat, Nose and Ear, 4; General Lying-in, 4; Hospital for Women, 3; London Lock (Male and Female), 3; National Heart, 3; Paddington Green (Children), 3; St. John's (Skin), 3; Seamen's Hospital Society (Tropical Diseases), 3; Chelsea (Women), 2; Clapham Maternity, 2; London Fever, 2; St. Columba's (Advanced Cases), 2; St. Paul's (Genito-Urinary), 2; Baby Hospital, Kensington, 1; Central London Ophthalmic, 1; Hospital for Epilepsy and Paralysis, 1; Hostel of St. Luke (Clergy), 1; Mothers' (Salvation Army), 1; Princess Louise, Kensington (Children), 1; Queen Charlotte's Maternity, 1; St. Thomas's (Babies), 1; Western Ophthalmic, 1; Winifred House (Children), 1. 42 London County Council Institutions. General Hospitals.— St. Nicholas', 3,246; Lewisham, 670; St. Alfege's, 196; Lambeth, 22; St. Stephen's, 10; Dulwich, 5; St. James's, 5; St. Olave's, 5; St. Charles', 4; Archway, 1; Fulham, 1; St. Pancras, 1; St. Andrew's, 1; St. Leonard's, 1; New End, 1; St. Mary Abbots', 1; St. Peter's, 1. General Convalescent Hospital.— Queen Mary's (Sidcup), 41. Public Health Institutions (with sick beds).— St. John's (Hospital), 2; St. Alfege's (Hospital), 3. Public Assistance Institutions (with sick beds).— Ladywell, 2. Special Hospitals:— (a) Fever and Smallpox.— Brook, 654; Park, 78; Southern (Upper), 30; North-Eastern, 21; North-Western, 21; South-Eastern, 17; Southern (Lower), 17; Northern, 16; Grove, 10; Western, 7; Eastern, 4; South-Western, 4; South Wharf, 2; Joyce Green, 1. (b) Tuberculosis.— Grove Park, 39; High Wood, 37; Colindale, 28; King George V Sanatorium, 22; Pinewood Sanatorium, 15; St. George's Home, 14; Princess Mary's, 8; Millfield, 7; St. Luke's, 7. (c) Children.— Queen Mary's, 34; The Downs, 15; Goldie Leigh, 12; St. Anne's Home, 11; Norwood, 7. (d) Epileptic.— Brentwood Colony, 3; Edmonton Colony, 5. (e) Others.— St. Margaret's, 8; Thavies Inn, 2. (f) Mental.— The allocation of cases to mental hospitals is not given. As far as possible cases from Woolwich are admitted to Bexley Mental Hospital, Kent, but in times of pressure this cannot be observed. The number of cases admitted to Maudsley Hospital, four certified institutions for the mentally defective and five mental institutions transferred to the County Council from the Metropolitan Asylums Board, are not classified geographically. The total number of cases, excluding mental cases, admitted to hospitals in that year was 9,283. 5,499 of these obtained treatment in Woolwich, 1,450 in Greenwich and 891 in Lewisham. Woolwich patients received treatment in hospitals situated in every Borough in London except Battersea and Stoke Newington. 43 SECTION IV.— HEALTH PROPAGANDA. As is to be expected health education now demands a greater proportion of the time of the Department, and there is evidence that, not only the converted, but the unconverted in health matters are being reached. This means of course that their attention has been attracted and their interest aroused. As it is necessary to foster that interest and to provide more instruction in health matters, every endeavour is made to bring the Council's health services to the notice of the inhabitants of the Borough and to supply instruction in the simple rules of healthy living and the prevention of disease. The Council's powers to provide health education are contained in Section 42 of the London County Council (General Powers) Act, 1926. The Council's activities on health propaganda may be classified as follows:— (a) Health Week.— The following is a copy of the report of the Public Health Committee to the Council:— "During the week 31st October to 5th November, we hired the Arcade Hall, Eltham High Street, which seats 240 persons (without the gallery), and arranged our programme on a sessional basis, one session being held each afternoon and one each evening. At each session a lecture was given and cinema films dealing with health subjects were shown before and after the lecture. On Saturday afternoon, which was reserved for children, it was necessary to hold a second session. A total of 3,207 persons attended during the week. The Council's cinema projector and lantern were used during the week, and proved very satisfactory. One of the shops in the Arcade was used as a Nursery during the afternoon sessions, and the opportunity was taken of providing a health propaganda display in the windows. We are very pleased with the results of this Health Week in Eltham, as there was evidence of a definite desire for such work in this part of the Borough. "We are grateful to the lecturers who gave their services and to those voluntary workers who assisted in running the nursery, and to all these, in accordance with the wishes of the Council, we have extended our sincere thanks." (b) Health Demonstration.— There are no large halls in Eltham and it is not possible to organise a Health Exhibition there in any way similar to that which is organised at the Woolwich Town Hall every three years. It was felt, however, that it might be worth while arranging a health demonstration on a small scale in the Council's Eltham Health Centre, during a period when the building was not being used for School Clinics. Unfortunately it clashed with a local holiday week and the attendances were not so good as had been expected. The report to the Public Health Committee was as follows:— 44 "During the week 25th to 30th July, demonstrations of the permanent exhibitions of the National Council for Maternity and Child Welfare and the National Association for the Prevention of Tuberculosis were shown at Eltham Health Centre. These demonstrations were primarily for those who attended the Council's Eltham Centres and Tuberculosis Dispensary, but were open to the general public as well. The attendances, especially in the latter half of the week when the tuberculosis exhibits were shown, were disappointing and numbered less than 300." (c) Health Lectures to Adults.— Two advertised lectures were given during the year—one in Woolwich and the other in Eltham, as follows:— Date Subject Lecturer January 18th "Rheumatism" Dr. J. C. Ashton February 17th "Common Errors in Diet" Professor H. Plimmer The lecture on Rheumatism was followed by two cinematograph films and Professor Plimmer's lecture was illustrated by lantern slides. (d) School Children.— Health talks to school children commenced in 1928, and have been continued once a month during the winter months ever since. The method of giving health instruction to school children was, however, changed during the session 1932-3. It so happened that the Libraries' Committee had also been giving cinema lectures to school children on general educational subjects, and it was thought that it might be a good thing to combine the two series. This was done, and such combined meetings were held in October, November and December. At each of these one health film was shown, as under:— October 17th "Don't Wait Until It Hurts" November 14th "Cleanliness is Happiness" December 12th "Giro the Germ" The alteration is a distinct improvement. The films and lectures, given in the early part of the year, were published in my Annual Report for 1931. (e) Informal Talks.— In 1929 a scheme for providing health talks to local organisations in their own meeting place was started and has continued ever since. The speaker is a member of the Department who talks on the particular work he or she is engaged on. In this way we establish a direct contact with the individual which is so essential in health education. Films are usually shown at the conclusion of the talk and questions are invited and answered. (f) "Better Health."— Arrangements for the supply of this magazine were altered during the year, as the following report to the Public Health Committee shows:— 45 "In December, 1929, we entered into an agreement with Sir Joseph Causton and Sons, Ltd., the printers, to give free supplies of this journal in exchange for local advertising rights. Since that time 2,000 copies have been supplied each month with the necessary space reserved for the Council's health propaganda. "Owing to the decrease in advertising matter, the printers are unable to maintain this free supply regularly, and we have therefore considered an alternative method of publication. "'Better Health' is the official journal of the Central Council for Health Education and their publishers have submitted an estimate for the supply of 2,000 copies per month at a cost of £7. This journal has met with a popular demand and has proved an excellent organ of health propaganda. We are, therefore, of opinion that arrangements should be made to continue its circulation by the Council." Copies are distributed each month through the Welfare Centres, Libraries and Schools, and a limited number are sent to residents in the Borough selected at random. The number of regular readers is increasing. (g) Health Services Booklet.— A booklet of 16 pages, giving details of the Council's Health Services under the following heads:— Care of the Mother and Child; Nursing Services; Ambulance; Infectious and Other Diseases; Disinfection; Vaccination; Sanitary Section; Health Publicity; Registrars of Births and Deaths; Public Baths, and Turkish Baths, may be obtained free of charge from the Health Department. (h) Central Council for Health Education.— This body, which was founded in 1927 in order to advise and assist local health and education authorities, insurance committees and other organisations interested in educating the community on matters of health, performs many functions of use to the Medical Officer of Health. It undertakes the organisation of and gives advice on health weeks and health exhibitions; it grants its official badge to approved health propaganda material; it sends weekly articles to the press; it holds a health education conference in London each year; it has issued official books on health exhibitions and health films and a panel of lecturers; it publishes a monthly journal called "Better Health," and it can help in other ways also. It is, in short, a valuable centre of information in health matters. During the year the Council made a contribution of three guineas to its funds. 46 SECTION V.— SANITARY ADMINISTRATION. Staff.— At the end of the year there were on the staff of the Sanitary Section of the Department one Chief Sanitary Inspector, ten male inspectors, one female inspector, and two part-time female inspectors. Water Supply.— The water supply of the Borough is under the control of the Metropolitan Water Board, and no complaints were received as to the quality of the water supply during the year. Removal and Disposal of Refuse.— House refuse is collected and disposed of by direct labour in Woolwich, and is under the control of the Works Committee of the Council. Collection is made once weekly with the exception of a small central area, where a twice-weekly collection is made. All refuse is disposed of by burning at the Council's Destructor, White Hart Lane. All tins are salved, treated in a hydraulic press and sold, but during the year it was difficult to find markets. The clinker is mixed with bitumen and used for surfacing certain roads in the Borough. Most of the dustbins in the Borough are of the moveable pattern; it was found necessary to take action for the renewal of 469 dustbins. During the year the London County Council formulated draft by-laws dealing, inter alia, with the removal and disposal of house refuse. By-law No. 7, which dealt with the construction of collection vehicles, specified the use of a vehicle with a lowloading line. The Council were of opinion that it would be premature to limit the work to vehicles with a low-loading line in view of the changing conditions in the construction of dust collection vehicles, and suggested that the by-law should be amended by deleting the words in italic:— "Use a suitable vehicle having a low-loading line or a suitable truck, carnage, boat, or barge or other vessel, constructed of or lined with metal or other equally suitable impervious material, and furnished with a suitable close-fitting cover so as to prevent the escape of the contents thereof and any dust or effluvium nuisance therefrom." By-law No. 10, which dealt with the collection of house refuse, specified a twiceweekly collection. The Council thought that this by-law should be amended to give local authorities power, by resolution, to exclude from the operation of the by-law, any part of their area in which they consider a twice-weekly collection not to be necessary for the time being. 47 At the end of the year these by-laws were still under consideration by the London County Council. Inoffensive trade refuse is removed by the Works Department at a charge of 5s. 0d. per load, and 884 loads were so dealt with. During the year a change took place in the method of collecting offensive trade refuse. At the beginning of the year it was the practice of the Council to collect this refuse by direct labour and to provide special air-tight receptacles for its collection and removal, for which service a charge of 6d. per receptacle was made. The collection was under the control of the Works Committee and the refuse was sold to a company at the price of 17s. 6d. per ton. The company, however, stated that, owing to the fall of the price of their product, they were unable to continue to pay the Council 17s. 6d. per ton, and submitted the following alternative proposals for the Council's consideration:— (a) The Council to be paid a minimum price of 12s. 6d. per ton for the waste fish, and for each £1 per ton increase in the market price for fish meal, this price of 12s. 6d. to be increased by 1s. 0d. per ton; (b) the Company to collect the waste fish from the various shops in the Borough and to make their own private arrangements with the owners of the shops regarding the method and time of collection; the Company to provide the necessary air-tight receptacles which would satisfy the requirements of the Public Health Department, and to guarantee the collection of the material every other day, or weekly, according to the requirements of the premises affected; (c) the Council to collect the waste fish and to cart it to a depot from which the Company would collect it, and cart it to their works free of charge, in return for the value of the refuse. The approximate cost per annum to the Council under these proposed schemes was as follows: (a) £305; (b) Nil; (c) £285. It was found that scheme (b) was adopted by 23 of the metropolitan boroughs and that, with one or two exceptions, all these borough councils leave the responsibility for the removal of the refuse entirely to the shopkeepers to make their own arrangements, and only intervene if the refuse is not regularly removed from the shops and the collection carried out in accordance with the London County Council By-laws connected therewith. After very careful consideration the Council accepted the offer of the British Feeding-Meals Co., Ltd., to undertake the collection of the offensive trade refuse from the shops in the Borough for a period of twelve months. The contract provides for the termination of the arrangements at any time in the event of the service not being satisfactory, and further for it being extended at the Council's option if the work is carried out to the Council's satisfaction. 48 As a result of this decision the supervision of the collection of offensive trade refuse reverted to the Public Health Department in accordance with the practice of the Council. Drainage.— With relatively few exceptions every house in the Borough is connected with the water-carriage system. New drainage and extensive reconstructions of old systems are supervised by the Borough Engineer. In all other instances alterations are inspected by the sanitary staff. During the year 48 complaints were received with regard to the defective action of combined drains. On investigation it was found that 196 houses in all were affected. In every case the drains were cleared. In all the systems, except seven, the obstruction was of a temporary nature. In eleven instances choked interceptors were found. Costs recovered from the owners amounted to £4 13s. 0d. In the following seven instances reconstruction was necessary, and the work was carried out by the owners after service of notices:— 120 to 122, Ann Street; 9 to 10, Sims Buildings; 64 to 76, Ann Street; 55 to 64, Prospect Place; 17 to 18, Fennell Street; 26 to 27, Fennell Street; 11 to 13, Morris Street. Cesspools.— The number of cesspools in the Borough is 13, 10 being in Plumstead and 3 in Eltham. This is a decrease of 17 on last year. A new sewer was constructed during the year, near the summit of Shooters Hill, and in consequence these 17 were abolished. In the draft by-laws, referred to above under refuse collection, by-law No. 3 dealt with the hours during which offensive material should be removed by road through London, and limited the period to between midnight and 9 a.m. The Council considered that difficulty would be experienced in emptying cesspools, particularly in Eltham where they are situated in outlying fields, within the practical limits of such hours, and suggested that the period should be extended to 10 a.m. Action Taken with Regard to Smoke Abatement.— Forty-nine observations were made of chimney shafts and one notice was served. Two offences were discovered and warning letters were sent. No legal proceedings were instituted. Complaints.— During the year 1932 there were 2,478 complaints of nuisances made to the Health Department and investigated by the Sanitary Inspectors of the Borough. Notices for the remedy or abatement of the defects or nuisances discovered were served upon the owner or person responsible under the Public Health (London) Act, 1891. Sanitary Inspection of the Area.— A summary of the inspections carried out by the Sanitary Inspectors will be found in Table No. 32. In connection therewith the number of Intimation and Statutory Notices served was 3,133 and 785 respectively. The Statutory Notices related to 612 premises and included 623 general, 100 ashpit, 32 water closet, and 19 paving notices. In addition to these notices under the Public Health (London) Act, 1891, 6 notices were served under the London County Council 49 (General Powers) Acts and By-laws, 4 under Woolwich Borough Council By-laws, and one under the Rats and Mice (Destruction) Act, 1919. In 130 instances the owners did not comply with the statutory notices and in each of these instances the Town Clerk sent a letter as a preliminary to legal proceedings. In all except six instances this was sufficient. In Table No. 33 will be found a summary of the nuisances abated and defects remedied. TABLE No. 32. Inspections. Housing Survey — Houses Inspected 2,554 Drains Tested by Smoke Test 133 Drains Tested by Water Test 23 Complaints Investigated 2,478 New Houses 650 Outworkers' Premises 433 Tents and Vans 83 Houses Let in Lodgings 448 Factories 322 Houses re Infectious Disease 933 Workshops 608 Houses re Smallpox Contacts 589 Workplaces 184 Houses re Verminous Cases 1,961 Theatres and Cinemas 13 Houses re Scabies Cases 166 Rag and Bone Premises 6 Houses re Other Diseases 153 Urinals Accessible to the Public 347 Overcrowding Investigated — Women's Lavatories 452 Rooms 45 Smoke Observations 53 Underground Rooms—Survey 2,092 Special Inspections re Rats 422 Underground Rooms Illegally Occupied 65 Miscellaneous 1,697 Re-Inspections 10,165 Drainage Inspections 1,549 TABLE No. 33. Nuisances Abated. Cleansing— Dilapidations— Interiors Cleansed 1,374 Walls 826 Rooms Cleansed 3,054 Ceilings 681 Floors and Hearths 239 Damp Conditions— Coppers 195 Walls 798 Stoves 278 Sites 13 Others 98 Roofs 856 Rain Water Pipes and Gutters 535 Verminous Conditions— Others 227 Rooms Cleansed 303 50 TABLE No. 33— continued. Defective Lighting— New Traps 226 Windows Repaired 163 Foul Pans Cleansed by Owner 22 „ Enlarged — „ „ „ „ Occupier 101 „ Additional 4 Additional W.C.s Provided 6 Doors and Fastenings Remedied 156 Defective Ventilation— Dust Bins Provided 469 Windows Rendered Usable 673 Underground Rooms Closed 8 „ Additional Provided 3 Other Means 3 Overcrowding—Cases Remedied 43 Water Supply— Defective Paving— Additional — Yards Re-paved 181 Re-instated 18 „ Repaired 186 Cisterns Cleansed 2 Scullery Floors Re-paved or Repaired 153 „ Covered 6 „ Removed 6 House Drains— Foul Accumulations— Defective Drains Repaired 214 Manure Removed 10 Choked Drains Cleared 268 Offensive Accumulations Removed 28 Vent Pipes Repaired 59 Soil Pipes Repaired 16 Back Yards Cleansed 63 Gullies Fixed 89 Dung Pits Provided 4 New Drainage 3 Rats— Drains Repaired in Consequence 41 Rain Water Tanks Repaired 8 Premises Rat Proofed 15 „ „ „ Abolished 2 Other Effective Measures 20 Sinks Repaired or Provided 237 Wastes Cleansed 69 Rag and Bone Premises— Wastes Trapped or Repaired 338 Premises Cleansed — Rain-proof Premises Provided — Water Closets— Vermin-proof Conditions Provided — Flushing Apparatus Repaired 239 „ „ Renewed 130 New Pans 245 Miscellaneous 146 Factory and Workshop Act.— The following Table is in the form adopted by the Secretary of State to provide for uniformity throughout the country in the presentation of certain particulars of this work which lend themselves to statistical treatment. 51 TABLE No. 34. Factories, Workshops, Workplaces and Homeworkers' Premises. 1.—Inspection. Including Inspections made by Sanitary Inspectors. Premises. Number of Inspections. Written notices. Prosecutions. Factories (Including Factory Laundries) 322 14 — Workshops (Including Workshop Laundries) 608 7 — Workplaces (Other than Outworkers' Premises) 184 5 — Homeworkers' Premises 433 1 — 2.—Defects Found. Description. Number of Defects. Found. Remedied. Referred to H.M. Inspector. Number of Prosecutions. Nuisances under Public Health Act:— Want of cleanliness 25 25 — — Want of ventilation 4 4 — — Overcrowding 2 2 — — Want of drainage of floors 4 4 — — Other nuisances 12 12 — — Sanitary Accommodation insufficient 1 1 — — unsuitable or defective 3 3 — — not separate for . sexes — - - - Offences under the Factory and Workshop Act:— Illegal occupation of — - — — ground bakehouses (s. 101) Other offences — — — — Total 51 51 — — 52 3.—Outwork in Unwholesome Premises, Section 108. Nature of Work. Instances. Notices served. Prosecutions. Wearing Apparel:— Making, etc. 1 — — Racquet and Tennis Balls 3 1 — The Rats and Mice (Destruction) Act, 1919.—Each district inspector is the rats officer for his area and investigates all complaints received. The total number of inspections made was 422. In 41 instances defective drains were repaired, 15 premises were rat-proofed, and other effective measures taken in 20 instances. National Rat Week was held from the 14th to the 19th November, and during it co-operation was obtained from the Borough Engineer and many large firms in the Borough. The number of baits laid in old sewers in Woolwich and Plumstead, which were regarded as infested, was 10,150. Offensive Trades.—There is only one offensive trade in the Borough, namely, a slaughterer of poultry. The premises were approved by the London County Council in November, 1931. Rag Flock Act.—Eight samples of rag flock were taken for analysis. Such material has to comply with the Rag Flock Regulations, in which it is laid down that the soluble chlorine in the form of chlorides must not exceed 30 parts of chlorine in 100,000 parts of flock. All the samples complied with the Regulations as the results of the analyses show, the number of parts of chlorine being respectively, 12.43, 12.53, 7.98, 10.65, 9.76, 11.54, 7.98, 8.87. Mortuaries.—The Public Mortuary is in Sun Street, Woolwich, and a temporary mortuary is provided in Eltham High Street. The following Table shows the use made of the mortuaries during the year:— TABLE No. 35. Sun Street Sun Street (Infectious) Eltham. All Mortuaries. Number of Bodies received: 1931 1932 (a) For Inquest — — — — — (b) For Custody 19 1 2 17 22 19 1 2 17 22 Number of Post-Mortem Examinations — — — — — 53 Cemeteries.—There are two cemeteries in the Borough, known as the Woolwich Cemetery and the Plumstead Cemetery, the Woolwich one being divided into two parts, the old and the new. Both are owned by the Council and both are in the parish of Plumstead. During the year the Council decided to purchase an area of land abutting on Rochester Way and including part of Coalpits Woods, and measuring about 27 acres, 2 roods, 30 perches, for a site for a cemetery at Eltham, at a cost of £7,000 and legal and surveyors' charges. After a local enquiry by the Minister of Health the site was approved and the purchase completed. After a local enquiry, the Minister of Health approved the provision and use for the purpose of burials, of certain land measuring approximately 3 roods, 27 perches, to be added to the churchyard of the Eltham Parish Church. There is also in Eltham a private burial ground within the grounds of Christ Church Priory, Eltham High Street, and during the year the Minister of Health asked for the Council's observations on an application for approval for the provision and use for the purpose of burials, of certain land having an area of about 80 square yards, and after considering a report by your Medical Officer the Council informed the Minister of Health that, on public health grounds, they had no objection to offer to the proposed extension. In the following Table is shown the number of interments in the different graveyards. The information relating to the cemeteries is given through the courtesy of the Town Clerk, and in the case of the Eltham Churchyard, through that of the Vicar of Eltham. Plumstead Churchyard was closed in 1930. TABLE No. 36. Number of Interments. 1930 1931 1932 Woolwich Cemetery 562 597 560 Plumstead Cemetery 736 792 765 Eltham Churchyard 183 304 232 Plumstead Churchyard 5 — — Exhumations.—During the year three exhumations under Home Office Licences were made in local graveyards. Removal of Infirm and Diseased Persons in Certain Cases.—It was not necessary to make any application to a Magistrate during the year. Legal Proceedings.—The particulars of the various prosecutions instituted under the Public Health (London) Act, 1891, and kindred Acts for offences associated with housing, are set out in detail in the following Table No. 37:— 54 TABLE No. 37. Prosecutions under Public Health and Kindred Acts. No. Date of Hearing. Offence. Situation. Result. 1 2nd March Foul long hopper W.C. pan which was cracked and constantly choking. 51, Southport Road Order to abate forthwith. 2 9th March Defective ceilings of ground floor room and top back room, defective floor of ground floor room and defective roof. 25, Brookhill Road Order to abate within 21 days. Costs 2s. 0d. 3 6th October Defective sink and untrapped sink waste pipe, dirty and defective walls of W.C., defective floor and dirty walls and ceiling of ground floor back room. 12, The Grove, Eltham Work done. Costs 10s. 6d. 4 20th October Dampness 9, Down Street Work done. Costs 10s. 6d. 5 3rd November Defective drains, defective paving, foul W.C., defective soil-pipe, etc. 119, Herbert Road.. Order to ibate in 28 days. Work to be carried out by the Council in default of the owner. 6 10th November Accumulation of offensive refuse. Horn Park Farm Work done. Costs 10s. 6d. Public Baths and Washhouses.—There are two main bathing establishments in the Borough, one at Plumstead and the other at Woolwich, and there is a smaller one at North Woolwich. At Plumstead there is a First Class Swimming Bath (capacity 120,000 gallons); a Second Class Swimming Bath (capacity 80,000 gallons); 64 Slipper Baths, and a separate building for Turkish and Russian Vapour Baths. There is also a Public Washhouse. At Woolwich there is a First Class Swimming Bath (capacity 120,000 gallons); a Second Class Swimming Bath (capacity 90,000 gallons), and 60 Slipper Baths. At North Woolwich there are 14 Slipper Baths. Through the courtesy of the Baths Superintendent I am able to say that the total number using the Swimming Baths during the year was 201,543, Turkish and Russian Vapour Baths, 23,699; Slipper Baths, 204,949, and the Public Washhouse, 20,873. During the year the baths at Plumstead and Woolwich were fitted with large filtration plants. After the installation had been completed samples of the bath waters were taken at different times and tested chemically and bacteriologically. The results of the examinations are shown in the following Tables Nos. 38 and 39. 55 TABLE No. 38. Results of Chemical Analyses. Date. Parts per 100,000. Albuminoid Ammonia. Oxygen absorbed in 4 hours. Free Chlorine. Nitrites. 11th March 0.008 0.168 0.08 Present 27th May 0.013 0.730 0.013 Present 27th May 0.012 0.735 0.012 Present 10th June 0.0074 0.04 0.03 Absent 10th June 0.0054 0.035 0.045 Absent 6th July 0.052 0.061 0.024 Practically Nil TABLE No. 39. Results of Bacteriological Examinations. Date. No. of organisms on gelatine plates at 22° C.— 3 days. No. of organisms on agar plates at 375 C.— 2 days. Bacillus Coli. 11th March 1,802 1,398 Present in 10 c.c. 27th May 16,550 10,050 Present in 25 c.c. 27th May 20,100 160 Present in 50 c.c. 10th J une 16 14 Not found in 100 c.c. 10th J une 10 7 Not found in 100 c.c. 6th J uly 14 3 Not found in 100 c.c. The makers guaranteed the plant to be capable of maintaining the filtered water up to the following standards:— (а) Chemical: Parts per 100,000, albuminoid ammonia, 0.02 ; oxygen absorbed in 4 hours, 0.08; nitrites absent. (б) Bacteriological: Total colonies not more than 200 per cubic centimetre on gelatine plates in three days. It will be noted from the tables shown above that, after the initial difficulties had been overcome and the staff had become accustomed to the use of the plant, these standards were reached and maintained. 56 SECTION VI.—INSPECTION AND SUPERVISION OF FOOD. The London County Council (General Powers) Act, 1932, contains important clauses dealing with food. It provides for the registration of premises for the sale of ice cream and preserved food and gives power to authorities to refuse to register, or to remove from the register premises which are unsuitable for the purpose. It enables the London County Council to make by-laws for promoting sanitary and cleanly conditions with respect to the manufacture, storage, transport or exposure for sale of any article intended to be sold as food. It enables food offered as a prize or for the purpose of advertisement to be dealt with in the same way as if it were exposed or deposited for sale, and it provides for the notification of cases of food poisoning or suspected food poisoning. The Act received the Royal Assent in July, and the powers of the Council in this respect were delegated to the Public Health Committee in October. The food premises in the Borough are kept under regular observation by the food inspector and the food stocks are periodically inspected by the district sanitary inspectors. Two inspectors are responsible for the inspection of meat at slaughterhouses and for the taking of samples under the Sale of Food and Drugs Acts. The following Table, No. 40, shows the food premises on the registers and the number of inspections made in respect of each type during the year:— TABLE No. 40. Premises. On Register 31st December. Number of Legal Proceedings. Inspections. Notices. Bakehouses 38 106 6 — Cowsheds 9 112 3 — Milkshops 83 300 1 — Ice Cream Premises 180 301 — — Slaughterhouses 5 20 — — Fried Fish Shops 58 250 10 — Butchers' Shops 101 185 12 — Premises where Food is prepared (other than above) 246 336 11 — Shops and Markets - 1,074 — — 57 Milk Supply.—The Borough Council is required to keep registers of all persons carrying on in the Borough the trade of cowkeeper or dairyman, and of all premises in the Borough which are used as dairies. The following summary shows the state of the registers at the end of the year:— No. Registered dairy premises 83 Registered dairymen with premises in Borough 66 „ „ „ outside Borough 21 Cowkeepers 4 Cowsheds 9 Purveyors of milk in sealed bottles 120 The standard of cleanliness in cowsheds and dairies and in other premises where milk is sold has been well maintained, as is evidenced from the periodic reports of the inspectors. Three samples of milk were examined for the presence of tubercle bacilli with negative results. Nine samples were bacteriologically examined at different times during the year. The results were as shown below in tabular form:— Bacteria per 1 c.c. January 2,683 — — February 37,300 69,700 — September 8,466 — — October 5,700 57,666 — December 26,333 35,000 35,333 Designated Milks.—Under the Milk (Special Designations) Order, 1923, the Council are authorised to grant licences to persons other than a producer to sell milk under special designations. Each licence automatically terminates on the last day of the year in which it is issued. In tabular form is shown below certain information relating to this Order:— TABLE No. 41. Number of dealers' licences issued to use the designation:— (a) "Certified" 5 (b) "Grade A" (Tuberculin Tested) 5 (c) "Grade A" 2 (d) "Pasteurised " 17 58 Number of supplementary licences issued to sell:— (а) "Certified" milk 2 (b) "Grade A" (Tuberculin Tested) milk 2 (c) "Grade A" milk 2 (d) "Pasteurised" milk 2 Number of licences issued for bottling establishments for Pasteurised milk 1 Forty-four samples of Pasteurised milk were bacteriologically examined during the year, including milk supplied to hospitals in the Borough. The results of the examinations are shown below. Such milk must not contain more than 100,000 bacteria per cubic centimetre. Bacteria per 1 c.c. January 1,710 2,753 — — February 1,726 3,796 4,633 4,920 5,776 5,920 7,796 16,013 17,660 24,350 59,650 March 3,730 4,023 8,860 18,526 38,300 April 3,586 4,016 7,620 8,690 24,950 May 3,830 9,233 10,266 15,533 40,166 June 6,860 7,013 8,813 48,300 September 4,693 5,863 7,016 26,433 457,000 October 40 55,000 185,000 November 3,483 — — — — December 41,000 42,000 64,000 Dried and Condensed Milks.—During the year twelve samples of condensed milk and five of dried milk were taken and it was found that the appropriate Regulations were being complied with in every respect. Agricultural Produce (Grading and Marking) Acts.—These Acts empower the Minister of Agriculture and Fisheries to make Orders for the grading and marking of agricultural produce. One mark—the National Mark—is used or will be used for all graded produce of England and Wales and by law it conveys a guarantee that the produce is of the grade stated. It is not compulsory for all such food stuffs to be so marked, but if marked, they must conform to the standard. In London the local authority is the Metropolitan Borough Council concerned, and in Woolwich the Medical Officer of Health, the Chief Sanitary Inspector and three Sanitary Inspectors have been appointed Officers under the Act. 59 Date of Regulations. Produce. 1929 Apples and Pears; Wheat Flour; Potatoes. 1930 Broccoli; Eggs; Glass-house-grown Tomatoes and Cucumbers; Strawberries; Dressed Poultry; Cherries. 1931 Canned Fruits; Canned Vegetables; Beef. 1932 Malt Flour and Malt Extract; Plums; Bottled Fruits; Bottled Vegetables; Honey; Cider. During the year the Regulations affecting Malt Flour and Malt Extract (1929) and Cider (1931) were revoked from the date of the new Regulations, and the Canned Fruits Regulations, 1931, were slightly amended. No offences were discovered during the year. Merchandise Marks Act, 1926.—Under the provisions of Section 9 of the above Act, Food and Drugs Authorities have power to execute any of the provisions of the Act, other than those relating to importation, in respect of food stuffs which are subject to an Order in Council made under the Act. The orders which so far have been made are as follows:— The Merchandise Marks (Imported Goods) Honey. No. 3 Order, 1928 Fresh Apples. The Merchandise Marks (Imported Goods) Currants. No. 5 Order, 1928 Sultanas. Raisins. Eggs in shell. Dried eggs. Oat Products. The Merchandise Marks (Imported Goods) No. 4 Order, 1929 Raw Tomatoes. The Merchandise Marks (Imported Goods) No. 5 Order, 1930 Malt Products. The Merchandise Marks (Imported Goods) No. 8 Order, 1931 Salmon and Trout. The Merchandise Marks (Imported Goods) No. 1 Order, 1932 Butter. These Orders prohibit the sale, or exposure for sale, respectively, in the United Kingdom, of the products mentioned above unless the goods bear an indication 60 of the country of origin. The term "sale" includes sale, wholesale, or sale by retail, and exposure for sale includes exposure for sale, wholesale, and exposure for sale retail. As a general rule imported produce does not require marking when sold in quantities not exceeding 14 lbs. in weight. The Public Health (Meat) Regulations, 1924.—Notice of intention to slaughter any animal must be given to the Council. The following Table, No. 42, shows the number of animals slaughtered and inspected in the Borough during the year. In 1931 the number was 25,491. TABLE No. 42. Month. Cattle. Sheep and Lambs. Pigs. Calves. Total. January 203 1,123 1,379 1 2,706 February 203 1,026 1,633 1 2,863 March 187 1,142 1,787 2 3,118 April 209 978 1,549 16 2,752 May 188 1,333 546 96 2,163 June 172 1,346 101 89 1,708 July 165 1,410 108 116 1,799 August 153 2,197 146 56 2,552 September 195 2,995 1,595 54 4,839 October 234 2,185 1,787 10 4,216 November 242 2,401 1,930 1 4,574 December 263 1,701 2,138 — 4,102 2,414 19,837 14,699 442 37,392 The number of whole carcases condemned on account of disease or injury was 20 (14 pigs and 6 sheep). In 1,782 instances partial condemnation was necessary in respect to 1,306 pigs, 166 sheep and 310 cattle. All shops and stalls where meat is sold are regularly inspected and, if any insanitary conditions are discovered, measures are taken to secure their abatement. Slaughterhouses.—There is no public slaughterhouse in the Borough. Slaughterhouses are subject to annual licence from the London County Council and, in the Table which follows, are shown those licensed at the end of the year. 61 TABLE No. 43. Situation of Slaughterhouse. Owner. Bostall Farm, Abbey Wood Royal Arsenal Co-operative Society, Ltd 14, Church Street Portlock, T. W. 33, Herbert Road Anderson, F. 6, Plumstead High Street Reed, H., & Co., Ltd. 38, Plumstead Common Road Reed, H., & Co., Ltd. Inspection of Imported Meat.—As I explained in my Annual Report for 1929, the Port of London Authority occasionally allow imported meat to be removed from the Port of London without examination on the understanding that the meat shall be taken to a wholesale depot and dealt with by the local authority. During the year 1,217 carcases of sheep were examined and all were passed as fit for the food of man, with the exception of 1 which was found to be affected with caseous lymphadenitis. Bakehouses.—There were at the end of the year 38 bakehouses in the Borough, of which 28 were factory and 10 underground. The inspections numbered 106, and 6 notices were served. The conditions on the whole were satisfactory. Fried Fish Shops.—There were 59 premises on the Register. They were inspected on 260 occasions, and 10 notices were served for breaches of the By-laws. Ice Cream, etc., Premises.—The number of premises where Ice Cream was sold or manufactured during the year was 185, but in many instances the sale was intermittent. 289 inspections were made and 20 notices served. Other Food Premises.—As a matter of routine a number of food premises, including eating houses, coffee stalls, butchers' shops and restaurants, are visited each week by the Food Inspector, and immediate action is taken in regard to any insanitary condition found. In addition, 2,438 visits were made to shops and stalls in the markets. Unsound Food.—There were 327 instances of unsound food being surrendered. These compare with 281 instances in 1931. Included in the food surrendered were: 13 cwts. of Beef; 4 cwts. Mutton; 18 cwts. Pork; 1 cwt. Ox Livers; 6 cwts. Sheeps' Offal; 1 cwt. Fish; 2¾ tons Potatoes; 1 cwt. Apples; 1 cwt. Pears; 3 qrs. Sweets, and smaller quantities of Veal, Plums, Tomatoes, Raisins, Condensed Milk, Tinned Salmon, Fruit, etc. Seizures of unsound food were made on 23 occasions and included the following:—Beef, Brawn, Salmon, Apples, Pears, Tomatoes, Prunes, Raisins, Pickled Cabbage, Bread, Flour, Biscuits, Cakes, Tinned Milk, Ground Rice, Pudding Powders, Custard Powders, Cake Mixtures, Cake Powders, Soup Powders and Sweets. On the Committee's recommendation offenders were cautioned by the Town Clerk in respect to 9 seizures and proceedings were taken in connection with 14 of the seizures, 26 summonses in all being issued, particulars of which are set out in the following Table No. 44:— 62 TABLE No. 44. No. Date of Hearing. Offence. Result. 1 26th January Exposure for sale of 110 lbs. of apples which were unsound and unfit for food. Fined £1. 2 5th September Exposure for sale of 4 lbs. of tomatoes which were unsound and unfit for food Fined £2. 3 6th October Exposure for sale of 1 box of marzipan which was unsound and unfit for food Fined £1 and £2 2s. Costs. 4 6th October Exposure for sale of 2 lbs. of chocolate fish shapes which were unsound and unfit for food Fined £1. 5 6th October Exposure for sale of 3 tins of salmon which was unsound and unfit for food Fined £1. 6 6th October Exposure for sale of flour which was unsound and unfit for food Fined £1. 7 6th October Exposure for sale of 4 jars of pickled cabbage which was unsound and unfit for food Fined £1. 8 6th October Exposure for sale of 18 lbs. 13 ozs. of raisins which were unsound and unfit for food Fined £1. 9 6th October Exposure for sale of 1 tin of flour, weighing 9 lbs., which was unsound and unfit for food Fined £1. 10 6th October Exposure for sale of 5 lbs. of sweets which were unsound and unfit for food Fined £1. 11 1st November Exposure for sale of 34 lbs. of pears which were unsound and unfit for food Ordered to pay 10s. Costs. 12 1st November Exposure for sale of 5 lbs. of pears unfit for food Ordered to pay 10s Costs. 13 1st November Exposure for sale of 3 lbs. of pears unfit for food Ordered to pay 10s. Costs. 14 3rd November Exposure for sale of 10 lbs. of apples unfit for food Fined £1. 15 3rd November Exposure for sale of 5 lbs. of plums, ¾lb. pears and 3½ lbs. of apples unfit for food Fined £1. 16 3rd November Exposure for sale of 2¾ lbs. of pears unfit for food Fined £1. 17 3rd November Exposure for sale of 6 lbs. of tomatoes unfit for food Fined £1. 18 3rd November Exposure for sale of 4½ lbs. of carrots unfit for food Fined 5s. 19 3rd November Exposure for sale of 4 lbs. of pickling onions unfit for food Fined 5s. 63 TABLE No. 44—(continued). No. Date of Hearing. Offence. Result. 20 3rd November Exposure for sale of 2 lbs. 10 ozs. of eschalots unfit for food Fined 5s. 21 3rd November Exposure for sale of 3 lbs. of tomatoes unfit for food Fined 5s. 22 3rd November Exposure for sale of 2 lbs. 12 ozs. of pears unfit for food Fined £1. 23 3rd November Exposure for sale of 2 lbs. 6 ozs. of tomatoes unfit for food Fined £1. 24 3rd November Exposure for sale of 2 lbs. 10 ozs. of pears unfit for food Fined £1. 25 3rd November Exposure for sale of 12 lbs. of pears unfit for food Fined £1. 26 3rd November Exposure for sale of 22 lbs. of plums and 6 lbs. of pears unfit for food Fined £1. Sophistication of Food.—The following Table, No. 45, gives details of the various analyses made under the Food and Drugs (Adulteration) Act, Public Health (Condensed Milk) Regulations, Public Health (Dried Milk) Regulations, and the Public Health (Preservatives, etc., in Food) Regulations. Five samples were taken on Sundays or public holidays and these were found to be genuine. TABLE No. 45. Article. Formal Samples. Informal Samples. Number Analysed. Number Adulterated. Milk 175 37 212 7 Cream - 10 10 - Condensed Milk (Full Cream) 3 4 7 - Condensed Milk (Skimmed) 5 - 5 - Dried Milk (Full Cream) 2 3 5 - Milk Foods 3 1 4 - Butter 23 12 35 - Cheese — 5 5 - Lard 6 4 10 - Tea 11 9 20 - Coffee — 14 14 - Cocoa - 4 4 - Tea and Milk - 1 1 - 64 TABLE No. 45—(continued). Article. Formal Samples. Informal Samples. Number Analysed. Number Adulterated. Tea Infusion - 1 1 - Dried Milk and Chocolate Powder 1 - 1 - Sugar 7 3 10 - Jam 3 10 13 - Honey - 3 3 - Baking Powder 1 3 4 - Candied Peel 2 - 2 - Dried Mixed Fruit 3 4 7 - Mincemeat 1 4 5 - Gelatine - 4 4 - Ground Cinnamon 1 4 5 - Ground Almonds 1 - 1 - Pepper - - 6 - Malt Vinegar 1 - 1 - Vinegar 5 5 10 - Mustard Paste 1 - 1 - Custard Powder 1 - 1 - Olive Oil 1 - 1 - Gravy Powder 2 - 2 - Sauce 2 - 2 - Sulphur Dioxide - 1 1 - Brandy 5 - 5 - Whisky 3 4 7 - Rum - 5 5 - Gin 1 4 5 2 Meat Paste - 4 4 - Fish Paste 2 6 8 - Tinned Fish - 1 1 - Sausages 19 9 28 4 Preserved Sausages 1 - 1 - Sausage Meat 1 - 1 - Luncheon Sausage 1 - 1 - Minced Meat 1 - 1 - Galantine 1 - 1 - Brawn 3 - 3 - Faggots 1 - 1 - 65 TABLE No. 45—(continued). Articles. Formal Samples. Informal Samples. Number Analysed. Number Adulterated. Tripe 3 - 3 - Veal and Ham 1 - 1 - Black Pudding 1 - 1 - Tinned Soup 2 1 3 - Tinned Peas 1 4 5 4 Tinned Beans 1 1 2 - Tinned Fruit 1 4 5 - Tinned Prunes - 1 1 1 Green Peas 1 - 1 - Bread Crumbs 1 - 1 - Milk Chocolate 1 - 1 - Orange Squash 1 - 1 - Ginger Brandy 1 - 1 - Zinc Ointment - 2 2 - Crushed Linseed - 4 4 - Camphorated Oil 1 4 5 - Powdered Rhubarb - 9 9 - Glycerine of Borax - 5 5 - Parrish's Food - 5 5 - 322 219 541 14 The Public Analyst has furnished the following figures showing the percentages of fat found in each sample of milk submitted for analysis during the last three years:— TABLE No. 46. 1930 1931 1932 4.5 per cent and over 2 1 3 4 per cent and under 4.5 per cent 1 19 12 3.5 per cent and under 4 per cent 68 112 121 3 per cent and under 3.5 per cent 60 57 68 Below 3 per cent — 5 7 131 194 211 66 Adulterated Samples: Action Taken.—The following Table, No. 47, shows the number of adulterated samples and the action taken in each instance where the sample was formal. TABLE No. 47. Sample No. Article. Formal or Informal. Result of Analysis. Result of Legal Proceedings or Other Action. 546 Milk Informal 6.66 per cent deficient in fat — 547 Milk Informal 5 per cent deficient in fat — 534 Gin Informal 42.26 per cent under proof — 553 Gin Formal 41.3 per cent under proof Summons dismissed on payment of £3 3s. 0d. costs. 22 Sausages Informal Contained Sulphur Dioxide 305 parts per million. — 23 Sausages Informal Contained Sulphur Dioxide 145 parts per million. — 89 Sausages Formal Contained Sulphur Dioxide 45 parts per million. Vendor cautioned. 90 Sausages Formal Contained Sulphur Dioxide 75 parts per million. Vendor cautioned. 64 Milk Informal 21.66 per cent deficient in fat — 60 Milk Informal 23.33 per cent deficient in fat — 120 Milk Formal 10.33 per cent deficient in fat Summons dismissed on payment of £2 2s. 0d. costs. 130 Milk Formal 6.33 per cent deficient in fat Fined £1 and £2 2s. costs. 155 Milk Formal Contained 11.41 per cent added water and deficient in fat 32.33 per cent Summons dismissed on payment of £2 2s. 0d. costs. 252a Tinned Prunes Informal Contained 7.27 grains of tin per lb. — Food Poisoning.—In London, since the 12th July, 1932, every registered medical practitioner attending on any person must, if he suspects or becomes aware that such person is suffering from food poisoning, forthwith send to the Medical Officer of Health a certificate in which he must state the name, age and sex of the person, the full postal address and particulars of the food poisoning from which such person is suspected to be suffering. 67 Cases of food poisoning arise from two main causes: (a) from bacterial contamination; and (b) from contamination by inorganic poisons. It may also arise from abnormal reactions of the individual or from inherently poisonous plants or animals. The first cause is the most important from a practical and administrative point of view. In due course every medical practitioner in the area was informed of this new duty placed upon him and, as is usual on such occasions, a considerable number of notifications of food poisoning were received during the first few weeks, but these fell off later on. The total number of notifications received was 56. In 45 houses only one case was notified, in four houses two cases were notified and in one house three cases were notified. The age and sex distribution is shown in the following Table:— TABLE No. 48. Cases of Food Poisoning Notified during 1932. Age Periods. Male. Female. Total. Under 1 — — — 1 and under 2 — — — 2 and under 3 — — - 3 and under 4 — 1 1 4 and under 5 — — — 5 and under 10 — 1 1 10 and under 15 — 1 1 15 and under 20 2 2 4 20 and under 35 6 9 15 35 and under 45 6 4 10 45 and under 65 11 8 19 65 and over 3 2 5 28 28 56 I he medical practitioner notifying is required to state on his certificate the food he suspects. In 27 instances meat, in one or other form—sausage, ham, mutton, beef, stew, pork, etc.—was suspected; in 20 instances fish—fresh, fried or tinned; in one instance ice cream, and in the remaining 8, fruit—fresh or tinned. Most of the cases were slight in character and there were no deaths. 68 In view of the large number of single cases which occurred, many of which were no doubt simple cases of food disagreeing with the individual concerned, I did not think it worth while to carry out bacteriological investigations, but where two or more cases occurred it appeared desirable that the matter should be bacteriologically investigated and the following notes on three such cases are of interest. It was not possible to obtain any material in the other two instances to enable any bacteriological examination to be made. (1) This outbreak involved three cases, all occupants of one house. The symptoms were of the usual type, vomiting, pains and diarrhoea. Silverside was suspected but the evidence was not convincing. The patients' stools were examined and an organism, which was subsequently identified as belonging to the Eastbourne type of the Salmonella group, was isolated from the stools of one of the patients, and positive agglutinations were obtained against this organism in all the cases. (2) This outbreak involved two cases and the suspected food was mutton stew. Sickness and diarrhoea occurred within a few hours. Specimens of cooked mutton and of the broth stated to have been made from the meat were obtained. No organisms of pathogenic significance were found in the meat, but in the broth an organism was found allied to B. Welchii and definitely toxic. (3) A man, aged 72, and his daughter ate some chilled sirloin. Twelve hours afterwards both were suffering from pains, vomiting and diarrhoea, but the daughter very slightly. A specimen of stool was examined which showed markedly large numbers of hæmolytic Bacillus Coli. The man was notified as suffering from food poisoning but the daughter was not. Chemical and Bacteriological Examination of Food.—In addition to the bacteriological examination of milk already referred to, a few other samples of food, particularly in connection with the notification of food poisoning, were submitted for bacteriological examination. The results of the chemical examinations are found in Table No. 45 and of the bacteriological examinations of milk after Tables Nos. 40 and 41, while those in connection with food poisoning are dealt with above. Nutrition.—The dissemination of knowledge and instruction on matters affecting nutrition is part of the Council's general scheme of Health Propaganda, q.v. By-Laws.—The London County Council had not, at the end of the year, formulated any by-laws in accordance with the powers given under the London County Council (General Powers) Act, 1932. 69 SECTION VII.—HOUSING. The following Table shows the main housing figures for the year set out under the headings given in Circular 1269, issued by the Ministry of Health for securing uniformity in the presentation of these statistics. TABLE No. 49. 1.—Inspection of Dwelling Houses during the Year. (1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 5,115 Inspections made 15,292 (2) Number of dwelling houses (included under sub-head (1) above) which were inspected and recorded under the Housing (Consolidated) Regulations, 1925 2,554 Inspections made 7,662 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 6 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 2,403 2.—Remedy of Defects during the Year without Service of Formal Notices.* Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their officers 2,310 * Includes intimation notices. 3.—Action under Statutory Powers during the Year. (a) Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling houses in respect of which notices were served requiring repairs - 70 (2) Number of dwelling houses which were rendered fit after service of formal notice:— (a) By Owners — (b) By Local Authority in default of owners — (b) Proceedings under the Public Health Acts:— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 612 (2) Number of dwelling houses in which defects were remedied after service of formal notices:— (a) By Owners 595 (b) By Local Authority in default of owners — (c) Proceedings under Sections 19 and 21 of the Housing Act, 1930:- (1) Number of dwelling houses in respect of which Demolition Orders were made 3 (2) Number of dwelling houses demolished in pursuance of Demolition Orders 27 (d) Proceedings under Section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 7 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit - (e) Proceedings under Section 3 of the Housing Act, 1925:— (1) Number of dwelling houses in respect of which notices were served requiring repairs — (2) Number of dwelling houses which were rendered fit after service of formal notices:— (a) By Owners — (b) By Local Authority in default of owners - (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close - 71 (f) Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925:— (1) Number of dwelling houses in respect of which Closing Orders became operative - (2) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling house having been rendered fit - (3) Number of dwelling houses in respect of which Demolition Orders became operative - (4) Number of dwelling houses demolished in pursuance of Demolition Orders - Inspection of Houses.—In accordance with the provisions of the Housing (Consolidated) Regulations, 1925, the systematic inspection of houses in the district was continued during the year. In all 2,554 houses were surveyed house-to-house, and their condition was recorded on special survey cards. It is the practice to secure the abatement of such nuisances as are found to exist by serving notices under the provisions of the Public Health (London) Act, 1891, but in a certain number of instances demolition orders were applied for. In tabular form is shown below a detailed statement of the specific action taken under the Housing Acts during the year. TABLE No. 50. Action under the Housing Acts. Premises. Action taken. Date. *Eltham Road, 114 Closing Order 2nd March. *Eltham Hill, 88 do. 8th June. *Raglan Road, 99 do. do. *Belson Road, 26 do. do. *'Prospect Place, 47 do. do. *Rectory Place. 16 do. do. *Barnfield Rbad, 19a do. 6th July. *Nightingale Place, 2 do. do. MarketHill,11 Demolition Order 28th July. Myrtle Street, 13 do. 5th October. Vicarage Road, 33 do. 2nd November. Chester Cottages, 3 Undertaking by owner to carry out specified works accepted. 8th November. Powis Street, 178 Representation do. do. 180 do. do. *Underground Room. 72 Increase of Rent and Mortgage Interest (Restrictions) Acts, 1920 and 1923.—There was only one application for a certificate under these Acts during the year, but after consideration the Council were unable to grant the application. They took the same course with regard to the case held over at the end of the previous year. Tents and Vans.—By-laws regulating the use of these were made by the Council in 1903. All tents and vans (which are few in number) were inspected regularly and steps taken to ensure that the By-laws were being observed. The total number of inspections made was 83. Houses Let in Lodgings.—No register is now kept of houses let in lodgings, but as the records of this Department in respect of individual houses are kept on cards, such houses are kept prominently before the district sanitary inspectors by means of "signals" on the cards which serve as reminders to the inspectors that they are dealing with houses that would formerly have been registered. During the year 448 inspections of such houses were made, 25 offences were discovered and 19 notices were served. New Houses.—The following Table, No. 51, shows the number of certificates of a proper and sufficient supply of water for new houses granted by the Public Health Committee at each of their meetings. Of these, 190 were in respect of houses built bv the Council. TABLE No. 51. Date of Meeting. Woolwich. Plumstead. Eltham. Total. West. East. 13th January — 2 2 13 17 10th February — — 4 18 22 9th March — — — 16 16 13th April — 6 8 16 30 11th May — 3 1 21 25 16th June — 4 9 118 131 7th July — — 6 22 28 28th July — — 25 47 72 14th September — — 33 33 66 12 th October — — 12 26 38 8th November — 1 2 127 130 7th December — 2 13 60 75 — 18 115 517 650 73 Council's Houses.—Six houses were erected on the Page Estate, 184 were erected on the Middle Park Estate, and 128 were in the course of erection there at the end of the year. A children's playing field, nearly four acres in extent, was opened during the year. It lies on the Page Estate, between Westhorne Avenue, Briset Road, Shawbrooke Road and the Bexleyheath railway line. In it are provided a sand pit, a paved playground, a shelter, a bubbly fountain and the usual conveniences. In the playground are provided a plank swing, a see-saw, a rowing see-saw swing, a giant stride, a joy wheel, a slide and 9 swings. Common Lodging Houses.—The following Table, No. 52, shows the details of accommodation available in each of the common lodging houses in the Borough. Each is licensed by the London County Council. TABLE No. 52. Premises. Accommodation Men. 60, Beresford Street 50 50, Woolwich High Street 22 93, Woolwich High Street 24 102, Woolwich High Street 22 4. Rope Yard Rails 15 7, Rope Yard Rails 24 10, Rope Yard Rails 51 10a and 11, Rope Yard Rails 62 21 and 21a, Rope Yard Rails 42 312 Census, 1931.—In considering the statistics relating to dwellings, rooms and families, it is necessary to bear in mind the following definitions adopted by the Registrar General and set out in the report on the Census relating to the County of London : — Private Family.—Any person or group of persons included in a separate return as being in separate occupation of any premises or part of premises is treated as a separate family for Census purposes, lodgers being so treated only when returned as boarding separately 74 and not otherwise. Private families comprise all such families with the exception of those enumerated in (i) institutions or (ii) business establishments or boarding-houses in which the number of resident trade assistants or resident boarders exceeds the number of members of the employer's or householder's family (including private domestic servants). Structurally Separate Dwellings.-—A structurally separate dwelling has been defined for the Census as any room or set of rooms intended or used for habitation, having separate access either to the street or to a common landing or staircase. Thus each flat in a block of flats is a separate unit; a private house which has not been structurally sub-divided is similarly a single unit whether occupied by one family or by several families. But where a private house has been sub-divided into maisonnettes or portions, each having its front door opening on to the street or on to a common landing or staircase to which visitors have access, then each such portion is treated as a separate unit. Rooms.—For the purpose of the Census, the rooms enumerated are the usual living rooms, including bedrooms and kitchens, but excluding sculleries, landings, lobbies, closets, bathrooms, or any warehouse, office or shop rooms. The following Table, No. 53, shows the number of structurally separate dwellings occupied, the number of rooms occupied, the number of private families, the population in private families, and the average number of private families per dwelling in 1921 and 1931, together with the percentage increase or decrease. The increase in the number of dwellings is practically entirely due to the number of new houses constructed in the last ten years and there has been very little conversion of large houses into self-contained flats. TABLE No. 53. 1921 1931 Increase or Decrease per cent. Dwellings 26,409 30,377 +15.03 Rooms 139,096 159,781 +14.87 Families 33,647 38,176 +13.46 Population in private families 131,956 137,979 +4.56 Families per occupied dwelling 1.29 1.28 -0.01 The following Table, No. 54, shows the number of private families, the number of structurally separate dwellings occupied, the number of rooms occupied, and the average number of persons per room in each of the Wards in the Borough. If this Table be compared with the preceding Table it will be seen that at the time of the Census there were 507 structurally separate dwellings or 3,731 rooms unoccupied. 75 TABLE No. 54. Housing Conditions in Wards. Ward. Private Families. Structurally Separate Dwellings Occupied. Rooms Occupied. Persons per Room. Dockyard 1,928 1,270 6,452 1.06 St. Mary's 1,401 1,020 5,003 1.03 River 2,911 2.063 10,164 1.07 St. George's 1,315 855 4,706 1.04 Burrage 2,455 1,665 9,306 0.86 Herbert 2,461 1,899 11,497 0.73 Glyndon 2,522 1,827 9,007 0.97 St. Margaret's 3,669 2,840 15,395 0.81 Central 2,577 1,825 9,926 0.81 St. Nicholas 3,545 2,556 13,142 0.98 Abbey Wood 3,025 2,462 12,113 0.86 Well Hall 3,281 3,077 14,239 0.90 Avery Hill 3,260 2,992 17,919 0.64 Sherard 3,826 3,519 17,181 0.99 38,176 29,870 156,050 0.88 The prevalent size of structurally separate dwellings, occupied and unoccupied, is four rooms, as 24 consist of one room, 260 of two rooms, 1,406 of three rooms, 8,477 of four rooms, 8,335 of five rooms, whilst 11,080 consist of six to eight rooms, and 795 of nine rooms or more. The following Table, No. 55, shows the distribution of private families according to the number of rooms occupied, together with the corresponding figures for 1921, and the distribution of the populations in these two years. 76 TABLE No. 55. Housing of Private Families. Number of rooms occupied. Number of Families. Increase or Decrease. Distribution per cent. 1921 1931 1921 1931 1 2,222 2,019 -203 6.6 5.3 2 4,751 5,273 +522 14.1 13.8 3 5,484 6,211 +727 16.3 16.3 4 9,202 10,093 +891 27.4 26.4 5 5,967 7,682 +1,715 17.7 20.1 6—7 5,013 5,994 +981 14.9 15.7 8—9 642 618 -24 1.9 1.6 10 or more 366 286 -80 1.1 0.8 Totals 33,647 38,176 + 4,529 100.0 100.0 It will be noted from the above Table that 46.5% of the private families occupy dwellings of four or five rooms and 18.1% reside in six or more rooms. In the administrative County of London the corresponding figures are 27% and 15.2 %. The following Table, No. 56, shows the conditions under which private families live according to the number of each dwelling. TABLE No. 56. Number of families living in 1921 Per cent 1931 Per cent Single occupation 19,367 57.56 22,567 59.12 2 to a dwelling 11,784 35.02 12,890 33.76 3 or more to a dwelling 2,496 7.42 2,719 7.12 33,647 100.00 38,176 100.00 Expressed otherwise, some three thousand Woolwich families no longer share a common water supply, common sanitary arrangements, or a common letter box, but the number of families living together in houses which have not been adapted for such occupation has increased by 1,329. 77 The following Table, No. 57, shows the distribution of private families according to the number of persons in the family and the comparative figures for 1921. In the last twenty years there has been a great change in the size of family. Families consisting of 1—4 persons show an increased percentage of the whole, whilst, correspondingly, families of five or more persons show a decreased percentage. The average size of family, which was 4.27 in 1911, fell to 3.92 in 1921, and 3.61 in 1931. TABLE No. 57. Distribution, according to size, of Private Families. No. of Persons in Family. Private Families. Rooms per Family. Persons per Room. Number 1931. Increase or Decrease 1921-1931 Distribution per cent 1931 1921 1931 1921 1931 1921 1 2,930 +641 7.7 6.8 2.23 2.06 0.45 0.48 2 8,525 +2,082 22.3 19.1 3.59 3.33 0.56 0.59 3 9,282 +1,569 24.3 22.9 4.05 3.85 0.74 0.77 4 7,462 +1,144 19.5 18.8 4.43 4.37 0.90 0.91 5 4,718 +328 12.4 13.0 4.71 4.63 1.06 1.07 6—7 3,945 —553 10.3 13.4 4.86 4.88 1.30 1.31 8—9 1,018 —534 2.7 4.7 4.98 5.14 1.67 1.62 10 and over 296 —148 0.8 1.3 5.27 5.64 2.04 1.88 38,176 4,529 100.0 100.0 4.08 4.04 0.88 0.96 One of the recognised standards of overcrowding and one adopted by the Registrar General is a density of more than two persons per room. The following tabular statement shows the population scheduled thus in each of the last three enumerations:— 1911 1921 1931 Private families living more than 2 per room 1,000 1,602 1,247 Percentage of total families 3.80 4.76 3.26 Population in such families 7,110 10,270 7,809 Percentage of total family population 6.32 7.78 5.66 The number of overcrowded families (as judged by the standard mentioned above) has been reduced since 1921 by 355, and the population therein by 2,461 but even though, these 1931 figures are in excess of those of twenty years ago. In the administrative County 13.1 per cent of the total population live more than two persons per room. 78 Bug Infestation of Houses.—This problem has received much attention from the Public Health Committee during the year owing to the apparent increase in the number of infested houses and the difficulties which arose in disinfesting them. The Council's powers in the matter are found in the London County Council (General Powers) Acts of 1922 and 1928. Briefly these are as follows:— (a) Section 9 of the 1922 Act enables the sanitary authority, at their own expense, on a report from the Medical Officer of Health, to cleanse, disinfect or destroy any articles infested with vermin, or likely to be so infested by reason of being used by any person so infested. (b) Section 10 of the same Act enables any sanitary authority on a report from their Medical Officer of Health, to require the owner or occupier of a verminous house to take such steps as may be necessary for the purpose of destroying or removing vermin. (c) Section 26 of the 1928 Act enables any sanitary authority, on a report from their Medical Officer of Health, to apply to a Petty Sessional Court for an Order for the removal and cleansing of a person infested with vermin to a cleansing station to enable him and his clothing to be cleansed, if such person does not consent to go there voluntarily. It should be noted that, so far as infested articles are concerned, the sanitary authority is responsible for disinfestation if they are so minded, and it will also be noted that the necessary legal procedure can only be set in motion by a decision of the sanitary authority after the receipt of a report from the Medical Officer of Health. If the legal position is strictly adhered to, delay inevitably ensues, and so, after very full consideration, the Public Health Committee decided that the Medical Officer of Health should be authorised to take the necessary steps to disinfest articles and premises without waiting for the authority of the Committee but subject to report to the Committee, and, in the case of difficult or recalcitrant persons, to the normal legal steps being followed. As a result of this decision it was possible to invite the co-operation of owners immediately after the sanitary inspector had discovered the verminous conditions, and as the Council's scheme described below became known, less and less difficulty was experienced with owners. In bug-infested houses there are usually other nuisances and so it is the practice to include, in intimation notices, bug infestation when such is discovered. In such cases, however, it is now the practice for a letter to be sent by me stating that the department is prepared to co-operate with the owner in arranging for the disinfestation of infested articles in the room or rooms infested, at the same time as his workmen are dealing with the infested portions of the structure of the house, and asking him to write and say whether he wishes to take advantage of this offer so that a date convenient to both parties may be fixed. This arrangement has worked very well. 79 The Council's scheme, in terms of a room, is as follows:— (a) Preliminary. (1) Intimation notice to owner and occupier that the room is infested with bugs. (2) Special "verminous" card completed by Inspector and handed to Inspector in charge of disinfection. (3) Letter from Medical Officer of Health to owner, offering co-operation. (4) Convenient day fixed by disinfecting Inspector and owner. (b) Disinfestation. First Day. Owner removes skirtings, architraves and other wood fixtures to walls. Subjects these to heat from a blow-lamp, strips the walls, applying the blowlamp flame to all holes and crevices. The disinfecting staff:— (1) Place all pictures in metal box. (2) Place in bags all bedding and other loose articles likely to be infested and suitable for steam disinfection. (3) Partially seal room. (4) Spray walls of room with weak disinfecting fluid, providing a moist atmosphere and possibly disturbing bugs in the walls. (5) Light sulphur candles—1 lb. for each 250 cubic feet. (6) Finally seal room. (7) Remove bedding and pictures to disinfecting station where the bedding is treated by steam, and the pictures are disinfested by a sulphur bomb in the metal box. The bedding is not returned until the next day, if this is at all possible, and the pictures are not returned until they have been stripped and re-backed. Second Day. The disinfecting staff again visit the house, unseal the room, take the bedsteads to pieces and carefully remove all eggs and dead bugs from the interstices; examine and cleanse all chairs and other articles of furniture where bugs or their eggs are likely to be found, and re-fix. The room is finally sprayed with a suitable disinfectant which leaves a fresh smell about the place instead of the characteristic buggy odour. In the actual disinfecting process it is useful to bear in mind that the bug takes up the most favourable position for attack and for this reason I attach the greatest importance to the removal of infested bedding and pictures and to the systematic cleansing of the bed. It is important also to have regard to where the 80 bug may escape to—to the roof space, to adjoining rooms or adjoining houses—and to take appropriate measures to deal with this situation. But one of the most valuable details is a careful search afterwards by trained disinfectors. (c) Subsequent Action. Ten days later the Inspector in charge of disinfection visits the house. If he is satisfied that there are no bugs, an order is given to the builder to replace the woodwork and to distemper. Ten days later a further visit is paid by the Inspector in order to satisfy himself that the de-bugging is complete. If he is not satisfied, the disinfestation is done again, but no articles are removed. If he is satisfied that the room appears to be free from bugs, the "verminous" card is handed to the woman sanitary inspector who makes a visit once a month for the first three months or until she gets three successive negative examinations, and then once every two months for the next six months, and it is proposed that she will continue to visit once a quarter until two years are complete. This scheme was started in August and, up to the end of the year, 172 rooms had been so disinfested. In actual practice it has been found that with the high concentration of sulphur dioxide used, a second disinfestation, except in rare instances, has been unnecessary. It looks, therefore, as if this high concentration killed eggs, but this observation is subject to the reservation that most of this work was done in the latter part of the year after the normal breeding season was over, and it may be that these results may not appear so satisfactory when the rooms are examined in the summer of 1933; or it may be that the results of disinfestation will not be so good in the early summer months. The life history of the bug is briefly as follows: the female lays eggs; these eggs hatch out and after five successive moultings the adult bug attains its being. Recent scientific thought seems to indicate that it is comparatively easy to kill the egg and that the bug is most difficult to kill in the stage just before it becomes an adult bug. If this is correct it means that in actual practice, in any form of gaseous disinfection, careful search of the premises has to be made by skilled observers immediately afterwards in order that any survivors may be dealt with. The present methods of getting rid of bugs are expensive and cumbersome, and a great deal of research work is necessary in order to discover some simple and economic method of dealing with the problem. It is not simply a question of adding a given amount of disinfectant to the air of a room, as there are two very variable factors in any operation—the extent and rate of leakage is never known and difficulties are experienced in getting an equal distribution of disinfectant throughout the air of the room. The temperature of the air of a room has to be taken into account, and the extent of penetration into walls, crevices and articles is not known. It is because of these variants that the room has to be specially inspected after disinfestation. 81 Three conclusions have been tentatively reached during the year:— Firstly : Successful disinfestation is entirely a matter of detail in dealing with several varying factors. It has to be thorough and it is in consequence expensive. Secondly : People do not like their neighbours to know they have bugs. They cannot help them knowing it, however, when such a scheme as outlined above is put in force. The mere fact that one of the Council's disinfecting vans visits a house where no ambulance has previously been, means in all probability that the house is infested with bugs. The woman in the bug infested house is at once subject to a considerable amount of comment by her neighbours, many of whom are not afraid of expressing to her what they think about her, even though their houses may be in the same state. I think, however, in addition to talking to her they try to get rid of their own bugs, more or less successfully. It may be, therefore, that such a scheme may have more far reaching consequences than the mere recapitulation of the work indicates. It is safe to assume that the average housewife will pay more attention to the eradication of bed bugs by the usual household methods, and her success or failure will depend on the amount of adjacent infestation, the state of the property and other similar factors. I do not think she can get rid of them when a house is really infested, but she may be able to do so in milder cases. A campaign, therefore, may lead to a change in public opinion with regard to bugs, and it may mean that the same influences which brought about the diminution of verminous conditions in school children may act once again in bringing about a diminution of bug infested houses. Thirdly: It used to be thought that bugs hibernated during the winter and that nobody need worry about them then. This view is totally erroneous; we found bug infested rooms easily enough during the winter and we found young bugs also, but the numbers were much smaller than in the hot months of the year. It is a matter for consideration, therefore, whether de-bugging should not be done systematically from January to December. It is possible to get rid of bugs in a house in the winter months, and in any event the number of infested houses is sufficient to keep a disinfecting staff employed on this work throughout the whole year. In these days of slum clearance and the building of new estates, the question of de-bugging is a matter of very great importance, particularly with the removal of tenants from bug infested houses to new houses. For this reason alone, if for nothing else, research work on bug disinfestation is essential. 82 SECTION VIII. PREVALENCE AND CONTROL OVER INFECTIOUS DISEASE. In London the institutional authority for infectious diseases is the London County Council. Woolwich cases are usually admitted to the Brook Hospital, Greenwich, the Park Hospital, Lewisham, or the Joyce Green Hospital at Dartford, but the more uncommon types of infectious diseases may be admitted to any of the County Council's infectious disease hospitals. The Borough Council is only responsible for investigating the origin of the diseases and for taking the necessary steps to prevent their spread. Observations on the working of the Vaccination Acts will be found in Section III, and such information as is available on the non-notifiable acute infectious diseases will be found in Section II. The following diseases are notifiable in the Borough:— Anthrax Ophthalmia Neonatorum Cerebrospinal Meningitis Pneumonia—Acute Primary Cholera Pneumonia—Acute Influenzal Continued Fever Poliomyelitis Diphtheria Plague Dysentery Puerperal Fever Encephalitis Lethargica Puerperal Pyrexia Erysipelas Relapsing Fever Enteric (or Typhoid) Fever Scarlet Fever Glanders Smallpox Hydrophobia Tuberculosis Malaria Typhus Fever Membraneous Croup Zymotic Enteritis The total number of primary notifications, excluding cases of tuberculosis which are referred to later on in this Section, was 1,172, compared with 1,879 in 1931, and 2,172 in 1930; but as 672 notifications were included in respect of Chickenpox in 1931, and 597 in 1930, the fall in the incidence of notifications of infectious disease is more apparent than real. Measles was present in epidemic form during the year. 83 TABLE No. 58. In tabular form are shown in the next five Tables statistics showing the incidence of infectious disease in the Borough in 1932 and previous years. Diseases. Total Cases Notified. Admissions to Hospital. Total Deaths. Diphtheria 233 232 8 Scarlet Fever 554 535 3 Enteric Fever 3 2 2 Puerperal Fever 5 5 4 Puerperal Pyrexia 35 31 — Erysipelas 44 26 4 Smallpox 7 7 — Pneumonia 247 150 81 Malaria 2 2 — Ophthalmia Neonatorum 7 2 — Encephalitis Lethargica 2 2 1 Dysentery 1 1 — Cerebro-spinal Meningitis 15 15 4 Poliomyelitis 6 6 — Zymotic Enteritis 11 7 12 *Measles (including German Measles) 3,135 226 25 4,307 1,249 144 *Not notifiable. 84 TABLE No. 59. Notification of Infectious Diseases (Including Tuberculosis), 1901 to 1932. Year. Smallpox. Diphtheria and Mem. Croup. Erysipelas. Scarlet Fever. Enteric Fever. Continued Fever. Puerperal Fever. §Puerperal Pyrexia. Pneumonia Primary. Influenzal Pneumonia. Malaria. Dysentery. Anthrax. Ophthalmia Neonatorum. Encephalitis Lethargica. Cerebro-spinal Meningitis. Poliomyelitis. ‡Zymotic Enteritis. *Pulmonary Tuberculosis. *Tuberculosis Non-pulmonary †Measles. x Chicken Pox. 1901 21 216 72 311 68 1 8 - - - - - - - - - - - - - 323 - 1902 228 233 98 267 50 1 11 - - - - - - - - - - - 189 — 646 301 1903 6 186 58 389 42 3 2 - - — - - - - - - - - 165 — 661 — 1904 6 163 74 472 25 1 5 - - — - - - - - - - - 186 — 1,240 — 1905 7 273 83 513 27 1 12 - - - - - - - - - - 212 145 — 465 — 1906 — 387 97 528 40 — 8 - - - — - - - - - — 366 176 — 825 — 1907 — 275 110 1,023 27 — 6 - - — - - - - - 1 - 93 150 — 1,453 — 1908 — 362 90 596 19 — 6 — - — — - - - - 1 - 173 154 — 519 — 1909 — 268 113 1,027 13 — 9 - - — - - - - - — - 149 206 — 768 — 1910 1 171 89 524 10 — 7 - - - — - - - - 1 - 102 196 — 396 — 1911 — 239 82 518 16 — 16 - - - - - - 8 - 1 3 866 375 — 801 — 1912 3 429 87 474 20 — 2 — — — — - - 20 — 1 3 129 689 — 775 — 1913 — 321 70 626 14 — 8 - - — — - - 14 — - 1 338 532 143 387 — 1914 — 416 107 714 18 — 7 — - — — - - 18 — 1 - 199 400 98 967 — 1915 — 286 138 601 31 — 6 - - - - - - 19 - 50 2 173 420 69 1,179 — 1916 1 271 95 232 9 — 16 - - — — - - 33 — 17 — 80 392 77 1,590 — 1917 — 277 79 147 12 — 12 - - - - - - 41 — 22 1 101 448 95 1,710 — 1918 — 240 61 222 12 — 14 - - - - - - 23 — 11 3 118 563 97 800 — 1919 4 398 63 243 26 — 7 - 123 — 61 7 1 34 3 7 1 123 394 80 1,886 — 1920 1 427 82 538 6 — 13 — 136 — 29 1 - 29 3 6 — 31 359 69 1,013 — 1921 — 592 59 1,351 11 — 14 — 187 49 10 4 - 32 9 2 — 454 285 71 481 — 1922 — 437 37 511 8 1 11 — 212 133 11 — - 26 3 2 4 31 245 60 2,698 — 1923 — 152 40 334 16 — 8 — 196 46 4 1 - 18 1 5 6 49 245 66 194 — 1924 — 195 45 440 11 — 7 — 249 105 3 1 - 27 17 12 5 13 273 69 2,679 — 1925 — 299 44 364 16 — 9 - 237 40 5 1 - 31 10 5 1 13 246 54 1,916 — 1926 — 393 46 411 8 1 4 7 259 33 5 — - 18 7 9 5 23 287 52 1,246 — 1927 — 278 65 478 9 — 8 30 280 36 3 1 - 19 6 4 3 12 269 84 457 — 1928 3 300 89 529 17 — 20 28 216 14 12 1 - 14 8 3 3 5 263 62 2,418 — 1929 5 496 80 567 7 — 15 38 293 90 5 — 1 17 4 9 4 8 250 52 151 — 1930 10 497 77 627 8 — 5 31 262 21 2 1 - 8 — 2 2 22 244 55 2,702 597 1931 3 281 80 387 3 — 8 41 327 44 3 — - 7 2 12 6 3 229 51 113 672 1932 7 233 44 554 3 — 5 35 199 48 2 1 - 7 2 15 6 11 235 48 3,135 - §Notification of Puerperal Pyrexia commenced October, 1926. †Measles notifiable from 1/1/1916 to 31/12/1919. *Voluntary notification to 1910; partial to 1912; all cases thereafter. ‡Compulsory Notification of Zymotic Enteritis commenced 1913. X Chicken Pox was again made notifiable from April, 1930, to 30th September, 1931. 85 TABLE No. 60. Ward Incidence of Infectious Diseases (excluding Tuberculosis), 1932. Diseases. Borough Dockyard. St. Mary's. River. St. George's. Burrage. Herbert. Glyndon. St. Margaret's. Central. St. Nicholas. Abbey Wood. Well Hall. Sherard. Avery Hill. Diphtheria 233 10 10 26 27 11 9 8 18 6 14 34 18 31 11 Scarlet Fever 554 49 26 52 58 48 29 25 70 27 44 41 27 33 25 EntericFever (including Typhoid Fever) 3 - - - - - - - - - - - - 2 1 Puerperal Fever 5 - - 1 - 1 - - - 1 - - 1 1 - Puerperal Pyrexia 35 3 4 6 2 1 1 5 4 1 3 2 - 2 1 Erysipelas 44 2 1 4 - 3 3 3 1 3 7 2 5 4 6 Smallpox 7 - - 4 - - - - - - - - 1 2 - Pneumonia 247 9 9 18 14 11 6 11 14 8 61 19 15 39 13 Malaria 2 - 1 - 1 - - - - - - - - - - Ophthalmia Neonatorum 7 1 1 2 - - - 1 - - - - - 2 - Encephalitis Lethargica 2 - - - - - - - - - 1 1 - - - Dysentery 1 - - - - - - 1 - - - - - - - Cerebro-spinal Meningitis 15 2 1 2 4 1 - 1 - - 2 - 1 1 - Poliomyelitis 6 - - - - 1 - - 1 - 1 1 - 1 1 Zymotic Enteritis 11 1 2 - - 1 - - - - 6 - - 1 - *Measles (including German Measles) 3,135 140 138 170 236 174 96 311 224 126 360 319 233 563 45 4,307 217 193 285 342 252 144 366 332 172 499 419 301 682 103 *Not notifiable. 86 TABLE No. 61. Cases of Infectious Diseases Notified 1932 (excluding Tuberculosis). 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 233 5 7 15 14 16 95 31 15 29 4 2 - Scarlet Fever 554 3 15 30 42 41 234 115 28 33 11 2 — Enteric Fever 3 - — — — 1 — — — 1 — 1 — Puerperal Fever 5 - — — — — — — — 4 1 — — Puerperal Pyrexia 35 - - — — — — — 1 30 4 — — Erysipelas 44 2 - — 1 — 1 1 2 7 7 16 7 Smallpox 7 - — — — — — 1 3 1 1 1 — Pneumonia 247 30 17 10 14 9 25 9 13 33 20 44 23 Malaria 2 — — — — — — — — 2 — — — Ophthalmia Neonatorum 7 7 - - - - - - - - - - - Encephalitis Lethargica 2 - - — — 1 - — — — — 1 — Dysentery 1 - - — 1 — - — — — — — — Cerebro-spinal Meningitis 15 1 4 1 - 2 - 1 4 2 - - - Poliomyelitis 6 - 1 1 — — 2 — 2 — — — — Zymotic Enteritis 11 4 1 1 — 1 2 1 — — — 1 — *Measles (including German Measles) 3,115 90 236 256 342 414 1,594 109 78 16 — — — 4,307 142 281 314 414 485 1,953 268 146 158 48 68 30 *Not notifiable. 87 TABLE No. 62. Deaths from Infectious Diseases (excluding Tuberculosis), 1932. Diseases. All Ages. Number of Deaths. Age Groups. Under 1 1- 2- 5- 15- 25- 35- 45- 55- 65- 75- Diphtheria 8 - - 2 6 - - - - - - - Scarlet Fever 3 — 2 — 1 — - - - - - - Typhoid Fever 2 — — — — 1 - - - 1 - - Puerperal Fever 4 — — — — 1 3 - - - - - Puerperal Pyrexia - - - - - - - - - - - - Erysipelas 4 1 — — — — 1 1 — — — 1 Smallpox - - - - - - - - - - - - Pneumonia 81 25 4 5 2 5 1 2 4 7 15 11 Malaria - - - - - - - - - - - - Ophthalmia Neonatorum - - - - - - - - - - - - Encephalitis Lethargica 1 — — — — — — — — 1 — — Dysentery — — — — — — — - - - - - Cerebro-spinal Meningitis 4 1 2 - - 1 - - - - - - Poliomyelitis - - - - - - - - - - - - Zymotic Enteritis 12 7 1 — — — — - 2 - 2 - Measles 25 5 8 3 8 1 — — — — — — 144 39 17 10 17 9 5 3 6 9 17 12 88 Diphtheria. Notification.—During the year 233 cases were notified compared with 281 in 1931, and 497 in 1930. The number of military cases was 11. The number of notifications received each quarter was as follows: First quarter, 42; Second quarter, 44; Third quarter, 79; Fourth quarter, 68. Multiple Cases.—The following Table, No. 63, shows the house distribution by wards. The term "house" is synonymous with the term "family," except in three instances where two families were involved. TABLE No. 63. Diphtheria: Multiple Cases. Dockyard. St. Mary's. River. St. George's. Burrage. Herbert. Glyndon. St. Margaret's. Central. St. Nicholas. Abbey Wood. Well Hall. Sherard Avery Hill Total Houses. Total Cases. Number of Houses in which 1 case occurred 8 7 17 13 9 9 5 14 6 12 32 9 20 6 167 167 2 cases occurred 1 1 1 2 1 — — 2 — 1 1 3 1 1 15 30 3 ,, - - 1 - - - 1 - - - - 1 3 1 7 21 4 ,, - - 1 - - - - - - - - - - - 1 4 Total Houses 9 8 20 15 10 9 6 16 6 13 33 13 24 8 190 222 Military - 1 - 10 - - - - - - - - - - - 11 233 Return Cases.—Four cases gave rise to four return cases. In one instance the primary case was re-notified and re-admitted to hospital. One patient who was admitted to hospital with Diphtheria was exposed to Scarlet fever in hospital owing to cross-infection occurring in the ward she was in. She was given a prophylactic dose of anti-scarlatinal serum and showed no signs of Scarlet fever whilst in hospital, but four days after her discharge from hospital her sister was notified to be suffering from Scarlet fever. On examination of the primary case, the child was found to be suffering from a nasal discharge, but there was no evidence that she had had Scarlet fever; the swab taken from her nose was negative to Diphtheria. It is possible that this child, through exposure to Scarlatinal infection, became a carrier, but the injection of anti-scarlatinal serum prevented her developing the disease. It is difficult to prove a person to be a Scarlet fever carrier, but the case is certainly suggestive. 89 Deaths.—There were 8 deaths from Diphtheria, compared with 6 in 1931, and S in 1930. Two of these deaths were in children under 5 years of age, and six were in school children. Home Isolation.—Three cases were isolated at home. Frequent visits are made by the district sanitary inspectors to all cases isolated at home in order to ensure that proper precautions are being taken for preventing the spread of the disease. Employees of the Royal Arsenal are not allowed to remain at work unless cases are removed to hospital or a certificate of efficient home isolation is issued by the Medical Officer of Health. No certificates were issued during the year. Antitoxin.—A supply of Diphtheria Antitoxin is kept at the Town Hall, the Plumstead Library and the Eltham Library, and is available for medical practitioners on application, at cost price, or free where there is inability to pay. The amount supplied during the year was 38,000 units. The total cost to the Council was £2 17s. 0d., all of which was recovered. Schick Test.—There are no clinics in the area where Schick testing and immunisation are carried out. Scarlet Fever. Notification.—During the year 554 cases of Scarlet fever were notified, compared with 387 in 1931, and 627 in 1930. There were 16 military cases. The number of notifications received each quarter was as follows : First quarter, 99 ; Second quarter, 189 ; Third quarter, 105 ; Fourth quarter, 161. Multiple Cases.—The following Table shows the house distribution by wards. The term "house" is synonymous with the term "family" except in 11 instances where two families were involved. TABLE No. 64. Scarlet Fever: Multiple Cases. Dockyard. St. Mary's River. St. George's. Burrage. Herbert. Glyndon. St. Margaret's. Central. St. Nicholas. Abbey Wood. Well Hall. Sherard. Avery Hill. Total Houses. Total Cases. Number of houses in which 1 case occurred 29 18 36 18 30 22 16 44 18 33 29 20 22 15 350 350 2 cases occurred 5 3 4 7 6 2 3 4 3 4 3 2 4 2 52 104 3 „ „ 2 — 1 1 2 1 1 3 1 1 2 1 1 2 19 57 4 „ „ 1 - - 1 - - - 1 - - - - - - 3 12 5 ,, „ — - 1 1 — — — 1 — — — — — — 3 15 Total Houses 37 21 42 28 38 25 20 53 22 38 34 23 27 19 427 538 Military - 2 - 14 - - - - - - - - - - - 16 554 90 Deaths.—There were three deaths from Scarlet fever during the year, including two in children under 5 years of age. In 1931 the number of deaths was five. Home Isolation.—Fourteen cases, or 2.5 per cent, were isolated at home, and in no instance did a return case occur. The same procedure as in Diphtheria was carried out. One certificate of efficient home isolation was issued. Dick Test.—This has not been employed in the neighbourhood so far as I am aware. Return Cases.—The following Table, No. 65, shows the number of return cases, the dates of admission to hospital, the dates of discharge from hospital, and some observations on the condition of the primary case on discharge. It will be noted from the Table that certain of these cases were discharged after less than five weeks in hospital, some indeed after less than four, and, in fact, these low figures appear more frequently than they did in the list of return cases in previous years, in pursuance of the modern tendency to shorten the stay of Scarlet fever patients in hospital. This practice will require close investigation in the future because the measure of return cases cannot be taken bv simplv recording the family return cases only. TABLE No. 65. Scarlet Fever: Return Cases. No. in Register Date Admitted to Hospital. Date Discharged. Total Days in Hospital. Onset of Secondary Case. Remarks on Primary Case. 86 24/3/32 12/5/32 48 14/5/32 - 94 26/3/32 3/6/32 68 24/6/32 — 105 2/4/32 21/5/32 50 6/6/32 Nasal discharge. 12/6/32 — 250 13/6/32 21/7/32 37 29/7/32 — 122 12/4/32 21/5/32 38 4/6/32 Nasal discharge. 153 3/5/32 30/6/32 57 22/7/32 — 232 7/6/32 2/8/32 55 1/9/32 — 360 1/9/32 13/10/32 41 18/10/32 Nasal discharge. 234 8/6/32 29/7/32 50 11/6/32 — 237 9/6/32 18/8/32 38 23/8/32 Nasal discharge. 247 11/6/32 13/9/32 62 21/9/32 Sores in nose. 5/10/32 — 348 23/8/32 22/9/32 29 26/9/32 — 365 6/9/32 7/10/32 30 13/10/32 Desquamation not complete. 13/10/32 17/10/32 — 25/10/32 — 371 9/9/32 11/10/32 31 16/10/32 Nasal discharge. 20/10/32 — 21/10/32 — 384 19/ 9/32 4/11/32 24 24/11/32 — 388 22/ 9/32 27/10/32 36 31/10/32 — 7/11/32 — 9/11/32 — 393 24/ 9/32 27/10/32 32 5/11/32 Nasal discharge. 419 17/10/32 18/11/32 31 22/11/32 — 428 21/10/32 17/11/32 26 25/11/32 Desquamation not complete 436 25/10/32 2/12/32 37 5/12/32 - 12/12/32 — 445 31/10/32 15/12/32 45 21/12/32 — 457 4/11/32 2/12/32 27 7/12/32 - 91 Smallpox. During 1932 the decrease in the incidence in this disease in the Metropolis continued. In all 1,233 cases were notified, as compared with 1,452 in 1931, and 5,152 in 1930. The incidence was highest in Lambeth, Poplar, Islington and Southwark. Seven cases were notified in Woolwich, and the diagnosis was confirmed in each case. There were no deaths. The Smallpox shelter was not in use during the year. No person was vaccinated by the Medical Officer of Health under the provisions of the Public Health (Smallpox Prevention) Regulations, 1917. In every instance vaccination or revaccination was offered to all contacts by the local public vaccinators. Erysipelas, Malaria and Dysentery. The number of notifications of Erysipelas received was 44, compared with 80 in 1931. One case of Dysentery was notified and two of Malaria : no case of induced Malaria was notified. Enteric Fever. Three cases were notified. One of these died. A second death occurred outside London, but was transferred to Woolwich in accordance with the usual rule of the Registrar General as the normal home address was here. It will be noted from the following Table, which gives details of each case notified, that the diagnosis was not confirmed in one instance. TABLE No. 66. No. Date Notified. Diagnosis. Final Diagnosis. Remarks. 1 3rd February Enteric Fever Enteritis — 2 11th April Typhoid Fever Typhoid Fever Died. 3 8th November Paratyphoid "B" Paratyphoid "B" — Anterior Poliomyelitis. Six notifications were received and all cases were admitted to hospital. The diagnosis was configmed in three of the patients aged 1, 15 and 18 respectively, but the hospital diagnosis of the other three cases was Acute Rheumatism, Sub-acute Rheumatism, and No Obvious Disease. It was not necessary to provide nursing assistance for any of these cases during the year. Cerebro-spinal Meningitis. I ifteen cases were notified during the year, but in two instances the diagnosis was not confirmed although one of these was diagnosed as a meningococcal carrier. The following Table, No. 67, shows the details of each case. 92 TABLE No. 67. Date Notified. Age. Sex. Ultimate Diagnosis. Remarks. 5th January 1 M. Cerebro-spinal Meningitis — 30th „ 19 M. do. do. Military caseDied. 8th February 19 M. do. do. Military case. 18th „ 1 F. do. do. Died. 17th March 4 F. do. do. — 9th April 18 M. do. do. Military caseDied. 17th „ 4 M. do. do. — 3rd May 21 M. do. do. Military case. 10th „ 16 F. do. do. — 25th „ 1 M. Meningococcal do. Died. 28th August 5/12 M. do. do. Died. 6th September 28 M. Cerebro-spinal do. — 22nd „ 11 M. Congenital Paralysis of the Insane — 13th December 2 M. Meningococcal carrier — 28th „ 1 F. Cerebro-spinal Meningitis — Encephalitis Lethargica. Two cases were notified and both were admitted to hospital. In one instance, in which the patient recovered, the diagnosis was confirmed, but in the other instance the death was certified as due to Cerebral Tumour. In 1931 the number of notifications received was two. Puerperal Fever and Puerperal Pyrexia. Forty cases were notified, compared with 49 in 1931, and 36 in 1930. In 35 instances the notification was Puerperal pyrexia. In seven instances the disease was a sequel to abortion. Treatment.—The Council's scheme for the treatment of these diseases provides for a Consultant, for hospital treatment, for bacteriological examination where necessary, and for nursing assistance. Specific sera may also be supplied. During the year Mr. Harold Taylor saw two cases. It was not necessary to provide nursing assistance and no bacteriological examinations were carried out. Only four cases did not receive hospital treatment. Deaths.—There were four deaths, compared with six in 1931, and four in 1930. 93 Ophthalmia Neonatorum. Seven cases were notified, two of which were admitted to hospital. Three cases were nursed at home under the Council's scheme, 113 visits in all being paid. The cost of this service was £5 13s. 0d. The following Table gives details of each case. The case notified on the 15th August was complicated by the fact that the eye was injured at birth. TABLE No. 68. Date Notified. Cases Treated: Vision Unimpaired Vision Impaired. Total Blindness. Deaths. Home. Hospital. 29th January — Yes Yes — — — 31st March Yes — Yes — — — 22nd June Yes — Yes — — — 29th June — Yes Yes — — — 15th August Yes — Yes — — — 30th September Yes — Yes — — — 3rd October Yes Yes — — — Zymotic Enteritis. Eleven cases of this disease were notified during the year, compared with three cases in 1931 and 22 in 1930. The number of deaths in children under two years of age, certified to be due to diarrhœal diseases, was eight. Whooping Cough. During the year 233 cases of Whooping Cough came to the knowledge of the Department, compared with 492 in 1931 and 73 in 1930. As this disease is not notifiable in the Borough, knowledge is usually obtained through the School Medical Service, but, exceptionally, cases are notified by medical practitioners and occasionally cases are discovered by the health visitors in their routine visits. Deaths.—There were eight deaths certified to be due to this disease, compared with nine in 1931. Measles. The two main sources of our knowledge of the incidence of Measles in the Borough are the School Medical Service and the health visitors. Occasionally, however, information comes through the local nursing associations and from parents. During the year 3,135 cases (including 82 cases of German Measles) were discovered. In 1931 and 1930 the corresponding figures were 113 and 2,702. 94 Measles occurs in epidemic form every two years and usually lasts for four months. The incidence in each of the twelve months of the year was as follows:— January 121 February 455 March 815 April 671 May 670 June 281 July 104 August 5 September 12 October 1 November — December From these figures it will be noted that the disease first assumed epidemic proportions in February, reached its peak in March, and fell away thereafter. The Council's scheme for dealing with Measles epidemics was put into force in the middle of February, two temporary health visitors being appointed for Measles work. They investigated every reported case of Measles from whatever source it was received: they visited cases absent from school from unknown causes and every case of suspected Measles. The staff health visitors made subsequent visits to cases where the children were under school age, but where they were of school age the subsequent visits were made by the temporary health visitors. Notices were sent to head teachers where the diagnosis of Measles was not confirmed and where suspect cases were diagnosed as Measles. The co-operation between the School Medical Service and the Department was excellent, visits being paid to every home where cases of Measles or suspected Measles were living, within 24 hours of the teacher sending the notification to the Department. The scheme worked very well in other respects. It enabled the normal routine work of the health visitors to be maintained with very little disturbance; it ensured the early diagnosis of secondary cases and their exclusion from school in an infectious state; it ensured the early provision of nursing assistance and it enabled arrangements to be made for the early admission of cases to hospital where necessary. In every way the Council's policy was justified. Home Nursing.—During the year 1,615 visits were made by the nurses of the local nursing associations to 130 homes. The cost to the Council was £80 15s. 0d. Hospital Treatment.—The number of children admitted to fever hospitals was 226, but there is no record of the number of children admitted to general hospitals. Deaths.—There were 25 deaths from Measles during the year, 16 of which were in children under five years of age. Prophylaxis and Specific Therapy.—As soon as it was evident that the disease was assuming epidemic proportions (and there is usually plenty of warning of this because Measles usually comes to Woolwich after it has been in epidemic form in other parts of the Metropolis for at least two months), leaflets giving advice about the disease were distributed through the mothers attending the welfare centres. As soon 95 as one case occurred in a school a supply of leaflets was sent to the head teacher of the infants' department to be distributed to parents. A supply of these leaflets was also available for the general public in the Council's libraries. Nowadays serum from convalescent Measles patients is available in small quantities. Injected in suitable doses this gives a temporary immunity to contacts. In one or two instances medical practitioners asked for it to treat contacts at home, and they were advised how to obtain it. On two occasions, when cases of Measles occurred in one of the local hospitals, this serum was used and no secondary cases occurred. Pneumonia. The incidence of Pneumonia was lower than in 1931, 247 cases being notified as compared with 371 in that year. Of these, 48 were influenzal. The number of deaths certified to be due to lobar or broncho pneumonia was 81, and to acute influenzal pneumonia, 11. The ward incidence of the Pneumonias is shown in Table No. 60. The following Table, No. 69, shows the number of notifications of Pneumonia received each month, classified by sex and according to type: it also shows the number of deaths occurring from acute primary pneumonia and influenzal pneumonia. TABLE No. 69. Monthly Incidence of Pneumonia. Month. Male. Female. Total. Type. No. of Deaths. Lobar. Broncho Influenzal. Acute Primary (not specified) Acute Primary Pneumonia. Influenzal Pneumonia. January 32 28 60 7 9 24 20 19 4 February 20 14 34 6 4 15 9 5 5 March 14 10 24 7 2 5 10 13 1 April 12 7 19 4 2 1 12 3 1 May 4 8 12 3 5 — 4 1 — June 5 3 8 — 1 — 7 2 — July 8 3 11 3 1 — 7 4 — August 4 3 7 1 1 — 5 1 — September 6 1 7 2 3 — 2 5 — October 12 1 13 4 2 1 6 5 — November 12 16 28 4 4 1 19 11 — December 15 9 24 6 6 1 11 12 — 144 103 247 47 40 48 112 81 11 96 Nursing.—Nursing assistance is provided by the Council for cases of Pneumonia and during the year 27 cases were nursed, 379 visits being paid by the nurses of the local nursing associations. The total cost to the Council was £23 13s. 9d. Anti-Pneumococcal Serum.—During the year the Council provided, free of charge, anti-pneumococcal serum (mainly Felton's) for the treatment of persons suffering from Pneumonia to those medical practitioners who considered this form of treatment suitable. The total cost to the Council was £96 18s. 1d. There is a growing consensus of opinion in this country in favour of the treatment of Pneumonia by this method, as the results in suitable cases are very striking. The best results, however, are obtained if it is used early in the disease. Tuberculosis. The Council's tuberculosis scheme was set out very fully in the Annual Report for 1930 and no substantial change took place during 1932. Notifications.—During the year, excluding duplicates, 235 cases of pulmonary tuberculosis and 48 cases of non-pulmonary tuberculosis were notified. Cases of tuberculosis are often notified more than once, and in this way during the year 72 duplicate notifications were received. The number of cases notified from each of the different wards of the Borough is shown in Table No. 70. TABLE No. 70. Ward Incidence of Tuberculosis, 1932. Ward. Pulmonary. Non-Pulmonary Dockyard 14 2 St. Mary's 11 2 River 20 3 St. George's 21 3 Burrage 13 4 Herbert 11 3 Glyndon 22 1 St. Margaret's 18 5 Central 9 2 St. Nicholas 28 6 Abbey Wood 11 4 Well Hall 21 3 Sherard 18 4 Avery Hill 18 6 Total 235 48 97 In the following Table appears a summary of cases coming to the knowledge of the Department in 1932. It includes notifications received from general practitioners, cases not notified but included in the death returns and cases transferred from other areas. It does not include notifications received from Medical Superintendents of hospitals on admission or discharge of patients or any duplicate notifications. Deaths occurring within the year are classified in the same Table by age and sex groups. TABLE No. 71. Tuberculosis: New Cases and Mortality, 1932. Age Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. 0-1 year — — 1 — - - 1 — 1-5 years — 1 1 5 — 1 — 2 5-10 „ 5 4 7 3 — - 1 1 10-15 „ 2 3 3 5 — 1 — 1 15-20 „ 12 19 4 4 2 8 1 — 20-25 „ 12 34 2 2 6 12 2 — 25-35 „ 26 23 2 2 13 14 1 — 35-45 „ 21 17 4 — 22 12 1 — 45-55 „ 20 14 2 1 17 0 — — 55-65 ,, 13 6 1 2 18 2 — 1 65 and upwards 7 1 2 1 5 - 1 2 118 122 29 25 83 56 8 7 The following Table, No. 72, shows the site of the disease in patients notified each year since 1928. TABLE No. 72. Year. Lungs. Meninges. Intestines and Peritoneum. Glands. Joints. Spine. Other Forms. All Causes. 1928 263 10 8 17 11 5 11 325 1929 250 7 7 16 11 6 5 302 1930 244 6 5 18 15 3 8 299 1931 229 11 5 18 8 2 7 280 1932 235 6 6 11 8 5 12 283 98 Cases of Tuberculosis in the District.—The usual steps were taken during the year to ensure that the Tuberculosis register correctly represented the number of cases of Tuberculosis in the district, and the following Table, No. 73, shows the changes which have taken place during the year. TABLE No. 73. Pulmonary. Non-Pulmonary. Totals. M. F. M. F. Number on Register on 1st January, 1932 540 404 129 135 1,208 Number of New Cases notified 116 119 27 21 283 Number of Cases restored 17 5 2 2 26 Other additions 7 6 4 1 18 Deletions 214 187 58 46 505 Number on Register on 31st December, 1932 466 347 104 113 1,030 Of the total number on the register on the 31st December, 92.91 per cent were on the dispensary register, i.e., had been dealt with in connection with the Public Health scheme for the treatment of tuberculosis. In 1931 the corresponding percentage was 86.5, and in 1930, 88.6. Deaths.—The following Table, No. 74, shows the number of deaths and the death rates each year since 1928. TABLE No. 74. Tuberculosis: Deaths and Death Rates. Year. Deaths. Death Rates. All Forms. Pulmonary. NonPulmonary. All Forms. Pulmonary NonPulmonary. 1928 165 145 20 1.17 1.03 0.14 1929 159 143 16 1.12 1.01 0.11 1930 165 150 15 1.17 1.06 0.11 1931 168 148 20 1.14 1.00 0.14 1932 154 139 15 1.05 0.95 0.10 99 In addition to the deaths recorded in the above Table, eight persons who had been notified as suffering from tuberculosis died during the year from other causes, and detailed information as to these is given in the following Table, No. 75. TABLE No. 75. Case No. Date notified as Tuberculosis. Cause of Death. 1 19/9/1931 Pericarditis. Chronic Intestinal Nephritis. 2 13/8/1923 Carcinoma of Thyroid. 3 26/9/1919 Chronic Parenchymatous Nephritis. 4 5/6/1930 Chronic Œdema. Chronic Nephritis. Bronchitis. Pleurisy. 5 16/3/1927 Myocarditis. Arterio Sclerosis. Senility. 6 24/4/1931 Congestion of Lungs. Myocardial Degeneration. Chronic Cachexia. 7 29/8/1915 Capillary Bronchitis. Acute Bronchitis. Chronic Fibrosis of Lung. 8 14/1/1932 Chronic Bronchitis. Senility. The period which elapsed between notification and death is shown below:— TABLE No. 76. Pulmonary. Percentage. NonPulmonary. Percentage. Not notified 10 7.17 3 20.00 9-1 month 21 15.08 10 66.66 1-3 months 15 10.77 1 6.67 3-6 9 6.62 1 6.67 6-12 14 10.05 — — 1-2 years 17 12.22 — — 2-5 29 20.84 — — Over 5 years 24 17.25 — — 139 100.00 15 100.00 100 The ratio of non-notified tuberculosis deaths to the total tuberculosis deaths was as one is to twelve. In 1931 it was as one is to eight, and in 1930 it was as one is to twelve. Public Health (Prevention of Tuberculosis) Regulations, 1925.—These Regulations provide for the compulsory discontinuance of employment of persons engaged in the handling or treatment of milk, who are suffering from tuberculosis. No case of this kind came to the notice of the Council during the year. Every milk vendor in the Borough is periodically reminded that the Tuberculosis Officer is willing to examine, free of charge, all employees or candidates for employment in the milk trade. No examinations, however, were made during the year. Staff.—This consists of one whole-time Tuberculosis Officer, two part-time Assistant Tuberculosis Officers, three Tuberculosis Health Visitors, one ClerkDispenser, and one Lay Organiser, who also acts as Secretary of the Care Committee. In accordance with the practice in recent years, one Tuberculosis Visitor attended a refresher course of two weeks during the winter. The Work of the Dispensaries.—The Council's Dispensary is situated at Maxey Road, Plumstead, and there is a branch Dispensary at 179, Well Hall Road, Eltham. The Eltham branch was opened in 1931 and more use of it is being made now than in that year. In accordance with the Minister of Health's instructions the Dispensary figures are shown for the Borough as a whole and not for individual dispensaries. One of the Tuberculosis Officers attends at the main Dispensary every week-day, but an evening session is held, instead of an afternoon one, on Thursdays. Eight separate clinical sessions in all are held for men, for women, and for children. The branch Dispensary is open on three half-days a week—Monday afternoons for men, and Wednesday and Friday mornings for women and children. The total number of attendances at the Dispensaries during 1932 was 4,935. In this connection it is interesting to point out that 254 of the persons notified during 1932 attended the Dispensaries, which is equivalent to 89.7%. The corresponding percentage in 1931 was 78.93, and in 1930, 78.6. A return of the work of the Dispensaries is given in Table No. 77. 101 TABLE No. 77. Return showing the Work of the Dispensaries for 1932. Diagnosis. Pulmonary. Non-Pulmonary. Total. Grand Total. Adults. Children. Adults. Children. Adults. Children. M. F. M. F. M. F" M. F. M. F. M. F. A.—NEW CASES examined during the year (excluding contacts):— (a) Definitely tuberculous 107 94 6 3 8 9 8 7 115 103 14 10 242 (b) Diagnosis not completed — — — — — - — — 2 1 — — 3 (c) Non-tuberculous — - - — — - — — 152 238 122 128 640 B.—CONTACTS examined during the year:— (a) Definitely tuberculous 4 6 - 1 — - 1 — 4 6 1 1 12 (b) Diagnosis not completed — — - — — - — — — — — — — (c) Non-tuberculous - - - - - - - - 90 118 99 101 408 C.—CASES written off the Dispensary Register as: (a) Recovered 37 38 3 2 11 9 12 10 48 47 15 12 122 (6) Non-tuberculous (including any such cases previously diagnosed and entered on the Dispensary Register as tuberculous) - - - - - - - - 256 366 223 232 1,077 D.—NUMBER OF CASES on Dispensary Register on 31st December:— (a) Definitely tuberculous 400 324 23 20 45 58 38 46 445 382 61 66 954 (6) Diagnosis not completed — — — — — — — — 2 1 — — 3 102 Return showing the Work of the Dispensaries for 1932—Continued. (1) Number of cases on Dispensary Register on January 1st 1,046 (2) Number of cases transferred from other areas and cases returned after discharge under Head 3 in previous years 11 (3) Number of cases transferred to other areas, cases not desiring further assistance under the scheme, and cases "lost sight of" 101 (4) Cases written off during the year as Dead (all causes) 105 (5) Number of attendances at the Dispensary (including Contacts) 4,935 (6) Number of Insured Persons under Domiciliary Treatment on the 31st December 255 (7) Number of consultations with medical practitioners: — (a) Personal 62 (ib) Other 1,048 (8) Number of visits by Tuberculosis Officers to homes (including personal consultations) 492 (9) Number of visits by Nurses or Health Visitors to homes for Dispensary purposes 5,708 (10) Number of:— (a) Specimens of sputum, etc., examined 471 (b) X-Ray examinations made in connection with Dispensary work 533 (11) Number of "Recovered" cases restored to Dispensary Register, and included in A (a) and A(fe) above 10 (12) Number of "T.B. plus" cases on Dispensary Register on December 31st 331 Number of Dispensaries for the treatment of Tuberculosis (excluding centres used only for special forms of treatment):— Provided by Council 2 Provided by Voluntary Bodies Nil The above Table gives all the figures required by the Minister of Health. It shows also the number of contacts examined during the year and it shows the extent of co-operation locally with medical practitioners. Observation Cases.—The number of Woolwich cases admitted to observation beds in institutions during the year was 35, 18 of whom were children. In 25 cases the symptoms suggested chest mischief; in 5, abdominal mischief, and in 2, glandular mischief. Whilst in hospital a definite diagnosis was made in 30 cases; in 2 instances the patients had not been discharged at the end of the year, and in one case a child was removed by its parents against advice; two others were returned 103 to the Dispensary for further observation and they are now regarded as nontuberculous. Eleven cases were diagnosed as suffering from tuberculosis and eight of these are now under treatment; the other three have subsequently been regarded as non-tuberculous. Nineteen cases were definitely diagnosed as non-tuberculous and their length of stay in these observation beds varied from two weeks to five months. Institutional Treatment.—The following Table, No. 78, shows the number of admissions to special hospitals, sanatoria, public general hospitals, institutions and training colonies:— TABLE No. 78. Admissions to Hospitals, etc. Special Hospitals. Sanatoria. Public General Hospitals. Training Colonies. Insured 113 56 91 9 Uninsured 54 32 55 4 Children 72 3 13 — 239 91 159 13 These figures refer to 365 patients and the monthly admissions were as follows:— January 34 February 51 March 48 April 42 May 42 June 40 July 49 August 54 September 38 October 48 November 25 December 31 Out-Patient Hospital Treatment.— Arrangements exist with different London Hospitals for special forms of treatment. During the year 12 Finsen Light treatments and 55 Ultra-Violet Ray treatments were given, and 312 Pneumo-thorax Refills were carried out. X-Ray examinations are made at the Woolwich War Memorial Hospital, and the total number so made during the year was 533. Of these, 427 were on new patients seen at the Dispensary during the year, 68 of which were positive. Dental Treatment.—Dental treatment is carried out under the Council's scheme at the School Clinic, Brewer Street. During the year 33 cases received treatment, the number of attendances being 78. The only charge made to patients is in connection with the supply of dentures, and then patients are assessed according to their means. Dentures were supplied in 12 cases at a cost of £58 16s. Od., and payments by patients amounted to £14 13s. lOd. In assessing patients, due regard is given to dental benefits they may be entitled to from approved societies. Shelters.—Twelve shelters are maintained by the Council for patients returning from sanatoria who are able and willing to continue this form of treatment. 104 Sputum Examinations.— During the year 471 specimens of sputum were examined at the Dispensary. Of these 44 were positive and 427 negative. Facilities for general practitioners are provided at the Woolwich War Memorial Hospital and 510 specimens were examined during the year, 78 being positive and 432 negative. Extra Nourishment.— Extra nourishment, in the form of butter, eggs and milk, is supplied to tuberculous patients on the certificate of the Tuberculosis Officer. The object of this measure is to help the ex-sanatorium patient and other suitable cases by the provision of such extra nourishment as will make the difference between progress and relapse. It is not intended for advanced cases of tuberculosis where real improvement cannot be expected. The expenditure on this service is limited to £2 per 1,000 population. Nursing.— Home nursing is provided for certain cases of tuberculosis, and in acordance with the arrangements entered into with the local Nursing Associations the number of visits paid by nurses during the year was 1,309, and the cost to the Council was £81 16s. 3d. Woolwich Tuberculosis Care Committee.— At the end of the year the Committee was constituted as follows:— Bodies. Woolwich Borough Council Trade Unions Employers Friendly Societies London County Council London County Council (Public Assistance Committee) London Insurance Committee Panel Committee for the County of London British Red Cross Society War Pensions Committee Woolwich Invalid Children's Aid Association Late Tuberculosis Dispensary Committee United Services Fund Representatives. Councillors B. A. G. Beaten, W. W. Burr, Mrs. L. E. Driver, Miss C. K. Lambeth, Mrs. E. L. Reeves, Miss G. E. Walters, J P. Mr. W. H. Fairchild, Mr. E. Ware. Miss L. Ames, Miss Fletcher, Mr. C. N. McLaren. Mr. W. A. Lyon, Mr. A. J. Rourke, Mr. F. Smyth. Dr. H. R. Kidner, Miss C. F. Aves. Miss C. K. Lambeth, Mrs. E. M. Newman, Mrs. J. Wood. Mr. S. H. Brown. Dr. H. M. Wise. Mr. J. O'Connell. Mr. A. R. Loader. Mrs. J. B. Great Rex. Mr. W. Dashwood, Mr. E. G. Dixon, J.P. Mrs. A. Evans. Ex-Officio. Voluntary Visitors Mr. G. F. Brazier, Miss D. A. Frye, Miss L. MacDermott. Tuberculosis Officer Dr. F. J. C. Blackmore. Medical Officer of Health Dr. J. MacMillan, D.S.O., M.C. The Committee undertakes all the care and after-care work of the Borough in regard to the tuberculous. It helps by the provision of clothing for necessitous patients entering institutions; for the purchase of surgical apparatus and nursing requisites; by supplementing financial asistance given by the voluntary organisations for in-patient treatment; by paying fares for varying periods in the case of patients going to and from hospital for out-patient treatment, and in many other ways. It assesses patients' payments for admission to London County Council institutions and 105 for dentures under the Borough Council scheme. It supervises the provision of extra nourishment under the Council's scheme. In all, during the year, it dealt with 748 applications. ARRANGEMENTS FOR DISINFECTION AND DISINFESTATION AND THE EXTENT OF THEIR USE. Disinfection.—The Council's Disinfecting Station is situated at White Hart Road, Plumstead, where there are installed two Washington Lyon steam disinfectors, one high-pressure steam washing disinfector, and one room for disinfecting articles which cannot be subjected to heat. The Station was used very much more during the year than previously owing to the amount of bug infested bedding and articles removed there for disinfestation. The Station is sometimes used for special disinfection at the request of inhabitants. A small charge is made for these disinfections and during the year 42 such disinfections were carried out, and charges amounting to £13 lis. 6d were paid. In tabular form is shown below the amount of disinfection which was carried out during the year. TABLE No. 79. Rooms disinfected after ordinary fevers 750 „ „ „ tuberculosis 282 „ „ „ verminous cases 172 „ „ for other reasons 22 Articles disinfected 40,933 Disinfestation.— In accordance with the terms of an agreement with the London County Council, disinfestation of school children is carried out at the Cleansing Station, White Hart Road. In recent years the number of children so sent has fallen considerably. Disinfestation of adults is carried out at times when the children are not there. The following Table shows the number of persons cleansed each year since 1928:— TABLE No. 80. Year. Children. Adults. Grand Total. Boys. Girls. Total. Males. Females. Total. 1928 377 1,584 1,961 22 17 39 2,000 1929 416 1,451 1,867 26 32 58 1,925 1930 477 1,386 1,863 11 10 21 1,884 1931 483 1,543 2,026 14 4 18 2,044 1932 560 1,613 2,173 8 4 12 2,185 A report on disinfestation of bug infested premises will be found in the Housing Section. 106 SECTION IX.— MATERNITY AND CHILD WELFARE. The Council's Maternity and Child Welfare Scheme embraces the following services:— (a) Administration of the Notification of Births Acts, 1907-15. (b) Home visits to mothers and children. (c) Establishment of Welfare Centres. (d) Establishment of an Artificial Sunlight Clinic. (e) The systematic medical inspection of toddlers. (/) Provision of maternity outfits. (g) Payment of compensation to midwives. (h) The appointment of a Specialist medical practitioner for consultation with general medical practitioners under the Council's scheme for the control of Puerperal Fever. (i) The services of a Consultant in exceptional cases of obstetric or ante-natal abnormality at home. (J) Provision of Home Helps in maternity cases. (k) An arrangement with the School Medical Treatment Committee for the treatment of minor ailments in young children. (l) An arrangement with the School Medical Treatment Committee for the provision of dental treatment to young children and to expectant and nursing mothers. (m) An arrangement with the Woolwich Invalid Children's Aid Association for orthopaedic treatment for children requiring such treatment. (n) Provision of nursing assistance for young children suffering from Measles, Ophthalmia Neonatorum, Zymotic Enteritis, Whooping Cough, Poliomyelitis, Pneumonia and Influenzal Pneumonia, and for mothers suffering from Puerperal Fever and Puerperal Pyrexia. 107 (o) Day Ambulance service for maternity cases. (p) Reservation of twelve beds for children under 5 years of age who are suffering from such conditions as are usually treated in a general hospital, at the War Memorial Hospital. (q) Provision of beds for the institutional treatment of midwifery for 144 cases per annum at the British Hospital for Mothers and Babies, and for 66 cases at the War Memorial Hospital. (r) Reservation of beds, for ante-natal treatment and emergencies of midwifery, at the War Memorial Hospital, equivalent to 18 weeks' treatment per annum. (s) An arrangement with the Woolwich Invalid Children's Aid Association for the convalescent treatment of children requiring such treatment. (t) Convalescent Home treatment for expectant and nursing mothers. (u) Arrangements for the supply and distribution to young children and nursing mothers, of milk and food-drugs at cost price, half cost or free, according to economic circumstances. (v) Collective instruction to expectant and nursing mothers. In addition to these services the Council have, at the request of the London County Council, undertaken to do such work as is necessary in the case of children under five years of age : — (w) Under the Blind Persons Act, 1920. (x) Under Section 6 of the Widows', Orphans' and Old Age Contributory Pensions Act, 1925. Staff.—The medical staff employed by the Council for these purposes consists of three whole-time Medical Officers, two of whom are also engaged in the Council's tuberculosis work ; one part-time Medical Officer for the Toddlers' examination clinic, and two Consultants whose services are available—one for the Artificial Sunlight Clinic and one as a Consultant in connection with cases of Puerperal Sepsis and difficult obstetric conditions occurring at home. The dental staff—two Dentists and an Anaesthetist—are part-time and are appointed by the School Treatment Committee subject to the approval of the Council. The health visiting staff consists of ten Health Visitors, two of whom are part-time Sanitary Inspectors and one the Artificial Sunlight Nurse. 108 Notification of Births Acts, 1907-15.— Every birth occurring in the Borough requires to be notified to the Medical Officer of Health within thirty-six hours of birth. As a matter of fact, only a very small percentage of births are not so notified. As soon as a notification is received pamphlets dealing with the care and comfort of mothers and infants are sent by post to every mother. Subsequently, between the tenth and fourteenth day, a visit is paid to the home by the Health Visitor who decides on her first visit the necessity for subsequent visits. It may be stated, however, that, broadly, the general basis of visiting is as follows : —three visits during the first year and one visit in each subsequent year up to the age of five years, or until the child goes to school. The Work of the Health Visitors.— The Council's Health Visitors divide their time between home visiting and attendance at the Centres. They are responsible for the visiting of all children under school age in their respective areas, including visits to cases of ophthalmia neonatorum, measles, zymotic enteritis, whooping cough, pneumonia and anterior poliomyelitis, but in measles epidemic periods it has been the practice to engage temporary Health Visitors for these particular visits. The following Table, No. 81, shows the classification of visits paid by the Health Visitors in 1932:— TABLE No. 81. Births—First visits 2,028 „ Revisits 17,215 Infant deaths investigated 47 Still-births investigated 26 Expectant mothers—home visits 719 Infectious diseases : — Ophthalmia Neonatorum—First visits 8 „ „ Revisits 9 Measles—First visits 4,334 „ Revisits 1,694 Puerperal fever—First visits 5 „ „ Revisits 1 Puerperal Pyrexia—First visits 19 „ „ Revisits 7 Zymotic Enteritis—First visits 6 Revisits 2 109 TABLE No. 81—(Continued). Pneumonia 96 Anterior Poliomyelitis 7 Encephalitis Lethargica — Visits unclassified 239 Visits unsuccessful 2,916 29,378 The Work of the Welfare Centres.—These are eight in number and are now all municipal. Infant welfare centres are held at all of them and at three of them ante-natal sessions are held weekly. At the end of the year the Council had under consideration the adaptation of a portion of the North Woolwich baths as an infant welfare centre in place of the rented premises at St. John's Church Hall ; and also the enlargement of Plumstead Centre to provide more accommodation for maternity and child welfare work and to provide rooms for the school medical service. In tabular form below are shown detailed statistics for 1932 and the consolidated statistics for the previous year:— TABLE No. 82. Centre. No. on Roll of Centre. No. of Attendances. Mothers. Children. Mothers. Children. Expectant Nursing. Expectant Nursing Town Hall 450 478 1,634 1,023 984 11,778 Plumstead 267 377 1,132 827 766 8,456 Eltham 314 149 1,021 727 272 5,646 Slade 6 96 390 6 189 3,604 New Eltham 5 36 398 6 70 4,352 St. Luke's — 41 355 — 53 2,494 North Woolwich 3 38 126 2 90 1,119 Beresford Street 31 87 126 33 185 1,113 Totals 1932 1,076 1,302 5,182 2,624 2,609 38,562 Totals 1931 1,163 1,259 5,128 2,757 2,639 36,103 The next Table, No. 83, shows the number of children classified by year of hirth and the number of attendances made by them during the year. 110 TABLE No. 83. Children in Attendance at each Centre. Year of Birth. Town Hall. Plumstead . Eltham. New Eltham. Slade. St. Luke's. N. Woolwich. Beresford St. Totals. 1932 489 319 259 99 111 79 40 35 1,431 1931 514 348 243 136 122 104 32 31 1,530 1930 292 216 198 62 66 65 20 26 945 1929 190 128 142 50 54 52 18 19 653 1928 103 88 120 31 26 32 12 14 426 1927 46 33 59 20 11 23 4 1 197 1,634 1,132 1,021 398 390 355 126 126 5,182 Attendances. 1932 3,871 2,643 1,834 1,205 1,212 615 387 281 12,048 1931 4,711 3,665 1,924 2,213 1,454 1,060 478 405 15,910 1930 1,879 1,366 840 504 437 346 104 289 5,765 1929 923 457 510 263 370 264 107 89 2,983 1928 305 257 371 122 105 110 34 45 1,349 1927 89 68 167 45 26 99 9 4 507 11,778 8,456 5,646 4,352 3,604 2,494 1,119 1,113 38,562 These figures, which do not include attendances at the special Toddlers' Clinic or the Sunlight Clinic, show an increase over any previous year, the highest previous figure being 36,103, recorded in 1931. Feeding of Infants in Woolwich.—In midsummer the usual enquiry was made, as in previous years, as to the type of feeding adopted in the case of infants attending the welfare centres. The method used was as follows:— (a) On the card of every child under one year of age attending a welfare centre between 13th June and 22nd July, was inserted once, and once only, the terms " Breast," or " Breast and Hand," or " Hand Fed." (b) The child's age was taken on the day on which this note was made. (c) At the end of the period the results were summarised for the whole Borough and the appropriate percentages worked out. The results of the enquiry are shown in Table No. 84 on the adjoining page- TABLE No. 84. Feeding of Infants attending Welfare Centres—13th June to 22nd July, 1932. Method of Feeding. 0-1 1-2 2-3 3-4 4-5 AGE IN MONTHS. 10-11 11-12 Grand Total 5-6 6-7 7-8 8-9 Total 9-10 Breast 57 77 49 38 42 37 24 19 15 358 3 2 1 364 Breast and Hand 6 20 12 14 10 10 10 13 20 115 16 11 6 148 Hand 6 21 25 34 27 34 38 40 36 261 47 60 64 432 69 118 86 86 79 81 72 72 71 734 66 73 71 944 percentages: Breast 82.6 05.3 57.0 44.2 53.2 45.7 33.3 26.4 21.1 48.8 4.6 2.7 1.4 38.6 Breast and Hand 8.7 16.9 13.9 16.3 12.6 12.3 13.9 18.1 28.2 15.7 24.2 15.1 8.5 15.6 Hand 8.7 17.8 29.1 39.5 34.2 42.0 52.8 55.5 50.7 35.5 71.2 82.2 90.1 45.8 112 Artificial Sunlight Clinic.— This Clinic was opened in October, 1927. The total number of patients treated during the year, including 100 whose course of treatment was not completed at the end of 1931, was 499. The total number of treatments given was 9,314; of these 6,728 were by carbon arc, 2,147 by mercury vapour lamp, and 439 by radiant heat lamp. The clinic is under the medical supervision of Dr. J. E. A. Lynham, who has furnished the following report on the year's work:— "The figures for the Sunlight Clinic for the past year again show an increase, not only in the total number of attendances but in the number of new patients received. The increase has been mainly amongst children suffering from general debility or from rickets, and may be attributed to the general depression and the relative lack of sunlight during the year. "The very efficient service of medical officers now established has resulted in the selection of a large number of patients for treatment in early stages of disease, thus enabling satisfactory results to be obtained in a comparatively short time. It will be noted, however, that whereas the number recorded as cured is not high, the number of new cases still under treatment is considerable, and many of these have already shown great improvement. Most of those appearing with septic conditions have been cured, and those suffering from skin diseases have responded satisfactorily. "The response of catarrhal children has not been so good, apparently owing to the widespread epidemics which occurred in the latter part of the year, and the number of cases with enlargement of the cervical glands may be attributed in part to the same cause. "A number of expectant mothers have also attended the Clinic, and the majority have shown a general improvement in health. "Efforts have been made to supply the poorer children with vitamin-containing foods where their circumstances are restricted. "The general conduct of the treatment has not been altered, the carbon arc and mercury vapour lamps being used as before, and the radiant heat lamp proving of considerable use in the treatment of the younger children. "Particular care is taken to refer children suffering from obvious diseases, such as enlarged tonsils or physical deformities, to special clinics for opinion and treatment, and patients are referred to the War Memorial Hospital for X-ray examination where it is thought desirable. "In most instances where treatment has been discontinued at the wish of the parents it has been owing to their removal from the district. The increasing number of attendances is evidence that the Clinic is performing useful service." 113 In tabular form below are shown the number and types of cases treated during the year:— TABLE No. 85. Cases Treated at Sunlight Clinic, 1932. Brought forward from 1932 New Cases. Total. Much Improved or Cured. Improved. I.S.Q. Ceased Treatment. Treatment not yet complete Rickets 24 116 140 19 40 3 21 57 Anaemia, Debility and Malnutrition 49 136 185 48 45 9 28 55 Catarrhal Children 10 35 45 7 9 4 5 20 Septic Conditions 1 30 31 26 — 1 — 4 Nervous Children 2 9 11 — 3 1 1 6 Enlarged Glands 6 20 26 4 10 — 3 9 Miscellaneous Nervous Conditions - 4 4 — — 2 1 1 Miscellaneous Skin Conditions 3 19 22 9 6 2 4 1 Other Conditions 3 18 21 5 4 1 3 8 Mothers 2 12 14 5 4 — 2 3 100 399 499 123 121 23 68 164 Toddlers' Clinic.— The scheme for the systematic medical inspection of toddlers was started in May, 1930, and no difficulty was experienced during the year in getting mothers to bring their children for yearly examination. Three sessions are held weekly, one at Woolwich, one at Plumstead and one at Eltham. The clinic is under the medical charge of Dr. Margaret Emslie and she reports below on the year s working. The results of an enquiry made by her into the prevalence of anaemia and heart disease appear at the end of the report as Appendix II. "The number of cases seen at the Toddlers' Clinic in the year ending December, 1932, amounted to 561 boys and 545 girls, full inspections, plus 449 re-visits, making a total of 1,555 consultations. The number of cases attending the clinic again show a gratifying increase. The consultations have been conducted on similar lines to the past) embodying an examination on the lines of school medical inspection but of a somwhat fuller nature, and discussion with the mothers of whatever points in the physique or general behaviour of the child struck the examinei as capable of improvement. Treatment has once again been provided through the local hospitals and municipal and other clinics, and in other cases through similar institutions in London. In all cases, when medical treatment was required, cases 114 were in the first place referred to their family medical attendant. Once more an attempt has been made to send for children in their birthday month as a starting point for the routine annual examinations, beginning so far as possible from the age of two, but the health visitors have been empowered to send other cases when the need arose and re-inspection cases have been seen at such intervals as seemed suitable." In Table No. 86 are shown the results of the examinations. TABLE No. 86. Medical Inspection of Toddlers, 1932. Disease, Defect or Condition. BOYS. Age last Birthday GIRLS. Age last Birthday. Total. 1 2 3 4 1 2 3 4 Total Children Examined 3 233 176 149 2 210 171 162 1,106 Nutrition— (a) Excellent 2 91 31 18 1 92 54 24 313 (b) Normal 112 90 51 1 88 86 69 497 (c) Sub-normal 1 27 55 71 — 29 28 65 Z 10 20 (d) Bad — 3 9 - 1 3 4 Muscular Tone— Excellent 2 87 101 83 - 89 96 123 581 (b) Good 1 141 75 03 2 117 73 39 511 (c) Sub-normal - 5 — 3 - 4 2 — 14 Clothing and Footgear— (a) Satisfactory 3 215 166 143 2 192 166 156 1,043 1 h\ T Tn<5nti<;fartnrv - 18 10 6 - 17 5 6 62 11J) u lloa lioia^iui \ (c) Not recorded - — - - - 1 — - 1 Cleanliness— (a) Excellent 3 185 156 137 2 191 160 149 983 (b) Fair - 46 20 12 - 16 11 13 118 (c) Dirty - 2 — — - 3 — — 5 ANAEMIA- Slight - 29 30 10 - 41 32 29 181 Moderate - 20 14 9 - 15 13 17 88 ti Severe - 1 1 — - o - 1 5 Lungs— Bronchitis - 9 14 12 _ 5 5 10 55 Asthma - - - 1 - 1 1 2 5 Nervous System— Minor Retardation - 37 10 5 1 15 5 4 77 Minor Epilepsy - 1 — 1 - 1 2 1 6 Cerebral Diplegia - — 1 — — — — 1 2 Chorea — — — 1 - — — 1 2 Behaviour Symptoms 1 88 67 27 1 88 45 34 351 Stnttpr - 1 1 3 - - — 1 6 OIU LLvi • > * • Facial Paralysis. . - 2 - - - - — — 2 Tic-facial - — 1 — - — - - 1 115 Medical Inspection of Toddlers, 1932—continued. Disease, Defect or Condition. BOYS. Age last Birthday. GIRLS. Age last Birthday. 1 2 3 4 1 2 3 4 Total. Alimentary System— Diabetes -- - - - - - 1 - 1 Worms - 2 8 2 - 7 5 5 29 Constipation - 11 13 3 — 28 11 11 77 Colitis - 1 — 1 — 2 - 1 5 Acidosis - 3 3 3 - 4 12 4 29 Prolapse - 1 — — - 1 - — 2 Genito-urinary System— Enuresis (nonbehaviour) - 1 2 1 - 2 2 1 9 Pyelitis - - - - — 1 — 1 2 Nephritis (Post- Scarlatina) - - - 1 - - - - 1 Urethral Caruncle - — — — - 1 — — 1 Rickets— Past or present— Slight - 58 39 20 1 43 24 14 199 Definite 2 76 77 55 - 55 66 36 367 Skin— Impetigo - 1 1 - - 3 4 2 11 Urticaria - 11 7 3 - 14 10 5 50 Eczema - 8 4 - - - - - 12 Ichthyosis _ 1 - - - - - - 1 Naevus - - - - - 1 - - 1 Alopecia - 1 — — - - — — 1 Eye— Blepharitis - 4 1 1 - 3 3 - 12 Conjunctivitis - - 1 - - - 1 - 2 Squint - 3 5 3 - 4 2 6 23 Styes - 1 - 1 - - - 1 3 Cyst - 1 - - - - - 1 2 Nystagmus - - — — - — - 1 1 Ear— Discharge-Otorrhcea - - 1 1 - - 1 - 3 Otitis Media - 2 2 2 - 2 2 - 10 Mastoid - 1 - - - - - - 1 Nose and Throat - 97 70 49 1 59 61 43 380 Enlarged Tonsils Enlarged Tonsils and Adenoids Adenoids.. J Teeth— Caries - 23 55 74 - 14 41 70 277 Hypoplasia - 3 3 3 - 4 4 1 18 Malocclusion - 23 11 3 2 50 15 7 111 Oral Sepsis - 1 1 2 Gingivitis - — — - - 1 1 - 2 Heart and Circulation— Heart Disease— (a) Functional (ex-congenital) - 30 34 33 - 28 33 23 181 (b) Congenital - — 1 - — — 1 2 116 Medical Inspection of Toddlers, 1932—continued. Disease, Defect or Condition. BOYS Age last Birthday. GIRLS. Age last Birthday. Total. 1 2 3 4 1 2 3 4 Deformities— Postural - - - 2 - - - - 2 Flat Foot - 2 5 1 - 2 3 1 14 Spinal Curvature — - - 1 - - 1 2 4 Congenital Dislocation - — 1 1 - — — — 2 General— Septic Arthritis - - 1 - - - - - 1 Rheumatic Symptoms - 1 3 5 - - 3 8 20 Haemophilia — - - 1 - - - - 1 Pituitary Dystrophy - 1 1 - - 1 3 - 6 Purpura — - - - - - - 1 1 Umbilical Hernia - 1 - - - 3 3 1 8 Jaundice — — 1 - - - - - 1 Pink Disease - - - - - - 2 4 6 Cretinism - 1 1 - - 1 3 Adenitis - 1 - 2 - - - 1 4 Abscess — 1 — 1 - — — - 2 1 he result of the examinations shows that the general condition of the children has been maintained there being an improvement on the figures for 1931, sub-normal nutrition being 25 per cent, as compared with 28 per cent last year and 26 per cent in 1930 ; anaemia, 24 per cent, as compared with 26.5 per cent in 1931 and 20 per cent in 1930. Rickets, however, showed some increase, 33 per cent of all cases, as compared with 27 per cent in 1931 and 22 per cent in 1930, in spite of a year outstanding in the amount of sunshine. In addition to the 33 per cent of cases showing signs regarded as definitely indicative of rickets, there were 18 per cent of cases showing minor signs that under X-Ray might have revealed a condition of pathological change likely under favourable conditions to proceed to spontaneous healing, or with unsuitable diet and environment to resolve itself into more florid rickets. The position in regard to rickets appears a difficult one. The incidence of the disease (or more properly deficiency) once again shows itself more heavily among the boys examined, 37 per cent, as against 29 per cent of the girls. The highest point of the rickets' curve, mapped according to age, occurred at the age of 3, not at the first examinations following infancy : but healing of the bony lesions appeared also to synchronise with this period since at the age of 4 there was a 33.3 per cent drop in the height of the curve. I he figures for dental caries, allied to the problems of dietetic and rachitic faults, namely, 8 per cent, 27 per cent and 46 per cent at the ages of 2 years, 3 years and 4 years are, for practical purposes, the same as those of the preceding two years. The figures shown give no indication of the comparative amount of caries present at the given ages in the cases examined to date, but an attempt is now being made to record the number of defective teeth observed in each case so that a truer 117 indication may be given in subsequent years of the average extent of the defects noted at ages 2, 3 and 4 which may itself vary within considerable limits and disguise improvements or otherwise in the total dental conditions of children under school age. Mention may perhaps be made of the high percentage of children showing malocclusion, a failure of proper alignment of the jaws and teeth resulting, in a majority of cases, from thumb-sucking or persistent use of the comforter, on which comment was made in connection with the enquiry into nervous habits in last year's report. The disability in this case is not only nervous—though important enough in that respect—but functional and aesthetic, and dentists teach us that poor alignment and irregularities in the end also conduce to caries. Ten per cent of the children showed this defect, which lends itself to corrective so-called " orthodontic " treatment in most cases as the result of an obvious bad habit. Of the 10 per cent more than double the cases showed themselves in girls— a finding on which it is perhaps difficult to offer first comment. The subjects adopted for particular enquiry this year were clinical—anaemia, heart conditions and rheumatism, and the results of the enquiry appear as Appendix II. Provision of Maternity Outfits.— In 1930 the Council agreed to supply sterilised maternity outfits for the use of necessitous mothers in order to ensure the necessary cleanliness in domestic midwifery and with a view to minimising the risks of maternity. They are supplied free, half cost, or cost price, according to the family income, the Council's economic scales being used as tests of necessity. During the year 78 applications were received; 77 were supplied— 40 free, 6 at half cost and 31 at cost price. Compensation of Midwives.— Whenever an assistant medical officer finds it necessary to recommend hospital treatment for expectant mothers referred to the Council's ante-natal clinics for ante-natal examination by midwives, the midwife loses her patient if the mother accepts the advice of the medical officer and is admitted to hospital. In these cases the Council make a payment of 10s. by way of compensation to the midwife subject to certain conditions, which are referred to in detail in my Annual Report for 1931, being complied with. During the year compensation was paid in 13 instances. Administration of the Public Health (Puerperal Fever and Puerperal Pyrexia) Regulations, 1926. The Council's scheme under these regulations was fully described in the Annual Report for 1928. The extent to which they were made use of is reported on fully in that part of the Infectious Disease Section of the report which deals with the notification of these diseases. Obstetric Complications in Private Practice.— In September, 1931, the Council arranged for the services of Mr. Harold Taylor, F.R.C.S., the Council's Consultant under the Puerperal Fever and Puerperal Pyrexia Regulations, to be available in such exceptional cases, and to pay him a fee of £5 Ss. Od. for each such case. Two cases were dealt with under this scheme during the year. 118 Home Helps.— During the year 16 applications were considered by the Committee, and 15 home helps were provided. The total cost of this service was £55 16s. Od. Treatment of Minor Ailments.— Children requiring medical or surgical treatment for certain minor ailments are referred to the School Clinics at Brewer Street, Woolwich, or the Eltham Health Centre, to a private practitioner, or to a hospital. During the year 181 were sent to these clinics, and for each case the Council paid 5s. Od. Children referred to them suffered from the following conditions : — TABLE No. 87. Brewer Street Eltham Health Centre Impetigo 4 36 Ear Discharge 12 33 Eyes 17 34 Miscellaneous 3 42 36 145 Dental Treatment.— For many years mothers and children requiring dental treatment were referred from the welfare centres to the school clinic, Brewer Street. During the year it was found necessary to provide facilities for the dental treatment of children at Eltham and arrangements were made, starting in October, for two dental sessions per month to be held at the Eltham Health Centre. The following Table, No. 88, shows the cases attending and the total attendances during the year. The number of sessions was 50, excluding anaesthetic days. TABLE No. 88. Expectant Mothers. Nursing Mothers. Children under 5. No. Attendances. No. Attendances. No. Attendances. Woolwich 84 161 39 122 268 304 Eltham — — — — 37 55 84 151 39 122 305 359 Dentures are provided free, at part cost, or at cost price, according to ability to pay, and payment is spread over many weeks. In consequence, the income received during the year includes money received in respect of dentures supplied in previous years. Thirty-three sets (complete or partial) of artificial teeth were supplied during the year at a total cost of £175 15s. Od. Payments by mothers amounted to £59 12s. 3d. 119 Orthopaedic Treatment for Children under Five Years of Age.—Children requiring orthopaedic treatment are sent to the remedial clinic of the Woolwich Invalid Children's Aid Association in accordance with the scheme adopted in 1925. The Council pay for children under five years of age sent by their medical officers to the Clinic, 2s. Od. per attendance for cases requiring massage or electrical treatment, and Is. 6d. per attendance for any other form of treatment. The cost of these services for the year was £230 10s. 6d. Only cases recommended by the Medical Officer of Health are included in this scheme, and payment is only made for the number of attendances approved by him. In detail, the children referred to the Clinic required treatment for the following conditions:— TABLE No. 89. Cases Treated at Orthopaedic Clinic, 1932. Type of Case. Number remaining over from 1931 New Cases. Total Cases. Number who completed treatment by end of year. Number with treatment not completed. Talipes (Club Foot) - 5 5 3 2 (Flat Foot) - 4 4 3 1 Rickets— General 9 39 48 40 8 Genu Valgum (Knock Knee) 9 31 40 34 6 Genu Varum (Bow Leg) 14 30 44 36 8 Infantile Paralysis — 1 1 — 1 Erb's Paralysis 1 2 3 2 1 Bad Posture 2 5 7 5 2 Muscular Weakness 2 2 4 3 1 Mouth Breathers — 1 1 1 — Other Deformities 1 — 1 1 — Other Diseases 2 5 7 4 3 40 125 165 132 33 Provision of Nursing Assistance for Certain Diseases.—In Section III cf the Report, the general scheme of nursing assistance is described in full. The extent to which these services have been made use of in respect of specific diseases is dealt with under these diseases, q.v.:— Day Ambulance.— In accordance with an agreement entered into with the London County Council, ambulances are hired from that body for the conveyance of mothers to maternity hospitals between the hours of 8 a.m. and 11 p.m., and, except in rare instances, the cost is recovered from the patient. During the year this service was used on 14 occasions. 120 Children's Beds.— Twelve beds have been reserved by the Council in the Woolwich War Memorial Hospital for the treatment of children under 5 years of age suffering from such conditions as are usually admitted to general or children's hospitals. Including those remaining in hospital at the beginning of the year, the number of children who received treatment during the year was 183 (147). Of these 147 (130) were discharged cured or very much improved in health, 10 (5) improved and 7 (3) died. Five (1) children were transferred to other hospitals, 2 (5) others were discharged showing no improvement, and the number remaining in hospital at the end of the year was 12. The surgical conditions for which these children were admitted included : — enlarged tonsils and adenoids, phimosis, mastoiditis, hernia, abscess and injury, and those admitted for medical treatment included children suffering from : —pneumonia, malnutrition, marasmus, anaemia and bronchitis. The figures for 1931 are shown in brackets. Institutional Midwifery.— (1) British Hospital for Mothers and Babies. There are 42 beds in this Hospital, and I am informed by Miss Gregory, the Secretary of the Hospital, that 732 babies were born during the year. At the ante-natal clinics in connection with this Hospital, 8,158 attendances were made, and at the infant clinics 2,646 attendances. In addition there were 182 extern cases. The number of mothers admitted under the Council's scheme was 139, the nett cost to the Council being £959 19s. Od. (2) War Memorial Hospital.— There are 7 maternity beds in this Hospital and I am indebted to Mr. R. S. G. Hutchings, the Secretary, for the following information regarding the admissions to the maternity unit during the year. The number of children born in the Hospital was 151, and 15 mothers were admitted for ante-natal or emergency treatment. The number of attendances made at the ante-natal clinic was 914. The number of cases admitted under the Council's scheme was 46, the nett cost to the Council being £551 2s. 6d. Ante-Natal Treatment and Emergencies.— The number of cases admitted for ante-natal or emergency treatment under the Council's scheme was 9. The reasons for admission were:— Haemorrhage, 2; Displacement, 1; Deformity of Pelvis, 1; Phlebitis, 1; Albuminuria, 4. Convalescent Home Treatment for Children under 5 Years of Age.— The necessary arrangements for this treatment are made by the Woolwich Invalid Children's Aid Association, to whom the Council give grants-in-aid for this purpose. During the year such grants were made in respect to 75 children, the total cost of whose convalescent treatment amounted to £470 Is. lOd. The Council's grants amounted to £150. The children were sent away for periods varying from 3 to 32 weeks, and payment was only made in respect of children sent to homes approved by the Medical Officer of Health. 121 Convalescent Home Treatment for Expectant and Nursing Mothers.— In June, 1931, the Council decided to make provision under their maternity and child welfare scheme for the convalescent treatment of expectant and nursing mothers. The scheme included payment of railway fares where necessary. It was resolved also to recover some of the cost from patients after consideration of each case on its merits. During the year five mothers were sent away. Supply of Milk, etc., to Necessitous Mothers and Children.—Under the provisions of the Maternity and Child Welfare Act, 1918, milk, etc., is provided by the Council for necessitous expectant and nursing mothers, and children under the age of five years, under the conditions laid down in Circular 185, issued by the Ministry of Health in March, 1921. The approximate cost of these services during the year was as follows:— Dried milk, £2,120 18s. 8d. Fresh milk, £3 6s. Od. Dinners, nil. Collective Teaching of Expectant and Nursing Mothers.— A special class in mothercraft is held every Tuesday afternoon at the Old Town Hall, Woolwich. The object of this class is to demonstrate to mothers suitable articles of attire for baby and to provide facilities for making them under expert supervision. The number of attendances during the year was 266. Blind Persons Act, 1920.— The Council, at the request of the London County Council, have arranged that home visiting of blind children under five years of age should be carried out by the Council's health visitors, and reports are furnished to the County Council, as the occasion arises, when the home conditions are unsuitable for blind children or it is advisable that the child should be admitted into a suitable institution. During the year one case came to the knowledge of the department. Widows', Orphans, and Old Age Contributory Pensions Act, 1925.—The local authority may, in case of desertion of a child who is an orphan, administer the payments on behalf of the child. No case under the provisions of this Act was dealt with during the year. 122 APPENDIX I. A CASE OF COW-POX. By J. Macmillan, D.S.O., M.C., M.B., D.P.H. On the 11th January, 1932, I was asked by a local medical practitioner to see a patient of his whom he suspected to be suffering from cow-pox. The patient was a milkman in the employ of one of the local farmers. I saw him in consultation with Dr. A. F. Cameron and the diagnosis was confirmed. The patient had never been vaccinated. In view of the rarity of this condition in London I am reporting on it rather fully. 1—Small ulcer with remains of pellicle 4—Adenitis. adherent to margin. S—Lymphangitis. 2—Pustule : ? abortive. 6—Severe onychia. 3—Deep-seated vesicles very like smallpox ' Brawny swelling . inflammatory. lesions on same site. 8—Lesions resembling primary vaccination. When first seen the lesions were present on the hands, arms and face, as shown in the diagram. The fully developed lesion was a vesicular ring with a central crust commencing to form, the whole lesion being about a quarter to three-eighths of an inch in diameter and distinctly raised on an indurated inflammatory base. It was obviously a lesion of inoculation. There was severe septic infection of the matrix of the nail of the left first finger from which a moderately severe lymphangitis extended to the axilla with adenitis of the epitrochlear and axillary glands. There were three lesions deep-seated on the right palm and these are indistinguishable from smallpox vesicles on the same site in smallpox patients. The lesion on the right upper eyelid was a shallow ulcer with the remains of the pellicle adherent to the margin and an area of surrounding inflammation. 127 Arrangements were made for the patient to be admitted to the Lewisham Hospital. In investigating the source of infection it was found that many cows were suffering from a vesicular eruption and accordingly arrangements were made for them to be examined by a veterinary surgeon on the staff of the London County Council. Mr. R. Bryden, F.R.C.V.S., examined them the next day and found that over 40 cows, out of a total of 78, were suffering from cow-pox or recovering from it. While in the Lewisham Hospital the patient was seen by Dr. J. E. McCartney, Director of Research and Pathological services, London County Council. He investigated the case and very kindly supplied the following notes:— " On January 14th, 1932, material was taken from a typical pock from this patient. The pock was on the dorsum of the left hand near the angle of the thumb and first finger, and was definitely purulent. The epithelium over the pock was cleansed with alcohol, and a small quantity of thick purulent material was withdrawn by means of a capillary pipette. " The hair from the flank of a young rabbit 'A' was removed with a depilating powder and the smooth skin scarified and the pock material inoculated on to it. The rabbit developed the typical appearance of vaccinia, with scab formation. Material from the scabs at the seventh day after inoculation was transferred to the scarified skin of a second rabbit ' B ' which resulted in the development of typical vaccinia lesions. " The same day that the human material was obtained, a visit was paid to the farm and the herd of cow-pox cows examined. There were extensive lesions on the teats of many of the cows but these had been treated with an ointment and were in process of healing. From one of the cows purulent material from under a scab, and some flakes of scab, were obtained. These materials were inoculated by scarification on the shaved flanks of rabbit ' C.' Typical vaccinia lesions were produced and at the seventh day material from these lesions was transferred to the scarified skin of rabbit' D ' which in turn developed vaccinia. On February 3rd, i.e., three weeks after the original inoculation of human and bovine material, rabbits ' A,' ' B,' ' C' and ' D,' which had recovered from the cow-pox lesions, were again shaved and the scarified skin inoculated with vaccine lymph obtained from the Government Lymph establishment. As a control, a normal rabbit ' E ' was shaved, scarified, and inoculated with the same calf lymph. The previously inoculated rabbits ' A,' ' B,' ' C ' and ' D ' showed ' no take,' while the control rabbit developed typical vaccinia lesions. These experiments show the condition in both the human and bovine subjects to be cow-pox, as smallpox material is not pathogenic to rabbits, and the recovered animals showed complete immunity to a known vaccine virus which was potent for a normal rabbit." 1 he patient was in Lewisham Hospital until the 22nd February when he was discharged perfectly well. A chart showing the distribution of the rash and photographs showing the lesions at different stages of development appear on adjoining pages. I am greatly indebted to the gentlemen mentioned above for their kindness and assistance in the matter of investigating this case. 128 APPENDIX II. INVESTIGATION INTO THE INCIDENCE OF ANEMIA, HEART CONDITIONS, PALLOR AND RHEUMATISM IN TODDLERS. By MARGARET EMSLIE, M.B., Ch.B. (Aberdeen). The number of children examined during the years 1930, 1931 and 1932 was 1,622, and the number of examinations was 2,425. The following matters were elicited from the investigation:— A. Anemia. Four hundred and seventy-eight anaemic children were found. Certain of them were examined on several occasions and anaemia may have been recorded at one examination only. On the whole, however, the figures would suggest that some degree of anaemia occurred in 30 per cent of the cases examined during the pre-school period. In the separate years the percentage was not quite so high. There was a slight preponderance of anaemia among the girls, but this was not uniform in each individual throughout the year. There was no sex preponderance amongst the severe cases. The degree of anaemia present was recorded clinically in the proportion—276 slight cases, 187 definite cases and 15 severe cases. The cases of anaemia were grouped as follows, according to age :—2 years +, 272 cases ; 3 years +, 142 cases ; 4 years +, 64 cases. Comparing these figures with the totals examined at the respective ages, the age incidence of anaemia is given as follows:— at age 2 +, 23.5 per cent; at age 3 +, 18.6 per cent; at age 4 10.6 per cent. The incidence of anaemia in the cases seen, therefore, is found to decline steadily from the age of 2 years towards school age. Seasonal incidence of ancemia. The number of cases of anaemia noticed per quarter was as follows:— 110, 109, 110, 149: total 478; the number examined each quarter was:— 497, 670, 584, 674: total 2,425. This gives a percentage of 22.1 and 22.1 for the two "winter" quarters, as compared with 16.3 and 18.8 for the periods April-June and July-September. The effect of comparative lack of sunshine is seen more clearly when the three darkest months (November-January) are compared with the three in which there is ordinarily a maximum of ultra-violet light (May-July). In the former case the figure is 23 per cent as compared with 14.7 per cent. This would confirm in a general way what has been indicated by other workers regarding the concentration of iron in the blood that takes place under the influence of ultra-violet rays. The size of family in which the anaemic child was reared (as translatable into overcrowding, comparative lack of air, poorer dietetic co-efficients for the larger family units) was observed with a view to discovering whether this played any part in the production of anaemic conditions. The average size of a " census " family in Woolwich is 3.6 ; the average size of family found amongst the anaemic cases was :—slight anaemia, 4.4; moderate anaemia, 4.8; severe anaemia, 4.5. The average for the anaemic cases, therefore, was slightly higher than for Woolwich as a whole, but not sufficiently so to allow of any deductions being arrived at. 129 Feeding in infancy was a factor which might be expected to enter into the production of anaemia, since the incidence of anaemia was found amongst the cases observed to decline steadily between the ages of 2 and 5, after the influence of a particular method of feeding in infancy might be passing off, and the percentage of iron also is notably less in cows milk than in human milk. The duration of breast feeding observed amongst the anaemic children was as follows:— breast fed not longer than 3 months, 46; between 3 and 6 months, 76; between 6 and 9 months, 222; over 9 months of age, 4. This gives a percentage amongst the anaemic children of 65.4 breast fed for 6 to 9 months, and 21 per cent breast fed for a period of 3 to 6 months. Only 13 per cent were breast fed for a lesser period than 3 months and could truthfully be described as artificially fed infants. The rate of breast feeding from 6 to 9 months for Woolwich as a whole, on the other hand, was 38 per cent in 1929— a year which would enter into these calculations^—and this rate has shown but very slight variations from year to year. The figures, therefore, would show not an apparent preponderance of anaemia amongst the artificially fed as might have been expected, but that far more of the anaemic children were breast fed than of the ordinary population— a finding that would make one look further back into antenatal conditions and the state of the health of the mother as an important factor in the causation of ansemia, if natural feeding during infancy is truly not a protective. In this relation it may be mentioned that the form of artificial food in general use at the infant welfare centres of the Borough is dried milk, but that not until 1932, i.e., after the period covering the infancy of the children examined, was a form of dried milk reinforced with iron utilised, as is now the case. The findings quoted, therefore, hold good not for breast feeding versus an "improved" method of artificial feeding as now advocated, but for the ordinary methods of bottle feeding advocated in centre work or arrived at of choice in non-centre cases by the mothers themselves. Anamia and general condition. The nutrition of the anaemic children, judged by their height-weight ratio and general appearance, was recorded as below average in 31 per cent of the total anemic cases and 46.6 per cent of the group marked severely anaemic. This compares with a percentage of 27 "below normal" cases for the total children examined in the three years 1930-32. There would therefore appear to be some association of anaemia with under-nourishment (or mal-nourishment) in the severer cases, but amongst the moderate or lesser cases of anaemia, under-nutrition was not noticeably more prevalent than amongst the general group of children examined. Anamia and rickets. Thirty-nine per cent of the total anxmic children showed definite rickets, compared with 29 per cent of the total children examined during 1930-32: an additional 18 per cent showed minor evidence of rachitic change. It would appear trom this that the incidence of anaemia plus rickets is higher than the incidence of either of these two conditions alone, i.e., there would appear to be some degree of association between the presence of rickets and of anaemia in the children submitted to examination. Further than this it is impossible to go, since neither the rickets nor the anaemia was necessarily seen in its initial stages during the age period under review. 130 Economic conditions and anamia. The question of anaemia as a sequel to undernourishment was further investigated under the heading of unemployment amongst the families observed total anaemic cases, 478; totally unemployed, 51; partially employed, 30; fully employed, 342; no record available, 55. This gives a percentage of 10.7, total, and 6.3 partial, unemployment amongst the anaemic cases. The figure for total unemployment amongst the insured population of Woolwich as a whole is 11.7; the figures for partial unemployment are not available. The statistics given, however, would suggest that the general ill-effects of unemployment have no particular bias in the production of anaemia (on grounds of poorer quality food, poorer housing, etc.), since the degree of unemployment amongst the anaemic families is less than amongst the population as a whole. Housing conditions of aneemic children. The housing accommodation of the children observed was found to be as follows:— Slight. No. of cases. Moderate. Severe. Percentage so living. Slight. Moderate. Severe. Rooms 108 66 7 39.1 35.3 46.6 House 5 43 — 1.8 22.5 — House and yard 9 6 — 3.3 3.2 — House and garden 135 61 7 48.9 32.6 46.6 No record 19 11 1 6.9 6.4 6.8 276 187 15 100.0 100.0 100.0 This gives an average of 60 per cent of all the children noted as anaemic living in families where the family was in sole occupation of the house, taking accommodation in the form of a house, house and yard, or house and garden, as equivalent to sole occupation. The remaining 40 per cent live in rooms. Thirty-nine per cent of all the families in Woolwich share dwellings so that the figures for the anxmic children more or less correspond to those for the community as a whole and show no obvious relation between housing problems and the production of anaemia. Hours of sleep. It was noted in a previous report (see Annual Report of Medical Officer of Health, 1930, page 116) that unwise management in regard to sleep seemed to account for a certain percentage of nervous difficulties amongst the children attending the clinic. It was particularly noted that, not only lack of sufficient sleep at night amongst the younger children, but long hours spent in bed during the day amongst certain groups, were factors likely to produce symptoms as a result of confinement, lack of air and sufficient exercise and light. The practice of noting the total 24 hours' sleep periods for each child examined is still carried out at the clinic and, in the case of the anaemic children, the daily amount of sleep averaged 13 hours, including an average mid-day rest of just over an hour. No fault can be found with this (on the grounds of undue confinement) taking it that the average includes a majority of children at the age of 2 rather than 4. But on the other hand it was clear in a number of cases that long rest periods during the day (including many of 3 hours and some even longer times) 131 meant an enforced lack of air, exercise and ultra-violet radiation during the best intervals of the day, that was bound to lower metabolism and impair vitality in the long run till anaemia became but a particular symptom of a generally impoverished state ot health. The cause of confinement was not always ignorance but might be domestic difficulties (e.g., inability to put the child out of doors, in rooms) or mistaken zeal as to a child's actual needs in the matter of rest during the day. As a matter of clinical interest, if not in illumination of this question of causes, the association of anaemia with certain other clinical conditions was observed. Ancemia and functional heart murmurs. Twenty per cent of the anaemic children showed heart murmurs at one or other examination, as compared with 16 per cent of the total cases examined. Of these murmurs 80 per cent were mitral murmurs. An additional 4.6 per cent of the anaemic children showed a modification of the first sound at the apex but not a murmur. Two cases only showed modification of cardiac rhythm. The incidence of heart symptoms to some extent ran parallel with the degree of anaemia shown, in that 25 per cent of the moderate or definite anaemia cases exhibited murmurs, as compared with 18 per cent only of the slight cases. The severe cases were too few to allow of similar comparisons. In 8 out of 209 anaemic cases re-examined at a later date, a murmur had supervened, i.e., in an additional 4 per cent, and in 4 of these rheumatic symptoms also were found. Ancemia and rheumatism. Six slight and 1 moderate case of anaemia showed symptoms that might be indicative of early rheumatism. This is a case incidence of 1.4 per cent as compared with 2.3 per cent for the total cases examined. The figures are too small to allow of any deduction. Ancemia with septic tonsils. Two hundred and thirty-six of the anaemic children showed definite tonsillar enlargement and in 57 cases tonsillectomy was recommended. T he standard adopted at the clinic in regard to the need for operation is a very conservative one. These figures compare with the general group of cases as follows:— Tonsils, or Tonsils and Adenoids, found to be Operation enlarged. recommended. Anaemic cases 50 per cent 12 per cent Total cases 41 per cent 5 per cent These figures would appear to indicate some association of anaemia with enlarged tonsils and a definite association with the septic case requiring operation, since amongst these children the operation rate is more than double that among the general group of children examined. This finding would tend to corroborate what has been suggested by other workers regarding the secondary and general effects of tonsillar infection. Ancemia and pallor. The relation of these symptoms, commonly considered by the lay public as interchangeable terms, is interesting. 10.8 per cent of the anaemic cases showed facial pallor. The same symptom was noted in 7 per cent of the general 132 cases with or without anaemia. The percentage of anaemic cases showing pallor, therefore, is a little higher than the percentage of children showing pallor amongst the general population. Moreover, 47 per cent of the pallor children were considered to be anxmic. It would appear, therefore, as if the association of facial pallor with anaemia in the popular idea is to some extent supported, but the correspondence is not absolute and an equal proportion of pale children was in fact found who showed not the slightest sign of anaemia judged by the condition of their mucous membranes. It was unusual for the pallor to coincide with the evidence of the anxmia when found, but one or two cases were observed in which a moderate degree of anxmia was followed at a later stage by exceeding pallor. Persistence of anamic symptoms. Two hundred and nine of the 478 anxmic cases were re-examined at an interval varying from 3 to 12 or more months. The results of re-examination were as follows:—of the totals re-inspected, 52 per cent showed improvement of the anxmia (irrespective of any other sign), 34 per cent appeared to be as before, and 14 per cent were worse. Of those re-examined at an interval of one year or longer, a higher percentage than at shorter intervals was found to be improved, namely 60 per cent. As already stated, in 8 cases an uncomplicated anxmia was found at the second examination to be accompanied by a heart murmur, and in 4 by symptoms of rheumatism. Those cases which were complicated by cardiac symptoms from the beginning are recorded in respect of these symptoms amongst the cardiac groups, the notes taken of the cardiac complications at re-inspections receiving attention in the corresponding part of the report. Final consideration. This brings one to the final consideration in these observations and that is the treatment available for the anxmic children under the conditions noted as prevailing at the clinic. For all anxmias taken as severe, medical treatment was adjudged to be necessary and the mother was immediately put into touch with, in most cases, hospital, so as to secure adequately correct diagnosis and continuity of treatment. The majority of other cases were advised solely on dietetic or hygienic lines, concentrating on a close scrutiny of the actual feeding and environmental conditions in the home as reported by the mother or, in some cases, by the health visitor. Many of these environmental conditions (e.g., overcrowding, lack of exercise, unemployment) have already been discussed, but the factor that loomed large in the offing and ;hat so far had not been probed, was that of diet—too big and evasive a subject to be dealt with exhaustively in the time available for questioning at consultations. Mothers are known, whether from pride, prejudice, or inattention, to be apt not to provide, when asked, an accurate picture of what their child eats and how its food is prepared. At best one can only generalise from the information provided and take heed of the fact that the conditions complained of are not limited to one group of cases or to one grade of income. Certain impressions, in view of these factors, stand out. It is, for example, impossible to be certain that any proportion of the children examined have milk to drink every day (i.e., something more than a portion of tinned skimmed milk in tea) and, it so, what amount. Many of the mothers admit to not measuring, or even thinking twice o\er, the amount once the infant stage has been passed and the child has come to be considered a member of the family. Many of the mothers own to making no milk 133 puddings at all or, at best, only patently inadequate ones. There appears, on the other hand, to be a general appreciation of the importance of green food and fruits in the child's diet— not now expensive foods— and most children seem to have a sufficiency of these where they will consent to eat greens or fruit at all. As much as possible was made of the importance of correct cooking in this connection in the talks that took place at the clinic. The question of cereals and white bread attracted attention, an almost universal use of the less valuable brands of prepared cereals being observed in preference to whole meal, porridge, brown bread, oat cake and similar foods. This might serve to account for a lack of salts in the diet, particularly where quick cooking and lack of trouble in serving was a characteristic of the family table, in addition to the compelling factor of price. Meat appeared to be an even more important factor, by default so to speak, and the legend of meat doing harm before the age of 7 years was found still to be abroad. Many children were condemned to beef cubes and beef extracts and to broths of poor quality where obviously meat itself could have been supplied. The consequent loss of protein, certain salts and certain vitamins was likely to be significant in a diet where fresh milk did not figure largely to redeem such losses. The question of vitamin starvation, particularly of the B type, was linked up with the same problem, and like some of the other faults that have been mentioned, was not confined to one class, nor indeed was it typical of the poorest class of household. Anaemia, poor muscle tone, pallor and constipation, have been proved elsewhere to mark a degree of vitamin deprivation widespread in modern communities and, in particular, the use of protein by the body has been found to be decided by its vitamin B supply. Possibly it is along these lines of inquiry that the prevention and correction of anaemia, of the types described here, may be worked out in due course. Summary. Anaemia, as diagnosed clinically amongst the children examined, has been studied with a view to determining its rate and manner of incidence, persistence, and concomitant symptoms, and possible causes. The following are the findings:— (1) Anaemfa, varying from slight to severe, was diagnosed in 30 per cent of the children examined during pre-school life. (2) There was no particular sex incidence. (3) The rate incidence of anxmia was heaviest amongst the youngest children examined (aged 2 years) and diminished steadily towards school life. (4) There was a higher percentage ot anaemia amongst the winter months. (5) The feeding of the anaemic children during infancy seemed to show that breast feeding conferred no protection on the children with regard to this condition, in tact the majority of the children found to be anaemic were breast fed for more than six months. (6) The nutrition of the anaemic children was not so good as the average for the total children examined, and there appeared to be some correlation between the occurrence of anaemia and rickets. (7) I here was no proof that anxmia was associated with unemployment or poor housing amongst the cases examined or that it could be associated with the larger type of family. 134 (8) There was some proof that lack of air and exercise, referable to unwise management, may have intervened in some cases. (9) There was found to be some clinical association between anxmia and facial pallor, functional heart conditions and septic tonsils, but there was nothing to suggest that anxmia in itself predisposed to or was a concomitant of early rheumatism. (10) In a majority of the cases re-inspected (60 per cent) the anxmic symptoms improved after a period of 12 months under simple dietetic and hygienic measures, but the improvement was not universal and in some cases other symptoms supervened. (11) In view of the lack of other positive evidence as to the cause of anxmia, the hazard is made that it may be related to questions of diet that are not, however, open, in an inquiry of this sort, to close correlation and control. Observations are made with regard to deficiency in protein and mineral elements and certain vitamins, and suggestions are offered for certain lines of improvement of diet in these directions. B. Heart Cases. The total number of cases showing cardiac signs or symptoms out of 1,622 children examined was 339 or 20 per cent. Compared with the total number of examinations the percentage of defects is not nearly so high since certain children only showed a defect after several examinations. Every clinical condition is recorded that came under attention at examination. (1) Nature of cardiac symptoms. (a) Of these 339 children, 75 per cent showed cardiac murmurs, 249 of which were presumed functional or temporary, and 8 were presumed congenital heart disease, i.e., 16 per cent of the total children examined showed heart murmurs. Of those considered to be functional cases, 192 showed apical murmurs, 25 basal murmurs and 32 a combination of apical and basal murmurs. The murmurs were recorded as soft in quality in 226 of the 249 cases and loud in 23. In 12 of the latter cases a loud murmur at the apex was accompanied by a murmur audible at the base. In 2 cases only was the presence of a diastolic murmur detected. (b) Modification of sounds. In 78 cases a modification of the first sound at the apex was noted without any accompanying murmur. In 3 of these cases a murmur was found at a subsequent examination but the majority were cases not seen a second time. (c) Disturbance of rhythm. Simple modification of rhythm in the torm of re-duplication of sounds, shortened diastole, increase of pulse rate, frequent extra systoles or other minor deviations were noted without other cardiac signs in 12 of the total cases. Of these, 7 were re-inspected after an interval and the rhythmic irregularity was found to have disappeared in 4, was still present in 1, and in 2 had given place to more definite cardiac disturbances, namely, apical and basal murmurs in 1 case and in 135 the other mitral murmur plus cyanosis. In 15 further cases disturbances of rhythm were found accompanying other cardiac signs or the general conditions considered in this inquiry, namely, pallor, anaemia or rheumatism. The rhythmic disturbances noted occurred in the following order of frequency:— re-duplication of sounds, 9; short diastole, 9; increased pulse rate, 7; extra systoles, 1; simple arrhythmia, 1. Care was taken to exclude simple nervousness in the cases noted as having an increase of pulse rate, and in each confirmatory examination was made. (d) Other cardiac conditions. Increased cardiac action (as apart from simple increase of rate) was noted in 3 cases; each of these also showed symptoms ol rheumatism and showed or subsequently developed a murmur. Apical thrill was noted in 3 only of the total cases and each of these cases showed also some degree of dilatation and 2 of the 3, pains suggestive of rheumatism. In none of these cases, however, was a murmur audible at the apex at the time of the examination. A thrill, on the other hand, was searched for in all cases showing apical murmur, but was not found. Seven cases showed displacement of the apex beat, of which one was without other signs ; 2 showed rheumatic symptoms plus apical thrill (as already noted); 1 showed tachycardia plus mitral murmur; 1 a mitral murmur preceding the dilatation; 1 antecedent anaemia, subsequently developing a murmur with the dilatation, and 1 anaemia plus apical thrill without other symptoms. Four only of the total cases showed cyanosis, of which 3 were, or had been, cases of Pink disease, and 3 had murmurs of a marked character. Two of these were considered possibly to be cases of congenital trouble. No case amongst the group marked functional complained of dyspnoea. In 5 of the cases whose only cardiac disturbance was a disturbance of rhythm or cardiac dilatation, anaemia was noted, in 2 pallor and in 7 rheumatism. There was no particular association of the severer degrees of anaemia with cardiac symptoms as compared with the lesser degrees of that condition. (2) Age incidence. Of those cases (totalling 214) showing cardiac signs without anaemia or rheumatism, 89 were noted at the age of 2 ; 80 at the age of 3, and 45 at the age of 4 and upwards, but these figures show no special age incidence and no increasing liability with age (see Table). Age. Percentage of total children examined. Percentage of heart conditions found. 2 47 41 3 31 37 4 22 21 (3) Association with ancemia and rickets. The co-existence of anaemia and cardiac symptoms is discussed in the first part of this report. Eighty-seven of the pure heart cases showed definite signs of rickets. This equals a percentage of 40. Minor signs of rachitis were present in an additional 46, equalling a further 21 per cent. Therefore, as in the case of anaemia, rickets is appreciably commoner among the cases showing cardiac abnormality than among the general run of children examined. The finding is a rational one since the poor muscle tone that is part of the rachitic disease must be liable to affect the heart as it is other muscles of the body and produce functional symptoms relative to that impairment pending general recovery of tone. 136 (4) Persistence of abnormal conditions. Only a proportion of the total cases discovered to be showing cardiac disturbances were examined a second time within the period of this inquiry. Of these, 28.5 per cent showed more notable disturbances at the second examination, 53.5 per cent showed less marked signs, and 18 per cent were as before. Included among the cases taken as showing increased disturbances are those that developed symptoms of rheumatism on top of cardiac signs. Even so, the figures would suggest a purely temporary character for the majority of defects found and a response to the advice given, generally on the lines of improved dieting and hygiene. No attempt was made to test those cases that simply had a murmur. The number of re-inspections is too small and the periods of observation too short to permit of comparisons of individual defects qua persistence or general results. A few notes on one or two points, however, have already been made. The chief consideration would be that, within the age period of the examinations, that is up to and including the end of the fourth year, there was no evidence of disability as the result of cardiac defect, apart from those cases marked congenital heart disease, even if one third of the total cases did show at some time or another some minor cardiac sign. But on the other hand, there was plenty of evidence to show that in this early age period, often considered " safe" from the point of view of cardiac infection, disturbances did exist that, in a percentage of cases did seem to go on and that might be the forerunners of defined organic defect and/or rheumatic disease in later childhood. C. Pallor. Facial pallor was found to exist in a large number of children, independently of pallor of the conjunctivae. As this symptom is taken by so many to denote anxmia in itself and is described as a frequent concomitant of early rheumatism in young children, the cases in which pallor was specially noted were submitted to further examination in certain particulars. Pallor and certain other conditions. Total cases showing facial pallor unaccompanied by anxmia (as herein described) or cardiac or rheumatic symptoms equals 51; total cases showing pallor plus anxmia, cardiac or rheumatic symptoms equals 60. Total cases showing pallor equals 111. Percentage of total children examined noted as pale equals 7 per cent. Percentage of children considered to be anxmic equals 30 per cent. Percentage of pale children considered to be anxmic equals 47 per cent. Percentage of anxmic children showing pallor equals 10.8 per cent. Therefore anxmia exists in 9 cases out of 10 without pallor of the cheeks, but of those children that are pale approximately one half are anxmic. Anxmia, therefore, should be specially looked for in cases where pallor is present, but the presence of a bright complexion does not contra-indicate anxmia. The percentage of pale children showing heart murmurs equals 22.5 per cent. The percentage of anaemic children showing heart murmurs equals 20 per cent. The incidence of heart murmurs in the two conditions, therefore, is similar and is higher than the incidence in the total children examined. The percentage of pale children showing putative rheumatic symptoms equals 3.6 per cent. The percentage of total children examined showing putative rheumatic symptoms equals 2.3 per cent. Therefore the incidence of symptoms likely to be indicative of early rheumatism is rather higher in pale than in other children. The percentage of 137 rheumatic children showing pallor equals 10 per cent. The percentage of total children examined showing pallor equals 7 per cent. Therefore, pallor is rather commoner in children suspected of early rheumatism than it is in children as a whole. Pallor and housing. Taking the 51 cases showing pallor as a symptom by itself, 26 lived in rooms, 1 in a house minus a yard or garden, 20 in houses with yards or gardens, and in 4 cases no particulars were obtainable. This gives a percentage of 57 children (of whom particulars are known) living in rooms or houses minus a place to play in out of doors. The percentage of families in Woolwich having sole possession of a house has already been given as 60, i.e., put otherwise, 40 per cent of Woolwich children are known to live in premises shared with other families, that are possibly rooms minus a garden. Comparing this with the 57 per cent of pale children living in rooms, it is obvious that there seems to be a connection between the lack of air and light suffered by people living in rooms without access to a garden, and the production of facial pallor. D. Rheumatism. Total number of cases showing symptoms that might be rheumatic, including possible chorea equals 44, equals 2.5 per cent of the total children examined. Of these, 20 showed some degree of anaemia. This equals almost 50 per cent compared with 30 per cent of total children examined showing anaemia. Anaemia would therefore appear to be to some extent a symptom accompanying the early signs of rheumatism. 10 per cent of the potential rheumatic children have already been recorded as showing pallor. Type of symptoms present. Apparently definite " rheumatism," 14 cases ; fleeting pains in limbs, 25 cases ; symptoms suggestive of chorea, 6 cases including 1 also showing pains. Joint swellings were a condition not commonly complained of. One third, therefore, of children showing signs suggestive of rheumatism appear to be fairly definite cases. In several cases the record of " acute rheumatism," " rheumatic fever was made on a previous diagnosis by the private doctor. Of the cases suspected of rheumatism or chorea, the following showed cardiac disturbances:— 2 modified first sound only; 15 soft mitral murmurs; 1 loud mitral murmur plus murmur at base; 5 basal murmurs; 1 cardiac dilatation without murmur; 3 disturbances of rhythm simply, and 5 further signs of carditis (in addition to a possible murmur at apex or base). This means that 60 per cent of the possible early rheumatism cases already showed some degree of functional cardiac disturbance and 40 per cent apical murmur present, with or without murmurs at the base or other cardiac signs. In 10 per cent there appeared already to be a definite degree of what is now called carditis." In 2 cases an apical thrill was felt. The incidence of cardiac disturbances (and the type of cardiac disturbance) is therefore much more noticeable amongst the children showing signs suggestive of rheumatism than amongst the children simply showing signs of anaemia. It would appear from these figures as if cardiac infection did accompany rheumatism even in its earliest stages and at an early age (at an age period at which rheumatism used to be considered not to exist) and as if the presence of a variety of cardiac disturbances, however minor in character, should he some warning of the risks of imminent rheumatism, even if signs be not already present. It was not found in the group of children examined that signs of carditis 138 (i.e., something more than a simple alteration of the heart sounds) occurred apart from the susceptibility to rheumatism noted at the time of the examination or at some subsequent period, in the form of pains of typical location and character. Order of appearance of symptoms. In 6 cases where evidence was available it appeared that the cardiac signs had preceded any subjective symptoms of rheumatism. In 3 others it appeared that the rheumatic pains came first. In the remaining cases there was no evidence to show which variety of symptom preceded the other. Rheumatism and chorea. Six children in all showed signs of chorea, of whom 5 showed heart murmurs but no rheumatism, and the sixth complained of.pains and showed severe anaemia, but had no abnormality in the heart sounds or rhythm. No nodules were found. Two of these children were only 2 years of age when the symptoms developed ; one was 3 and three were 4. Three of the rheumatic children also complained of symptoms as early as 2 years of age and 15 at 3 years of age. Persistence of symptoms. Six only of the rheumatic children were re-examined some time after the examination at which symptoms were first noted. Of these, 3 reported improvement in the pains (all cases with cardiac murmurs), 2 were as before and 1 was reported to be worse. The period covered by this observation varied from 6 months to 2 years. Summary of rheumatic cases. (1) 2.5 per cent of the total children examined showed signs that were possibly those of early rheumatism. (2) One third of the cases showed fairly definite signs, including some cases of acute rheumatism or (reported) rheumatic fever; the remaining two thirds showed fleeting pains that, combined with other symptoms, might signify rheumatism. (3) Anaemia was a concomitant symptom in half the cases. (4) Sixty per cent of the cases showed some minor cardiac disturbance; 40 per cent showed definite murmur; 10 per cent suggested some degree of actual carditis. There was no clear indication of whether the rheumatic symptoms ordinarily preceded the carditis or the heart disturbances the rheumatism. (5) Six children in all, or .3 per cent of the total, showed signs of choreic disturbance but only 1 had rheumatic pains and that case had apparently a normal heart. (6) The results of re-inspection were not sufficient to show whether the rheumatic symptoms were cumulative or not, or whether they responded to general hygienic or dietetic treatment. (7) It would appear that the watch for rheumatism (in view of its liability to affect the heart from its early stages) must begin at an earlier age than has been customary, since the cases observed were found to start from 2 years of age. (8) The number of cases was not sufficient to allow of any inquiry into other conditions such as housing, economic status, etc., as factors in the causation of rheumatism. 139 APPENDIX III. METEOROLOGICAL OBSERVATIONS TAKEN AT THE ROYAL OBSERVATORY, GREENWICH, DURING THE YEAR 1932. Week ending. Temperature of the Air. Departure from average mean air temperature for 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. 9 55.9 27.1 46.2 + 8.1 . 46.3 3 0.62 " 16 54.5 34.9 46.4 + 8.3 46.1 4 0.78 " 23 53.7 29.8 46.3 + 7.6 46.0 2 0.10 " 30 47.3 28.1 37.3 - 2.1 45.8 - — Feb. 6 48.1 27.9 39.6 - 0.0 45.0 - - " 13 41.5 21.8 32.5 — 6.6 44.2 2 0.09 " 20 46.3 29.7 39.2 — 0.3 43.3 3 0.05 " 27 48.7 32.2 41.3 + 1.3 43.3 2 0.15 Mar. 5 48.7 23.0 36.2 - 4.3 43.1 1 0.01 " 12 51.4 23.9 37.2 - 3.8 42.9 2 0.22 ,, 19 53.8 21.0 39.0 - 2.7 42.3 - — " 26 54.9 31.4 44.0 + 1.7 42.5 2 0.40 April 2 58.6 37.4 46.5 + 2.0 43.3 7 0.96 April 9 58.9 33.9 45.6 - 0.6 44.4 6 0.71 " 16 53.7 31.5 42.5 - 3.8 44.8 6 1.01 " 23 60.4 33.6 44.7 - 3.6 44.8 4 0.39 ,, 30 66.2 38.2 50.0 + 12 45.3 5 0.19 May 7 63.9 35.3 46.0 - 4.1 46.6 4 0.65 " 14 67.8 35.1 50.6 - 1.2 46.9 4 1.25 " 21 75.7 43.1 60.6 + 7.2 48.5 4 0.54 " 28 67.0 35.7 50.6 - 4.9 50.4 5 1.57 June 4 72.9 42.6 54.6 - 2.8 50.9 4 0.10 " 11 77.2 41.1 55.7 - 2.5 51.6 1 0.19 " 18 78.0 45.6 61.2 + 2.4 52.7 — — " 25 75.2 43.9 57.5 - 3.1 53.4 - — July 2 84.6 50.3 64.7 + 3.1 54.3 3 0.47 July 9 84.3 47.4 64.1 + 1.9 55.1 2 0.31 " 16 88.1 52.9 66.0 + 3.0 o6.4 1 0.56 " 23 77.5 46.3 59.0 - 4.2 56.6 3 0.48 " 30 78.7 50.0 60.6 - 1.9 56.6 6 1.56 Aug. 6 82.2 54.0 63.1 + 1.0 57.1 4 1.18 " 13 87.8 52.6 67.9 + 5.6 58.2 1 0.15 " 20 98.9 52.3 71.3 + 9.2 59.0 1 0.22 " 27 79.0 51.0 62.5 + 16 59.6 2 0.16 Sept. 3 80.3 50.8 63.4 + 3.5 59.6 4 1.22 " 10 74.8 45.3 59.0 + 0.0 59.0 5 0.30 " 17 77.3 51.9 62.5 + 4.8 58.8 2 0.04 " 24 67.1 43.6 52.8 - 3.2 58.3 4 0.94 Oct. l 66.1 42.3 53.4 - 1.4 57.3 3 0.20 140 APPENDIX III.—continued. Week ending. Temperature of the Air. Departure from average mean air temperature for 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. Oct. 8 63.6 36.8 48.3 4.5 55.9 3 0.21 ,, 15 60.1 36.3 48.9 — 1.8 54.8 7 1.25 ,, 22 64.8 38.8 53.2 + 4.1 54.0 6 1.21 ,, 29 58.2 31.8 46.1 — 1.5 53.6 7 2.62 Nov. 5 59.8 32.0 49.1 + 2.3 52.2 5 0.12 „ 12 49.9 33.0 44.4 — 0.3 51.6 2 0.05 ,, 19 49.0 35.3 42.0 — 0.9 50.5 3 0.20 " 26 56.4 32.9 46.3 + 4.2 49.7 7 0.50 Dec. 3 50.5 30.1 43.0 + 1.8 49.0 4 0.37 " 10 44.1 29.0 37.7 — 3.4 47.8 — — ,, 17 53.0 32.6 43.2 + 2.7 46.3 1 0.03 " 24 55.1 40.0 48.4 + 9.5 46.7 2 0.15 " 31 48.9 33.4 41.6 + 2.9 46.5 3 0.12