LON 73 REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE CITY OF LONDON FOR THE YEAR 1947 LONDON: Printed by Drake, Driver & Leaver, Ltd, Rosebery Avenue, E.C. I. 1948. STAFF. MEDICAL OFFICER OF HEALTH. Date of Appointment. White, Charles Francis, O.B.E., M.D., Ch.B., D.P.H., D.T.M Dec., 1937 CLERICAL STAFF. Gray, Charles M. Principal Assistant and Vaccination Officer Mar., 1911 Blunt, Harold F. 1st Class Assistant May, 1924 Stout, James Erl Threadgold, Arthur W. Peters, E. J. Wilson, J. C. General Clerical Assistants July, 1930 Nov., 1923 Nov., 1935 Jan., 1936 BETTS, C. Gurney, Miss M. L. Temporary Clerical Assistant Clerical Assistant April, 1920 May, 1939 SANITARY INSPECTORS. McGrath, William Richard Mar., 1922 Harrington, George Edwin Dec., 1925 Sillett, David Ernest April, 1926 Neale, William G. C. July, 1928 Thorpe, Robert C. Mar., 1930 Hudson, Leslie A. April, 1934 Aldhous, H. J. April, 1935 Scott, A. E. R. Oct., 1938 Campbell, J. W. Sept., 1946 MEAT INSPECTION STAFF. Grace, L. B. A., M.R.C.V.S. Veterinary Officer and Chief Meat Inspector June, 1934 Slatter, Charles First Senior Inspector of Meat May, 1908 Murray, Samuel B. Mellish, Cyril E. Thompson, Frank E. Lee, W. R. Garrard, S. S. Morris, W. L. Meat Inspectors Sept., 1911 Jan., 1912 July, 1924 July, 1930 Sept. 1946 Sept. 1946 Bernhardt, D. R. Seymour, K. D. Probationary Meat Inspectors May, 1931 July, 1935 RODENT OFFICERS. Carter, J. Sept., 1944 Assistant Rodent Officers. Cooper, J. S. (Foreman Assistant Rodent Officer) Aug., 1943 Tremayne, L. R. Nov., 1943 Hayes, H. Nov., 1943 Tanner, H. W. Nov., 1943 Pennycook, J. Nov., 1943 Mason, G. A. Dec., 1946 TUBERCULOSIS SISTER AND HEALTH VISITOR. Backhouse, Miss S. A. June, 1931 (Retired 1/10/47) TUBERCULOSIS NURSES AND ASSISTANT HEALTH VISITORS. Chandler, Miss B. N. Dec., 1945 Davies, Miss M. (temporary part-time) May 1946 KEEPER OF THE MORTUARY. Steggles, T. Dec., 1918 DISINFECTOR. Hastings, T. June, 1920 (Retired 31/12/47) MESSENGERS. Tierney, T. E. (temporary) Dec., 1926 Ascott, J. J. (temporary) Mar., 1947 LABOURERS. Burton, John H. (General Duties at Mortuary) Mar., 1936 Lawrence, F, H. (General Duties at Mortuary) May, 1936 Berry, E. F. (General Duties at Mortuary) July 1946 Ludgate, G. (General Duties at Smithfield Market) Oct 1906 Morris, W. F. (General Duties at Smithfield Market) Mar., 1925 Prevost, A. C. (General Duties at Smithfield Market) Feb., 1926 Mann, Ernest V. (General Duties at Smithfield Market) Jan., 1928 Lawrence, Charles J. (General Duties at Smithfield Market) Feb., 1928 Tapper, T. J. (General Duties at Smithfield Market) Aug., 1946 (Resigned 1/11/47) Graham, Mrs. (Bath Attendant and Cleaner) June, 1927 Powell, W. F. (General Duties at Smithfield Market) Dec., 1947 1 report of the medical officer of health for the city of LONDON for the year 1947. To the Right Honourable The Lord Mayor, Aldermen and Commoners of the Corporation of London. Public Health Department, Guildhall, E.C. 2. July, 1948. My Lord Mayor and Gentlemen I have the honour to submit the following report on the work of my department during 1947. Vital Statistics. Though the day population of the City is estimated to be over half-a-million the resident population is so small that vital statistics are of little value. For example, the total number of live births was 47 including 2 illegitimate births; but these two were newly born infants found dead in lavatories on railway stations in the City. They are presumed to have been illegitimate and they have to be accepted as City deaths, though there is no reason to believe that their mothers were resident in the City. The infant mortality rate for legitimate infants was therefore nought, but for illegitimate infants it was 1,000 and for all births 42.5 per 1,000 births. Similarly the single still-birth recorded refers to the body of a still-born child found in Puddle Dock, Upper Thames Street. There is no reason to suppose that it was a City child, the body probably floated into Puddle Dock from the River Thames, but it must be accepted as a City still-birth, and the still-birth rate therefore appears as 21.28 per 1,000 total births. National Health Service Act. During the year progress was made with the arrangements for the taking over by the County Council on "the appointed day," July 5th, 1948, of the "personal health Services." The County of London is to be divided into nine divisions for the administration of these services, and the City is in Division 5 with Bethnal Green, Stepney and Poplar. Details of the scheme remain to be settled, but it seems probable that, for some time, the existing City services will be undisturbed, except for the change in administrative responsibility. Mass Miniature Radiography. The Mass Radiography Unit of the London County Council operated in the City between June 25th and November 13th, 1947. Arrangements were again made for the Unit to be stationed in St. Bartholomew's Hospital, and it is desired to acknowledge gratefully the courtesy of the Governing Body of the Hospital in affording the facilities and the helpfulness of the Staff in preparing the accommodation. Owing to the large number of volunteers for examination, the Unit remained in the City longer than was at first intended. This caused some inconvenience to the hospital and delayed a scheme of internal re-organisation, but the unfortunate results of closing down until all those who had applied for examination before the List day fixed for the acceptance of applications had been given an opportunity to be X-rayed, was recognised and consent to the necessary extension was graciously granted. I do not know which Authority will be responsible for the operation of Mass Radiography Units after the appointed day for the coming into operation of the National Health Service Act, but it seems probable that in future the necessary accommodation may not be available at St. Bartholomew's Hospital. Large numbers of workers have come forward for examination on both occasions that the Unit has visited the City, and employers have readily granted facilities for attendance. It is therefore desirable that accommodation should be found in the City whenever a Mass Radiography Unit is available. Undoubtedly St. Bartholomew's Hospital is from all points of view the best situation, but if a change has to be made other accommodation must be found, and Gresham College occurs to me as very suitable, if the Gresham Committee would agree. The total number of City workers whoso names were submitted for examination was 22,702. Of these 19,575 (10,803 men and 8,712 women) were actually examined. Of these 611 persons (3.1 per cent.) were asked to attend for a full-size X-ray film; 234 showed old healed lesions; 206 (1.1 per cent.) were referred to their doctors as probably tubercular; 16 showed lesions of the heart. The percentagc of examinees reported as probably tubercular was the same as on the last visit of the Unit in 1945. The figure of 1.1 por cent. may appear small, but when it is realised that it means that in a crowded suburban train there are probably five or six persons; or in a big football crowd five or six hundred; or coining into the City daily some 5,000 persons who probably have consumption and aro unaware of the fact, it is easy to appreciate why the tubercle bacillus is ubiquitous in urban communities and that, if we are to bring pulmonary tuberculosis under control, we must not neglect any means at our disposal for diagnosis at the earliest possible stage of the disease. Shortage of beds in sanatoria should not deter us. The care of the consumptive is not a question of sanatorium treatment or nothing. Many will recover unaided, never having known that they had had the infection; but many more will recover, evon in their own homes, if the disease is diagnosed and if they receive and follow sound advice as to their mode of life. Moroover, once the disease is diagnosed, the open case can be detected and tho control of the sproad of infection can be extended. 2 It is easy to bring the facilities for mass radiography to the notice of the employees of large firms, but it is difficult to make them known to the employees of the very numerous small firms. Moreover, when there are only a few employees, they may fear that a request by an individual employee for time off to attend for X-ray examination may excite suspicion in the mind of the employer that such individual has reason to fear that he or she has, at best, a weak chest, and if a second visit for a full size X-ray is necessary, suspicion, may be deepened. An effort was made on this occasion with limited success, to bring in the small firms. A total of 812 persons (458 men and 354 women) from 126 such firms were examined. The staff of the X-ray Unit kindly undertook to examine after office hours a limited number of persons who were specially anxious that their employers should not know of their visit. Special arrangements were thus made for 91 persons (44 men and 47 women). Infectious Diseases. Poliomyelitis, As you are aware there occurred during the year 1947 the most serious and widespread epidemic of Poliomyelitis this country has ever experienced. The popular name "Infantile Paralysis" must be dropped because it gives the public quite an erroneous idea as to the age incidence, the symptoms and the results of the disease, which is not confined to infants or even children. Paralysis is not invariably a symptom and permanent paralysis is not an inevitable result, indeed some 50 por cent. of cases make a complete recovery without any residual paralysis at all. Though there were cases in every Metropolitan Borough the City residents escaped. I was notified of 11 persons who worked in the City but resided elsewhere, who developed the disease, and of 15 persons employed in the City who were contacts with cases in their homes. The recommendations of the Ministry of Health in regard to adult contacts were followed. Such contacts were instructed that they should remain at work unless they had any departure from their normal health, in which case they should stay at home until their doctor gave them a certificate that there was no question of them developing Poliomyelitis. In a few cases contacts were employed in canteens. These were personally interviewed, and the need for scrupulous cleanliness in the handling of food was impressed upon them. In no instance did a second case develop in a business house, either from an original case or a contact. There may well have been an element of luck in this entirely satisfactory result of the recommendations. The epidemiology of poliomyelitis presents most interesting problems, but in the face of an extensive and widespread epidemic occurring at a time when economic survival depends on maximum production, it is essential to reduce absenteeism to a minimum. Where schoolchildren were concerned, the exclusion of contacts for three weeks was justified, but this question did not arise in the City. The only swimming bath is at St. Bride's Institute. In this the water is chlorinated and chlorination was stepped up. There was a good deal of public anxiety about swimming baths and the attendance at St. Bride's fell very considerably, so no question of overcrowding arose, despite the hot weather, and the bath was not closed. It was suggested that swiming galas should be discouraged, though the layout of the baths is such that there is not room for many spectators. There are no cinemas in the City and no question of attendance at school camps or organised holiday homes arose. Scarlet Fever. Generally speaking any attempt to control the spread of Scarlet Fever by swabbing throats and isolating carriers would be useless, but the following instance in which this was successfully done may be of interest. In July, 1947, it was reported that three boys from St. Paul's Choir School had been removed to hospital suffering from scarlet fever. One previous case had occurred on April 14th and one on May 18th, both of which were discharged from hospital on May 31st. In view of the fact that the school is a small residential one, only 34 boys, and that it is a very self-contained community in term-time, with comparatively few outside contacts, it seemed probable that the recrudescence of scarlet fever was due either to missed cases or carriers. The school was visited and all the boys examined, but no missed cases were detected. Arrangements were made for all the boys to have their temperatures taken morning and evening, and for any who had a rise of temperature to be isolated in the sick bay. The dormitory arrangements were good, the room light and well ventilated, the beds well spaced and tall lockers between each two beds at the head end. Professor Garrod, the bacteriologist of St. Bartholomew's Hospital, was asked whether in such a small, closed community, he would be prepared to endeavour to find a carrier by bacteriological examination of swabs from the noses and throats of the boys. This Professor Garrod readily consented to do, and on July 15th every boy was swabbed. Meanwhile two further cases of scarlet fever had occurred in the school and had been promptly removed to hospital. As the result of the swabbing three boys (C. and two brothers A. L. and I). L.), were found to be harbouring hæmolytic streptococci (Group A); C. and D. L. in the throat only and A. L. in the nose and throat. These boys were promptly isolated and an endeavour was made to clear the condition with pencillin and sulphathiazole snuff. On July 15th the Medical Superintendent of the Grove Hospital was asked if he would be good enough to inform me of the type of streptococcus responsible for the disease in any of the boys from the Choir school in his hospital. He replied that he did not usually type the hæmolytic streptococci for their cases of scarlet fever, but under the special circumstances he would comply with my request. Ultimately the Medical Superintendent reported the strain of streptococcus was Type 3. The streptococci from the three suspects were also typed at the Central Public Health Laboratory, Colindale. C. was found to harbour Type 18 and was exonerated from suspicion and released from isolation. A. L. was found to harbour Type 3 in both nose and throat and so was most probably the 3 c tarrier responsible. In the case of D. L. the type was not identified, but it was considered desirable retain him in isolation with his brother. Despite treatment the brothers L. were not clear early in August when the school term ended. They were allowed to go home as there were no other children there, and their parents were asked to bring them up for re-examination just before the Autumn term began and before they actually returned to school. The boys went to Professor Garrod's laboratory on September 9th. Swabs were taken and it was found that in both boys the carrier condition had cleared during the holidays and they were permitted to return to school. No cases occurred in the school after the isolation of the three suspected carriers, and none have occurred since. Food Inspection. The total amount of meat delivered at Smithfield Market was 289,883 tons, some 50,000 tons more than in the previous year. The amount of diseased or unsound meat surrendered at the Market was 212 tons; 50 tons more than in 1946. At Leadenhall Market and City shops the amount of meat condemned was 23 tons, and in the Cold Stores 5 tons. Of the foodstuffs delivered at riverside wharves or at premises in the City, 454 tons were condemned as unfit for human consumption. Food and Drugs Act, 1938, and Food Regulations. Of 397 samples submitted to the Public Analyst, 7 (1.8 per cent.) were found to be adulterated or below the required standard of composition. Legal proceedings were not instituted as in each case it was considered that a caution would ensure compliance with the required standards in the future. 35 samples of milk were submitted for bacteriological examination. All but one passed the Phosphatase Test showing satisfactory pasteurisation, but 22 failed on the Methylene Blue test showing inferior keeping quality. No doubt this latter figure was unusually high by reason of the exceptionally hot summer. Ice Cream. On May 1st, 1947, the Ice Cream Heat Treatment Regulations came into force. Briefly, the Regulations require "cold mix" (i.e., ice cream constituted from a powder and clean water only) to be converted into ice cream within one hour of reconstitution from the cold mix powder, and thereafter the temperature must not be allowed to rise above 28°F. Ice cream mixture made in any other way must be pasteurised, then quickly cooled and kept at a temperature not exceeding 28°F. until sold, and if the temperature rises above 28°F., the mixture must be re-pasteurised before sale. The object is to start with a baeteriologically clean mixture, and then to ensure that it remains only for the minimum time at a temperature at which any pathogenic organisms, which subsequently gain access, could grow and multiply. The control of temperature-time requirements really necessitates recording thermometers which can be inspected at any time. Such provision in large plants does not present great difficulties, but it seems doubtful whether the small manufacturer will be able to produce satisfactory evidence that the time-temperature requirements have been fulfilled. For the presont the necessary recording thermometers are not available and the Ministry of Health have extended until May 1st, 1949, the period of validity of the special defence of inability to obtain cooling apparatus and thermometers. Without much knowledge of recording thermometers, I have not great confidence in the reliability of the records which will be obtained under the conditions in which some will be operating. Fourteen samples of ice cream were taken during the summer months and were submitted for bacteriological report. Judged by the methylene blue test, using the technique recommended by the Public Health Laboratory Service, 4 were satisfactory (2 Grade 1 and 2 Grade 2). 10 samples were unsatisfactory (Grade 4). In nine instances a total bacteria count and a determination of coliform organisms were also carried out and in each instance this test confirmed the methylene blue grading. 9 samples were submitted to the Public Analyst. The fat content ranged from 10.85 per cent. down to 0.8 per cent. The samples which were poorest in fat were also the dirtiest. In the case of three unsatisfactory samples, the ice cream was manufactured outside the City and the Medical Officers of Health of the districts concerned were informed. During the year there were 15 new registrations for the sale of ice cream, and in one instance the use of premises for the sale of ice cream was discontinued. Handling of Food. There is great scope for improvement in the handling of food at almost every stage from the producer to the consumer. Under existing legislation, officers of Local Authorities can require the provision of the means for cleanliness of premises, equipment and personnel, though at the present time even these have to be scaled down becausc of scarcity of materials of all kinds. But neither legislation nor inspection can ensure that the means of cleanlinoss are constantly and fully used. This can only be achieved by close supervision by persons who are trained in food hygiene and can exercise control and take disciplinary action when ncccssary; or by the training of tho actual food handlers until cleanliness becomes a habit. How can such training be given and could it bo made compulsory ? Some persons arc naturally clean or have been brought up to habitual cleanliness, but even they would benefit from some instruction, since there is more in cleanliness than meets the eye. Others are naturally casual and careless or think that in their menial tasks they cannot do any harm, whatever their sins of omission or commission. How can the importance of scrupulous cleanliness be brought home to all those who are concerned in the handling, transport, storage, preparation or serving 4 of food or in the cleansing of premises or equipment? The extent to which people now take meals in restaurants and canteens has resulted in an increase in cases of bacterial food poisoning, because more persons may be infected from a single source, and high standards of food hygiene are therefore more important than ever. If there were competition for customers it might be worth while experimenting with the issuo of Certificates to establishments which attained a satisfactory standard' of hygiene in premises, equipment and staff, but at the present time there are more customers than can be accommodated, and the exhibition of a food hygiene certificate would bo of no material value. Moreover there is a shortago of labour and therefore it is difficult for managers to enforce standards. Until general conditions are easier it. seems impossible to make much progress, but no opportunity should be missed of emphasising that food hygiene depends primarily on the individual food handlers, none of whom would deliberately poison anybody, but many of whom do in fact cause food poisoning by ignorance, indifference or carelessness. Strike at Bishopsgate Goods Depot. In April, as a result of a strike amongst the cartage men employed by the L. & N. E. Railway at Bishopsgate Depot, a number of small consignments of perishable foodstuffs accumulated at the Parcels Depot. About a ton of poultry and rabbits and a quantity of shell-fish became unfit for human consumption. On the initiative of one of your food inspectors, a quantity of sound pies, poultry and shellfish were, with the consent of the Strike Committee, removed to the local hospitals in a van hired for the purpose. Had this food remained in the parcels office to the end of the strike, it would have become unsound. Strike of Cleansing Department Staff. In May there was a strike of members of the Corporation's Cleansing Department. This did not lead to any loss of foodstuffs but caused anxiety by reason of the accumulation of food refuse, particularly in Billingsgate and Leadenhall Markets. A plan was drawn up for appointing 18 sites in the " blitzed " area of the City, easily accessible and well away from inhabited buildings, where refuse could be dumped by the occupiers of premises. It was proposed to burn as much refuse as possible on these sites and to treat the remainder so as to minimise any nuisance from smell and flies. The strike collapsed the day before the scheme was to be put into operation, but the list of sites and a spot map is filed in case of similar trouble in the future. Dumping of Refuse in War-damaged Premises. Considerable trouble was experienced during the year from the dumping of refuse in the open basements and derelict buildings in areas of the City destroyed by enemy action. The principal difficulty has been with discarded fish-boxes in the Billingsgatearea. Every effort was made to get these boxes salvaged, but nobody would accept the responsibility for collecting them from the deep, open basements into which most of them were thrown. Meanwhile, during the hot summer complaints were numerous, and so it was decided to abate the nuisance by burning them on the sites, on a Sunday when adjacent business premises were unoccupied. The burning was carried out on two occasions, under close supervision as to fire risks, at a total cost for labour of about £50. The owner of unoccupied property is responsible for the abatement of any nuisance on his premises. The conditions arising from war damage are exceptional, but when nuisance arises from the unauthorised dumping of refuse on or in "blitzed" premises, the owner is called upon to carry out the necessary work. Naturally the owner feels aggrieved that he is involved in expense through no fault of his own. This is particularly the case when all that remains of his premises is the deep, open basement, clear of all rubble, the removal of anything from the bottom of which is a laborious business. The alternative would appear to be the enclosure of basements by solid fencing to a height of.six feet or more. This would be expensive and unsightly. Though special bye-laws making it an offence to deposit refuse on any war-damaged site, whether public or private property, would not entirely prevent the nuisance, they would at least entitle the police to take action if they observed the dumping of refuse, whatever its nature, on any private property. Housing. During the year 47 families were rehoused and at the end of the year 378 families remained on the waiting list. In my last annual report I referred to the Corporation's proposal to erect a block of some 250 flats on a "blitzed" site in the Bridgewater Square area. After much discussion the scheme had to be abandoned, as the Minister of Health was unable to approve the compulsory purchase of the site. The Public Health Committee have since given careful consideration to the possibility of finding a site outside the City, on which flats could be erected for the relief of the City's housing problem. There is no need for me to emphasise the importance of the provision of suitable .and sufficient housing' accommodation, though the ill effects, physical, psychological and social, of the post-war housing problem, can only be fully appreciated by those who are brought into personal touch with homeless, overcrowded or wretchedly housed families. Medical Examinations of Staff. Your Medical Officer of Health carries out the medical examination of candidates for appointment to the staff of any of the departments of the Corporation, and of any members of the staff who appear to be unable to carry out their duties because of ill health. During the year 254 persons were so examined. In addition medical examinations or enquiries have to be made in cases of prolonged sickness. These frequently involve correspondence with medical attendants and hospital superintendents. Enquiries were made in regard to 21 cases, and the courtesy with which such enquiries were answered is gratefully acknowledged. 5 Cremation. The number of cremations carried out at the City of London Crematorium during 1947 was 1,195 as compared with 1,011 in 1940 and 364 in 1937. As Medical Referee for your Crematorium, I was invited to submit a memorandum of evidence for the Inter-departmental Committee on the Cremation Act, 1902, and the Cremation Regulations made thereunder, and to attend before the Committee to give verbal evidence. It was made clear that my evidence was personal and based on some 12 years experience as a Medical Referee, and that the Burial Board was in no way responsible for the views expressed. In my opinion the time is approaching when cremation will be the usual, not the exceptional, method of disposal of the dead and the public will quite reasonably demand that the formalities, which must be complied with before cremation can take place, shall be reduced to a minimum. The main purpose of the Cremation Regulations is the prevention of the rapid and final destruction of the evidence of crime, but the comparison is not between a certainty of detection of crime if the body has been interred and the impossibility of detection if cremation has taken place. Even with earth burial, suspicion of foul play must first reach the ears of the police, then there must be exhumation and an examination, which might fail to reveal the evidenco of a crime which had in fact been committed. Much would depend on how the person had been killed, and the time which had elapsed between burial and exhumation. It is certainly not practicable to require, as a routine, all sorts of special enquiries before earth burial is permitted, and therefore the requirements antecedent to cremation should be no stricter than is necessary to cover the difference in the risk that evidence of crime may be destroyed. A statutory declaration by the nearest surviving relative or an executor, made before a Commissioner for Oaths, must frequently occasion distress and inconvenience or delay and is not a safeguard, because if there had been foul play anybody who had been an accessory would hardly be worried by the comparatively minor matter of a false declaration. The careful and conscientious completion of the Confirmatory Medical Certificate may also occasion distress, delay and expense, and is of little if any value, unless the medical attendant has been too easily satisfied as to the cause of death or is himself a party to a crime. The absolute integrity and the full sense of responsibility of the medical attendant who is called upon to certify the cause of death are the only safe-guards, and it is therefore suggested that he should be required to complete and sign a special certificate or, if he does not feel that he can do so, report the circumstances to the coroner. The Registrar of Deaths would require to see the special certificate as well as the death certificate, before signing his certificate for disposal by cremation. Such a scheme would abolish the Statutory Declaration, the Confirmatory Medical Certificate and the Medical Referee. It may seem a very drastic change but, having been responsible for the authorisation of some thousands of cremations, I am satisfied that this proceduro would not be less effective in the prevention of the concealment of crime than are the existing regulations, and though this degree of simplification may not be achieved at once, it cannot be very long delayed. Staff. Your staff, which is still below pre-war strength, has worked very satisfactorily during the year, and I have pleasure in recording the following examination successes:— Miss B. N. Chandler, Tuberculosis Nurse and Assistant Health Visitor, obtained the Diploma in Social Science of the London University. Mr. H. J. Aldhous, Sanitary Inspector, passed Part 1 of the Final Examination for the Degree of B.Sc. (Estate Management) of the London University. I have to record with regret the retirement on account of ill-health of Miss S. A. Backhouse, Tuberculosis Sister and Senior Health Visitor. Miss Backhouse was appointed Tuberculosis Nurse at your Tuberculosis Clinic in June, 1920, but remained a member of the staff of St. Bartholomew's Hospital till June, 1931, when she was appointed to your permanent staff, combining the duties of Tuberculosis Sister and Health Visitor. Miss Backhouse gave devoted and most efficient service despite the handicap of poor health. Many City mothers and children will remember her with affection, and many tuberculous patients with gratitude. You have given practical expression to your appreciation of her work by adding 10 years to her pensionable service. I am glad to record that Miss Backhouse has made good progress, and though she cannot again be fit for her former duties, we wish her many years of quiet but happy retirement. I have the honour to be, Gentlemen, Your obedient Servant, CHAS. F. WHITE, Medical Officer of Health. 6 STATISTICAL INFORMATION. Area.—601 acres (including the Temple and Tidal Water and foreshore). Population.—Registrar-General's estimate for 1947, 6,400. Annual Rateable Value.—As at October, 1947, £6,314,072. Annual Sum received from Penny General Rate.—Estimated £20,000. Births:— Total. M. F. Legitimate 45 24 21 1 Birth Rate per 1,000 estimated resident population, 1947 7.03 Live Births, Illegitimate 2 2 — Still Births 1 — 1 Rate per 1,000 total (live and still) births 21.28 Deaths:— Deaths under 1 year 2 2 Nill Death Rate per 1,000 estimated average population 9.22 Deaths (all ages) 59 44 15 Deaths from puerperal causes (Headings 29 and 30 of the Registrar-General's Short List):— Rate per 1,000 total Deaths, (live and still) births. No. 29. Puerperal sepsis Nil 0 No. 30. Other puerperal causes Nil 0 Death Rate of Infants under one year of age:— All Infants per 1,000 live births 42.55 Legitimate Infants per 1,000 legitimate live births 0 Illegitimate Infants per 1,000 illegitimate live births 1,000 Deaths from Cancer (all ages) 10 Deaths from Measles (all ages) 0 Deaths from Whooping Cough (all ages) 0 Deaths from Diarrhoea (under 2 years of age) 0 Vaccination.—Of the 518 births notified to the Vaccination Officer during 1946, 230 had been successfully vaccinated by the end of 1947; 14 had died before the age for vaccination and none was insusceptible. Vaccination was postponed in 3 cases, and 185 had removed into other districts. Three cases were pending. There were 83 cases of conscientious objection. The Public Vaccinator performed 11 revaccinations during 1947. MATERNITY AND CHILD WELFARE. No. of City Births notified (including still births) 44 Visits by Health Visitors:—Under one year 183 Over one year and under 5 years 283 Ante Natal 62 Ophthalmia 3 Home Helps 0 777 packets of Dried Milk were supplied to children 0-2 years of age; also 97 packets Farex and 72 bottles Radiostoleum to mothers and children. Liquid Milk, Cod Liver Oil and Fruit Juices were distributed through the Child Welfare Centre to mothers and children on behalf of the Food Office. The two deaths under one year referred to above in the paragraph on Statistical Information both relate to newly born infants found murdered in different Railway Stations in the City. The still-born child referred to was found in Puddle Dock, Upper Thames Street. No evidence of infestation by head lice was observed in any City child. INFANT WELFARE CENTRE. No. of Sessions (including sessions for Diphtheria Immunisation and Schick Testing) 101 Attendances:—Under one year 690 Over one year and under five years 604 Mothers 30 Dentures provided Nil Home Helps provided Nil No. of children, under five years, immunised against Diphtheria 31 No. of children, over five years, and under 15, immunised against Diphtheria Nil No. of injections 37 No. of Post Schick Tests and Readings 14 DOMESTIC HELP SERVICE. Owing to the small resident population of the City, it has been neither necessary nor practicable to engage whole-time domestic helps. In every case where domestic help was urgently needed ad hoc arrangements have been made through the Honorary Welfare Officer. During 1947 domestic help was provided in 12 cases, the total hours of work being 3,068. 7 INFECTIOUS DISEASE. Notifications received:— Total cases notified. Cases admitted to Hospital. These consisted of the following:— Cerebro-Spinal Meningitis 2 2 Food Poisoning 1 — Scabies 7 — Measles 8 1 Scarlet Fever 6 5 Tuberculosis 18 8 Erysipelas 1 - Diphtheria 2 2 Whooping Cough 4 1 Dysentery 1 1 SMALLPOX AND TYPHUS FEVER CONTACTS. Cases of Smallpox occurred on ships arriving at Liverpool and Southampton. Contacts were allowed to leave the ships on condition that they gave to the Port Health Authorities their names and the addresses of their destination. These names and addresses were communicated to the Medical Officers of Health of the districts to which the contacts were proceeding, who were responsible for surveillance of the contacts. In the City enquiries were made in regard to 2 contacts and appropriate action taken. Under the Public Health (Aircraft) Regulations, 1938, notifications are received of passengers arriving in this country by air from areas infected with Typhus or Smallpox. Enquiries were made in connection with 111 passengers during 1947. PROVISION OF HEALTH SERVICES—TUBERCULOSIS. Tuberculosis Dispensary:— No. of Sessions held 204 No. of Patients attending:— Residents 235 798 Non-Residents 563 No. of New Patients 219 No. of Resident Patients admitted to Sanatoria, Hospices, etc. 5 No. of Artificial Pneumothorax Refills given 271 No. of Visits made to Home 71 No. of Contacts kept under observation 9 Milk was supplied to two patients during the year. The Minister of Health, during 1943, made available to local authorites funds for the payment of allowances to persons who have to give up remunerative work in order to undergo treatment, cither at home or in sanatorium. So far as the County of London is concerned the London County Council are the Assessing Authority for the payment of allowances, but the Minister has' laid down a scale of payments which is as follows:— A tuberculous married man with a dependent wife or a tuberculous wife whose husband is dependent on her income, receives jointly 39s. per week while the patient is undergoing treatment at home, this sum being decreased by ten shillings should the patient be in sanatorium. A single person is entitled to 25s. per week while away from work but not in sanatorium, such payments ceasing if the patient enters sanatorium. Additional sums are payable in respect of dependent children or infirm persons, and allowances are made towards rent. These payments are only payable where treatment is hoped to be "curative," and are not payable to "incurables," and in the former case must only be paid for six months after discharge from sanatorium except with the approval of the Minister. The object of these allowances is to enable patients to undergo curative treatment. During the year allowances were paid to six patients, in accordance with the above-mentioned scale. VENEREAL DISEASE CENTRE. Sessions held daily except Sunday. During the year a total of 1,223 persons attended the V.D. Treatment Centre at St. Bartholomew's Hospital. Cases of Syphilis numbered 385 (230 males and 155 females). Cases of Gonorrhœa numbered 280 (276 males and 4 females). Cases of Soft Chancre numbered 1 (male). 557 cases (489 males and 68 females) attending were found not to be suffering from any venereal disease. Of the cases of Syphilis attending for the first time only 27 were in the primary stage, 27 were in the secondary stage and 34 in later stages. 9 were cases of congenital syphilis. 237 eases of syphilis were still under treatment or observation from the previous year. 35 who had been removed from the register, returned suffering from a relapse. 12 cases attended Bart's for the first time but had commenced their treatment elsewhere. Of the cases of Gonorrhoea, 111 attended in the first year of infection and 33 in later stages. 78 were continuing treatment or observation from the previous year; 12 were cases which had relapsed and 46 attended Burt's for the first time having commenced their treatment elsewhere. 37 cases of Syphilis ceased to attend before completion of treatment, and 32 after completion of treatment but before final tests of cure. 8 43 cases of Gonorrhoea ceased to attend before completion of treatment, and 82 after completion of treatment but before final tests of cure. The one case of Soft Chancre, dealt with for the first time during the year, did not complete treatment. The total number of attendances of all cases was 14,680, of which 11,830 were for the individual attention of the Medical Officer and 2,850 were for intermediate treatment. 58 cases of Syphilis received in-patient treatment involving a total of 80 in-patient days of treatment. The Laboratory work included 60 microscopical examinations for Syphilis, 836 microscopical examinations for Gonorrhoea, 7,476 serum tests, and 293 Cerebro-Spinal fluid tests. Of the cases attending the Treatment Centre for the first time during the year, 750 were from the County of London, 20 from Surrey, 15 from Kent, 5 from Middlesex, 10 from Essex, 2 from Herts, and 1 from Bucks. The London cases were responsible for 14,440 of the total attendances. BACTERIOLOGICAL EXAMINATIONS. The following specimens were examined during the year:— Disease Result. Specimen. Suspected. Positive. Negative. Throat Swabbing Diphtheria 0 5 DIPHTHERIA ANTI-TOXIN. Quantity provided to private practitioners Nil. MEAT INSPECTION. Amount of meat delivered at Smithfield Market, 289,883 tons. Amount of diseased or unsound meat surrendered to Meat Inspectors at Smithfield Market, 212 tons 17 cwts. 2 qrs. 3 lbs. Amount of meat surrendered to Meat Inspectors at Leadenhall Market and City shops, 23 tons 11 cwts. 3 qrs. 4 lbs. Amount of meat surrendered to Meat Inspectors at Cold Stores, 5 tons 2 cwts. 1 qr. 20 lbs. No. of Prosecutions instituted, Nil. No. of Examinations (Diploma in Public Health), 2. PUBLIC HEALTH (MEAT) REGULATIONS, 1924. The improvement in carriage of meat noted in past reports has been maintained, although, of course, the quantities carried are very much less than in pre-war years. 34 infringements were noted in connection with the transport of meat in private cars, but the fault was remedied on each occasion on instructions given. PREMISES WHERE FOOD IS PREPARED AND OFFERED FOR SALE. All these premises are subject to regular inspection. Without exception all criticisms have received immediate attention. ITINERANT FOOD VENDORS. Constant inspections of barrows and of itinerant food vendors have been maintained and no difficulty has been experienced in connection with this class of trade. FOOD INSPECTION. The food delivered at riverside wharves and premises in the City has consisted of the customary varieties, and has been the subject of constant inspection. 454 tons 12 cwts. 1 qr. 2 lbs. were condemned as unfit for human consumption. 75 tons 18 cwts. 1 qr. 5 lbs. of this food were utilised for stock feeding, fertilizing or manufacturing purposes. The remainder, consisting of 100 tons 8 cwts. 0 qr. 9 lbs. was destroyed either by the Cleansing Department of the City Corporation, being useless for stock feeding purposes, or else on the sites on which it was condemned. FOOD AND DUGS ACT, 1938, AND FOOD REGULATIONS. 397 samples have been submitted to the Public Analyst; 33 of these were formal samples and 364 were informal samples. Seven samples were reported against. The percentage of adulterated samples was 1.8. Cautions were administered and legal proceedings were not necessary. One application was received for registration as a purveyor of milk, which was granted. Eight Supplementary Licences were issued under the Milk (Special Designations) Regulations, 1936-46. MILK SAMPLES—PHOSPHATASE AND METHYLENE BLUE TESTS. 35 samples-of milk were submitted to the Bacteriologist for examination by the Phosphatase and Methylene Blue Tests. These tests respectively give indications of the adequacy of the heat treatment and of the keeping quality of the milk. In one instance the milk was unsatisfactory to the Phosphatase Test; in twenty-two cases to the Methylene Blue Test and in four samples there was evidence of dirt. Particular attention has been paid to the premises through which the milk had passed and to the method of transport and handling, and where the purveyors had premises outside the City from which the milk was sent out, communications were forwarded to the Medical Officers of Health of the Districts concerned. The results of these Tests have been forwarded in monthly returns to the Ministry of Food, Milk Division (Quality Branch.) 9 ICE CREAM. Sampling of Ice Cream was continued during the Summer months. 14 samples were submitted to the Bacteriologist and 9 were analysed by the Public Analyst. In April, the Minister of Health in exercise of the powers conferred upon him by the Food and Drugs Act, 1938, made The Ice Cream (Heat Treatment, etc.) Regulations, 1947, which became operative on 1st May. Briefly, the Regulations require that, with the exception of evaporated cold mixes, i.e., powder to which cold water only is added and which is then converted into ice cream within an hour of such reconstitution, the ingredients of ice cream shall be heat treated, after being mixed and that the mixture shall then be coolcd until the freezing process is begun. After freezing, the ice cream must not be sold—and this applies to cold mixes as well—unless it has been kept at a temperature not higher than 28°F. or if its temperature has risen above 28°F. unless it has again been heat treated and then kept at not more than 28°F. after having been frozen. When the above-mentioned samples were procured the temperature of the mix was taken at the same time and in no instance was it found that the stipulated figure was exceeded. Above the temperature of 28°F. the mix would tend to becomo liquid and this would of course militate against its ready sale. In a circular letter referring to these Ice Cream Regulations it was stated that the Minister of Health had given further consideration to the prescription in the Regulations of a bacteriological standard of cleanliness for ice cream, but he was still not satisfied that there was any test the reliability of which was sufficiently established to justify its use as a statutory test. He therefore recommended the Methylene Blue Test in accordance with the particulars published in the Ministry of Health's Monthly Bulletin for March, 1947. The basis of the Methylene Blue Test which as mentioned above is used also for the examination of milk, is, that living micro-organisms use up dissolved oxygen and the rate of removal of oxygen is roughly proportional to the number of organisms present. As concentration of oxygen is reduced the Methylene Blue loses its colour. On the basis of experimental results it was suggested that the Test be given a trial for assessing the bacterial cleanliness of ice cream. Tentatively the cream was placed into four gradings according to the time taken to reduce the methylene blue, i.e., from 0 hours to 4½ hours or more. This test afforded an index of contamination but in some cases and especially where previous results had been bad, it was considered advisable to have a complete bacteriological examination as well. Resulting from the sampling and examination of ico cream, communications were forwarded to the Medical Officers of Health of three districts where the cream had been manufactured, and in two cases the particular Medical Officers concerned intimated that the manufacturers premises from which the cream had been sent out were undergoing overhaul. In accordance with the powers conferred by the Food and Drugs Act, 1938, and in order to see that the requirements of that Act and of the above-mentioned Regulations had been complied, with premises where ice cream has been manufactured, sold or stored for sale have been inspected. There have been 15 new registrations for the sale of ice cream, and in one case the use of promises for that purpose has been discontinued. SANITARY CIRCUMSTANCES. The general sanitary supervision has been maintained and in this connection 4,233 inspections have been made. As a consequence of these inspections, it was necessary to serve 71 Intimation Notices. Six Statutory Orders were served. No legal proceedings were necessary. Tenement Houses were inspected and the only common lodging house in the City was kept under regular supervision. HOUSING. The total number of dwelling-houses inspected for housing defects was 55. In 33 defects were found and in 30 these defects were remedied. There are nine houses on which it is intended to place a Closing Order as soon as there is reasonable prospect of the occupants being able to obtain suitable alternative accommodation. FACTORY ACT, 1937. Factory premises have been under such supervision as has been possible having regard to their needs, and the following gives details of the work carricd out:— PART I OF THE ACT. 1.—INSPECTIONS for purposes of provisions as to health (including inspections made by Sanitary Inspectors). Premises Number on Register Number of Inspections Written notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 643 (including 505 kitchens) 611 (including 551 kitchens) 128 (including 85 kitchens) — (ii) Factories not included in (1) in which Section 7 in enforced by the Local Authority 385 308 8 - (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) 1 - - - TOTAL 1,029 979 136 Nil 10 PART I OF THE ACT—continued. 2.—CASES IN WHICH DEFECTS WERE FOUND. (If defects are discovered at the premises on two, three or more separate occasions they are reckoned as two, three or more "cases") Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness (S.l.) 618 260 - - - Overcrowding (S.2) 1 — — — — Unreasonable temperature (S.3) — — — — — Inadequate ventilation (S.4) 31 7 — — — Ineffective drainage of floors (S.6) 7 1 — — — Sanitary Conveniences (S.7) (a) insufficient 12 1 — - — (b) Unsuitable or defective 12 31 — — — (c) Not separate for sexes 3 4 — — — Other offences against the Act (not including offences relating to Outwork) 613 308 17 17 — TOTAL 1,297 612 17 17 Nil SHOPS ACT, 1934. 145 inspections of shops and warehouses have been carried out. Any defects have been remedied without recourse to legal proceedings. One Notice was issued. CATERING LICENCES. Before issuing licences for the establishment of catering businesses, the Local Food Control Officer refers cases to your Medical Officer of Health in order that licences may only be issued in respect of premises which are suitable from a public health point of view. During 1947, 140 premises were inspected and reports forwarded to the Food Controller. PHARMACY AND POISONS ACT, 1933. 69 firms were registered under this Act, 67 of which were re-registrations. The few infringements which were noted were all remedied without difficulty on the request of the Medical Officer of Health. PHARMACY AND MEDICINES ACT, 1941. The provisions of the above Act were carried out without recourse to legal proceedings and without special difficulty. FERTILIZERS AND FEEDING STUFFS ACT, 1926. The provisions of the above Act were carried out without recourse to legal proceedings and without special difficulty. 55 inspections were made. MERCHANDISE MARKS ACT, 1926. AGRICULTURAL PRODUCE (GRADING AND MARKING) ACT, 1928-1931. No difficulty was experienced during the year in regard to the administration of the above Acts. CITY MORTUARY. Bodies received 61 Post Mortem Examinations made 44 Inquest on bodies 28 Inquests held at Holloway Prison 2 Inquest on fires 2 DISINFECTION AND CLEANSING OF VERMINOUS PERSONS, ETC. Export of Clothing:— No. of articles disinfected 63,092 Fees received £146 General Disinfection. Infectious Diseases, etc.:— Articles of clothing and bedding disinfected 24 Rooms disinfected after cases of infectious disease 29 Lockers at Post Offices disinfected 512 Verminous rooms disinfected 112 Ambulances disinfected 1 Cleansing of Persons:— No. of scabeous persons bathed 14 No. of verminous persons bathed 168 No. of scabeous and verminous articles disinfected 2,118 Cleansing of Schoolchildren:— No. of children cleansed 2,062 No. of articles disinfected 2,162. 11 RAT REPRESSION. Your Rodent Officer, Mr. Carter, has submitted the following report on the progress of rat repression within the boundaries of the City during the year. The work has been carried out under the Rats and Mice (Destruction) Act, 1919. and in compliance with the general "Direction" issued to all Local Authorities by the Minister of Food, in exercise of his powers by virtue of the Infestation Order, S.R. & 0.680, 1943. These powers have since been transferred to the Ministry of Agriculture and Fisheries. The department engaged on this work comprised the Rodent Officer and six assistants or operators. It has not been necessary to serve Statutory Notices under the Act, as occupiers of property have readily co-operated, it being generally realised that the primary factor in achieving the maximum results in work of this nature, was the co-ordination and application of the measures taken by operators, whose sole concern is the destruction of rats and mice. The work was divided under three headings, inspections of blocks of properties to ascertain the presence of rats and mice, surface treatment of premises found to be infested, and periodical maintenance treatment of sewers. A total of 3,194 premises were inspected during the period under review, embracing all types of properties, from riverside wharves and warehouses, blocks of offices, factories, kitchens, workshops, to domestic dwellings. Pre-baiting and poisoning have been the principle means of extermination with trapping as a secondary measure, and in all instances the measures advised by the Infestation Branch of the Ministry have been adhered to. The character of infestations remains fairly constant, in a ratio of 9: 1 Ship (Black) rat and Common (Brown) rat respectively. Altogether, 705 infestations of rats, and/or mice were treated and this entailed 8,759 re-visits for operational purposes. In the process of pre-baiting, 18,226 initial points were selected, and 88,980 pre-baits were put down. Approximately 11 cwts. of poison bait, spread over 11,123 poison points, was used in surface properties. These measures resulted in an estimated kill of 7,269 rats and of this number 2,183 bodies or 30 per cent. were picked up. Trapping was the means of destroying 484 rats, and added to those found after poisoning, gives a total of 2,667 bodies taken from premises. As explained in previous reports, the estimated figure is a minimum and could possibly be increased by 30 per cent. It is relatively unimportant, but at the same time useful for record purposes. The best test of the results of a treatment is the freedom of the property from live rats, at least for a, reasonable time. As agreed with the Ministry of Agriculture and Fisheries, two sewer maintenance treatments were applied in May and December. The May treatment resulted in an estimated kill of 502 rats, and the December treatment 725 rats, of which 47 bodies were found on the benches of the sewers. Assessing the value of this work, the effect on surface infestations of Common rat must be considered, as there is always a possibility of a connection, and it is reasonable to assume that the small number of Common rat infestations found in premises is in some measure attributable to these treatments. Unfortunately this work does not affect the Ship (Black) rat, which lives and breeds solely above ground. A considerable number of mice infestations were treated and satisfactory results were obtained. Altogether 330 bodies were found after poisoning and trapping. There has been an increase in this type of infestation. This appears to be due to the carcless disposal of food scraps and wrappers, usually deposited in waste-paper baskets in offices, and thrown on the floors in factories, etc. Pre-war most business premises were cleaned at night, but now this is mainly carried out in the early morning, so that waste food, orange peel, sweet wrappers, &c., are left all night to attract rats and mice, and provide the neccssary sustenance. In such cases the provision of small metal bins is advised. The value of preventive measures is realised, and where practicable, structural and incidental rat proofing is advised and combined with extermination measures. Unfortunately, many premises treated were beyond structural proofing against Ship rat, or alternately it entailed work which could not be undertaken at the present time. Many of the older properties have lost their original identity owing to internal alterations and additions over a number of years, and such alterations have in many cases provided excellent harbourage and runs through the structures from one building to another, a facility of which the ship rat is quick to take advantage. It is understood that the Minister of Agriculture and Fisheries contemplates frosh legislation in the near future to supersede the present Act, in the light of knowledge and experience gained and conditions existing to-day. As far as the City conditions are concerned, an exceliont opportunity is provided for including in any such legislation the compulsory rat proofing of all properties to bo erectcd in the future. This would entail close co-operation between architects, builders, and competent officials of Local Authorities in every case. Such proofing would include the elimination of external pipe services providing runs, or, if used, the provision of "rat guards" at roof gutter level, and between the lowest external window and ground level. Where possible, internal pipe services should not be eased, and in every instance sealed off at floor and ceiling levels. False ceilings, floors, and panelled walls should be avoided. Water storage tanks and automatic flushing cisterns must always be covered, and enclosed raised inspection platforms avoided. All doors providing entry to the building at roof level, should be rat proofed and selfclosing. Ventilation louvres in lavatories should be avoided and wire mesh substituted. These items are by no means exhaustive, but lack of attention to such details has in the past been responsible for infestations in many cases. 12 It cannot be over-emphasised that the reduction of the rat problem to a very low level, is as much in the hands of the general public as the exterminator. Maintenance of a high standard of hygiene, careful disposal of waste food, and avoidance of structural and incidental harbourage, will do much to assist our efforts. In conclusion, the terms of the "Direction" have been complied with as far as practicable, having regard to the problems peculiar to the City, the character of the infestations, and the types of property.