WES83 City of Westminster. ANNUAL REPORT (ABRIDGED) FOE THE YEAR 1917 BY FRANCIS J. ALLAN, M.D., C.M., D.P.H. Camb., F.R.S. Ed. Medical Officer of Health. TOGETHER WITH REPORT BY THE TUBERCULOSIS MEDICAL OFFICER. Printed by Order of the Council. LONDON: HARRISON AND SONS, PRINTERS IN ORDINARY TO HIS MAJESTY, ST. MARTIN'S LANE, W.C. ' Annual Report on the Health and Sanitary Condition of the City of Westminster. (Abridged.) 1917. To the Mayor, Aldermen and Councillors of the City of Westminster. I have the honour to submit to you my Annual Report for the year 1917. The usual tabular statements required by the Local Government Board and Home Office have been prepared, but as these bodies do not require them to be submitted this year, I have not included them in this Report. They will, however, be available for issue later if required. The Registrar-General has adopted the following estimates of the Civil Population of Westminster, for the year 1917 :—For death-rates, 122,016 ; for the birth-rate, 130,047. The former is an estimate of the civilian population, the latter of the total population based on the assumption that the ratio between the total and the civilian population is the same in the City as in England and Wales as a whole. The actual civil population, however, disclosed through the applications for various purposes to the Food Control Committee, and through other sources, appears to be much larger, and is probably somewhere about 160.000. This is chiefly due to the influx of persons engaged in various forms of War work. Evidence of this is found in the inquiries made in connection with notifications, especially of tuberculosis. As might be expected, the number of births recorded is again lower, the net number being 1,544, including 10 for whom no address was avail- A2 4 able. The continual decrease, unfortunately, is in the number of legitimate children, who numbered 1,348 in 1917 ; in the pre-War year, 1913, the figure was 2,057. Illegitimate births showed an increase from 176 to 196 in the same years. Of the 1,315 births registered, notification was received of 1,020 (35 being of still-born children). Information was received from the medical officers of other boroughs and of the County Council, of 378 Westminster infants born and notified elsewhere. The birth-rate for England and Wales is down to 17.8 per 1,000 of population, showing a decrease of 3" 1 on the figures for 1916, a reduction, as compared with the year preceding the War, of 14 per cent. The London rate is estimated as 17' 5 per 1,000. Death occurred in 160 instances in children under 1 year of age, giving a rate of 103" 6 per 1,000 children born in the year, the average of the five preceding years being 87. For legitimate children the rate was 83 (average 77), for illegitimate 239 per 1,000 (average 188). Deaths of illegitimate children have been high during the last three years, partly due to the number of newly-born infants (10, 13 and 9) found in parks and elsewhere, whose death was due to injury, accidental or intentional. In the three divisions into which the City is divided under the Maternity and Child Welfare Scheme, the figures (omitting the homeless) were:— Legitimate. Illegitimate. Total. Pimlico— Births 581 91 672 Deaths 42 17 59 Rate 72 186 87 Soho— Births 368 51 419 Deaths 33 9 100 Rate 89 176 100 St. John and St. Margaret—- Births 398 45 441 Deaths 37 12 49 Rate 92 266 110 The infantile death-rate for London was 103 per 1,000 births, 97 for England. In Westminster there has been a steady increase in the proportion of premature births, as a cause of death, and also in the number of children born in an enfeebled condition, bronchitis and pneumonia have caused an increase, but, on the other hand, there were fewer deaths from stomach and bowel complaints. There is a rise in the number of deaths attributed to syphilis. 5 The proportion of deaths per 1,000 births from various grouped causes in the last four years is set out below:— 1914. 1915. 1910. 1917. Measles 0.9 3.5 0.5 3.9 Whooping cough 5.5 1.5 1.6 1.9 Septic diseases 2.3 1.5 - 1.9 Bronchitis and pneumonia 11.5 14.1 15.4 16.8 Stomach and bowel complaints 12.5 15.1 12.7 7.1 Syphilis 1.4 5.0 4.9 8.4 Congenital malformations 7.4 4.5 6.7 5.8 Prematurity 16.6 20.7 20.9 27.2 Neglect and injury at birth 4.6 7.7 6.7 6.7 Debility from birth and atrophy 6.9 10.7 5.5 13.6 Tuberculosis 0.9 3.0 4.4 2.6 Other causes 6.9 3.5 3.4 7.1 The number of still-births notified, or which were known to have occurred, was 35 in 1917, the number in the three preceding years being 56, 53, 57. Between the ages of 1 and 5, 73 deaths occurred. Maternity and Child Welfare.—The names of 615 expectant mothers were sent in by hospitals, found by the visitors, or personally l itified; 153 attended the Mothercraft classes, making 634 attendances, 1,675 visits were paid to them at their homes. First visits paid to infants under one year of age numbered 1,466, subsequent visits, 2,869. Children over that age, 9,779. Medical inspections were attended by 1,016 children, 603 being new cases, the total attendances were 2,641. At the 190 Mothercraft Classes which were held, the total attendances were 2,686, 385 persons attended, of whom 133 were expectant mothers. At the 31 Cookery Classes 426 attendances were registered. The Health Visitors also visit children suffering from measles, whooping cough, and ophthalmia neonatorum and some of the non-pulmonary tuberculous children in co-operation with the Tuberculosis Visitors and Invalid Children's Aid Association. The total number of visits paid during the year was 15,843, of which 11,543 were made by paid visitors, 4,300 by voluntary visitors. In the Soho and St. John's areas the work has been carried out by the Westminster Health Society, by arrangement with the Council. In the Pimlico area, the Society's visitors co-operated with the Council's Visitor during the first six months, and were also responsible for the mothercraft classes and weekly infant medical inspections. 6 ties, however, arose, and the Society withdrew the assistance they had given in that area. The Council decided to undertake the whole of the Maternity and Child Welfare work in that area, and also to inaugurate a clinic for expectant mothers. A special Committee is to be appointed to deal with this branch of work, which is assuming increased importance, meanwhile a re-arrangement of duties of the Council's Visitors in that area has been effected whereby the Health and the Tuberculosis visitors will be available for both branches. The medical inspection of children and the clinic for expectant mothers have been placed under Dr. Shinnie's care as a temporary measure. The mothercraft classes have, meanwhile, been in abeyance. The Health Society has provided a trained nurse (who is also a midwife) to act as a monthly nurse from the Rochester Row Centre. She is also available for pre-natal and ordinary health visiting. Arrangements have been made to pay for the services of medical practitioners when called in by registered midwives in cases of emergency in necessitous women, according to a scale laid down by the British Medical Association. Supplies of dried milk have been provided at each of the three Health Centres, to supply nursing mothers and infants, but the demand has been small, as little difficulty has been experienced in obtaining milk from dairymen. The general death-rate.—The net number of deaths of Westminster people was 1,896, slightly higher than that recorded (1,827) in 1916. Of these, 1,014 were of males, 852 females, in both instances above the numbers in 1916. On the Registrar-General's estimate, the death-rate would be 15"5 per 1,000 ; on the 160,000 estimate, 11.8. The rate for London is given as 15'0 per 1,000. Infectious Disease.—The number of notifications, 469, were again remarkably low. There were 10"9 scarlet fever (2 deaths), 163 diphtheria (11 deaths), 14 enteric fever (4 deaths), 14 cerebro-spinal meningitis (8 deaths), 1 poliomyelitis (1 death), 46 erysipelas, 7 puerperal fever (3 deaths), and 29 cases of ophthalmia neonatorum. In addition, 1,111 cases of measles and 815 of German measles were notified. All but 200 occurred in the first 6 months of the year; 24 deaths occurred. Visits were paid by the Health Visitors to 905 families in which there were one or more children affected. Hospital treatment was given to 124 persons suffering from measles and 92 of those with rubella ; 50 of the former and 83 of the latter were adults, soldiers, servants, residents in hotels, boarding houses and in business 7 premises. Of tho children sent to hospital, 29 were from the War Refugee Home in Poland Street. Arrangements have been made with the three Nursing Associations serving Westminster to attend cases of measles and ophthalmia when called upon. There is much scope for preventive treatment, and the experiments which have been made in this direction in the Army in dealing with persons exposed to infection of cerebro-spinal meningitis, leads one to hope that the application of disinfectants in spray or gaseous form to the throat and nose may be effective in preventing the development of measles, diphtheria, whooping cough and septic conditions of the throat. Whooping cough caused 5 deaths ; 85 visits were paid to children by the Health Visitors. Ophthalmia in newly-born infants.—In addition to the 29 notified cases, 4 other cases were discovered, and 17 cases of slight inflammation were also reported by the Health Visitors. With two exceptions, recovery took place without injury to vision. One illegitimate infant, not notified, lost sight of both eyes. Three of the children died, one from pneumonia, the other two did not thrive. Syphilis existed in two instances; in three the gonoeoecus was isolated from the discharge from the eye. Enteritis was given as the cause of death in 21 instances, 18 being due to chronic forms of bowel complaint. Tuberculosis.—In 1917, 396 new cases of pulmonary tuberculosis were notified, and 35 died who had not been notified in Westminster, a total of 431. The totals in the preceding six years, 1911-16, were: 423, 512, 475, 390, 317, 391. Tuberculosis cases among persons living in common lodging-houses and homeless persons have steadily declined, and were half what they were five years ago, but among the general public, in 1916 and 1917, there was an increase, both of males and females —males, in the four years, 1914-17 were 186, 155, 1S3, and 209; females were 105, 95, 135 and 164. The increase among males was 6 between the ages of 1 and 10 years, 5 between 15 and 20 years, 5 between 20 and 25, and 15 between 35 and 45. At other age periods there was a decrease. Among females there was an increase in each age group from 5 to 45 years, being specially marked between 20 and 45. To some extent the rise among the males was due to the cnlling-up of aliens for Army service, a number of whom were found suffering from chronic tuberculosis which had not been notified previously in 8 minster, thus the number of Russians was double that recorded in 1914. There were also a few cases of men discharged from the Army. The number of males who had been ill previous to coming to live in Westminster showed an increase in 1916, but there was a decrease in 1917. Among females, however, there were 51 such cases, compared with 29 in 1916, and 28 in 1915. Most of these were women who had come in to "Westminster to work at occupations resulting from the War. Confinement in offices and workshops, living in lodgings, and difficulties with food, brought about a breakdown in cases in which the disease had been arrested or was quiescent. Of non-pulmonary forms, there were 66 new cases notified, and 10 died who had not been notified. The totals in the preceding three years were 72, 72 and 81. Of the 76, 7 had been ill before corning to Westminster. Deaths occurred of 194 persons suffering from pulmonary tuberculosis (111 of whom had been notified in 1917); and of 29 non-pulmonary (17 being 1917 cases). Tuberculosis Dispensary.—A report on the working of the Dispensary by the Tuberculosis Medical Officer is appended hereto. It shows an increase in the number of persons who attended and in the total attendances. A gratifying feature of the Report is the close co-operation existing with medical practitioners, and is shown by the number of patients sent by them for the Medical Officer's opinion, and by the consultations with them at patients' houses. This leads to the earlier recognition of the illness, and gives a better chance for treatment. The number of consumptive patients visited during the year by Miss Sanders and Miss Sayle was 907, non-pulmonary 221, and suspects 622. The total number of visits paid was 3,697. In addition, 326 visits were paid by voluntary visitors, chiefly to suspects and nonpulmonary cases. The number of cases remaining at the end of the year, allowing for deaths and removals, was: pulmonary, 626; non-pulmonary, 171; suspects, 561. Advantage was taken in 326 instances to obtain a bacteriological report on the sputum from suspected persons, and in 67 the presence of the organism was detected. Disinfection.—A very large amount of disinfecting work has been done during the year, 295,007 articles of bedding and clothing having been treated at the Station. The bulk of this, 250,238 articles, were sent in by the Military Authorities or from hostels almost entirely for 9 minous conditions. Most of the civil work arose from the same cause. Dressings (211 tins) from hospitals and medical inspection rooms were collected and destroyed. At the Cleansing Station, 442 Westminster children (213 for lice, and 199 for scabies), and 31 adults were bathed and treated. In addition, 33 adults and 82 children were dealt with at home on account of scabics. The Disinfecting Superintendent paid 517 visits in connection with verminous cases. By arrangement with the County Council, 80 school children from Chelsea, Battersea, Lambeth and Holborn were sent to the Westminster Cleansing Station for attention. Sanitary Inspection—Plans received numbered 233, one-third of the number submitted in pre-war years; these chiefly dealt with reconstruction of premises, re-drainage, provision of new w.c.'s, lavatories, kc. Two buildings were erected or converted for use as hospitals, 10 as hostels for soldiers, and a number of premises were altered for use as offices. Difficulty was experienced in obtaining the prompt abatement of insanitary conditions through shortage of labour, but it was noticeable that while painters, &c., could not be obtained for tenement dwellings, brewery and-licensed premises throughout London were being lavishly re-painted and decorated inside and out. 1,112 intimations of nuisances and 37 statutory notices were served, both of these being below the average. Police Court proceedings had to be taken in 12 cases. Overcrowding (13 cases) was less in 1917 than in the preceding year, when there were 47 cases, and only three underground rooms were reported to be illegally used. Tenement houses have been regularly inspected, 3,640 visits having been paid. The difficulty experienced in previous years to prevent emission of black smoke continued, but, on the whole, owners have exercised care, and only 66 complaints were made. In one case, a summons had to be issued. Housing.—The higher estimate of population mentioned earlier is borne out by the return of unoccupied properties, prepared by the City Comptroller, which shows a considerable reduction in the last two years 31st March. 1916. 1917. 1918. Houses and shops 809 738 593 Residential flats 437 403 226 Total 1,246 1,141 819 a 3 10 In the census year 1911, there were 1,308 unoccupied houses and shops in a total of 14,213, and 1,568 flats in a total of 10,631. Half of the empty houses are in the Grosvenor, Knightsbridge St. George and the Hamlet Wards. The Local Government Board has pointed out to local authorities that it is recogniscd that for some time after the end of the war many difficulties which have brought the building of houses for the working classes almost to a standstill will continue to prevail, and that throughout the period of the war there will be an increasing arrear of such building. The question of the provision of these houses appears to the Board to be one of the most pressing of post-war problems for which immediate preparation should be made, and realising that private enterprise will be quite unable to grapple successfully and speedily with this arrear, the conclusion has been arrived at that for the years immediately following the war it will be necessary to rely far more than in the past upon local authorities to provide the houses required, with their road, water, and drainage accompaniments. In Westminster, the question of providing houses for the working classes has been considered in' the past, and the conclusion come to was that the only class of building which existing conditions^ would permit was blocks of flats. Four such blocks were erected by the Council, and a scheme has been formulated for the erection of others on the site of the old workhouse in Poland Street, at present used for War refugees. The Council found that it was necessary for a number of people, such as these employed late at night and early in the morning, to live in the vicinity of the places in which they work, and they, therefore, thought it desirable to provide accommodation for such people. For a large number, they were of opinion that it would be better if they lived in the suburbs. Many persons object to tenement houses and to blocks of flats, and would prefer a cottage with a garden out of London, but the time occupied in the journey to and from work, and the expense entailed, prevent them availing themselves of better accommodation at a rent lower or not more than they pay for two or three rooms in Westminster. At present, suitable cottages in the suburbs, or in the outlying Metropolitan boroughs are not to be obtained, but, doubtless, such will be provided as soon as the War terminates. At the same time, it will be necessary to provide better facilities for reaching them. A considerable number of houses, especially in the Victoria Ward, which were originally built for occupation by a single family, have now a family on each floor, or are boarding houses. It would not be 11 ally difficult to make each tenement self-contained, and provided with scullery, water supply, larder and sanitary conveniences. An improvement of this kind on a large scale could not be undertaken by the present holders of the leases—in most cases sub-leases—who depend for their income upon the boarders or tenants, but would Lave to be undertaken by the freeholder or by the Council. It is fi aently found that in order to make the most out of the house, the best l ooms are let, and the leaseholder lives in the basement, which, although complying with legal requirements, is generally the least desirable part of the dwelling. Factories, Workshops, and Work Places have been frequently inspected. Many have undertaken Government work, and alterations have had to be made in consequence. The conditions under which work is now carried out in factories and workshops under Government control, have been much improved through the action of the Special Committee appointed by the Ministry of Munitions. From complaints which have reached me from t me to time it would appear desirable that the welfare of those engaged in clerical work should receive equal attention. The number of outworkers employed was about the same as in 1916, but a reduction has taken place in the number doing tailoring work, while there is an increase in those employed in making dresses and lingerie. Food Supply.—The introduction at the beginning of the year of methods of Food Control very considerably increased the work of the Public Health Department, to which was relegated the duty of seeing that the numerous Orders of the Controller were observed. The Public Meals Order and the Cake and Pastry Order especially led to frequent visits to restaurants, hotels, tea shops, and bakers, and advantage was taken in the course of these visits to inspect the general conditions of the premises. Later in the year, restrictions were placed on the sale of meat, jams, tea, coffee, butter, &c., &c. Some 5,000 visits were paid for the purpose of checking contraventions of the Orders. Difficulty was experienced by many of those engaged in business in understanding the Orders, and not a few were ignorant of their existence. These had to be explained to them, and assistance given as to how the Orders were to be carried out. This was especially the case with regard to the Food Registers, and occupied much time and patience. Some 400 contraventions (besides many trivial ones) were reported, and prosecutions resulted in about half that number. Many of the offences were due to carelessness, but a small proportion were undoubtedly wilful attempts to evade the Orders. 12 Sale of Food and Drugs Ads.-—The usual number (1,800) of samples were taken during the year. Of these, 920 were of milk, of which 13.6 per cent. did not comply with the Regulations. In 1916, the percentage was 112, and the average of the previous five years was 8.2. The figures for each quarter were:— 1917. No. of Samples. Adulterated. Per cent. Excess of water, Deficient in fat. Both defects. lft Quarter 205 30 14.6 16 14 2 2nd „ 228 40 17.5 24 16 1 3rd „ 251 35 13.9 12 23 1 4th „ 236 20 8.5 17 3 1 Total 920 125 13.6 69 56 5 Proceedings were taken in respect of 81 infringements; in four cases the milk carrier was summoned as well as the owner, and, on the conviction of the former the summons was withdrawn against the latter. Eight retailers were summoned twice during the year. Warranties were proved in 27 cases, and the summons dismissed. During the latter part of the year there was evidence that milk re-constructed from dried milk was being added to new milk. In one case milk made from powder was detected having a large excess of water (51 per cent.), and a 3 per cent. deficiency of fat. One dairyman was fined for refusing to sell to the Inspector, later in the year he was fined for selling milk with 1G per cent, of added water. Three samples of separated and skimmed milk were taken, and one was found to have an excess (22.7 per cent.) of water. Cream.—72 samples of what should have been pure cream were taken, and 25 of these were found to contain preservatives, and should, therefore, have been sold as preserved cream. Ten summonses under the Food and Drugs Acts and 1 under the Milk and Cream Regulations were taken out. Preserved cream was sampled on 97 occasions. Taking all the creams containing preservatives, in the winter months the number containing boric acid per lb. was 48, 36 not exceeding 17½ grs., 11 between that and 22½ grs., and 1 between 22½ and 25 grs. In the summer months, in 74 samples, 42 did not contain more than 17½ grs., and 20 were between that and.22½ grs., there were 3 between 22½ and 25 and 5 between 25 and 28 grs.; four samples exceeded that amount, one being 36.8 grs., these last were in the quarter ending-September, and the vendors were summoned. Eight summonses were issued for failure to affix proper labels that 13 preserved cream was not suitable for invalids and infants, as required by the Regulations. Butter.— 271 samples were taken, of these, 10 turned out to be margarine, half being in the first quarter of the year. One sample contained an excess of water (0.7 per cent.). Proceedings were taken in 7 instances for not properly labelling margarine. Cheese, 3 samples, and 12 of cream cheese, were taken. One of the latter proved to be a curd cheese containing a very small percentage of fat. Samples were taken of lard, and substitutes for lard and butter prepared from nuts. Two of the nut lards contained 11 per cent, and 7 per cent, of water respectively. In one instance, nut lard was sold as ordinary lard. Olive oil, which is now difficult to obtain, was sampled on 18 occasions. With two exceptions, the samples were found to be genuine, these two had been mixed with other cheaper oils, one to the extent of 5 per cent., the other at least 25 per cent. Meat pies, brawn, soups, fish and meat pastes and sausages were examined, and were found to be almost all free of boric acid preservative, and, where present, averaged about 7 grs. per lb., in no case exceeding 16.3 grs. Bottled shrimps were found containing 49.7 grs. of boric acid per lb. Arrowroot, cocoa, coffee proved genuine. Two samples of vinegar were diluted with water, one to the extent of 3 per cent., the other, 7 per cent. Tinned and bottled vegetables.—77 samples of peas, spinach, French beans, mixed vegetables, were examined; 58 were coloured with copper—under 1 gr. in many, and under 2 grs. in the majority ; 15 were under 3 grs., and 6 had 3 grs., or slightly over. In three instances, the amounts ran up to 4. 4, 4. 8 and 7. 19 grs. All these were foreign produce, and probably the increase in the amount of copper is due to the loss of skilled labour. These canned articles are largely used in hotels and restanrants, the chefs of which apparently prefer to use them, even when fresh vegetables are obtainable at cheaper rates, the reason given being that they save time in marketing and in preparation. Unsound Food.—The total amount of fruit and vegetables condemned was 73 tons 8 cwts. 59 lbs.; delay in transit being responsible in the case of foreign fruit. Of fish, 8 cwt. 91 lbs. were condemned. Beef, 2 cwt. 34½ lbs. Sausages, 6 cwt. 28 lbs. ; 15 fowls, 6 turkeys, 120 sweetbreads, and 14 calves' scalps were also found unfit for food. War Bread, as made at first, was not satisfactory, and there was a tendency to the development of " ropiness," which necessitated a quantity 14 having to be destroyed. There is still considerable variation in the quality and texture of the loaves, due chiefly to the variation in the composition of the flour." While not so attractive to persons accustomed to white bread, and requiring more thorough mastication, War Bread is more nutritious than the pie-War white bread. Allegations were frequent that its consumption caused a skin rash. A number of persons in Westminster who were having internal treatment for it, were cured in a short time by baths and the application externally of remedies for scabies (itch). National Kitchens were opened in Westminster by voluntary agencies, and there are now five working successfully. They ought to be a boon not only to persons out at work all day, but to all classes of the community who are "carrying on" without servants. To the ordinary Working man's family, they should be specially advantageous by supplying nourishing, well-cooked food at a reasonable price. The mother with a family to look after, does not always have the time to spare from her household duties to buy to the best advantage, and frequently the food provided consists of articles which need a minimum of preparation and cooking. Obtaining food from communal kitchens is opposed to our usual habit and custom, and at first many refused to avail themselves of them under the idea that they were accepting charity. There was, therefore, some prejudice to be overcome at first. It is not improbable that communal kitchens which would cater for mi lie-class people, would be equally, if not more, successful than th. already existing. War Work.—A considerable amount of work has devolved upon the Public Health Department in connection with the utilisation of dwellings as private hospitals for officers; the erection or conversion of existing premises into clubs and rest huts; the inspection of billets, guard-rooms, &c.; removal and destruction of dressings from hospitals, &c. As noted above, a very large amount of disinfection of Army clothing and bedding has been carried out for verminous conditions. Apart from the disagreeableness and irritation caused by the presence of such vermin, it is now recognised that they are the means whereby Typhus Fever and Trench Fever are communicated from one person to another. The former disease is, fortunately, rare among our soldiers, but the latter is not so, and it is quite possible that men who have suffered from Trench Fever, returning to their homes in a verminous condition, may thereby convey the disease to the civil population. Some improvement has taken place during the past year in treating the condition before men return to this country. 15 The premises of Firms contracting for the supply of food for the Army have been regularly visited, and the quality of the meat, vegetables, &c., used and the methods employed, have been kept under supervision. Outworkers' premises, where Army work was being carried on, have received spccial attention. The visitation of air-raid shelters, especially after their use, has thrown additional work on the District Sanitary Inspectors. Many of these shelters have been crowded for hours, and the condition of the places afterwards required very thorough cleansing and disinfecting. The risks run by persons, especially children, in these shelters is considerable. The conditiona are favourable for contracting infectious and contagious diseases, and undoubtedly illness and death have resulted in a number of instances through persons rushing insufficiently clad from their houses to these shelters on cold nights. As it is unnecessary for many of the people to leave their homes, it may be desirable to take steps to restrict the use of these shelters to persons really requiring such protection. I have the honour to be, Mr. Mayor, Aldermen and Councillors, Your obedient servant, FRANCIS J. ALLAN. May, 1918. 16 ANNUAL REPORT OF THE TUBERCULOSIS DISPENSARY. 1917. By Andrew J. Shinnie, M.D., D.P.H., Tuberculosis Medical Officer. I have the honour to submit niv second annual :eport on the work performed at or in connection with the dispensary at 1, Pimlico Road. This report represents the first complete year of the Council's tuberculosis scheme—last year's report dealt only with the period from the commencement of the scheme on April 1st to December 31st, 1916. In accordance with the injunction to economise paper I propose to state the few observations I have to make with the utmost brevity and to add a few statistical facts. Sir Arthur Newshclme in a recent paper discussed the question of tuberculosis as a war and after-war problem. His views on the subject of tuberculosis carry so great authority that I think it would be well to consider some of the points which he raised. He pointed out that the death rate from tuberculosis showed a steady decline to the year 1915, but that in 1916 there had been a considerable increase, particularly in regard to women. He seemed to think that this increased death-rate was mainly attributable to an increase in acute infections such as influenza, pneumonia and bronchitis, which tend to lower individual resistance and thus allow latent tuberculosis to blossom forth. My experience of the dispensary leads me to concur in this view. Many cases are now coming to light showing active tuberculosis where the disease had remained dormant for a considerable number of years. He also laid stress on the fact that tuberculous subjects attracted by the high wages now obtainable had taken up work in factories, &c., and were thus liable to infect their fellow workers. The return of the tuberculous soldier to his home was also a factor to be reckoned with in accounting for the increase in tuberculosis by local infection. A certain degree of shortage in fats and some of the customary articles of diet of the people has accounted in some instances for the outbreak of active tuberculosis in quiescent cases. He regarded "Housing" as the most important condition in measures taken to deal with tuberculosis and divided this question into two sections: (1) Housing of the healthy; (2) Housing of the sick. Under the latter head he quoted Koch's axiom " Tuberculosis is a bedroom infection." He hoped that further initiative would be shown by sanitary authorities in providing hospital accommodation for the infectious tuberculous cases, and pointed out that in London there 17 was a marked tendency for advanced cases to die in hospitals and infirmaries which would have a favourable influence in reducing the amount of infection in the homes. The war had tended to slow down the machinery of tuberculosis schemes and he regretted that "contact" examination had not received the attention that it deserved owing to inevitable causes. He pleaded for closer co-operation between medical officers of health, general practitioners and tuberculosis officers. In conclusion, he urged that as the death-rate from tuberculosis in Germany had been doubled and in this country tuberculosis still claimed one in every ten deaths, it should be regarded, not as a problem which could be postponed till after the war, but ought to demand the earnest attention of local authorities as a menace which was assuming ominous proportions during the war. The two chief responsibilities that are entrusted to a local authority are the health and the housing of its citizens. It has long been recognised that the root cause of tuberculosis infection lies in bad housing. Poverty, intemperance, and overcrowding are inter-related fattors. Tuberculosis is a social or family disease. In the stagnant air of gloomy overcrowded basement dwellings tuberculosis is encouraged to spread. By far the greater number of consumptives have been infected in infancy or childhood by tuberculous parents amidst such conditions. No specific medical treatment has yet been discovered for tuberculosis. Prevention must, therefore, be the watchword. Four lines of action appear to suggest themselves:— (1) Improved social and economic state of the workers. (2) Better housing conditions—abolition of basement dwellings, and in other areas of the custom of making the largest and best lit room the " workroom." (3) Municipal isolation of the infectious cases. (4) Special care of the children of consumptives especially during adolescence. The hope of the anti-tuberculosis campaign lies in preserving the health of children who are the contacts or relatives of consumptives. A considerable proportion of those children show either suspicious signs of tuberculosis or the disease in a quiescent or dormant form. As in 1916 we have directed our chief efforts to obtaining convalescent or sanatorium treatment for those cases. Even in regard to contacts who show no signs of the disease we prefer to keep them under observation at the dispensary in order that the examination of their lungs may be repeated. Contact 18 examination, therefore, so far from being neglected is regarded as tlie most important work of the dispensary. In 1917, 286 contacts were examined. Of these 206 were children under 16 years of age and 18 of them showed signs of pulmonary tuberculosis at the first examination. In those 18 children the disease had not previously been discovered. As pointed out in last year's report the disease is more insidious in onset and more difficult of detection in childhood than in adults. A recent memorandum from the L.C.C. has introduced the subject of day sanatoria for children, suggesting that Borough Councils in London should consider the establishment of such sanatoria in connection with their municipal tuberculosis dispensaries. At the present time there are five day sanatoria in London, viz., Camberwell, Bermondsey, Fulham, Battersea, Hammersmith. With the exception of the last, all are run in connection with the voluntary tuberculosis dispensaries of the Central Fund for the Prevention of Tuberculosis. These institutions have been in existence for over a year and may be said to have now passed the stage of experiment. The dispensary medical officers who are in charge of the respective day sanatoria are unanimous in acclaiming the good results which have been obtained after a year's trial. The children selected for treatment are those which have " passed through " the dispensary. They are therefore in a sense all dispensary patients. The L.C.C. as education authority supply the teacher and all educational appliances. The necessary ground, shelters, wraps, rest chairs, &c., are provided by the voluntary or municipal authority, who also provide the midday meal. The cost of this works out at 3d. or 4d per head and is recovered from the parents. In concluding these remarks on contacts and tuberculous children generally, I must add that I have been impressed with the fact that, of those child contacts who present definite or suspicious signs of the disease, the larger number live in basement dwellings. This is, of course, chiefly evident in the Pimlico area. It is encouraging to note that medical practitioners in Westminster are showing still further confidence in the dispensary by sending up patients for the opinion of the tuberculosis medical officer. In 1916, 80 were sent; in 1917, 148. In 1916, 25 consultations were held with private doctors; and in 1917, 88. Many of those patients were seen at their homes in consultation with the private doctor. During 1917 there was a considerable increase in the work performed for recruiting and national service medical boards. This is a sphere of work 19 in which tuberculosis dispensaries have been of great national benefit. If the arrangement had been in force throughout the country during the first two years of the war, the national exchequer would have been saved thousands of pounds in full pensions to consumptives whose splendid patriotism made them answer the call but whose physical condition rendered them a source of danger to their fellows. Since 1916 all recruits showing doubtful chest signs are referred to the local tuberculosis dispensaries. The T.M.O., besides his experience of chest disease, is able to guide the medical board by his knowledge of the local conditions, family history, predisposition to tuberculosis, fitness for certain types of duty, &c. The medical boards have been good enough to write from time to time expressing their gratitude for the help given by the stall of the dispensary. In 1916, 3 recruits were referred for expert opinion; in 1917, 140. Of 140 recruits, 37 were found to be suffering from pulmonary tuberculosis, 71 to have doubtful signs or signs of arrested or quiescent disease, and 32 were non-tuberculous. I am glad to say thaf most of the 71 with doubtful signs were totally rejected by the medical boards. Insurance Patients 70 applied for sanatorium benefit through the dispensary. 47 were recommended for sanatorium treatment. 16 were recommended for hospital treatment. 4 were recommended for domiciliary treatment. 3 were recommended for homes for the dying. 70 Of 47 sanatorium cases— 33 received sanatorium treatment. 7 refused sanatorium treatment for various reasons. 1 awaiting treatment on December 31st. 1 transferred to Middlesex. 3 were granted domiciliary treatment. 2 went to the infirmary. Of 16 hospital cases— 4 admitted to hospital. 4 granted domiciliary treatment. 1 sent to sanatorium. 7 went to the infirmary and died there or returned home and died. 20 Of 4 domiciliary cases— 1 moved into country. 1 went into infirmary and died. 2 received domiciliary treatment. Of 3 for homes for dying- All died at home. There is still reason for complaint that insured patients have to wait too long before gaining admission to hospitals and sanatoria, but a change of policy on the part of the Insurance Committee has mitigated this to a certain extent. Patients are now admitted for a month's treatment. During this period the patient should learn a good deal as to how to safeguard his health on sanatorium principles when he returns. He ought also to have learned how to render his condition non-infectious to others. If at the end of the month in sanatorium, the case is regarded as a curable one, then the period of sanatorium treatment is extended for months if necessary so that the best possible result may be attained. With regard to chronic cases of moderate severity the first month's treatment may be extended by a few weeks in order that the patient may pick up his powers of resistance in healthy surroundings with the help of good nursing, generous diet and rest. He may hope to return *atly improved in health and able, perhaps, to resume his occupation at least for a time. Cases which are not likely to show any improvement from sanatorium treatment are discharged at the end of the first month. Under this new policy it is hoped that a larger number of patients may obtain sanatorium treatment in a given time. In regard to extra nourishment, the Insurance Committee have restricted this grant to patients who are waiting for a bed in a sanatorium and to those who have been recently discharged. This policy is sound both medically and economically—a striking contrast to the former indiscriminate dole which was often a placebo to dying cases. Uninsured patients— 19 patients were recommended to the L.C.C. for institutional treatment. 10 women : 5 received sanatorium treatment, 2 moved out of the city, 2 refused treatment, 1 went to the infirmary. 9 children received treatment but some of them had to wait four months before they were admitted. Very good results were recorded from L.C.C. sanatorium treatment. Patients were kept in sanatorium for long periods and the disease in most cases seemed arrested; but the return to homes where there was some degree of hardship has, unfortunately, in one or two instances, led to the undoing of this fine achievement. 21 As regards dispensary treatment, this has occupied a somewhat more prominent position than during the first year of the dispensary. Some 12 insured patients received special treatment and some 510 uninsured patients were treated. Among the latter it was found that a great proportion would have been unable to obtain treatment suitable to their condition if the dispensary had not been in existence. Tuberculin was administered to 5 patients, 3 of whom are still receiving it. No striking result can be recorded, but in one case it would seem to maintain the patient's power of resistance and enable him to continue at work. Some special forms of drug treatment have been tried with varying degrees of success. The giving of iodine as an antiseptic in colloidal form by injecting it direct into a vein opens up a new field of research. I am not aware that this drug, administered in this form, has been tried before in cases of pulmonary tuberculosis. Having had satisfactory experience of its effects on other conditions I resolved to try it in pulmonary tuberculosis. I selected two cases of acute type where the tubercular infection was complicated by pneumococcal or other mixed organisms. The results were encouraging. Both patients said that they felt much better; the temperature came down to a lower level, night sweats were greatly modified, cough and sputum were reduced. The injections had to be discontinued as enemy enterprises made their homes unsuitable for sick people. Both were sent into the infirmary at Hendon where the treatment was not continued. I am of opinion that there is a sphere in which antiseptics such as iodine, eusol, &c., may prove to be of great benefit in cases of lung consumption when injected directly into the blood stream. In order to carry out this line of investigation properly it would be necessary to have two or three beds attached to the dispensary where the patients would be carefully nursed and treated, and observations accurately kept by the medical officer. I sincerely hope that this suggestion may some day be put into practice by the Council. Other antiseptics of recent origin such as Yadil have been employed. One cannot pronounce any definite opinion yet as to their efficacy, but symptoms have, in most of the cases treated by this type of drug, been ameliorated. We have again to acknowledge with gratitude the assistance rendered by Westminster Hospital in the diagnosis of chest and other conditions by X-ray#. Patients have been interchanged between the hospital and the dispensary for special treatment and the arrangement continues to be of great service. Interim Tuberculosis Care Committee.—A committee for dealing with -adult cases, similarly constituted to the one already existing, was formed 22 In addition, representatives from the London Insurance Committee and War Pensions Committee were elected on it. The functions and duties of those committees have already been described by the medical officer of health. So far the results of their deliberations have been disappointing as regards constructive action. Assessments on parents have been duly made and home conditions have been discussed, but beyond this little has been achieved, as the committee has no funds to administer. It is proposed in the county of Surrey to make grants from county funds in order to allow authorised care committees to deal in a practical form with tuberculosis after-care problems. This is what is required in Westminster, so that the tuberculosis care committee may be able to grapple tangibly with the needs of the patient in his home life and in his work. War Pensions Committees.—A considerable degree of overlapping has occurred in regard to the treatment of discharged tuberculous soldiers. Some time ago it happened that the W.P.C. through their medical referee were arranging for institutional treatment for a case, when at the same time the patient being an insured person was being treated and arranged for by the tuberculosis medical officer in conjunction with his panel doctor as authorised by the Local Government Board. The objects of the two parties are sometimes identical and sometimes divergent. Surely this example points the need for a unified health control. Consider the needless waste of time of medical and non-medical officials on one such case! The confusion and overlapping is still going on but in a very much less flagrant fashion owing to a working arrangement which was agreed upon by the officials of the local branches of the W.P.C. and the tuberculosis medical officer. New patients were sent for examination, See., by the following :— Recruiting or National Service Boards 140 Medical practitioners 148 Health visitors 280 London Insurance Committee 17 Westminster Health Society 27 St. Henry Fund 12 Westminster City Council 2 Friends, other patients, &c. 66 London County Council 12 War Pensions Committee 5 Infant clinic 4 Hospitals 5 718 2 3 In 1916, new patients, 553. Total attendances, 1917, 2,352; 1916, 1,380. 1916 patients who were attending in 1917 320 New patients in 1917 718 Individuals who attended during 1917 1,038 Diagnosis in 718 new patients:— Pulmonary tuberculosis 214 Other forms of tuberculosis 36 Not tuberculous 281 Suspected to be suffering from tuberculosis 187 718 At 2,352 total attendances, complete examinations were made in 1,611 instances. Visits to homes by T.M.O., 197. Visits by health visitors to dispensary cases, 2,481. Written medical reports, 636 : 170 to L.C.C. and London Insurance Committee; 466 to medical practitioners. 128 specimens of sputum were sent to the dispensary for examination. 5 patients were sent to Westminster Hospital for X-ray diagnosis or special treatment.