City of Westminster ANNUAL REPORT FOR THE YEAR 19 20 BY FRANLS J. ALLAN, M.D., C.M., D.P.H. Camb., F.F..S. Ed., Medical Officer of Health Printed by Order of the Council. L 0 N D 0 N : Harrison and sons, ltd. printers in ordinary to his' majesty, st. martin's lane, w.c.2. Annual Report on the Health and Sanitary Condition of the City of Westminster. 1920. Mr. Mayor, My Lords, Ladies and Gentlemen, I have the honour to present my Annual Report for the year 1920. It includes Returns required by the Ministry of Health and Home Office. The replies to the questions asked by the various departments of the Ministry, especially those relating to Tuberculosis work, occupy a good deal of space and make the Report larger than is desirable in the interests of economy. In reviewing the various activities of the Public Health Department, one cannot help being struck by the great increase in the number of duties which have been placed upon local authorities in the last twenty years. It is impossible in an Annual Report to give an idea of the great amount of detail work which has to be carried out. Much more office and clerical work has to be performed by the Medical Officer, and the preparation of the Annual Report has, to a considerable extent, to be done in overtime. During the year Conferences have been held to consider how best the administration of Public Health matters in London may be improved. The subject is a complicated one, involving the duties performed by the County Council, the Borough Councils, the Metropolitan Asylums Board and the Boards of Guardians. The recommendations of the Conferences were in the direction that administrative duties should fall upon the central authorities, leaving those of aw executive character to the Borough Councils. A Conference of representatives of the County Council and the Borough Councils was also held to consider the best means for dealing with measles, and of verminous conditions as affecting both children and adults, and suggestions were made which may prove helpful in improving the services rendered. In 1920 the number of births recorded were considerably above the average, and thus much extra work fell upon the Maternity and Child Welfare Centres, and the effect will last through the next five years, (3399)Q A 2 iv even though the birth-rate may fall, as these children are kept under observation until they enter school. The Council appointed the Public Health Committee as the special Committee for Maternity and Child Welfare, and they formed a Sub-Committee to which four representatives of other bodies were added. The lady members of the SubCommittee have taken much interest in the working, visiting regularly the two Centres under the Council's direct control. Among other things they consider the circumstances of applicants for the service of the midwife and for grants of milk, and decide upon the contribution which should be paid in each case. Extensions of the work have taken place in various directions—the sub-division of the Pimlico area into two, the addition of new ante-natal and medical inspection clinics, the provision of dental treatment for children under five years of age and for mothers and expectant mothers. The result of this kind of work has been very encouraging; the death-rate of young'children has been reduced to half, and it is to be expected that the improved health obtained will show its effects right on through adult life, as it is in the first few years that the foundation of good or bad health is laid. Statistics show that a child born now has an increased expectation of living eleven years more than if he had been born twenty years ago. The year 1920 was generally a healthy one for the whole country, due probably to the absence of any extremes of heat or cold; but in the autumn there was a serious amount of scarlet fever and diphtheria. Considerable anxiety existed throughout the year lest typhus fever and other zymotic diseases should be introduced into this country from eastern Europe. Typhus fever transported from Russia into Poland raged with great severity, and immigrants might easily bring it to England. A scheme for an international permanent health Committee was framed by the League of Nationsf and assistance was given to Poland to cope with the disease. These efforts, coupled with the vigilance exercised by the Port Sanitary Medical Officers, happily prevented it gaining a landing in this country. Had it done so the improved sanitary conditions, and especially the reduction in the number of persons infested with vermin through which the disease is spread, would probably have prevented any extensive outbreak of typhus fever here. I have the honour to be, Your obedient servant, FRANCIS J. ALLAN, Medical OJJiccr of Health. March, 1921 PART I. A. STATISTICS. Population. The Registrar-General has adopted the following estimates of the Population of Westminster for the year 1920 :—For death-rates, 132,615; for the birth-rate, 137,769, an increase of about 5,000 in each instance over the estimate for 1919. The former is an estimate of the Chilian population. It is difficult to make a correct estimate, consequently any rates calculated thereon cannot be regarded as reliable, and must be subject to correction when the results of the Census to be taken in 1921 are published. As the year 1920 has been taken as a 53 week year, the populations upon which the death and birth-rates have been calculated are 135,165 and 140,418 respectively. Births. The number of births registered in Westminster was 1,731, of these the home address of 89 was elsewhere, and therefore these have to be deducted, but 618 children were born to residents of Westminster in institutions in other parts of London, adding these the nett number was 2,260, to which should be added 6 infants whose bodies were found in Westminster and whose birth had not been registered, making a nett number of 2,266. During the war years the number of births fell from 2,157 in 1914 to 1,459 in 1918, the decrease being in legitimately born infants, illegitimate infants showing an increase. In 1919, while there was a slight decrease in the latter, the legitimate infants increased from 1,234 to 1,383. In 1920, there has been a marked increase in the legitimate, the nett number of these being 2,047. Calculated on the estimate of population given above, a birth-rate of 16.1 per 1,000 persons results ; the London birth-rate was 26 • 5 and for England and Wales 25.4, both showing great increase over the rates of the preceding year (18.3 and 18.5). The birth-rate for the whole country is the highest of the decade, and the number of births the highest ever recorded. 2 Births Registered. Births Notified- In Westminster. Belong elsewhere. Born out of Westminster. Nett. Total. Alive. Stillborn. 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 2,520 2,365 2,110 2,134 1,992 1,860 1,721 1,643 1,325 1,138 1,210 1,731 39 49 60 49 35 15 71 175 159 146 98 89 270 276 311 264 276 312 329 342 378 458 480 618 2,751 2,592 2,361 2,349 2,233 2,157 1,979 1,810 1,544 1,459 1,592 2,260 1,612 1,674 1,562 1,501 1,462 1,386 1,292 1,330 1,020 911 1,004 1,327 1,571 1,621 1,507 1,469 1,424 1,347 1,250 1.288 985 888 977 1.289 41 53 55 32 38 39 42 42 35 23 27 38 The notifications received numbered 1,327, in 19 instances twins were mentioned. The number of notifications received from midwives was 943. The number of still-births notified was 38, but information was received of 20 other confinements in which a dead child was born, 17 of these occurred in hospitals or infirmary ; 5 were illegitimate ; 5 sets of twins. Number Born. Number of Deaths under 1 year. Number remaining at end of year. Boys. Girls. Boys. Girls. Boys. Girls. 1913 1,120 1,113 111 102 1,009 1,011 1914 1,120 1,037 103 68 1,017 969 1915 1,006 973 103 79 903 894 1916 889 921 84 67 805 854 1917 756 788 94 64 662 724 1918 789 670 84 64 705 606 1919 786 814 74 63 712 751 1920 1,117 1,149 104 63 1,013 1,086 For each 1,000 girls born, there were in— 1913 1,006 boys. 1917 914 boys. 1914 1,080 boys. 1918 1,177 boys. 1915 1,033 boys. 1919 965 boys. 1916 965 boys. 1920 972 boys. Maternity and Child Welfare. There has been a marked increase during the year in the work in connection with mothers and infant welfare. The Pimlico Road Centre was found to be too far away for mothers from part of the arc attend, and for some time past the Council had been endeavouring to find a suitable house in the neighbourhood of Vau.xhall Bridge. Such a house could not be found in the preceding year, but in 1920 they obtained No. 15, Bessborough Street, and a fresh centre has been formed there and a portion of the Pimlico area allotted to it. The result has fully justified 3 this course, as the attendances at the medical inspection are already so numerous that an additional session is urgently required. At Rochester Row Centre an additional session for children has been instituted. Expectant Mothers.—The names of 786 were sent by hospitals, doctors and midwives, voluntarily notified or found by visitors, and to these, and to 189 cases brought forward from 1919, 2,796 visits were paid at their homes, besides numerous interviews at the Centres; 149 were carried forward to 1921, and 54 moved out of Westminster before the confinement took place. Of the 772 who were confined, 724 had live and 34 stillborn children, while there were 34 miscarriages. 225 attended the Mothercraft Classes at the various Centres. Pre-natal cases.— Pimlico. Bessborough. Greek Street. Rochester Row. Total. Brought forward from 1919 40 25 57 67 189 New cases 1920 221 102 225 238 786 261 127 282 305 975 Result— Confined—live child 194 107 200 223 724 Confined—stillborn child 6 1 18 9 34 Miscarriage 5 4 1 4 14 Moved away before finement 17 12 10 15 54 Carried forward to 1921 39 3 53 54 149 Twins (3) — (3) (3) Interviews at Centres .. .. .. .. 1,112 The sources of information were:— General Lying-in Hospital 146 Westminster „ 69 St. George's „ 19 St. Thomas's „ 26 King's College „ 2 Found by Health Visitors 98 Applied at Centre 153 Charing Cross Hospital 81 Middlesex „ 89 Royal Free „ 2 City of London „ 5 Queen Charlotte's „ 8 Private doctors and midwives 87 4 Ante-natal Clinics.—The object of these clinics is to ascertain if any abnormal conditions exist calling for treatment or for special attention at the time of delivery. Attendances were made as follows :— Centre. Sessions. First Attendance. Subsequent Attendances. Total. Pimlico Road 50 121 144 265 Bessborough Street 9 18 10 28 59 139 154 293 Attendance during Confinement.—The Council's midwife attended necessitous women and emergency cases in the Pimlico area. Eighty women were attended and 1,111 lying-in visits paid. She also paid 206 visits to expectant mothers, and 78 to infants, a total of 1,443 visits. She also attended on 55 occasions at the Ante-natal Clinics at both centres, and on 26 other occasions at Pimlico Road, besides assisting when available at the children's inspections. In the St. John and St.. Margaret's area, the Health Society has appointed two midwives. They attended 143 cases, paying 1,894 visits. They also paid 390 visits to expectant mothers and 168 in connection with infant health. In addition, 4 confinements were attended and 18 visits paid in the Pimlico area, making a total of 2,470 visits paid. In each area a sub-committee considers the cases and decides whether any contributions should be paid towards the expenses. In both districts the midwives act as monthly nurses where doctors are in attendance ; and also in co-operation with St. George's and Westminster Hospitals, where students are attending; there were 82 of these cases, included in the figures given above. Lying-in Hospital Accommodation.—There is now no hospital in Westminster specially devoted to this class of work. The general hospitals take in special cases requiring operative or other treatment, and one Home has resident midwives to attend unmarried mothers admitted thereto. That there is a desire on the part of many to enter a lying-in home for their confinement is shown by the fact that 618 infants were born in such institutions in various parts of London and the suburbs. A proposal made by the Women's Section of Comrades of the Great War to open a Maternity Home in conjunction with the Council was considered. The Council expressed the opinion that such a Home is badly required, but did not think time was opportune to incur the large annual expenditure suggested. Information was received of women being discharged 5 from Lving-in Hospitals ten days after their confinement, who thereafter had to receive medical attention, and a resolution was adopted asking that the Ministry may sec their way to consider the question of the desirability of making it, in future, a condition of their grant that mothers shall not be discharged from the Institution until fourteen days have elapsed following confinement, or such further period as may be necessary in cases requiring mcdical treatment. Mortality in Child-birth.—Ten cases of puerperal fever were notified with 2 deaths. Three were inmates of hospitals, 2 having been sent in from Rescue Homes for their confinement. Six women died after child-birth from complications : eclampsia 3 ; postpartum hemorrhage 1 ; cæsarean section 1 ; rupture of uterus 1; making a total mortality of 3.53 per 1,000 confinements. Ophthalmia Neonatorum.—See under communicable, diseases. Home-helps.—Before the war, some women were employed to undertake the work of the home while the mother was laid up or away in hospital, but during the war these women found more remunerative work or were relieved of the need of employment, and it has not been possible to get others to take their places. On the other hand, there appears to be some disinclination to leave a stranger in charge, and preference is given to a relative or neighbour. Convalescent Homes.—The Council had arranged that mothers after confinement may go for a stay of 2-3 weeks at St. Mary's Home, Birchington-on-Sea, but as accommodation could not readily be obtained, the Council decided to avail themselves of other Homes where vacancies could be obtained. No mothers were sent in 1920. In the Soho area, similar facilities are provided by the St. Henry Fund, of which the Medical Officer of Health is ex-officio a trustee. Others were sent away through various charitable agencies. Mothercraft Classes.—These exist at each Centre and are attended by mothers both before and after confinement. The class at the Pimlico Centre is under the care of Mrs. Coleman and Mrs.Grice,of the Westminster Branch of the British Red Cross Society, the former superintending the class giving instructions to the mothers and supervising the cutting out and making of garments for the children, the latter, with the assistance of other ladies, looks after the children who accompany their mothers. It is proposed to start a similar class at Bessborough Street so soon as the assent of the Ministry can be obtained. 6 Mothercraft classes are also carried on at the two other Centres by the Health Society. Particulars relating to these classes are given below Mothercraft Classes. Pimlico Road. Rochester Row. Greek Street. Total. Number of classes 48 85 94 227 Total attendances 425 1,913 1,509 3,847 Average attendances 8.8 22.5 16 - Highest number of attendances 17 40 35 - Number of expectant mothers 46 82 97 225 Number of attendances by expectant mothers 183 497 344 1,024 Number of other mothers 29 76 141 246 Number of attendances by other mothers 242 1,416 1,165 2,823 Attendances of children in nurseries 283 1,247 849 2,379 during classes— Under 1 year 127 278 306 711 Over 1 year 150 969 543 1,668 Garments made 315* l,239† 1,237‡ 2,791 * Does not include garments made of mothers' own material, † Does not include cradles, cot blankets, mothers' outfits for confinement. ‡ 107 mothers did not attend the classes, but were interviewed re clothes at the office and bought 329 garments not included in the above. Materials are purchased in quantity and sold to the mothers at cost price. 7 Infamy amd Early Childhood.—The number of visits paid by the Health Visitors in the four areas into which the City is divided, is shown in the accompanying table :—• Total. 725 1.475 2.164 7,294 10.733 5,760 28,151 Total. Vol. 122 299 222 2,635 5.958 2,045 11,881 28,151 Staff. 603 1,176 1.942 4,659 4.775 3,115 16,270 Greek Street. Vol. 19 92 92 657 2.909 400 4,169 8,428 Staff. 172 223 433 1,124 1.730 577 4,259 Rochester Row. Vol. 21 37 9 475 1,400 176 2,118 5,685 Staff. 169 492 535 1,071 1,015 285 3,567 Bessborough Street. Vol. 15 9 28 72 181 116 421 722 Staff. 21 35 40 108 42 55 301 Pimlico. Vol. 67 161 93 1,431 1,468 1,953 5,173 13,316 Staff. 241 426 934 2,356 1,988 2,198 8,143 Pre-natal— First visits Other visits Children under 1 year of age— First visits Other visits Children over 1 and under 5 years— Visits Children of school age— Visits See also visits paid by mid wives, ante. Visits were paid in connection with— Pimlico. Bessborough Street. Rochester Row. Greek Street. Total. Still-births 11 - 15 18 44 Deaths of children 87 6 44 39 176 Infectious disease 609 7 496 253 1,365 Total 707 13 555 310 1,585 8 Arrangements are made with the three local Nursing Associations for nursing children in their homes ; 2,017 visits were paid to 159 sick children. Besides the visiting, numerous consultations with the Health Visitors take place with mothers at each of the Centres. A very considerable amount of clerical work has to be undertaken in keeping records of each case, in correspondence with hospitals, bodies giving convalescent treatment, War Pensions Committees, &c. For example, in cases of expected confinements notified by hospitals, a report is sent giving information as to the condition of the home, and other particulars. Special visits were paid to children of deceased soldiers who were boarded out in Westminster. Infant consultations are held at each of the four Centres. At the Rochester Row Centre the increase of work necessitated an additional session being held each week. A similar state of affairs is now manifesting itself at Bessborough Street, the average attendance being 45 at each session. The following are details of the attendances:— 9 Attendances at Infant Consultations. Centre Number of Sessions. First Attendances. Subsequent Attendances. Total. Total. Under 1 year. Over 1 year. Under 1 year. Over 1 year, Under 1 year. Over 1 year. 1, Pimlico Road 101 401 82 2,581 603 2,982 685 3,667 15, Bessborough Street 15 64 27 471 121 535 148 683 100, Rochester Row 77 36 41 1,279 290 1,615 331 1,946 60, Greek Street 48 220 25 861 267 1,081 292 1,373 241 1,021 175 5,192 1,281 6,213 1,456 7,669 The average attendances were Pimlico Road, 36'. per session (before Bessborough Street was opened the average was 3S.0, since it has fallen to 31.0)— Bessborough Street 45.9 Rochester Row 25.2 Greek Street 28.5 In addition to the inspections by the medical officer stated above, 379 attendances for weighing only were made at Rochester Row, and 315 at Greek Street, chiefly of children of school age. Ante-natal Clinics and Infant Consultations for infants in connection with their Maternity Department are held by Charing Cross, Middlesex, and York. Road Lying-in Hospitals. 10 At the North Centre, GO, Greek Street, classes were held by Dr. Lewin for Nasal Hygiene, especially in connection with cases of adenoids and faulty nasal conditions. A DentalClinic was opened on October 20th at the Western Dispensary, Rochester Row, being staffed by a dentist and anaesthetist, and nurses provided through the County Council. The clinic is open on Wednesday mornings, and is available for mothers and children, except on the fourth Wednesday in each month, when the session is reserved for tuberculous patients. Ten ordinary sessions were held and five special sessions for gas extractions up to the end of the year; 24 patients attended, making 57 attendances. Mr. W. H. Turner reports that the majority of the patients were in a very bad dental condition and required a considerable amount of treatment. It is already evident that the Clinic is meeting a great need in the district. The following is a summary of the cases:— (1) No. of mothers or 'fexpectant mothers15 „ extractions112 „ fillings16 „ other operations 17 „ dentures required 18 (2) „ children under school age 5 „ extractions12 „ other operations 3 (3) „ tuberculous cases 4 „ extractions 30 „ fillings and other operations 9 „ dentures required 8 Day Nut series.—There is now one, the OlgaLynn Nursery, 147, Warwick Street. Another opened during the war has been given up. Hospital Treatment.—The Ministry include in their scheme the provision of an observation ward for ailing babies. This has not yet been provided as there are so many general and special hospitals in or near the City. They, however, do not altogether meet the need as admission thereto is dependent upon the accommodation available, and the opinion of the staff as to whether a case is sufficiently ill. Negotiations were opened to secure beds in a hospital for children, but the conditions proposed were not such as could be agreed to by the Council. A ward, however, has been set aside for children requiring observation at Charing Cross Hospital in connection with the Infant Consultation Centre there, but beds are occasionally available for other children. 11 Homes for Mollicrs and Infants.—There were seven Homes in Westminster for unAarried mothers, but four of these have removed to suburban districts. Another Home, which formerly admitted maternity cases, now restricts its activities to Rescue Work. They were inspected during the year. Of the remaining two, one admits mothers before and after confinement for varying periods till they can be passed on to other Homes, or placed in service, about 50 pass through this Home annually. The other admits women from Rescue Homes for confinement, after which they may stay for a period or return to the Home from which they came. Supply of Milk.—Grants of milk free or at reduced prices were made to 247 expectant and nursing mothers and to children under 5 years of age. Except in a few instances ordinary milk was granted, in the others, dried milk. The amount expended was £239 7s. 3d. for " fresh " milk, £4 8s. 8d. for dried ; total, £243 15s. 11d. Applications for milk are required to be accompanied by a certificate from the medical officer of one of the Centres, or from a hospital or dispensary medical officer. A committee was formed at each of the four Centres to consider the applications and the circumstances of the applicants, and to decide whether milk should be granted, and if so whether free or at reduced cost. Their decisions are forwarded to the Public Health Department, from which the necessary orders are issued. Each case is re-considered monthly. In cases in which the applicant is already in receipt of Poor Law Relief, or in which it is considered that such relief is required, reference is made to the Guardians, so that one authority only deals with the matter. In cases with little or no income the Guardians are able to assist with other food as well as milk. In addition to the above, dried milk is kept at all the Centres, and is supplied to suitable cases at cost price. The amount so supplied was 6,253 lbs., making a total of 6,291 lbs. sold at cost and at reduced charges. Deaths. 1,772 deaths were registered in the City in the 53 weeks. After deducting 933 deaths of non-citizens in public institutions in the City, and adding those of 761 citizens who died in other districts, the corrected total is 1,600, and is equivalent to an annual rate of 11"8 per 1,000 persons, calculated on the estimated civil population. The London death-rate for 1920 was 12 4, for England and Wales 12*4. The number of deaths and the death-rates per 1,000 for a series of years are shown below:— 12 Year. Number of Deaths. Death-rate. London Rate. 1911 2,005 12.5 150 1912 1,984 12.5 13.6 1913 2,030 12.7 14.2 1914 1,946 12.7 14.4 1915 2,138 15.7 161 1916 1,827 13.7 14.3 1917 1,896 15.5 150 1918 2,062 163 18.9 1919 1,819 14.2 13.4 1920 1,600 11.8 12.4 As previously explained, it is impossible to state the rates with any degree of accuracy, and in the years 1916-18 especially the population is believed to have been higher than the Registrar-General's estimate. The rates for 1920 are a marked improvement over those of 1918 due to the lower mortality from influenza. The deaths of males were 831, females 769. The number of deaths attributed to various causes and at various age periods are set out in the table appended to this section of the Report. Under 1. 1 to 2. 2 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to. 65. 65 and up. Total. M. 103 9 11 10 20 120 281 277 831 F. 64 9 10 17 33 102 236 298 769 1920 167 18 21 27 53 222 517 575 1,600 1919 140 24 31 33 80 265 570 676 1,819 There is an increase in the number of deaths under 1 year, corresponding to some extent with the increased number of births, but at every other age period there is a decrease. This is chiefly due to the diminution of deaths from influenza (from 220 to 41). This was counterbalanced, especially at the higher ages, by an increase in deaths from diseases of the heart and arteries (215 to 306), probably after effects of influenza in the previous year. The wards showing increases in deaths from these diseases were chiefly Victoria and St. John's, Conduit, Grosvenor and St. Anne's. Broncho-pneumonia and pneumonia also gave an increased mortality at the higher ages, which may possibly have been influenzal in character, as bronchitis deaths were 100 less. Deaths from cancer rose from 166 to 227. Deaths from accidents and from suicide were both fewer than in 1919, but deaths from alcoholism and cirrhosis of the liver rose from 11 to 23. The deaths were distributed in the wards in the years 1919 and 1920 as follows:— 13 1919. Total. 1920. 1919. Total. 1920. M. F. Total. M. F. Total. Conduit 17 9 14 23 St. Anne 93 53 44 97 Grosvenor 115 47 55 102 Gt. Marlborough 54 19 18 37 Hamlet 82 17 31 48 Pall Mall 46 26 7 33 K. St. George 134 48 54 102 Regent 74 43 18 61 Victoria 483 210 254 464 Charing Cross 32 15 11 26 St. Margaret 75 62 44 106 Covent Garden . 06 31 36 67 St. John 388 198 168 366 Strand 68 42 7 49 Homeless 98 11 8 19 When the Census figures are available it will be possible to ascertain the relative death-rates. It is evident, however, from the above figures, that males predominate in some wards, such as Regent, Pall Mall and the Strand, while in others, Knightsbridge St. George and Victoria, there are more female residents. Infantile Mortality.—The corrected death-rate of infants for Westminster was 73-6 deaths per 1,000 births, and for London 75. These are the lowest recorded. Below are given figures for both births and deaths of infants corrected, distinguishing legitimate and illegitimate births, showing the rates for a series of years Year. Legitimate. Illegitimate. Total Rate, Westminster. Total Rate, London. Births. Deaths. Death-rate per 1,000 Births. Births. Deaths. Death-rate per 1,000 Births. 1902 3,275 410 125 186 32 172 127 140 1903 3,035 345 113 150 25 166 116 130 1904 2,920 320 109 134 40 298 118 145 1905 2,971 305 102 149 24 161 105 130 1906 2,744 285 103 187 38 203 110 131 1907 2,764 269 97 163 34 208 103 116 1908 2,739 266 97 174 27 155 100 113 1909 2,548 232 91 203 26 128 93 108 1910 2,399 189 78 193 25 129 82 103 1911 2,195 210 95 166 33 198 103 129 1912 2,194 168 76 155 27 174 83 91 1913 2,057 184 89 176 29 164 95 105 1914 1,995 147 73 162 24 148 79 104 1915 1,798 141 78 181 41 225 92 112 1916 1,632 110 68 178 41 230 83.4 89 1917 1,348 112 83 196 48 239 103.6 104 1918 1,234 112 86.6 225 36 155 100 108 1919 1,383 99 71.5 217 41 188 87.5 85 1920 2,047 123 60 219 44 200 73.6 75 Five-Yearly Averages. 189296 - - - - - - 159 157 18971901 - - - - - - 150 159 190206 - - 111 - - 200 115 135 1907- 11 - - 92 - - 164 96 114 191216 - - 75 - - 188 87 100 (3399)Q B 14 The death-rate of legitimate children gives a better guide to the improvement which has taken place during the last 20 years than does the combined rate. Climatic conditions doubtless have had some influence, as, for example, the very hot summer in 1911, but to these conditions may rather be attributed the fluctuations which occur from year to year, while the steady fall in the. rate may be ascribed to the greater attention given to child life, and to improved sanitary conditions. The illegitimate death-rate has always been much higher, and its influence on the total rate is shown above. Many of the illegitimate births and deaths (and a few of the legitimate) are not really Westminster cases. Women come from the country to stay in rescue and other home3 for a few weeks before their confinement and afterwards conn return to the Homes for a time, while others return home, having boarded out the babies in Westminster or elsewhere. In other cases mothers and babies come to Westminster from Homes in other districts. The recent removal of several of these Homes from Westminster will probably produce an improvement in this respect. Whether the laxity of moral conduct be a result of the war, lapse of parental control or other causes, from a public health point of view, it must be deplored that 20 per cent. of the babies born die either from being born unhealthy or want of subsequent care, as compared with the 6 per cent. of legitimately born infants. In the three divisions into which the City is divided under the Maternity and Child Welfare Scheme, the figures (omitting the homeless] were:— Centre. Legitimate. Illegitimate. Total. 1920. 1919. 1918. 1920. 1919. 1918. 1920. 1919. 1918. Pimlico— Births 930 634 531 99 107 85 1,029 711 616 Deaths 58 37 44 25 15 11 83 52 55 Death rate per 1,000 births 62.4 61 82.8 252 140 129 80.6 73.1 89.2 Greek Street— Births 526 354 367 74 56 57 600 410 424 Deaths 26 29 30 5 5 7 31 34 37 Death-rate per 1,000 births 49.4 82 81.7 67.5 89 122 51.6 83 87.0 Rochester Row— Births 593 420 359 35 44 51 028 464 410 Deaths 39 28 36 7 10 9 46 38 45 Death-rate per 1,000 births 65.7 66.6 81.8 200 227 176 73.2 83 109.7 15 The rate of 49'4 in legitimate children in the Greek Street area is remarkable. The causes of death of children under 1 year of age in the three areas are set forth in Tables appended, and a summary showing the proportion of deaths per 1,000 births from various grouped causes in the last seven years is set out below :— 1914. 1915. 1916. 1917. 1918. 1919. 1920. Influenza 0.4 0.5 — — 6.81 5.62 — Measles 0.9 3.5 0.5 3.9 0.68 1.87 2.21 Whooping cough 5.0 1.5 1.6 1.9 3.4 0.62 — Septic diseases 2.3 1.5 — 1.9 — — 0.44 Bronchitis and pneumonia 11.5 14.1 15.4 16.8 16.35 10.00 12.80 Stomach and bowel complaints 12.5 151 12.7 71 10 89 8.75 9.29 Syphilis 1.4 50 4.9 8.4 613 5.62 2.64 Congenital malformations 7.4 4.5 6.7 5.8 4.76 3.75 6.19 Prematurity 16.6 20.7 20.9 27.2 23.3 21.2 15.40 Neglect and injury at birth 4.6 7.7 6.7 6.7 8.17 7.50 7.07 Debility from birth and atrophy, rickets, atalectasis 6.9 10.7 5.5 13.6 8.17 13.12 11.48 Tuberculosis 0.9 3.0 4.4 2.6 6.13 2.50 1.76 Other causes 6.5 3.0 3.4 7.1 5.45 6.82 4.34 77.4 90.8 82.7 103.0 100.24 87.50 73.62 Infant death-rates are usually stated as so many per 1,000 births which occur in the same year. But only a proportion of the deaths are of children born in the same year, thus, of the 167 infants dying in 1920, 29 were infants born in 1919. Consequently a year with a high birth-rate following a year with a low one may show a reduced infantile rate. If the birth-rate in 1921 falls again, then the converse may take place and the infantile death-rate will be higher in 1921 than in 1920. The RegistrarGeneral calculated the death-rates for the years 1912-17 inclusive on the estimated population under 1 year of age, showing the effect of a high birth-rate on the deaths in the succeeding year. Worked out on this method, the infantile death-rate shows a continuous fall in each of the war years in England and Wales from 117 to 94. 16 MALES Table I.—Causes of, and Ages al, Death during the year 1920. Causes of Death. Corrected Deaths in the City at subjoined Ages. Deaths in Wards (at all Ages). All ages. Under 1. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Conduit. Grosvenor. Hamlet of Knightsbridge. Knightsbridge St. George. Victoria. St. Margaret. St. John. St. Anne. Great Marlborough. Pall Mall. Eegent. Charing Cross. Covent Garden. Strand. Homeless. Smallpox — — — — — — — — — — — — — — — — — — — — — — — — Measles 8 3 2 1 1 — — 1 — — — — — 2 2 3 — — — — — 1 — — Scarlet fever 2 — 1 — — — 1 — — — — — — 1 — 1 — — — — — — — — Influenza 19 — — — — 1 7 8 3 1 2 1 1 2 3 3 — — 2 1 1 1 — — Whooping-cough 3 — 2 1 — — — — — — — — — — — — — — — — — — — — Diphtheria, Memb. croup 6 — — 1 2 1 1 1 — — — 1 — 2 1 1 — — — — — — — — Cerebro-spinal meningitis 1 — — — — — — 1 — — — — — — — — — — — — — — — — Poliomyelitis — — — — — — — — — — — — — — — — — — — — — — — — Enteric fever 1 — — — — — — — — — — — — — — — — — — — — — 1 — Diarrhoea, enteritis 15 14 — — — — — — — — — — — 9 2 3 — — — — — 1 — — Erysipelas 1 — — — — — — — — — — — — — — — — — — — 1 — — — Puerperal ferver — — — — — — — — — — — — — — — — — — — — — — — — Other septic diseases 6 1 — — 1 — 1 — 3 — — — — 2 — 1 1 2 — — — — — — Syphilis, Ac 8 6 1 — — — 1 1 — — — 1 — 2 — — 1 1 — 1 — 1 — 1 Diabetes 9 — — — — — 3 2 4 — — 1 — 2 1 2 1 1 1 — — — 1 — Rheumat ic fever 1 — — — — — — — 1 — — — — — — 1 — — — — — — — — Tuberculosis of meninges 2 1 — 1 — — — — — — — — — — — 2 — — — — — — — — Tuberculosis of lungs 82 1 2 2 — 3 25 43 — — 4 — 4 24 2 26 3 1 1 5 — 2 8 2 Tuberculosis of peritoneum 2 1 — — — — — 2 — — — — — — 2 — — — — — — — — — — 17 Other forms of tuberculosis 2 — — — — — 2 — — — — — — 1 — 1 — — — — — — — — Malignant growths 103 — — — — 1 8 54 40 1 4 1 10 19 5 31 6 4 6 6 2 3 4 1 Congenital debility, malformation, and premature birth 50 50 — — — — — — — 1 1 1 2 24 6 6 4 1 — 2 — 2 — — Old age 27 — — — — — — — 27 1 1 1 — 7 — 6 3 4 — — — 2 1 1 Meningitis and convulsions 1 1 — — — — — — — — — — — — — 1 — — — — — — — — Loc. ataxia and general pnralysis 7 — — — — — 3 2 2 — — — 2 1 — 1 — — 1 — — 1 1 — Other diseases of nervous system 16 — — — — — 2 6 8 — 2 — 1 4 1 4 — — 1 — 1 1 1 — Valvular diseases of heart 41 — — — 1 1 10 19 10 — 4 2 3 11 4 13 1 — — 1 L — — — Other circulatory diseases 114 2 — — — — 11 40 61 2 12 2 9 32 12 26 3 2 — 5 — 4 3 2 Bronchitis 88 2 — 1 — — 3 24 58 — 5 — 1 14 8 23 10 — 2 1 — 1 11 3 Broncho-pneumonia 35 13 1 1 1 — 3 6 10 — 2 2 2 11 2 7 2 1 — 3 1 1 1 — Pneumonia, other forms 50 1 — 1 — 5 13 17 13 — 1 2 5 9 1 11 4 1 1 4 2 3 6 — Other respiratory diseases 7 — — — — — — 4 3 — 1 1 1 2 — — — •— 1 — — — 1 — Alcoholism 4 — — — — — 3 — 1 — — — — — 1 1 — — 1 1 — — — — Cirrhosis of liver 11 — — — — — 1 9 1 — 2 — 1 2 1 2 — 1 1 — — 1 — — Appendicitis and typhlitis 7 — — 1 1 3 2 — — — — — — 3 1 1 1 — — 1 1 — — — Other digestive diseases . 22 3 — — — 1 1 12 5 1 1 — 1 6 4 5 — — 1 1 2 — — Bright's disease, &c. 23 — — — — — 4 12 7 1 — — 1 6 2 5 — — 1 l 2 2 2 — Cystitis, &c 15 — — — — 1 — 3 11 — 2 — 3 4 — 1 1 — 2 1 — 1 — — Accidents and diseases of parturition — — — — — — — _ — — — — — — — — — — — — — — — — Deaths by accident or negligence 19 2 — — 1 2 4 7 3 — 3 — — 2 2 1 4 — 2 3 1 — 1 — Deaths by suicide and murder 11 1 — — — 1 4 5 — — — — — 1 1 2 1 — 3 1 1 — — 1 Other defined diseases 10 2 — — 2 — 3 3 — — — 1 1 2 — 4 1 — — — 1 — — Diseases, ill defined or unknown 2 1 — 1 — — — — — 1 — — — — — 1 — — — — — — — — All causes 831 103 9 11 10 20 120 281 277 9 47 17 48 210 62 198 53 19 26 43 15 31 42 11 18 FEMALES. Table I.—Causes of, and Ages at, Death during the year 1920. Causes of Death. Corrected Deaths in the City at subjoined Ages. Deaths in Wards (at all Ages). All ages. Under 1. 1 and under 2. 2 and under 5. 5 and under 15. 15 and undor 25. 25 and under 45. 45 and under 65. 65 and upwards. Conduit. Grosvenor. Hamlet of Knightsbridge. Knightsbridge St. George. Victoria. St. Margaret. St. John. St. Anne. Great Marlborough. PaU MaU. Regent. Charing Cross. Covent Garden. Strand. Homeless. Smallpox — — — — — — — — — — — — — — — — — — — — — — — — Measles o 1 1 — — — — — — — — — — 1 — 1 — — — — — — — — Scarlet Fever 3 — — 1 2 — — — — — — — — — — 2 — — — — — — — — Influenza 22 — — — — 1 5 8 8 2 3 2 4 6 1 3 — — — — — 1 — — Whooping-cough — — — — — — — — — — — — — — — — — — — — — — — — —Diphtheria, Memb. croup 4 — 1 — 3 — — — — — — — — 1 — 2 1 — — — — — — — Cerebro-spinal meningitis 1 — — — — — — 1 — — — — — 1 — — — — — — — — — — Poliomyelitis — — — — — — — — — — — — — — — — — — — — — — — — Enteric Fever 1 — — — — — 1 — — — — — — — — — 1 — — — — — — — Diarrhoea, enteritis 12 7 2 — — — — — — — — — — — — — — — — — — — — — Erysipelas — — — — — — — — — — — — — — — — — — — — — — — — Puerperal Fever 2 — — — — — 2 — — — — — — — 1 1 — — — — — — — — Other septic diseases 13 1 — — — 2 3 3 4 1 2 — — 4 2 1 — — — 1 — 2 — — Syphilis, &c. — — — — — — — — — — — — — — — — — — — — — — — — Diabetes 9 — — — 1 — 1 5 2 — 1 — 1 1 2 3 — — — — — 1 — — Rheumatic fever 2 — — — — — — 2 — — — — — — — 2 — — — — — — — — Tuberculosis of meninges 3 — — — 3 — — — — 1 — — — — — 2 — — — — — — — — Tuberculosis of lungs 57 2 — 2 1 12 23 16 1 — 2 2 4 21 5 13 5 1 — 1 1 2 — — Tuberculosis of peritoneum 4 — — 1 1 1 — 1 — — 1 — — 1 — — 2 — — — — — — 19 Other forma of tuberculosis 6 — 1 — — 1 3 — — — — — — 2 — 2 — — — — — 1 — — Malignant growths 114 — — — — — 13 56 45 2 12 6 5 44 8 23 1 — 1 2 1 6 3 — Congenital debility, malformation, and premature birth 32 32 — — — — — — — — 1 1 5 6 3 10 2 — — 2 1 1 — — Old age 47 — — — — — — — 47 — 2 3 5 15 1 14 1 1 — 1 — 1 1 2 Meningitis and convulsions 1 1 — — — — — — — — — — — — — — — — — — — — — — Loc. ataxia and general paralysis 3 — — — — — 1 2 — — — — — 2 — 1 — — — — — — — — Other diseases of nervous system 18 — — — — 1 2 9 6 1 — — 1 3 3 4 1 1 — 2 1 1 — — Valvular diseases of heart 43 — — — — 1 4 20 18 2 5 5 3 10 5 6 2 4 — — — — 1 — Other circulatory diseaae8 108 — — — 1 2 9 38 58 2 7 5 4 37 4 24 11 3 — 1 2 5 — 3 Bronchitis 83 4 — — 1 — 2 17 59 1 3 — 6 30 2 20 f 6 5 — 1 1 — 2 Broncho-pneumonia 27 8 2 2 — 1 — 3 11 — 1 2 1 13 — 5 2 — — 1 — 2 — — Pneumonia, other forms 33 1 — — 1 3 7 11 10 — 4 — 2 13 1 4 2 — 3 1 1 1 1 — Other respiratory diseases 10 — — — — — 1 4 5 — 2 — 1 1 1 — 1 1 — — — 5 — — Alcoholism — — — — — — — — — — — — — — — — — — — — — — — — Cirrhosis of liver 8 1 — — — — 2 4 1 1 3 — — 2 — — — — 1 — 1 — — — Appendicitis and typhlitis 7 — — — 2 2 — 3 — — — — 1 2 1 1 — — — 1 — 1 — — Other digestive disesaes 25 1 — 1 — 2 2 12 7 — 1 1 5 7 2 2 1 — — 1 2 2 1 — Bright's disease, &c. 23 — — — 1 — 2 10 10 — — 1 1 5 — 9 1 1 — 2 — 3 — — Cystitis, &c. 2 — — — — 1 1 — — — — — 1 1 — — — — — — — — — — Accidcnts and diseases of parturition 6 — — — — — 6 — — — — 1 1 2 — 1 1 — — — — — — — Deaths by accident or negligence 17 4 1 2 — 2 3 3 2 2 — 2 6 — 4 2 — — — — — — 1 Deaths by suicide and murder 8 — — — — — 5 2 1 1 1 1 — 1 1 — 1 — 2 — — — — — Other defined diseases 12 1 1 1 — — 4 3 2 — — 1 1 3 — 3 — 1 — 1 — 2 — — Diseases, ill defined or unknown 2 — — — — 1 — — 1 — — — — 1 1 — — — — — — — — — All causes 769 64 9 10 17 33 102 236 298 14 55 31 54 254 44 168 44 18 7 18 11 36 7 8 20 Table V.—Infant Mortality, 1920. Nctt deaths from slated causes a' various ages under One Year of Age in the City of Westminster. causes of death. Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3— 4 Weeks. Totnl under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Months. 9 Months and under 12 month?. Total Deaths under 1 Year. Measles — — — — — — 1 — 4 5 Whooping cough — — — — — — — — — — —Erysipelas — — — — — — — — — — Umbilic.il sepsis — — 1 — 1 — — — — 1 Tuberculosis — — — — — 1 — 2 1 4 Syphilis 2 — — — 2 2 1 1 — 6 Meningitis — — — — — — — — — — Bronchitis — — 1 1 2 4 — — — 6 Pneumonia (all forms) 1 1 4 — 6 8 4 3 2 23 Diarrhœa — — — 1 1 2 1 1 — 5 Enteritis 1 1 — — 2 3 6 4 — 15 Gastritis — — — — — — — 1 — 1 Injury at birth 9 — — 1 10 — — — — 10 Neglect at birth 5 — — — 5 — — — — 5 Murder 1 — — — 1 — — — — 1 Atelectasis 3 — — — 3 — — — — 3 Congenital Malformations 7 — 2 — 9 1 2 2 — 14 Premature birth 30 4 — — 34 1 — — — 35 Atrophy, marasmus — — — 2 2 5 1 — — 8 Debility from birth 11 — — — 11 1 — — — 12 Rickets — — — 1 1 1 1 — — 3 Accidents 1 — — — 1 1 — — 1 3 Other causes — — 1 — 1 — — 5 1 7 Totals 71 6 9 6 92 30 17 19 9 167 Nett Births in the year— Males. Females. Total. Legitimate 1,000 1,047 2,047 Illegitimate 117 102 219 1,117 1,149 2,266 Nett Deaths in the year of— Males. Females. Total. Legitimate infants 76 47 123 Illegitimate infants 28 16 44 104 63 167 The causes of death of the Illegitimate were :—Measles 1, tuberculosis 1, bronchitis 2, pneumonia 4 enteritis 4, syphilis 5, neglect at birth 5, murder 1, atelectasis 1, congenital malformation 1, prematurity 5, marasmus and debility from birth 7, rickets 2. 7 infants had no known address, and the births of G of these (3 male, 3 female) were not registered, the dead bodies having been found, but the deaths are included in the above Table. 21 Table V, continued.—Infant Mortality, 1920. Nett deaths from stated causes at various ages under One Year of Age in Pimlico Ana ( Victoria, Kniglitsbridgc St. George and llamlet Wards). CAUSES OF DEATH. Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3—1 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. j 3 Months and under 6 Months. 6 Months and under 9 Mouths. 9 Mom lis and under 12 Months. ] Total Deatht under One Year. Measles — — — — — — — — 1 1 Tuberculosis — — — — — — — 1 — 1 Meningitis — — — — — — — — — — Bronchitis — — — 1 1 — — — — 1 Pneumonia (all forms) 1 1 4 — 6 4 4 2 2 18 Diarrhœa — — — 1 1 2 1 1 — 6 Enteritis 1 1 — — 2 2 2 2 — 8 Gastritis — — — — — — — — — — Syphilis i — — — 1 1 — — — 2 Injury at birth 2 — — — 2 — — — — 2 Atelectasis 3 — — — 3 — — — — 3 Congenital malformations 3 — 1 — 4 1 1 1 — 7 Premature birth 14 4 — — 18 1 — — — 19 Want of attention 1 — — — 1 — — — — 1 Atrophy, marasmus and debility froivi birth.. 5 — — 1 6 3 1 — — 10 Accident — — — — — — — — 1 1 Rickets — — — 1 1 — 1 — — 2 Other causes — — 1 — 1 — — 1 — 2 Totals 31 6 6 4 47 14 10 8 4 83 *Tett Births in the year— Legitimate 930 Illegitimate 99 Nett Deaths in the year of— Males. Females. Total. Legitimate infants 36 22 58 Illegitimate infants 17 8 25 Deaths of infants with no known address, or found in streets, parks, &c CAUSES OF DEATH. Under 1 Week. ]—2 Weeks. 2—3 Weeks. 3—4 Weeks. Total un»ler 4 Weeks. 4 Weeks and under 3 Months. 3 Months and un<ler 6 Months. f> Mouths and under 9 Months. 1 9 Months and under | 12 Months. j Total Deat hs winter 1 Year. Syphilis — — — — — — — 1 — l Bronchitis — — — — — 1 — — — l Neglect at birth 4 — — — 4 — — — 4 Murder 1 — — — 1 — — — — 1 5 — — — 5 1 — 1 — 7 Males. Females. Legitimate — — Illegitimate 3 4 22 Table V, continued.—Infant Moktalitv. 1920. Nett Deaths from stated causes at various ayes under One Year of Age in St. John and St. Margaret Wards. CAUSES of DEATH. Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3—4 Week6. Total under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under 1 Year. Diphtheria — — — — — — — — — — Influenza — — — — — - — — — — — Measles — — — — — — — — 3 s Whooping cough — — — — — — — — — — .Umbilical sepsis — — — — — — — — — — Tuberculosis — — — — — — — — 1 2 Meningitis — — — — — — — — — — Bronchitis — — 1 — 1 2 — — — 3 Pneumonia (all forms) — — — — — 2 — — — 2 Diarrhœa — — — — — — — — — — Enteritis — — — — — 1 4 2 — 7 Gastritis — — — — — — — 1 — 1 Syphilis — — — — — — — — — — Rickets — — — — — 1 — — — 1 Injury at birth 5 — — 1 6 — — — — 6 Congenital malformations 2 — 1 — 3 — 1 1 — 6 Premature birth 6 — — — 6 — — — — 6 Atrophy, marasmus — — — 1 1 1 — — — 2 Atelectasis 1 — — — 1 — — — — 1 Debility from birth 1 — — — 1 1 — — — 2 Accident — — — — — 1 — — — 1 Other causes — — — — — — — 3 1 4 Totals 15 — 2 2 19 10 5 7 5 46 Nett Births in the year— Legitimate 593 Illegitimate 35 Nett Deaths in the year of— Males. Females. Total. Legitimate infants 25 14 39 Illegitimate infants 5 2 7 23 Table V, continued.—Infant Mortality, 1920. Nett Deaths from, stated causes at various ages under One Year of Age in the North, District (Grosvenor, Conduit and Strand Borough Wards). CAUSE OF DEATH. Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3—1 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under 1 Year. Diphtheria — — — — — — — — — — Influenza — — — — — — — — — — Measles — — — — — — 1 — — 1 Whooping cough — — — — — — — — — — Umbilical sepsis — — 1 — 1 — — — — 1 Tuberculosis — — — — — — — 1 — 1 Bronchitis — — — — — 1 — — — 1 Pneumonia (all forms) — — — — — 2 — 1 — 3 Diarrhœa — — — — — — — — — — Enteritis — — — — — — — — — — Syphilis 1 — — — 1 1 1 — — 3 Injury at birth 2 — — — 2 — — — — 2 Atelectasis — — — — — — — — — — Congenital malformations 2 — — — 2 — — — — 2 Premature birth 10 — — — 10 — — — — 10 Atrophy, marasmus — — — — — 1 — — — 1 Inanition and debility from birth 4 — — — 4 — — — — 4 Pickets — — — — — — — — — — Accident 1 — — — 1 — — — — 1 Other causes — — — — — — — 1 — 1 Totals 20 — 1 — 21 5 2 3 — 31 Nett Births in the year— Legitimate 526 Illegitimate 74 Nett Deaths in the year— Males. Females. Total. Legitimate infants 15 11 26 Illegitimate infants 3 2 5 24 B.—Commonicable diseases. The details respecting the notifications of infectious disease received are set out in the form required by the Ministry on the adjoining page. The following summary shows the number of cases which came to the notice of the Department in 1919 and 1920. 1919. 1920. 1919. 1920. Small-pox 1 — Poliomyelitis — — Cholera (C). Plague (R) — — Encephalitis lethargica 4 3 Diphtheria 133 229 Ophthalmia neonatorum 25 — Erysipelas 75 70 Measles 516 703 Scarlet fever 239 395 German measles 159 45 Typhus fever — — Pneumonia 187 112 Enteric fever 9 14 Malaria 33 10 Relapsing fever (R) — — Dysentery — 3 Continued fever (C) — 1 Trench fever — — Puerperal fever (C) 5 10 Anthrax 2 — Cerebro-spinal meningitis 4 4 Smallpox.—No cases were notified, but two cases occurred in persons who were employed in Westminster. Contacts were carefully watched and no secondary cases developed. Information was received of 176 persons coming to Westminster who had been in contact with cases, or coming from infected ports. These were kept under observation. The Public Vaccinators and the Vaccination Officers have forwarded the following particulars for the year:— Ordinary vaccinations 1,707 Re-vaccinations 102 None were performed by the Medical Officer of Health under the Public Health (Smallpox Protection Regulations, 1917). Scarlet fever.—There was a sharp increase of this disease in the latter part of the year, but the total number of cases was below the average of pre-war years. 5 cases were fatal—1.25 per cent. of the cases notified. Diphtheria also increased, and the number of cases was larger than in any preceding year. Medical men were supplied with antitoxin free for all cases of diphtheria unable to be moved or in which any delay was likely to occur; 55 bulbs were so supplied. 10 persons died from diphtheria; 4-3 per cent, of the cases notified. Swabbings from 331 throats were submitted for bacteriological examination. 25 City of Westminster.— Cases of Infectious Disease Notified during tlu year 1920. Notifiable Diseases. Cases Notified in the Citt or Westminster. Total Cases Notifibd in each Ward. removed to Hospital. At all Ages. At Ages—Years. Conduit. Oroavenor. Knightsbridge St. George. Victoria. St. Margaret. St. John. Hamlet of Knightsbridge. Pall Mall. Regent. Great Marlborough. Charing Cross. Covent Garden. Strand. St. Anne. Homeless. 0 to1. 1 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to 65. 65 and upwards. Small-pox — — — — — — — — — — — — — — — — — — — — — — — — Cholera (C). Plague (R) — — — — — — — — — — — — — — — — — — — — — — — — Diphtheria 229 3 42 123 35 20 6 — 1 8 20 57 13 92 3 2 5 3 3 10 1 8 3 219 Erysipelas 70 1 — 3 5 21 23 17 — 2 2 20 3 16 3 2 5 — 1 4 1 1 10 29 Searlot fever 394 1 52 270 44 27 — — 1 17 21 116 23 167 10 3 7 5 4 14 1 5 378 Typhus fover — — — — — — — — — — — — — — — — — — — — — — Enteric fever 14 — — 2 4 6 3 — — 1 4 2 2 1 1 — — — — 1 — 2 — 8 Relapsing fever (R) — — — — — — — — — — — — — — — — — — — — — — — — Continued fover (C) 1 — — — 1 — — — — — — — — — — — — — — — — — — 1 I'ucrperal fever 10 — — — 2 8 — — — — — 5 — 3 — 1 1 — — — — — — 5 Grebro-spinal meningitis 2 — — — — — — — — — — — — — — — — — — — — — — 2 Polio-mylitis — — — — — — — — — — — — — — — — — — — — — — — — Encephalitis lethargica 3 — — 1 — 1 1 — — . — — 1 2 — — — — — — — — — 1 Ophthalmia neonatorum 28 28 — — — — — — — — 4 10 — 5 1 — 2 1 1 — — 3 1 10 Pneumonia 112 9 10 14 10 35 28 6 — 6 7 35 6 30 3 — 3 3 1 3 2 3 10 73 Malaria 10 — — — — 10 — — 1 3 — 3 1 2 — — — — — — — — — 1 Dysentery 2 — — — — 2 — — — — — 2 — — — — — — — — — — — 1 Trench fever — — — — — — — — — — — — — — — — — — — — — — — — Totals 875 42 104 415 101 129 61 23 3 37 58 254 48 318 21 8 23 12 10 32 5 22 24 728 Correction has been made for errors in notification or revision of diagnosis. Cases not notified: Cerebro-spinal meningitis, 2; Scarlet fever, 1; Dysentory 1. 26 Typhoid fever.—The cases of this disease were 14 ; 3 being cases of Paratyphoid B. Nine of the persons affected were infected elsewhere before coming to Westminster. In three cases there was a history that the patients had eaten watercress. In two, no probable source of infection was found. There were two deaths. Measles.—Notices were received from schools of 563 children suffering or suspected to be suffering from Measles. Of these, 8 were found to be ill from other complaints. Most of the schools notify fairly promptly, but with a few there is frequently considerable delay, so much so in some instances that when the Health Visitor calls, she finds that the child has recovered. Some improvement to ensure more prompt notification is necessary if visiting is to be of any use. At present the delay appears to be caused through intimation having to be given first to the school attendance officer and then waiting until he reports. A scheme has been adopted by the Education Authority with the intention of expediting notification by which when a school is specially affected with measles, a nurse will be detailed to visit the school daily to examine the children. Doctors and parents notified 40 cases, and 72 others were found by the Visitors visiting other cases. Information was also received of 36 adult cases moved to hospital or nursing homes, 18 being from hotels or clubs. There were also 45 cases of Rubella (Rose rash or German measles), mostly in children. The total cases of both diseases numbered 748, of whom 669 were children under 15 years of age. Of the latter, 38 were admitted to hospital or infirmary. Visits were paid to 421 houses in which children were ill—frequently there were several ill in one house. The total visits paid by the Health Visitors were 718. Nurses were called in to assist in 32 instances, and paid 4 74 visits No doctors attended in 161 cases. Deaths occurred in 10 instances. The ages were : under 5 years, 8 ; between 5 and 15, 1 ; and over 45, 1. During the months of February and March, unprotected children were excluded from the Infants' Departments of the following schools :— Holy Trinity, St. Anne's, Millbank, St. Martin's, St. Margaret's, St. Mary's Hide Place, and Brompton (C. of E.) Diarrhoea and Enteritis.—27 deaths occurred—only a few of the deaths being from the acute form of enteritis which occurs during the 27 hot months of the year; 23 of the deaths were of children under 2 years of age; the other 4 persons over 45. Puerperal Fever.—10 cases were notified and 2 deaths occurred. One of the cases was probably scarlet fever. Influenza.—This complaint was certified as the cause of 41 deaths— 19 males and 22 females, all in adults. Serum for preventive inoculation was provided by the Ministry and 42 bottles (sufficient to treat G72 persons) were supplied free to medical men in Westminster. The results obtained were regarded as satisfactory by some, but not by others. Cerebrospinal Fever.—Four cases occurred, 1 male and 3 females; two of the cases died in the Infirmary. Encephalitis Lelhargica.—Three cases occurred, one male (age 54) and two females (12| and 40 years). No deaths were recorded. Whooping Cough.—62 cases came to the knowledge of the Department, 3 deaths occurred, all of children under 2 years of age. Visits were paid by Health Visitors and Nurses as follows:— Health Visitors. Nurses. Puerperal fever 18 Ophthalmia neonatorum 197 421 Measles 718 474 Influenza 69 Pneumonia — 386 Whooping cough 125 137 Bronchitis 421 Epidemic diarrhœa — 10 Other complaints — 99 1,058 2,017 The total number of cases attended by nurses was 159. Ophthalmia Neonatorum.—28 cases were notified, but 16 others in which the eyes were more or less affected came to the knowledge of the Department through the Health Visitors. In three cases, the affection seemed to have appeared after the midwife had ceased attendance, in one bad case a mcdical man went away on holiday just after seeing the patient and did not notify. He was severely censured by the Public Health Committee. Applications were made by the mother to the Health Centre, and the child was immediately removed to hospital, and this was the 28 only case in which any permanent injury resulted, one eye w'|ch was ulcerated having an opacity left when it healed. Two children notified in other Boroughs came to Westminster; 3 moved from Westminster, and 2 who were in the Infirmary did not return. Thirteen of the infants were born in Institutions, 3 were illegitimate, and 3 eventually died. Transmigrants.—The County Council, in May, 1920, addressed a letter to the Home Secretary calling his attention to the lack of proper accommodation provided for aliens travelling from the Continent to America, and vice versa, while passing through London. The method adopted by the shipping agents was to house these persons in common lodging houses, chiefly in the East End of London (similar use was made of one in Westminster). These places were considered unsuitable, and in addition the persons housed in them were free to mix with the general public. In view of the serious menace to the public health occasioned by the temporary accommodation of transmigrants from countries where typhus and typhoid, smallpox and other dangerous infectious diseases are prevalent, it was proposed that suitable buildings should be acquired for the purpose of housing such persons. The Home Secretary agreed that it was desirable to protect the public from the dangers involved in the scattering of alien transmigrants over a large number of common lodging houses and private premises, and the shipping companies to meet the views expressed, desired to utilise the vacant workhouse in Poland Street for housing these people. The City Council refused to agree to this, on the grounds that the construction of the building was unsuitable (the Ministry of Health on the report of their Architect had previously declined to allow the workhouse to be used for the temporary accommodation of persons dishoused on account of the structural condition, want of air and light), and that it was undesirable to bring persons coming from countries in which infectious and contagious diseases were prevalent, from the port of landing to premises in Central London and to a district already containing a large foreign element. The City Council suggested that it would be better to house these people in premises near the point where they disembark. It was also suggested that the question be considered whether it is necessary to bring these transmigrants through London, and whether it would not be possible to dispatch them from Tilbury or Harwich by special trains to the ports at which they would re-embark. It is understood that premises in East Londonhave since been acquired. Plague and Typhus.—19 persons coming from plague and typhusinfected countries were kept under observation. 20 Tuberculosis. In 1920, 276 new cases of pulmonary disease were notified and 33 persons died who had not been notified in Westminster, a total of 309 against 353 in 1919. Non-pulmonary forms of tuberculosis gave 58 new cases. The reduction in pulmonary cases is restricted to males, 172 against 227, notwithstanding the inclusion in the males of 58 ex-soldiers and sailors. Female cases show a slight increase, 137 against 126. The number of asylum cases decreased from 40 during the war to 16, showing that these institutions were returning to normal conditions. Military eases in barracks in Westminster which were excluded during the war were again made notifiable in 1920. The figures for a series of years are shown below Pulmonary. Total. Non-Pulmonary. Total. Total of all forms. General Population. C.L.H. and no Address. Males. Females. Males. Females. Males. Females. 1911 193 119 109 3 424 — — 77 501 1912 233 154 115 10 512 — — 59 571 1913 203 174 89 8 474 91 86 177 651 1914 186 105 94 4 390 34 38 72 462 1915 155 95 59 8 317 46 26 72 389 1916 183 135 64 9 391 42 39 81 472 1917 209 164 51 7 431 42 34 76 507 1918 293 225 40 4 562 50 55 105 667 1919 197 122 30 4 353 35 23 58 411 1920 143 133 29 4 309 29 29 53 367 Since 1914 the number of ex-soldiers and sailors notified was 257, and there were 25 cases among refugees. A return required by the Ministry is appended, also a table showing the distribution of the cases in the various wards of the city. (3399)q 0 36 Tuberculosis.—Notifications received during 1920. 1020. Age periods. Number of notifications on Form A. Primary notifications. Total notifications, on Form A, Including cases previously notified. 0 to 1. 1 to 6. 6 to 10. 10 to 15. 15 to 20. 20 to 25, 25 to 35. 35 to 45. 45 to 65. 55 to 65. 65 and up. Total new cases. Pulmonary— Casuals— • Males — — — — 2 2 3 6 6 4 4 27 33 Females — — — — — — — 1 1 — — 2 5 General— Males 1 2 5 9 9 18 29 28 14 16 1 132 147 Females — — 1 8 11 12 32 26 16 7 1 114 128 Non-pulmonary— Males 1 4 7 5 1 3 3 1 3 — — 28 28 Females — 3 7 5 1 2 1 — — 1 — 20 22 Total 2 9 20 27 24 37 68 62 40 28 6 323 363 Number of notifications on Form B. (School medical Inspection.) Number on Form C. Admissions to. Number on Form D. Discharges from. Primary notifications. Total notifications, including cases previously notified. Poor Law institu• tions. Sanatoria. Poor Law institutions. Sanatoria. Under 5. 5 to 10. 10 to 16. Total. Pulmonary— Males — — — — — 14 92 4 77 Females — — 1 1 1 6 42 3 36 Non-pulmonary— Males — — — — — — 2 1 1 Females — — 3 3 3 — 4 — 2 Total — 4 4 4 10 140 8 116 Deaths registered but not Dotified:—Casuals—Males 2, ages 50, 61; females 2, ages 23, 52. General—Males 11, nges 20/12, 30, 35, 40, 46, 46, 54, 57, 57, 69, 73; females 18, ages 1/12, 8/12, 4, 12, 21, 29, 31, 32, 34, 34, 41, 45, 46, 47, 50, 56, 56, 61. Non-pulii.onnry—Males 1, age 38 ;. females 6, ages 2, 2, 2, 8, 11, 52. 31 (3399)q o 2 Tuberculosis.—Table showing distribution in Wards of notified and unnotified cases, 1920. 1920. All Ages. Conduit. Grosvenor. Knightsbridge St. George. Victoria. St. Margaret. St. John. Hamlet of Knightsbridge. Pall Mall. Regent. Great Marlborough. Charing Cross. Covent Garden. Strand. St. Anne. Homeless Pulmonary— Common Lodging-houses, &c. Males 29 — — — 2 — 6 — — — — — 12 1 8 Females 4 — — — — — 1 — — — — — — — 1 2 General— Males 143 2 10 2 50 9 23 1 4 9 6 5 11 3 8 1 Females 133 1 6 6 50 11 29 3 1 6 3 6 4 — 7 — Non-pulmonary— Males 29 — — 1 12 3 9 — — 1 — — — — 1 2 Females 29 1 3 — 11 3 7 — — — — — 3 — 1 — 367 4 19 9 125 26 75 4 5 16 8 11 18 15 19 13 Insured Persons. Military Cases. Ex-Soldiers and Sailors. Asylum Cases. 111 previous to Rosidenoe in City. Pulmonary— Males 82 4 51 5 41 Fomales 67 1 — 11 35 Non-pulmonary— Males 4 — 8 — 5 Females 2 — — — 3 155 5 59 16 84 32 The number of deaths of unnotified cases is shown below:— 1913. 1914. 1915. 1916. 1917. 1918. 1919. 1920. Pulmonary 32 46 40 31 35 41 27 33 Non-pulmonary 25 13 24 21 10 14 8 7 These cases may have been notified elsewhere, or have been unsuspected cases in which medical assistance has not been sought, or cases not diagnosed until after death; this particularly applies to the nonpulmonary cases, in which the cause of the illness may be obscure. Enquiry was made with respect to such cases. Some of these cases are of persons who, although feeling ill, have continued at work and have not sought medical assistance. A sudden haemorrhage occurs and death results. There are, however, other cases in which the medical attendant does not notify under the belief that it has already been done by someone else, perhaps in another district. I agree with the suggestion that has been made that every doctor who is consulted by a tuberculous patient should be required to notify, independently of whether he has reasons to believe that the case has already been notified by another doctor, as at present is the regulation. Surgeons, in particular, not infrequently fail to notify cases, apparently from ignorance that non-pulmonary tuberculosis is notifiable. In the second Table details are given of ex-soldiers or sailors, asylum cases and of persons ill before coming to Westminster. The nationality of the persons notified is as usual varied, representative of the cosmopolitan nature of the population of Westminster. Those not of English birth were:— M. F. M. F. Irish 8 2 French 6 3 Scots 2 0 German 1 1 Welsh 0 4 Italian 3 3 Canadian 1 0 Polish and Russian 6 1 Austrian 1 1 Swedish 1 0 Chinese 1 0 Swiss 1 0 Dutch 0 1 The Polish and Russian were Jews. Non-pulmonary Tuberculosis.—The parts of the body affected were: M. F. M. F. Spine 5 2 Kidney and Hip 1 1 bladder 6 0 Bones and joints 4 4 Mesentery and Cervical glands 9 9 bowels 1 8 Meninges of brain 1 3 Ear 0 1 Reproductive organs 1 0 Skin 0 1 33 Infection of,children is derive^from two sources, directly from a human source, indirectly from a bovine source through milk containing the bacillus. The report of the inspectors of the London County Council shows that last year 913 samples from churns of milk consigned from 32 counties to the various London railway termini were examined with the result that 61, or 6-5 per cent., yielded tubercle bacilli as against 7-4 per cent, in 1918, 10-3 per cent, in 1917, and 8-7 per cent, in 1916. Dr. Brownlee has for some time been making a statistical inquiry into the epidemiology of tuberculosis on behalf of the Medical Research Committee. He finds that the prevalence of bovine tuberculosis as shown by the percentage of samples of milk, is highly correlated with the standard death rate of the county of origin, and that there is a large positive correlation between the milk infection rate and the death rate under 5 from tuberculosis, especially with the death rates from tuberculosis affecting the meninges and abdomen. While a proportion of the cases are due to the bovine variety of the bacillus, the greater number are due to direct infection. Tuberculosis Dispetisary.—Dr. Chapman, Medical Inspector of the Ministry and Dr. Menzies, on behalf of the County Council, have made a survey of the dispensaries in London, and their report was issued during the year and received the consideration of the Public Health Committee. The report concluded with a number of recommendations to render the dispensaries more efficient. The County Council adopted these recommendations, which have also been approved by the Ministry. So far as Westminster is concerned, only three points required to be dealt with. (1) Home Visitation by the Tuberculosis Mcdical Officer.—"In order to enable the officer to deal adequately with the individual patients and also to afford him material for studying the relation of environmental conditions of the disease in his area, home visiting is very important, and it should be the recognised duty of the tuberculosis officer to visit, at least once, the homes of the patients." It was considered that more home visiting should be done and a re-arrangement of his duties was effected to enable the tuberculosis officer to devote more time to carry out this recommendation, with the result that the visits paid by him rose from 21 and 20 in the first two quarters of the year to 54 and 70 in the latter two. It should be pointed out, however, that in the years previous to 1919 he was able to pay more visits to the homes (see below under " Home Visiting "). (2) Transference of school children attending for Observation.—In order to give the tuberculosis officers more time for that intensive study 34 of doubtful cases that is necessary if they are to be diagnosed in a reasonable time, and also to relieve the congested condition at many dispensaries, it was recommended that school children in whose cases a positive diagnosis of tuberculosis is not made at a first examination or after a brief period of study at the dispensary, but whose general condition renders prolonged observation desirable, should be reported with short notes to the divisional school medical officer for this purpose, and for such special care, milk, meals, &c., as the school organisation provides. A child whose case took a favourable course would not return to the dispensary unless the tuberculosis officer had expressed a desire to see it after a stated interval, while one in whom unfavourable signs or symptoms developed would be referred back to that officer with any notes of the condition of the child observed by the school medical officer. This recommendation has also been adopted and 50 children have been transferred from the dispensary supervision to that of the school medical officers. (3) Cod Liver Oil and Malt, &c.—The Public Health Committee found that the amount spent on cod liver oil and malt extract and roboleine considerably exceeded the estimates provided. This increase was chiefly due to the enhanced price of these articles. The Committee considered that even at the price paid it was better to improve the health of delicate children and adults by their administration than having later to spend perhaps ten times as much in trying to cure the patients when tuberculosis was definitely diagnosed. However, in view of the recommendation of the Ministry that " the practice of treating patients on a large scale and over prolonged periods with medicine, cod liver oil, &c. Bhould be discouraged " the Committee decided that, in future, patients who, in the opinion of the tuberculosis officer, are in need of cod liver oil, &c., should be required to pay two-thirds of the cost price of the articles, except in necessitous cases when they should be supplied with the oil, &c., pending consideration and fixing by the Committee of the amount each necessitous patient should be assessed to pay for such articles. The ideal which the Ministry consider should be aimed at is to keep the patients in attendance at the dispensary by providing an efficient means of " following up " and not by means of medicines. They think that the majority of cases might, without disadvantage, be seen at longer intervals, when it would be possible on account of the smaller numbers attending, to make the necessary enquiries, examinations, &c., and to impress essential advice as to personal and home hygiene, diet, &c., and to leave symptomatic treatment as far as possible to practitioners. 35 At tlie Council's dispensary, the aim has always been that it should be a means for the detection, diagnosis and prevention of the disease, and not a place for curative treatment, except in cases requiring tuberculin or some special form of treatment. The Ministry ask that certain information be incorporated in the Annual Report and specify 18 headings under which it is to be given. I have referred these questions to Dr. Shinnie to reply. He reports as follows :— (i) Address of Dispensary; 1, Pimlico Road, S.W. Staff:—Dr. A. J. Shinnie, Medical Officer. Miss Sanders Miss Alexander Miss Walding Miss Clark Visitors. Miss Price, Nurse and Clerk. Dr. Braxton Hicks, Bacteriologist. (ii) Applies to County Councils. (iii) Co-operation with general and special hospitals, &c.—The Tuberculosis Dispensary is affiliated by official agreement with Westminster Hospital. By the terms of this agreement patients attending the dispensary may be referred for the purpose of further diagnosis or for special treatment. During 1920 36 cases were so referred. As regards diagnosis of chest conditions it has not been found necessary to utilize the services of the Westminster Hospital physicians mainly for the reason that there are no beds available in the hospital for the purpose of observation of chest cases. This need has been amply met by the Insurance Committee for the insured of both sexes, including non-insured ex-soldiers, by the lease of observation beds in Brompton and other chest hospitals. As regards the diagnosis and treatment of other than chest conditions the assistance rendered by the staff of Westminster Hospital cannot be too highly praised. An increasing number of cases have been referred to the throat and nose department, the orthopaedic, and skin departments. The conditions for which patients have been referred have been mostlythoseof a non-tuberculous nature occurring in tuberculous subjects, e.g., enlarged tonsils and adenoids, nasal and laryngeal diseases, skin diseases such as psoriasis, spinal conditions requiring massage and exercises, &c. The department of remedial exercises under the direction of Mr. RockCarling has been of great benefit to children of t uberculous tendencies, e.g., with malformed chests. The charge of 2s. per attendance which the hospital has lately had to enforce has unfortunately proved a drawback. A few eases of surgical tuberculosis in children, e.g., hip disease and 36 glands, have been referred to the hospital and admitted as in-patients. Also a very few cases have been referred for general surgical treatment, e.g., for cancer. The relations of the tuberculosis officer with other hospitals have been most cordial. "Westminster is better supplied with hospitals than almost any city in the world, and it is found that the families of the older residents have their favourites among the hospitals. Generations of one family prefer St. George's Hospital for all conditions ; others, St. Thomas', and so on. No difficulty has been experienced in obtaining admission for cases of acute illness in patients who came to the tuberculosis dispensary but were found not to be tuberculous. Diseases of special regions: eye cases, gynaecological and genitourinary cases, &c., have been referred to and have been treated at the various special hospitals in and around the City. A letter of introduction is written by the tuberculosis officer for the patient to take to the hospital. This always ensures attention from the hands of the appropriate physician or surgeon. In this way the Tuberculosis Dispensary has been a clearing house for many ailments not necessarily connected with tuberculosis. School Clinics.—Defects of a minor nature found in school children, e.g., dental caries, errors of refraction and throat conditions, are notified at once by letter to the local organiser of the L.C.C. School Care Committees. She refers the cases to the school doctor, who decides as to whether treatment is necessary. Treatment is provided at the school clinics at Rochester Row, Gerrard Street, &c. There is, however, sometimes considerable delay in obtaining treatment and occasionally the school doctor does not agree that treatment is necessary. There is need for closer co-operation between the school medical service and the tuberculosis service. Towards the end of 1920 the education authority evolved a scheme by which children who were deemed by the tuberculosis officer to be no longer in need of dispensary treatment or supervision were referred to the school medical officer for supervision and if necessary, general treatment, such as cod liver oil, milk in school, &c. A special form of transfer card giving the medical history is filled up at the dispensary and sent to the school doctor. Oilier Institutions.—The loss of the Infirmary at Hendon has been markedly felt in dealing with certain types of cases of tuberculosis. Advanced and infectious cases of tuberculosis now tend to remain and die at home. Sir Arthur Newsholme has for many years laid great stress on this very point as a cause of the spread of infection. Patients in an advanced stage used to be willing to apply to the Guardians for treatment 37 because the accommodation for tuberculous cases of this sort was complete and satisfactory at the Hendon institution. During 1920 it has been almost impossible to suggest to a patient that he should seek admission to the infirmary. Tuberculous patients have been boarded out in other institutions and the treatment received has been complained of by the patients, so that they now refuse to seek admission to the Infirmary unless they are destitute. (iv) Co-operation of Medical Practitioners, <£c.—Practitioners throughout the City were circularised when the dispensary was established in 1916. They were informed that the chief functions of the dispensary were (1) to be a consultative centre, where doubtful cases might be sent for diagnosis; (2) for the examination of the contacts of notified cases; (3) a centre of information as regards obtaining sanatorium treatment, and where special methods of treatment such as tuberculin injections, &c., could be demonstrated. They were also informed that the services of the tuberculosis officer were freely available to them for the purpose of consultation at the homes of patients. It was stated clearly that it was not the intention to usurp the place of the general practitioner as medical attendant of the consumptive. Medical practitioners in the district have shown confidence in the dispensary from the beginning. Most of them are on intimate terms with the tuberculosis officer and it is a common custom for practitioners to call at the dispensary in order to talk over the various cases in which the tuberculosis officer is also interested. Case records are shown and the progress of patients is discussed. Many of the patients have been coming to the dispensary for periodic examination for several years. Practitioners occasionally bring patients to the dispensary for examination, but more frequently they telephone asking the tuberculosis officer to meet them at the patient's* home, when the consultation can take place at the bedside. The number of persons sent to the dispensary by practitioners for the opinion of the tuberculosis officer has steadily increased. In 1919 it was 129, in 1920 it was 150. This is remarkable, in view of the fact that the total number of new7 cases examined at the dispensary has been declining since 1918:— New Cases. 1916 553 1917 718 1918 779 1919 607 1920 592 38 The number of consultations by the tuberculosis officer with medical practitioners has also increased from 79 in 1919 to 92 in 1920. Practitioners are always informed by letter (if urgent by telephone) of the tuberculosis officer's opinion in new cases sent by them and as to the progress of old cases should any special point arise such as change of treatment. New patients who are actually under the treatment of panel or private doctors are not examined unless with the doctors' written consent. Exceptions are made in cases sent by the Ministry of Pensions and other health authorities. Typewritten hk- 11 cal reports by the tuberculosis officer to practitioners on cases numbered 410 in 1920. In 1919 they numbered 302. Carbon copies of those reports are filed in the dispensary case records and form very important data in the history of the case. Practitioners have, from time to time, expressed their appreciation of the regularity with which reports on their cases are sent to them. Periodical Reports on Insured Person • under Domiciliary Treatment.— The Insurance Committee send reminders to panel practitioners concerning six-monthly reports on insured consumptives. Those reports by the panel practitioners are sent to the tuberculosis officer, who notes the contents and sends the reports to the Insurance Committee. The Insurance Committee consider those reports and return them to the tuberculosis officer with appropriate comment. They are then filed with the dispensary case record. In Westminster those domiciliary reports have never fulfilled any very useful purpose. Practitioners have complained of many fruitless journeys made to the homes of patients for the purpose of making reports. Many of the patients are at work and have not been under treatment for two or three years. In cases showing breakdown or lack of progress, practitioners in Westminster, as a rule, are not slow in acquainting the tuberculosis officer, and calling in his assistance. Moreover, all the insured consumptives who are not quite permanently established in good health attend regularly at the dispensary for examination on an average every four months. In the intervening periods they may or may not be under regular medical treatment by their panel practitioners. Some patients attend the dispensary once a year for examination. They keep their appointment dates remarkably. well. Practical experience has shown in this district at least that the domiciliary reports of panel practitioners do not furnish the tuberculosis officer with information of which he is not already in possession, either by the patients' own periodic visits to the dispensary or by general facts supplied by the health visitors. 39 (v) Following up Palienls in whom Diagnosis is Doubtful.—Causes of this description are requested to attend the dispensary at frequent intervals until the tentative diagnosis made at the first attendance is confirmed or negatived. No " following up " of this class of patient has been found necessary. The issue in question is of more importance to the patient than to anyone else and our experience is that he attends regularly and follows out other instructions in his own interest. Home visits are paid by the health visitors, while doubtful cases are under observation and valuable information is often obtained in this way, which may have an important bearing on the cases in question. For instance, the presence of an old case of " open " tuberculosis which has always been regarded as " winter cough " at home may form an inductive link which cannot be overlooked. Weekly records for four weeks, fortnightly if necessary for eight weeks, with a period of twelve weeks in a very few cases as a maximum total period of observation, usually suffice to make a definite diagnosis. Observation can be much more accurate and results can be obtained more quickly when patients are in bed and under skilled supervision. This has been recognised by the London Insurance Committee, who accept cases recommended by tuberculosis officers for observation with a view to definite diagnosis. Beds are reserved in the three large London chest hospitals for this purpose. The question is of special significance in the cases of ex-soldiers applying for pensions on the grounds of tuberculosis contracted on military service. No such provision is made for the uninsured patients, who include children. The provision of hospital observation beds mitigates, in a measure, one of the grave defects in tuberculosis dispensary schemes, namely, the want of a few beds in connection with a dispensary. If they existed, the tuberculosis officer could observe his own cases under his direct supervision. In cases which come to be regarded as " arrested tubercle " or " nontuberculous," contact is still maintained by periodic visits to the homes by health visitors. In many instances such patients attend the dispensary at six-monthly intervals fixed by appointment. (vi) Examination of Home Contacts.—The health visitors who work under the direction of the tuberculosis officer visit all notified cases of tuberculosis. If the patient is under treatment at a hospital dispensary, they encourage the home contacts to go to the hospital for examination. In a few cases the private doctor undertakes the examinations. In f instances the school medical records are of sufficiently recent date acceptance. In most circumstances the duty of contact examination falls to the tuberculosis officer. This is best done at the dispensary from 40 a clinical point of view, because light is good and more accurate observations can be made. From a "preventive" standpoint, the examinations are best done at home because an inspection of the general conditions there can be made at the same time. The health visitors make arrangements for the examination of contacts, either in the homes or at the dispensary. Generally speaking, no objection is raised to those examinations, although it is sometimes difficult to impress parents and other relatives with the usefulness of the procedure. The number of contacts examined by the tuberculosis officer increased from 139 in 1919 to 221 in 1920. Further progress has been made in this direction and the number should be considerably greater in 1921. The measures described in the previous paragraph as to "following up" are carried out in regard to contacts who have been examined. (vii) Special Methods of Diagnosis and Treatment.—Clinical observation and the correct interpretation of physical signs by an experienced physician are the best methods of estimating the condition of a patient. In cases showing but slight symptoms and indefinite signs use is made of radiography, both by screening and photograph. The Council has sanctioned an expenditure which permits of one case being radiographed each week. The radiography is not done at the dispensary but the radios are made by a skilled radiographer and the plates are sent to the dispensary where they form part of the clinical records. Some thirty cases were radiographed in 1920. Extremely valuable information has thus been obtained which, in 28 of the cases, confirmed the provisional diagnosis. It would be a profound mistake, however, to assume that in every case where the radiogram shows well marked peribronchial fibrosis, the patient is suffering from active tuberculosis. In cases where a definite diagnosis cannot be made at the first examination, a temperature record is begun. In a few cases four-hourly temperatures are taken. The health visitors instruct the patients in their own homes in correct temperature taking. The thermometers are the property of the Council and are "lent" to patients. A list of them is kept and they are called in when no longer required. During observation periods patients report once a week, bringing their temperature records. Temperature is an important means of gauging the activity of the disease in early cases. Diagnostic injections of old tuberculin and Von Pirquet reactions have been employed to a limited extent. Neither method gives much indication of the activity of the disease. In point of fact, it is in the quiescent cases where the application of the test is useful and further—it is of greatest import when the result is negative. If repeatedly negative, tuberculosis 41 can be excluded. Some seven injections of tuberculin were given for diagnostic purposes, two proved positive, five negative. The two positive cases were indefinite as regards physical signs and X-ray, but had slight temperature and complained only of general malaise: five Von Pirquet reactions were performed on children under the age of five, who had indefinite signs and symptoms. Two were positive. The Council provides for the examination of specimens of sputum. The examinations are made by the City bacteriologist at his laboratory. In every new dispensary case having expectoration an examination is made. In a certain number of old cases re-examinations are made where previous results proved negative. No restriction is placed on the number of specimens sent for examination. Negative sputum results are not held to preclude a diagnosis of tuberculosis in cases presenting other features of significance; 239 specimens were examined for the dispensary in 1920. In 31 tubercle bacilli were found. In 4 cases where the sputum proved negative on repeated examination of samples submitted by the patient to the City bacteriologist, positive results were obtained in hospital to which the patients were sent for observation. Treatment.—Reference has already been made to hospital and sanatorium accommodation for the purposes of observation and treatment. This department is entirely under the administration of the Insurance Committee for the insured and of the London County Council for the uninsured. It ought to be mentioned that there is a distinct lack of accommodation for "hospital" or advanced cases in women and in men who have not served in the fighting forces in the late war. Domiciliary treatment for all insured consumptives is carried out by the practitioners in the district. The experience of five years leads one to believe that this form of general and symptomatic treatment has been carried out efficiently and satisfactorily. It is interesting to record that 21 ex-service men who were discharged from various institutions more than two years ago as unlikely to derive benefit from further sanatorium treatment have made steady improvement under domiciliary treatment. In four instances bacilli can no longer be found in the sputum. All are Turban Gerhardt III cases with marked anatomical, changes in the lungs and are still regarded as unfit for work which entitles them to full treatment allowances and extra food. During the two years since discharge from sanatorium they have been entirely free from financial anxieties, their dependents being provided for. Their diet has been ample and nourishing and they, have been leading lives of ease. Their fortunate state must surely be the outcome of such a happy triad, ease of mind and of body and unrestricted diet. They now have no symptoms 42 of an acute nature. If such provision could be obtained for the civilian consumptives, both male and female, the death rate from phthisis might well be halved. Dispensary Treatment.—The only special method of treatment which has been used during 1920 is that of tuberculin inoculation. Fifteen patients received tuberculin injections. Eleven of those were nonpulmonary cases, glands, skin and joint. Four were lung cases. The periods of treatment varied from 8 weeks to 1 year. The preparation used was Bacillary Emulsion. Marked results were obtained in the gland cases, four of whom have been discharged cured. Four cases were not proceeded with after a few weeks on account of poor tolerance. Of the four lung cases, two have shown continuous and satisfactory improvement. Insured patients, except for a few on tuberculin inoculation, are not treated at the dispensary. Uninsured patients who cannot otherwise obtain prolonged routine treatment are treated there. Many proprietary preparations have been tried in former years, but no striking results can be recorded. Colloidal Iodine by the mouth and intravenously has been tried. Nascent Iodine has also been given and many other antiseptic preparations. Again, it must be said that no accurate investigation of any therapeutic measure can be conducted unless patients are under constant and skilled supervision—in observation beds. The dispensary is mainly a consultative rather than a treatment centre. In 1920, 1,153 individual patients were attending, but only 525 of those actually received treatment at some period during the year. (viii) Relative Value of Forms of Treatment.—This has been discussed in the preceding paragraph. A few general remarks only need be added. Tuberculin is of wider application and of greater benefit in non-pulmonary than in pulmonary cases. In pulmonary cases it benefits selected cases, particularly those in whom a certain degree of resistance is already established and without evidence of much systemic disturbance, e.g., night sweats. Antiseptics offer a promising field of research both by inhalation and intravenous administration. This cannot, however, be thoroughly investigated at a dispensary. Graduated labour also can only be properly practised at a residential institution. The measures of treatment which appear to have yielded the best results are those which follow the dictates of common sense, but are unfortunately available only to the few—freedom from the anxiety of having to earn, freedom from the physical and mental efforts of earning and the enjoyment of a generous diet in which there is an ample proportion of animal fat. (ix) Dental Treatment.—A dental clinic was established by the Council in the latter part of 1920, and one day per month is set aside for 43 tuberculous patients. The services of a skilled dental surgeon and anaesthetist are available for patients attending the tuberculosis dispensary. Ex-service patients are not entitled to treatment as they are already provided for by the Ministry of Pensions. Four patients have been treated since October, 1920. A scheme is under consideration whereby patients may obtain dentures, part of the cost being borne by the Council or a charitable agency. (x) Nursing.—Until two years ago the district nursing associations gave their services gratuitously for bedridden consumptives. A charge of 1s. 3d. is now imposed for each nursing visit. Most dispensary patients are unable to pay this charge and a scheme is being drafted whereby the nursing of those cases may form a legitimate expense in the Council's scheme for the treatment of tuberculosis. Extra Nourishment is provided for tuberculous ex-service men through the Insurance Committee from funds supplied by the Ministry of Pensions. The recommendation is made by the tuberculosis officer and it is always agreed to. Extra food for civilians is obtained with very great difficulty and then only for three months after discharge from sanatorium. No provision for extra nourishment is made for uninsured patients. The tuberculosis officer has sometimes been able to obtain small doles for short periods from church charities and similar bodies. If patients can bring themselves to appeal to the Guardians they are always generously treated in the matter of extra nourishment. (xi) Non-pubnonary Tuberculosis—Treatment of.—As already alluded to in the first paragraph of this report, cases of this nature are as a matter of tradition treated in the appropriate departments of the great hospitals of the City. They are sent there by their doctors or naturally gravitate there of their own accord. The tuberculosis officer is sometimes requested to co-operate with the hospitals in obtaining convalescent or sanatorium treatment for such cases. In this way a number of insured patients are sent to the Sea Bathing Hospital at Margate. A very few cases of spine and hip disease have, with the kind co-operation of Sir Henry Gauvain, been sent to Lord Mayor Treloar's Hospital at Alton. Only children up to the age of 12 are taken at Alton. The period of treatment there is usually prolonged beyond six months and as the number of beds is limited, the waiting list for admission is a long one. The Invalid Children's Aid Association, a voluntary body which receives subsidy from public funds, works closely in touch with the hospitals in the matter of obtaining convalescent treatment for orthopaedic cases. This body is also largely instrumental in assisting patients in the purchase of surgical 44 appliances which have been prescribed for them in hospital. The arrangements are made through the Almoner's department and the Association collect the payments or proportion of the cost from the patients by instalments. Those who are unable to meet the full cost of surgical appliances are thus assisted by the Association, who contribute the balance from their funds. Of the 592 new cases which were dealt with at the dispensary in 1920, only 31 were found to be suSering from non-pulmonary tuberculosis. About half of this number had been hospital cases at some previous period in their history. Only four cases of bone and joint tuberculosis were entirely fresh cases, i.e., were diagnosed for the first time at the dispensary. It is therefore apparent that in this City cases of non-pulmonary tuberculosis, apart from glands, are dealt with at the many hospitals both general and special, which exist within its boundaries. (xii) Care and After-Care.—A committee consisting of representatives of ofiicial, voluntary, and charitable bodies interested in problems of tuberculosis was formed under the auspices of the London County Council in 1916. The medical officer of health is its chairman and the tuberculosis officer attends in the capacity of medical adviser, assisted by the health visitors, who have intimate knowledge of the social and domestic conditions of cases. As pointed out in previous reports, the work of this committee is seriously hampered because there are no funds at its disposal with which to carry out schemes of assistance for individual cases. The functions of the committee are defined in its title, Tuberculosis Care Committee. Those functions include improvement of the home conditions while patients are away in sanatoria, advice as to change of employment on their return and assistance in obtaining such employment. Such bodies as the War Pensions Committee, Charity Organization Society, &c., &c., report through their representatives on the committee as to action taken in individual cases and thus co-operation is stimulated and overlapping avoided. At the present time, however, the discussions which take place touch only the fringe of the problem of "after care." It is undoubtedly the most important aspect of antituberculosis effort and deserves a greater measure of public attention than has been focussed on it in the past. The tuberculous ex-soldiers are the only class of cases for whom a serious attempt, at after care has been instituted. The War Pensions Committee have powers to assist them with clothing, diet, treatment for dependents, removal to better homes, and schemes of training for employment. Their treatment allowances are, or course, the alpha and omega of after-care principles. It has already been pointed out how moderately-advanced cases among ex-service men 45 have gradually recovered a good measure of their former health under the beneficent authority which compensates them for their invalidism, The lot of the consumptive who is not entitled to such compensation is a hard one. (xiii) Arrangements for Finding Employment for Patients.—During the war considerable success was achieved by individual members of the "care" committee who adopted certain cases with a view to finding them suitable employment. Posts such as stable hands, carmen and gardeners in the country were obtained by personal influence. Outdoor messengers, parkkeepers, &c., were selected as suitable occupations in town. During 1920 it has been almost impossible to find employment for the healthy and much more difficult for the disabled. A measure of success has been achieved (again in the case of ex-service men) by the joint scheme of the Ministries of Pensions and Labour for the training of patients. But even in this instance there have been extraordinary delays and disappointments. In the case of boys leaving school the school care committees working in conjunction with the Junior Advisory Committee of the Education Authority have been of considerable service in finding suitable apprenticeships for those young patients who are but slightly affected with tuberculosis. (xiv) Supply of Shelters.—The conditions are such that "shelters" of the type supplied to patients in suburban or rural districts cannot be made use of. Back yards are small, much overlooked and considerably cut off from fresh winds and sunshine; they are, therefore, unsuitable for this purpose. (xv) Special Points as to Local Incidence of Tuberculosis.—There has been no evidence to show that any one occupation has more influence than another on the local incidence of tuberculosis. Westminster is not the centre of any special industry. There are no great factories employing thousands of hands engaged in the production of a particular commodity such as can be found in certain of the boroughs of London as, for example, in Woolwich, where so many are employed at the Arsenal, although The Army Clothing Depot at Pimlico is the nearest approach thereto. The tailoring industry in Soho conducted mostly by aliens working in their homes on orders for the large shops, does not show the incidence of tuberculosis which might be expected from the conditions in which they work and live. The occupation which heads the list of notified cases of tuberculosis is that of clerks. A great many clerks are employed in Westminster in the large shops, banks, Government and business offices. A fair proportion of those live in the City in order to be near their work. Domestic servants, including those employed in hotels, (3399)q D 46 restaurants and clubs come next. Large private residences and hotels are numerous in Westminster ; there is, therefore, a large population of servants, waiters, &c. (xvi) Measures Adopted or Proposed for the Prevention of Tuberculosis.—Westminster has always been in the van in the adoption of preventive measures. The medical officer of health on his appointment some twenty odd years ago obtained sanction for and put into force the following measures, which have had a distinct influence in the decline of tuberculosis in the City from 1902 to 1914. (1) Free examination of sputum by skilled bacteriologists at the cost of the Council. (2) Voluntary notification of pulmonary tuberculosis which was well supported and carried out by the practitioners until the compulsory notification regulations of 1912. (3) Printed cards of information and advice on tuberculosis were distributed to the homes of patients and "suspect" cases by sanitary inspectors and later by health visitors, who were appointed specially for the purpose of visiting and assisting consumptives. (4) Disinfection of rooms and bedding on the departure or death of patients. (5) Free distribution of sputum flasks, or pocket spittoons, to patients. (6) Provision of bed and bedding, clothing, &c. The above measures have been in force for almost 20 years. The free examination of sputum specimens sent by medical practitioners has been of more far reaching importance than most people realise. By its means the disease could be diagnosed in cases who otherwise would have been labelled "chronic bronchitis" even unto death. Measures of isolation and treatment could be undertaken which were bound to have an influence in the limitation of infection in the succeeding years. (7) The greatest measure of pre-Insurance Act days was the lease of sanatorium beds by the Council. Westminster residents were sent to sanatorium free or on a contributory basis according to their means. Only the curable types of cases were eligible for the Council's scheme. This was a thoroughly sound, economic principle in dealing with the treatment of tuberculosis. Finally, the Guardians of Westminster had a large institution of modern. construction situated in the open country beyond Hendon. Tuberculous cases were drafted from the infirmary in London to this more suitable institution with its sunny aspect and open surroundings. Patients seldom offered any objection to going into the infirmary when it was pointed out to them that they would be transferred 47 to a place where sanatorium principles prevailed. Thus many chronic infectious cases spent long periods there, away from their homes, and were often able to resume work for a period when discharged. Advanced eases drifted there and died, which also lessened the risk of infection at home. (8) The demolition of slum areas, which are by nature breeding grounds for tuberculosis, and the removal of insanitary conditions went steadily forward as part of the Council's policy until interrupted by the war. Simultaneously the Council provided its own municipal dwellings and encouraged similar projects by private bodies such as the Peabody Trust. The last block of dwellings to be constructed by the Trust was completed in 1913. Those dwellings contain many flats of three and four rooms, complete with every convenience. They are well planned, well lit and airy, and should ensure a healthy standard of living. Since 1919 the processes of demolition and construction have been resumed. There are difficulties in the way—enhanced freehold values, &c. and progress will be slow, but there is no greater preventive measure against tuberculosis than the eradication of foul, dilapidated, and overcrowded houses. (9) Tuberculosis Dispensary Scheme.—This was established by the Council in 1916 and fulfils its function in the prevention of tuberculosis in the ways already described in this report; facilities for diagnosis of early and doubtful cases by co-operation with the medical practitioners of the district; examination of home contacts of definite cases; selection of cases for sanatorium and hospital; periodic examination and supervision of cases after sanatorium treatment, inspection of and advice in the homes; a centre of information for outside bodies interested in the welfare and employment of consumptives. (xvii) Special Difficulties Encountered.—The difficulties experienced in the campaign against tuberculosis are those which exist in all urban areas at the present time. The chief of these is the lack of housing accommodation. There are many instances in Westminster where patients and their families would gladly move from their two or three-roomed tenements into small houses in the suburbs if they were obtainable. The demand for the working-class houses erected by the London County Council in the Roehampton and Wormwood Scrubs districts is far in excess of the number erected or in process of erection. Also the rents and travelling expenses seem to put them beyond the reach of Westminster workers. There are instances of overcrowding among families where one or more consumptives may be found, and those cases have been dealt with as far as possible under the existing sanitary enactment The expense of finding an additional room when unemployment is so (3399)q D 2 48 prevalent is in most cases an insuperable problem. During the war this difficulty did not arise. Work was plentiful, wages were high, and air raids made vacancies for those who had to live in central London and who desired more accommodation. The question, of overcrowding, especially with reference to tuberculosis, is not an aggravated one in Westminster. The problem exists, but not in the form or to the extent prevalent in other metropolitan districts, where vast communities of the working classes are housed. On consideration of the reports made on the home conditions of notified cases of tuberculosis, it may be stated that not more than 20 per cent, dwell in homes which are insanitary in some degree or which are the subjects of overcrowding in the sense generally accepted as a basis for legal notice. Another difficulty which has already been discussed is the lack of hospital accommodation or isolation for advanced cases in women and in men who were civilians throughout the war period. The danger of infection does not arise so much from the actually bed-ridden cases, but from those who are partly ambulant, e.g., women in an advanced stage of the disease who go about their household duties, cooking and washing for their families though hardly fit to walk. Some of those would be willing to enter a hospital even if only to enjoy a period of rest. This point also raises another difficulty, which has previously been brought forward— that of finding a " deputy mother " for the married woman with children, who requires sanatorium treatment. A few instances have occurred where women in an early stage of the disease have been unable to accept sanatorium treatment because there was no one to look after the children. Similar circumstances occur among men (non-military or naval), where the wage earner feels that he cannot afford to lose his wages in order to spend a few months in a sanatorium. He also feels that on his return his post will no longer be waiting for him in these times of slack trade and surplus labour. This question is also associated with the great difficulty in finding employment of a suitable nature for the consumptive after sanatorium treatment. This has been discussed in connection with "after care." In conclusion, the substance of this report may be summarised in a recommendation which is suggested by the experience more particularly of the last two years. It may not be practicable, but it points the way to the methods which in the future, may be the most fruitful in the prevention and cure of tuberculosis. That is the adoption of a scheme of treatment and after-care for the general population affected by tuberculosis similar to that now in force for ex-service patients. This scheme embraces all ameliorative measures, but, of course, is applicable only to military and naval "attributable " cases. As a postscript, it might be 49 added that without doubt the most serious difficulty encountered in tuberculosis work during 1920 has been in getting "attributability" recognised by the Ministry of Pensions. A few bona fide cases have endured exhausting struggles and delays before their just claims were recognised. Dispensary Statistics. 1920. 1919. New patients 592 607 Old patients attending 561 490 Individuals who attended 1,153 1,097 Contacts examined 221 139 Total attendances 5,267 4,882 Written medical reports to L.C.C., L.I.C., W.P.C., &c 1,284 1,439 To medical practitioners, &c. 410 302 Consultations with medical practitioners 92 79 Visits paid by medical officer 165 96 Visits by health visitors to dispensary cases 4,767 4,159 Sputum examinations 239 255 Patients were examined at the instance of the following sources Ins. U nins. Medical practitioners 97 53 Ministry of Pensions 1 2 War Pensions Committee 27 1 Insurance Committee 37 3 London County Council — 5 Friends, &c. 17 84 Westminster Health Society 1 20 Health visitors 26 151 Jewish Board of Guardians 2 12 Schools — 24 Other sources 9 20 Of the 221 contacts examined— 43 were found to be suffering from tuberculosis. 35 were doubtful cases. 143 were free from the disease. Insured Patients. 168 patients applied for sanatorium benefit through the Dispensary. 66 were recommended for sanatorium treatment, 55 were admitted. 50 81 were recommended for hospital treatment, and 60 were admitted. 1 is awaiting admission at the close of 1920. 17 applications were cancelled for domestic or other reasons. 4 died before admission. 10 were refused institutional treatment. 21 were recommended for dispensary or treatment at home. Uninsured Patients. 36 patients were recommended to L.C.C. for institutional treatment. 26 for sanatorium, and 10 for hospital. 29 were admitted, 4 applications were cancelled, 2 the L.C.C. were unable to deal with, and 1 died before admission. Diagnosis made in 592 New Patients at First Attendance, Subject to Revision Later. Pulmonary tuberculosis 152 Non-pulmonary tuberculosis 31 Non-tuberculous 281 Diagnosis doubtful 124 4 patients were not examined Discharged Soldiers. Total No. ex-service men seen during 1920 for the first time 102 Sources from whence they came:— War Pensions Committee 29 London Insurance Committee 28 Medical practitioners 30 Health visitors 8 Various sources 7 Admitted to sanatorium 35 Not requiring institutional treatment 67 Discharged from sanatorium improved 16 Discharged unfit 10 Discharged fit for work 19 Working at their old jobs 41 (This is so far as can be ascertained from medical case sheets.) Died before admission to sanatorium 1 Died after discharge 1 The Dispensary dealt with 185 of the 327 persons primarily notified in 1920, deducting asylum cases, the percentage was 62.7. Andrew J. Shinnie. 51 Home Visiting.—The tuberculosis medical officer paid 165 visits to the homes of patients. The number of visits paid in previous years was:— 1016 257 1918 237 1917 197 1919 96 The tuberculosis visitors paid 7,563 visits (3,613 in the Pimlico area and 4,934 in the rest of the City), 4,934 being paid to persons attending the dispensary. In addition, visits were paid by health visitors to families in which there were cases. The total visits paid in previous years were:— 1916 4,653 1918 4,266 1917 4,023 1919 6,908 The numbers of cases of tuberculosis on the register at the end of the year are 1,289 pulmonary (including 100 casuals) and 359 non-pulmonary. These figures include a number of old cases in which the disease is arrested. All the cases are not visited for various reasons, such as those resident in asylums, casuals who are mostly inmates of institutions, besides persons able to provide for their own needs. The number of cases of the regular visiting list is shown as follows Total. At 1st January, 1920 1,073 New cases in 1920 334 Visited during year 1,407 Deaths and removals 253 Remaining at end of year 1,254 In addition to these there are 1,821 contacts and suspects remaining, who are being kept under observation. 605 visits were paid to 188 discharged soldiers and sailors, 12 of whom died during the year. Deaths.—157 deaths were certified to have been due to tuberculosis Pulmonary. Non-pulmonary. Males 82 6 Females 57 12 139 18 and in addition 9 males and 2 females who had been previously notified died from other causes, viz.: bronchitis, 4; enteric fever, 1; influenza, 1; pneumonia, 1; disease of ethmoid, 1; cancer, 2. Of the 309 new cases of pulmonary disease recorded in 1920, no less than 100 (87 pulmonary, 13 non-pulmonary) died during the year, 52 being males and 48 females. The remaining deaths were of persons 52 notified in previous years, dating back to 1910, 16 were 1919 cases and 13, 1918 cases. The death-rate for 1920 was : pulmonary, 103; non-pulmonary, 13 per 100,000 population. For London 101.7 and 21 respectively. In the subjoined table the rates are set out from 1881. The death-rate, 116 per 100,000 population, compares favourably with pre-war rates as shown below. Deaths from Tuberculosis. Years. Pulmonary. Non-jjulinonary. Total. Deaths. Rates. Deaths. Rates. Deaths. Rates. 1916 annual 164 124 37 27 201 151 1917 194 147 29 22 223 169 1918 186 148 31 24 217 173 1919 134 105 21 16 155 121 1920 139 103 18 13 157 116 1881-90 average 208 89 297 1891-95 — 184 — 80 — 264 1896-1900 „ — 174 — 70 — 244 1901-05 „ 302 169 70 40 372 209 1906-10 218 132 58 34 276 166 1911-15 195 128 37 25 232 153 1916-20 163 125 27 20 190 146 It is suggested that the lowness of the death-rate in the last two years is to be accounted for by the heavy toll taken by influenza in 1919, but allowance ought to be made in 1917 and 1918 for the great increase in the population in Westminster in these years, when there was an influx of war workers. The averages of 5 yearly periods show a continuous reduction in the pulmonary rate in each period during the last 40 years, the rate in the last 5 years being 35 per cent, less than in the 10 years 1881-90. The average rate in the last 20 years is 28 per cent, less than in the former. The periodjshowing the greatest [reduction] was the five years 1906-10. In the non-pulmonary deaths, the reduction has been very considerable in the last 20 years, viz., from 70 to 20 per 100,000. The death-rates from all forms of tuberculosis per 100,000 of population were for:— England and Wales. London. 1915 151.5 199 1916 152.9 188 1917 162.4 231 1918 169.4 213 1919 125.8 145 1920 112.8 123 53 bacteriological laboratory. Examinations were made as follows:— Swabbings from throats in suspected Diphtheria 331 Swabbings for suspected Gonorrhea 3 Blood in suspected Typhoid 3 Sputum for Tuberculosis 407 (226 of these specimens were sent from the Tuberculosis Dispensary). The expenditure on the first three was £'19 7s. 5d., and for Tuberculosis £54 4s. 6d. Disinfection. The number of articles treated was 56,797, of which 4,388 articles were sent in by the military authorities or from hostels chiefly for verminous conditions. Average 1912-15. 1916. 1917 1918. 1919. 1920.[/### Rooms 2,059 1,324 814 722 941 1,196 Articles disinfected 46,539 119,303 281,895 153,048 50,496 49,542 Articles washed 5,150 5,377 8,015 6,551 5,759 7,185 Articles destroyed 1,514 5,214 5,097 3,048 543 70 Books disinfected 654 1,593 12 4 77 42 Vehicles 7 1 1 1 2 5 The motor van during 1920 ran 3,335 miles on 309 days and carried 2,737 cwt. of goods, the highest amount in any one day being 150 cwt. The consumption of petrol was 404 gallons. Cleansitig of Persons.—The number of Westminster children suffering from head and body lice treated at the cleansing station was 461, an increase over the number in 1919. This is probably partly due to the greater activity of the school nurses in sending cases to the Station at the first signs of infestation, and to more stringent action where parents persistently send their children to school in an unsatisfactory condition. Head lice. Body lice. Scabies. Total. Children 440 21 99 560 Adults 6 66 16 88 446 87 115 648 The lice-affected children were all of school age, but 15 of the scabies children were under that age. All the lice cases were dealt with at the Station, but 43 of the scabies cases were treated at home. 54 By arrangement with the County Council school children from Battersea, Chelsea, Holborn, Kensington, Lambeth and St. Marylebone were sent to the Station for cleansing, these numbered 503 for head lice, 34 for body lice, and 86 for scabies. Each case implies a number of attendances for treatment, and the disinfection of the clothing, besides which in the Westminster cases the bedding, &c., is removed for disinfection at the same time that the persons affected are being treated. Lately, an improved method has been adopted in dealing with head lice cases whereby, as a rule, the head can be cleansed at one attendance, and without cutting the hair. In dealing with the Westminster cases, 346 visits were paid to the houses. Difficulty is frequently encountered in dealing with adults, as there is no compulsory power under which they can be compelled to be cleansed, except in the case of inmates of common lodging houses. Neither is there compulsory power to cleanse children who are not of school age, but it is usually easy to persuade parents to allow them to attend at the Station along with the other children. Mortuaries. The number of bodies removed to the Council's mortuaries under order of the Coroner, or to await burial, was 296; in 2 instances death was the result of infectious disease, anthrax and measles. Inquests were held at Horseferry Road, where the Coroner's Court is situated, in 269 cases, and there were 8 adjourned inquests. Post-mortem examinations were made in 148 instances at Horseferry Road. The number of dead bodies taken to the mortuaries for purposes of inquest and to await burial during the last 18 years are:— Total. For Inquest. To await Burral. Total. For Inquest. To await Burial. 1903 393 341 55 1912 324 284 40 1904 388 322 59 1913 328 286 42 1905 370 307 61 1914 323 295 28 1906 345 283 61 1915 376 349 27 1907 358 281 77 1916 309 252 29 1908 364 298 66 1917 278 265 13 1909 291 258 33 1918 285 242 43 1910 333 281 52 1919 308 209 39 1911 373 334 49 1920 296 269 26 There are resting placcs for the dead at Drury Lane, Ebury Bridge, or Dufours Place, but the public make very little use of them. PART II. C. House Inspection, &c. Below is a list of details of the work done in connection with insanitary conditions. In many cases some of the work specified was in premises, parts of which were occupied as workshops:— 1920. 1920. Complaints received and dealt Sanitary Work completed:— with 1,015 Drains:— Premises inspected on complaint, &c. 1,797 Manholes built repaired aud 423 House to house inspection 2,834 cleansed 337 Subsequent visits 20,886 „ covers fixed or repaired 418 Premises (registered), visits to 3,241 Overcrowding found 3 Tested by smoke 30 Other infringements 556 ,, chemical 147 Sanitary Work completed:— ,, water 556 Houses:— air 20 Cleansed throughout 516 Fresh air inlets fixed or „ partially 913 repaired 187 Overcrowding—rooms 20 Soil Pipes:— Light or ventilation proved 310 Fixed 319 Ventilated 214 Roofs repaired 565 Repaired 333 Floors and staircases repaired 608 Tested by smoke 159 „ chemical 152 Underground rooms:— Illegal use 4 „ water 66 Closed 3 „ air 170 Yards, areas, paved or repaired 417 Water-closets:— Constructed.. 1,139 Damp walls remedied 240 Repaired 674 Offensive refuse removed 282 Ventilated and light improved 412 Keeping of animals discontinued 37 Cleansed or limewashed 998 Verminous premises cleansed 196 V entilated lobbies provided 336 Filthy or unwholesome beddine. &c. 16 Unstopped .. 17* DrainB:— Traps ventilated 850 Constructed 219 Flushing cisterns fixed 1,173 Amended and repaired 303 „ „ repaired 419 Ventilated 164 Waste Pipes:— Unstopped and cleansed 150 Constructed 1,941 Interceptor traps fixed 107 Repaired 278 Cleansed and scaled off from sewer 61 Unstopped 136 Trapped 2,174 Gully traps fixed 810 Ventilated 1,789 Defective traps abolished 223 Disconnected from drain 134 56 1920. • 1920. Sanitary Work completed:— Sanitary Work completed:— Rainwater Pipes:— Water Supply:— Fired or repaired 584, Cisterns defective,abolished 38 Disconnected from drains 54 Taps off main provided 367 Urinals:— ripes repaired 344 Constructed 103 Dust Bins:— Repaired or improved 53 Movable, provided 236 Cleansed 102 „ repaired 26 Water Supply:— Fixed, abolished 4 Provided 394 Stables:— „ additional in Drained 3 ment houses 69 Paved 3 Certificates granted 0 Cleansed 3 Cut off 14 Dung receptacles provided 3 Reinstated 42 Dung accumulations Cisterns fixed 137 moved 74 „ cleansed 219 Garages constructed 27 „ covered 241 Petrol interceptors provided 2 1,210 intimations of nuisances (exclusive of smoke nuisances), &c., and 45 statutory notices were issued; 1,626 letters were written. Police Court proceedings had to be resorted to in respect of 12 properties, and in one case for the non-removal of an accumulation of manure. In one of the cases the defendant failed to comply with the Magistrate's order to abate the insanitary conditions in his house within one month, and was fined £5 or one month's imprisonment. Plans.—602 sets of plans were examined during 1920. Of these 53 were plans of new buildings, several of these buildings being very large and covering large sites. Failure to send in plans or to give notice occurred in 33 instances, and to send in plans in 41 instances. Prosecution occurred in three instances and penalties were inflicted: £2, £2 and £1 1s. costs, £5 and £2 costs. Infringement of By-laws in connection with erection or alteration of buildings, 18. Revenue Act.—One application for certificate under this Act, which gives relief from the payment of Inhabited House Duty, was received and granted. Water Supply.—Fourteen notices of withdrawal of water supply were received from the Metropolitan Water Board. It was reinstated on notice. The reasons given for cutting off the supply were: house empty, 1; non-payment of rates, 13. Additional water supply to tenement houses was provided in 69 instances. 57 Rat Repression.—The campaign against rats was continued throughout the year; 31 specific complaints were investigated and steps taken to destroy the vermin, and to remove the source from which they came. In the week commencing 1st November a united attack was made throughout the country. Amongst other steps taken, hotels, restaurants, stores, &c., were circularised asking for a special effort to be made and offering assistance. The co-operation of the Highways Department was also invited, and during the week 15,555 baits were laid in the Council's sewers and at the various wharves used as dust shoots. All of the baits were taken, but the actual number of dead rats seen was only 106. Probably the dead bodies were carried away in the sewers, but in one instance the rats escaped through a defective drain and died under the floor of a house where they were subsequently found. Smoke Prevention. The following is a summary of the work done in connection with smoke prevention:— 1920. Complaints received ... 29 Observations taken 2,123 Notices issued— Preliminary 87 Statutory ... 1 Summonses ... There is still considerable difficulty in obtaining suitable fuel, and that which has been supplied is frequently of low quality. According to the Departmental Committee on Smoke and Noxious Vapours Abatement, domestic chimneys contribute, at the least, 50 per cent, of the total smoke nuisance, and at least 6 per cent, of the bituminous coal burnt in domestic fireplaces escapes unconsumed into the atmosphere as soot. The Committee state that for various reasons domestic chimneys have hitherto been exempted from the legislation which deals with the emission of black smoke from locomotives, manufactories and trade processes and they add that in their final report they will consider whether any legislation with regard to domestic smoke should be recommended. The damage to buildings caused by smoke is mainly due to the sulphuric acids contained in the products of combustion, but it is pointed 58 out that particles of soot united with these acids materially enhance their injurious effect. The acids become more concentrated, and the tarry content of the soot makes the mixture more adhesive. The soft stone of many public buildings is readily attacked, but even the most durable stones are being rapidly disintegrated by the acid soot. The effect of breathing air containing such material, especially during fogs, is apparent in increased mortality. Common Lodging Houses. Accommodation is provided in registered Common Lodging Houses for 1,529 men and 57 women. Bruce House, Kemble Street, 706 men. 40, Great Peter Street (Church Army), 57 women. 108, Regency Street, 8 men. 7, St. Ann's Street, Great Peter Street (Salvation Army), 593 men. 16, Strutton Ground, 222 men. In addition there were during the year three Rest Houses used by Ex-service men. Two of these still remain, and it seems desirable that they should be registered, as to aK intents and purposes they are Common Lodging Houses. During the year the deaths of 88 persons who had been inmates of Common Lodging Houses, were recorded; 13 of these were from tuberculosis. Houses let in Lodgings.—At the end of 1919 there were 1,200 houses on the register, during 1920 this number has been reduced to 1,164, chiefly through the demolition of houses in Great Peter Street and Chadwick Street. 3,241 visits were paid to such houses and notices were served with reference to 559 defects. As has been pointed out previously, many of these houses are partly used as work places and consequently more visits than those stated have been paid to the premises. New by-laws drawn up by the County Council under the Housing and Town Planning Act were submitted in draft for the consideration of each Borough Council. Suggestions for their amendment were submitted by the City Council, and a revised set of by-laws were approved, but have not yet been put in force. Housing.—During the year, and especially in the latter half, the difficulty of finding housing accommodation in Westminster became distinctly easier, probably due to the increased number of new houses erected by the County Council and by suburban authorities. The City Council continued during the year considering likely sites for building, but on going into the financial question, it was found that no scheme could 59 be produced without a large annual deficiency, which would mean a substantial increase in the rates for many years, in addition to the penny rate which the ratepayers of Westminster have to contribute towards the County Fund, the Council therefore did not feel justified in embarking upon a separate Housing Scheme. This decision was acquiesced in by the Minister of Health on the advice of the London Housing Board after a careful consideration of all the circumstances. I pointed out in my last Report that much of the housing difficulty in Westminster was due to the presence in the City of persons who had come to work therein temporarily. Many have gone, but there are still a number employed in Government offices. During the year the private houses used for war purposes have been given up and have been re-let either as whole houses or converted into flats. Through the difficulty in obtaining house room in outlying districts, there are a number of persons living in Westminster who are employed in other parts of London and even outside, as far away as Woolwich, Hayes, Beckton and elsewhere. The Peabody Trustees have acquired an island plot of land between Great Peter Street, Chadwick Street and Horseferry Road, on which they are erecting accommodation for 93 families—approximately 500 persons. A number of the houses on the site had been condemned and pulled down in past years, and, during 1920, a number of the remaining houses have been closed. Most of them were old and worn out. The new buildings will be in 3 blocks; at present two only are being proceeded with, the third block at the Horseferry Road end will be begun on the completion of the other two, and the houses on this part of the site are being left until then. The Council came to the assistance of those who were displaced and have rented from the Guardians the disused casual wards in Wallis's Yard, which they converted into tenements for 70 people, the cost being borne by the late owners of the site and the Peabody Trustees. Section 6 of the Housing (Additional Powers) Act, 1919, requires the consent of the County Council to be given where it is proposed to demolish houses occupied as dwellings or to convert such to business purposes. In each case the observations of the City Council have been invited. In certain cases objection was taken to the scheme, in others it was required that alternative accommodation be provided for the persons to be displaced. Many of the leases on the Duke of Westminster's estate are falling in, especially in St. John's Ward, and the houses are being taken over by a firm who are having a survey made of each house with a view to the remedying of any defects existing. In a few years' time all the leases in this neighbourhood will have expired, and the area seems a suitable one 60 for reconstruction on a town-planning scheme. The leases of houses in other parts of the City belonging to the same estate are expiring shortly, and many of the sites are suitable for the erection of an improved type of house. The power to increase rents has enabled landlords to spend more on the upkeep of their property, but in several instances the security of tenure which is given to a tenant has operated detrimentally and landlords have been unable to turn out tenants who are dirty and destructive. With regard to the remedying of defects found on inspection, notices were served under the Public Health (London) Act, and not under the Housing Act. No action was taken under Sections 17, 18 or 28 of that Act. The figures as to defects found are given in the table above. 61 D. WORKSHOPS, &o. The following shows the state of the register of work premises at the end of 1920:— Work Premises. Total Number. Tailors, outfitters, shirt maters, hat, cap, and helmet makers 980 Dressmakers, milliners, embroiderers, lace makers, blouse makers, costumiers, lingerie makers, children's outfit makers, feather dyeing, corset makers, furriers, &c. 1,007 Leather workers, boot and shoe makers, harness makers, &c. 30 Carpentry, upholstery, carvers, gilders, &c. 40 Surgical and dental instrument makers 13 Tobacco manufacturers 25 Wig makers and hair workers 46 Printing, bookbinding, lithographers, envelope making, stationers, publishers, &c. 46 Jewellers, silversmiths and burnishers, diamond cutters and polishers, engravers, &c. 100 Metal workers 140 Miscellaneous—Basket making, fancy work, shoe ornaments, hat pins, stamp sorters, postcard tinters, fan makers, artificial flower makers, &c. 80 Florists 33 Laundries 40 Bakehouses 84 Photographers 21 Jewel case makers 8 Inspection. Premise!. Inspection!. Number of Intimation Notices. Statutory Notices. Prosecutions. Factories •244 13 - - Workshops 3,405 310 0 1 Workplaces (Including restaurant kitchens, &c.) 1,160 103 8 Total 4,809 435 17 1 (3399)q E New workshops are always being discovered, at the same time the occupation of premises on the register is constantly changing. The use of 185 workshops was discontinued, and 313 additions were made to the register during the year. 62 Defects found.—1920. Particulars. Number of Defects. Number of Prosecutions. Found. Nuisances under the Public Health Acts:— Want of cleanliness 427 1 Want of ventilation 37 — Want of ventilation of gas stoves 27 — Overcrowding 21 — Want of drainage of floors 10 — Sanitary accommodation— Insufficient 37 — Unsuitable or defective 215 1 Not separate for sexes 70 — Total 847 2 Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouses — — Breach of special sanitary requirements for bakehouses (included above) 2 — Other offences — — Other Matters. Class. Number. Visits to Out-workers' premises 1,385 Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act 44 Absence of means of warming — Matters referred by H.M. Inspectors 208 Workrooms measured 165 Underground bakehouses in use at the end of the year 67 Outworkers.—Employers in certain trades, particularly those engaged in the manufacture of articles of clothing, who give out work to be done in the people's homes, are required twice a year to send in lists of the names and addresses of such persons so that the places where the work is carried on may be inspected, and steps may be taken in case of infectious disease to prevent infected articles being given out from or returned to the shops if in course of manufacture. Notices were sent to 75 employers who neglected to send in returns, and those who failed to reply were visited by an Inspector. In all cases returns were secured without proceedings having to be taken. The number of such lists received in 1920 was 762, 375 in February, and 387 in August. The handling of 63 these lists requires a considerable amount of clerical work, as the names and addresses of persons living out of Westminster but receiving work from employers in Westminster have to be sent to the M.O.H. of the district in which they live; thus 5,602 names and addresses were distributed to 121 other local authorities. They in their turn send names of persons living in Westminster receiving work from employers in their districts. Only 373 were received, showing that a considerable amount of work is sent out of Westminster, not only to other Metropolitan Boroughs, but all over the country. All the Metropolitan districts are represented, in the following proportions:— Battersea 74 Bermondsey 9 Bethnal Green 19 Camberwell 40 Chelsea 22 City of London 30 Deptford 7 Finsbury 23 Fulham 53 Greenwich 1 Hackney 33 Hammersmith 86 Hampstead 20 Holborn 123 Islington 106 Kensington 85 Lambeth 112 Lewisham 26 Paddington 96 Poplar 7 St. Marylebone 564 St. Pancras 464 Shoreditch 21 Stepney 207 Southwark 54 Stoke Newington 8 Wandsworth 73 Woolwich 2 The districts around London had 295 names, Willesden taking 108 of these. (3399)Q E 2 64 City of Westminster. Outworkers. 1920. Trade. FEBRUARY LISTS. AUGUST LISTS. Number of Outworkers. Received from other Authorities. Sent to other Authorities. Addresses in City. Number of Outworkers. Received from other Authorities. Sent to other Authorities. Addresses in City. Boot making 407 7 371 43 400 4 370 34 Brace making 9 — 9 — 12 — 12 — Brush making — — — — — 1 — 1 Corset making 1 — 1 — 1 — 1 — Cutlery, ctc. — — — — — 2 — 2 Dress making 302 41 275 68 334 46 311 69 Dyeing and Cleaning 9 — 6 3 11 — 7 4 Embroidery. 62 4 58 8 55 2 50 7 Engraving — 1 — 1 3 — — 3 Furriers 33 7 31 9 20 2 18 4 Feather working 1 — 1 — 1 — 1 — Glove making 2 — 2 — 2 — 2 — Hat making — 3 — 3 — — — — Lace making — 1 — ] — — — — Lamp shades, etc. 50 — 45 5 69 1 61 9 Laundries 8 4 — 12 12 4 3 13 Lingerie, etc. 112 11 107 16 144 — 137 7 Shirt making 126 3 89 40 120 3 84 39 Tailoring 3,349 104 1,725 1,728 3,456 119 1,782 1,793 Theatrical costurhes 16 — 14 2 7 — 5 2 Tie making 1 — 1 — 1 — 1 — Umbrella making 3 — 3 — 16 — 16 — Upholstery and Carpets 2 2 — 4 2 1 — 3 Waterproofing 2 — 2 — 1 — 1 — Totals 4,495 188 2,740 1,943 4,667 185 2,862 1,990 65 After adjusting the lists, it appears that the actual nuniber of outworkers resident in Westminster is 1,325; this is less than the apparent number shown on the accompanying table, as more than one employer may send work to the same person. These live in 788 houses, which have been visited specially by the woman sanitary inspector, and also by the male inspectors in the course of their ordinary work. Defects relating to cleansing of walls or defective or insufficient W.C. accommodation, unventilated gas heaters, dirty floors, presence of bugs, &c., were found and amended in a number of instances. No prosecutions were taken for doing outwork in unwholesome premises (Sec. 108) or in infected premises (Sec. 109, 110). 66 E. FOOD SUPPLY. During 1920 visits have been paid to the various classes of business, and intimations were served in respect of 584 premises, followed by 3 statutory notices. Restaurants.—The kitchens of hotels and restaurants are inspected at least once a quarter. Ice-cream Premises.—There were during the year 155 places where this commodity was made or sold, and these were kept under supervision; 232 visits were paid. Bakehouses.—At the end of 1919 there were 17 above-ground and 67 underground in use. During 1920 the number in use were 21 above and 63 below ground. All the bakehouses were inspected, and cleansing carried out twee a year. In two cases, severe cautions were given that prosecutions would be instituted if greater attention was not given to cleanliness. Milkshops.—At the end of 1920, 479 names of persons selling milk were upon the register. These include persons selling milk on rounds, who had no shop or store. 703 visits were paid during the year, besides those paid by the two inspectors talcing samples under the Food and Drugs Acts, to premises in which milk is sold. Cowhouse.—There is only one remaining. At the Annual Licensing Sessions in December, the number of cows which might be kept was reduced from 19 to 6. There are no slaughter-houses in Westminster. During the war and up to the middle of 1920, by an Order of the Ministry of Food, no new retail food business could be opened without permission. This has been of considerable benefit, as all such applications were referred to the Public Health Department for a report as to the suitability of the premises. In a number of instances the premises were found to be quite unsuitable, and in others permission was granted subject to alterations being effected. In 1920, 4 applications were considered, 3 were passed, 2 of them only after considerable improvements were carried out, and one was refused as unsuitable. 67 The experience gained under the Order confirms what I have advocated for many years, that places where food is dealt in should not be allowed to be opened without permission from the local authority, and I would again urge that steps be taken to give local authorities this power. The attention of the County Council was called to the need for further powers by the Westminster Council before the war, and the question is again receiving attention with a view to necessary legislation. Exposure of Food for Sale in Public Streets.—The County Council has also under consideration the question whether further powers are needed for regulating, in the interests of public health, the conditions under which articles of food are exposed for sale in public streets, a matter which has been mentioned in previous Annual Reports. It has been urged upon the County Council that food is frequently offered for sale under conditions which render it liable to contamination by the urine of dogs, human expectoration, and the splashing of petroleum, lubricating grease, road disinfectants and chemicals, by vehicles, &c. In view of the importance of the question the County Council's inspectors were instructed to keep observation and to make inquiries, particularly in those localities where street trading is carried on. It has been found that meat, fish and vegetables are frequently deposited on the footway and roadway of the street, or on boards, or in baskets and boxes within a few inches of the street level, and are consequently liable to contamination by dust and the urine of dogs. Among the articles so exposed were vegetables which are usually eaten uncooked (watercress, onions, lettuce, radishes £nd tomatoes). In a number of cases dogs have been seen voiding urine on vegetables, and in one case on some sheep's heads. As to butchers' and fishmongers' shops, the fronts of which are usually open, it was found that the benches and boards of the former are not less than 2 feet above the pavement and of the latter, not less than 18 inches. In the case of provision dealers, the shops are not so frequently open in front and it does not appear that provisions are usually deposited within 2 feet of the pavement. Inspection of Food.—The food exposed for sale in shops and on stalls in the street markets has been regularly inspected every day (including Sundays). The following list shows the quantity of food condemned and destroyed during the year. The bulk of it was submitted by the owners or purchasers for the opinion of your officers:— 68 Articles of Food Submitted. Tons Cwts. Lbs. Tons. Cwts. Lbs. Almonds 0 0 30 Pears 9 19 0 Asparagus 1 0 0 Parsnips 2 15 0 Apples 3 0 0 Pineapples 18 3 0 Apricots 0 0 56 Plums 0 1 56 Bananas 2 3 0 Potatoes 34 11 0 Beans 0 1 0 Tomatoes 0 8 0 Carrots 3 0 56 Tomato puree 0 0 77 Cherries 1 0 56 Turnips 5 0 0 Currants (Red) 0 0 56 Beef (Corned) 18 16 36 Dates 0 0 72 Mutton 0 0 56 Garlic 0 1 0 Bacon 0 6 24 Gooseberries 0 0 28 Venison 0 1 49 Grapes 1 12 0 Skate 0 1 0 Greengages 0 1 56 Haddock 0 0 84 Leeks 0 0 56 Whiting 0 0 56 Oranges 1 10 0 Kippers 0 0 40 Peaches 0 1 0 Condensed Milk, 467 tins; Self-raising Flour, 2½ cwts.; Butter, 2 lbs.; Rabbits, 38; Fowls, 30; Salmon, 4 tins. 69 Sale of Food and Drugs Acts. Samples Purchased under the Sale of Food and Drugs Acts, showing result of Analysis and subsequent Proceedings for year 1920. Number. Article of Food. Number of Sampies Purchased. Genuine. (Inferior in brackets.) Adulterated. Prosecutions. Convictions. Withdrawn or Dismissed. Fines. Costs. 1 Milk 977 90s (31) 38 20 14 6 £ s. d. £ s. d. 30 10 0 15 19 0 2 do. separated 7 5 2 2 2 — 2 0 0 1 3 0 3 Cream 23 16 7 5 5 — 12 12 6 1 13 6 4 do. preserved 20 16 4 5 do. whipped 1 — 1 6 do. cheese 1 (1) 7 Butter 124 123 1 8 Margarine 135 134 1 9 Lard 1 (1) 10 Dripping 40 40 11 Flour, self-raising 26 26 12 Baking powder 3 3 13 Mustard 5 5 14 do. mixture 2 2 15 Jam 18 18 16 Meat pies (various) 60 50 10 17 Sausage rolls 8 6 2 18 Sausages (various) 124 109 15 1 1 — 2 0 0 0 12 6 19 Brawn 2 2 20 Meats, potted (various) 20 17 3 21 Fish, potted (various) 38 31 7 22 Beans 4 — 4 23 Peas 49 17 22 8 8 — 40 0 0 9 7 0 24 Spinach 1 — 1 1 1 — 10 10 0 5 5 0 25 Lime juice 5 1 4 26 Lemon squash 4 1 3 27 Olive oil 48 48 28 Salad oil 18 18 29 Aspirin tablets 9 9 30 Camphorated oil 27 23 4 2 2 — 0 10 0 Selling margarine in plain wrapper — — — 10 10 — 22 0 0 1 1 0 No name and address on milk can — — — 1 1 — 2 0 0 Totals 1,800 1,628 (33) 139 50 44 6 122 2 6 35 1 0 Summary proceedings were ordered to be taken in 50 instances, 20 cautions were issued, the attention of the vendors was called to the report of the Analyst in 5 instances, and no action was taken with regard to G4 samples which deviated slightly from the standard or were test purchases not taken officially. There were 13 non-official samples purchased during the year. 70 Milk.—977 samples of ordinary milk were taken during the year. The Analysts have graded the samples submitted to them into four groups:—Good. quality, in which the fat was over 3.8 per cent.; fair quality, in which the fat was between 3.3 and 3.8 per cent.; and poor or inferior quality, in which the fat was between 3 per cent, (the official standard) and 3.3 per cent., or in which the non-fatty solids were between 8.5 and 8.6 (if the fat was also below 3.8). Adulterated are those below the official standard of 3 per cent, for fat and 8.5 for solids not fat. District. Total. Good Quality. Fair Quality. Poor Quality. Adulterated. No. Per cent. No. Percent. No. Percent. No. Per cent. South 434 168 38.7 197 45.3 59 13.5 10 2.3 North 543 281 51 7 165 303 72 13.2 25 4.6 1920 977 419 45.9 362 370 131 13.4 35 3.5 1919 1,073 375 34.9 428 39.8 201 18.7 69 6.4 1918 919 320 34.8 302 32.8 194 21.2 103 11.2 1917 920 329 3.57 304 330 162 17.6 125 13.6 1916 919 235 25.5 360 39.1 221 22.8 103 11.2 1915 937 303 32.3 327 34.8 225 24.0 82 8.70 1914 894 250 27.9 364 40.7 217 24.2 63 7.04 1913 910 255 28.0 313 37.6 233 25.6 79 8.60 1912 873 251 28.7 297 34.0 252 28.8 73 8.30 1911 911 305 33.3 311 34.1 218 23.9 77 8.40 1910 947 332 35.0 328 34.6 179 18.9 108 11.40 Last year I reported a marked improvement as regards actual adulteration, and this year there is again a very low percentage of adulteration. So far as the quality of the milk is shown by chemical analysis there has never been so high a percentage of "good quality" milk, but there is much room for improvement as regards its cleanliness and keeping properties. Provision was made in the Milk and Dairies (Consolidation) Act of 1915 for securing a more adequate supervision of the conditions under which milk is produced, handled and distributed, but that Act has not yet been brought into operation and is now to be amended in certain respects, especially as regards an extension of the system of classification of milk. Sunday Samples.—20 of the samples of milk were taken on Sundays during the year, all of which were reported genuine. Samples talcen in course of Delivery— (а) At Railway Stations.—2 samples of milk were taken on arrival at Charing Cross Station. One was reported of fair quality and 1 poor. (б) On Delivery at Shops, &e.—16 samples of milk were taken as it was being delivered by wholesale firms to retail customers, including 71 shops, hotels and hospitals. Of these samples, 8 were good, 4 fair, 4 poor, and 0 adulterated. These samples were taken in consequence of previous samples having been found below the limit (including cases where a warranty defence was set up). Twenty prosecutions were taken with regard to adulteration.—10 for fat abstracted, 8 for added water, and 2 for both fat abstracted and water added. Cautions were given to sellers whose milk contained less than 5 per cent, of added water, or had less than 5 per cent, of fat abstracted. Warranties were set up as a defence in 6 instances and were successful. It is the general opinion that the provisions of the Sale of Food and Drugs Acts with regard to warranty defences (especially in the case of milk) operate to the prejudice of the purchaser and the public health, and that they should be repealed. Further, a cowkeeper whose milk is below the standard but proves that it is as given by the cow should not be allowed to sell such milk, as it means that either the cow is inferior or being improperly fed. The Public Health (Milk and Cream) Regulations, 1912 and 1917. Samples Analysed during the Year, 1920. Milk.—977 samples were examined for the presence of preservative and every sample was reported as being free. Cream. Number of samples examined for preservative. Number containing preservative. 24 8 Action Taken. 6 prosecutions ordered Samples contained respectively 37.8, 25.9, 20.8, 16.8 and 112 grainB boric acid per lb. 3 vendors cautioned after ex- Samples contained respectively 14.7, 11.2 and 7.0 planation received, grains boric acid per lb. Preserved Cream. Number examined. Without preservative. Preservative under amount stated on label (0.4 per cent.). Preservative over amount stated on label. 20 3 17 0 Action taken nil Samples contained respectively 26.6, 24.5, 21, 20,3, 18.9, 18.4, 18.2, 10.8, 16.8, 16.6, 14, 14,9.1, 8.4, 7.7, 6.3 and 5.8 grains of boric acid per lb. 72 Meat Pies.—Of GO samples of various kinds of meat pies 10 contained boric acid varying from 16.8 to 2.1 grains per lb. One unofficial sample contained 25.9 grains per lb. Sausages.—124 samples were taken, 15 of which contained boric acid, the quantity varying from 30.9 to 1.0 grains per lb., and the vendor of the sausages with the highest amount was fined £2 and 12s. 6d. costs. Potted Meats.—20 samples were taken, 3 of which contained boric acid, varying in quantity from 13.3 to 8.6 grains per lb. Potted Fish.—38 samples were taken, 7 of which contained boric acid varying in quantity from 14.3 to 4.0 grains per lb. Beans.—4 samples of bottled beans were taken and respectively contained 1.8, 1.6, 1.1 and 0.9 grains crystallised sulphate of copper per lb. A notice on the bottles stated that a small quantity of colouring matter was used. Peas.—49 samples were taken of which 32 contained copper sulphate— in 8 of these, there was 3.7, 2.7, 2.5, 2.3, 2.2, 2.0, 1.8, 1.3 grains per lb. respectively; the vendor of each of these samples was prosecuted the last three on account of no disclosure of the presence of copper. The total fines amounted to £40, with £9 7s. costs. The quantity of copper sulphate in the remaining 24 adulterated samples varied from 1.9 to 0.3 grains per lb. and a notice that the sample contained colouring matter was printed on the label. Spinach.—1 sample was taken and found to contain 4.5 grains of copper sulphate per lb. Proceedings were instituted and a fine of £10 10s. was inflicted with £5 5s. costs. Lime Juice and Lemon Squash.—5 samples of the former and 4 of the latter were taken. Seven contained salicyclic acid varying from 3¼ to 0.9 grains per pint. A notice was printed on the label of each bottle to the effect that a small quantity of the acid had been added. . Camphorated Oil.—27 samples were taken and 4 were found to be deficient of the prescribed amount of camphor to the extent of 17, 12, 9 and 2.25 per cent, respectively. The vendors of the first three samples were prosecuted—two were fined, each 5s., and one dismissed on the production and proof of a warranty. Food Controller's Orders.—The local Food Control Committees were dissolved as from the 30th June, 1920, and their functions, as regards the enforcement of the Food Controller's Orders, were transferred to the 73 Divisional Food Commissioner. The Council had undertaken the enforcement of these Orders and appointed the Medical Officer of Health and his stall to do it and to prosecute where necessary:— The total number of summonses issued was 974. On 786 of these summonses there were convictions; 73 were withdrawn, 51 were dismissed under the Probation of Offenders Act on payment of costs by the defendants, and 57 were dismissed without payment of fines or costs by the defendants, while 7 were adjourned sine die. The total fines inflicted were £4,538, and the total costs ordered to be paid amounted to £1,182 4s. 6d. In addition numerous cautions were administered. The supervision of the registers of catering and residential establishments and institutions, of which there were 2,440, was particularly irksome. Committees were empowered to grant, on application, extra rations to persons suffering from certain specified diseases, on certificates from medical practitioners that such persons needed extra rations. Each application and re-application was submitted to the Medical Officer of Health. Where such extra rations were granted, special permits were issued, available for one month, and renewable monthly. The number of such applications considered and disposed of was approximately 1,500. Retailers of controlled foodstuffs were required by the respective Orders to be registered bv the Committee. The following table sets out the description and number of retailers registered:— Retailers of— Number registered. Retailers of— Number registered. Bacon, Ham and Land 340 Miscellaneous Meats 263 Bread 111 Milk 150 Butter and Margarine 303 Potatoes 201 Cheese 109 Sugar 306 Flour 368 Sweetmeats 295 Jam and Syrup 280 Tea 432 Meat 87 HARRISON AND SONS, LTD., PRINTERS IN ORDINARY TO HIS MAJFSTY, ST. MARTIN'S LANE, W.C,