City of Westminster. ANNUAL REPORT FOR THE YEAR 1924 by FRANCIS J. ALLAN, M.D., C.M., D.P.H. Camb., F.R.S. Ed., Medical Officer of Health and Administrative Tuberculosis Officer. Printed by Order of the Council. LONDON: HARRISON AND SONS, LTD., PRINTERS IN ORDINARY TO HIS MAJESTY, ST. MARTIN'S LANE, W.C.2. City of Westminster. ANNUAL REPORT FOR THE YEAR 1924 by FRANCIS J. ALLAN, M.D., C.M., D.P.H. Camb., F.R.S. Ed., Medical Officer of Health and Administrative Tuberculosis Officer. Printed by Order of the Council. LONDON: HARRISON AND SONS, LTD., PRINTERS IN ORDINARY TO HIS MAJESTY. ST, MARTIN'S LANE, W.C,2. rp Annual Report on the Health and Sanitary Condition of the City of Westminster. 19 2 4. Mr. Mayor, My Lords, Ladies and Gentlemen, I have the honour to present my Annual Report for the year 1924. It includes Returns required by the Ministry of Health and Home Office. As this is the last annual report which I shall have the honour to present to you, I should have liked to have given a description of the conditions existing 25 years ago, when the City was re-incorporated, and compare it with it as now existing. Such a survey would have to be fairly exhaustive, and as many points in connection therewith have been dealt with in recent Reports, especially since the last Census, it is not necessary to repeat them now. I have, however, taken the opportunity to include in the body of this Report information showing to what extent the health of the citizens of Westminster has improved as the result of the activities of the City Council in all matters relating to hygiene. The Council at its inception found that improvements initiated by their predecessors were in progress, such as the formation of Aldwych and Kingsway, which was brought about by the official representation made by me with respect to a large area extending north of the Strand which had a density of 900 persons per acre, rising in parts to as many as 1,200 crowded into old dark houses in narrow courts and alleys. The average number of persons per acre in London at the time was 60. Dwellings were being built by the County Council on the Millbank site, and that neighbourhood was being opened out and other improvements were in process of being carried out. There still remained a number of unsavoury localities to which the Council turned their attention, in some of which proceedings were taken to close the houses as unfit for habitation, and in others the owners had to take steps to remove the insanitary conditions. By-laws giving certain powers of inspection of tenement houses had been adopted but had not been put into execution in parts of the City. (3692)Q A 2 iv Two women Sanitary Inspectors were apointed in 1904 to assist in this. Overcrowding in some parts of the City existed to an extent not approached in Westminster, even during post-war times. During the first few years I find that in some 500 instances this was dealt with. The use of underground rooms for habitation had been permitted, particularly in one area, and this was stopped in 150 instances. The law then only allowed action to be taken if the underground room was the only one in the occupation of the tenant, if he rented another room in a floor above it permitted him to use the underground room. The law is now more stringent and last year only seven instances were found in which it was infringed. The supply of water to houses was very restricted, there was seldom, even in the best houses, means for obtaining water above the ground floor, and cisterns had to be provided. These were frequently in the backyards, uncovered and liable to contamination. Now water can be drawn direct from the main and supplies have been made available to the tenants on all floors of a tenement house. This improvement was helped by the alteration in the mode of charging for water. The system of charging extra for any water laid on to floors above the ground floor was abolished and instead a fixed charge made on the rateable value of the house. The removal of refuse from houses was done only weekly or fortnightly (except in the area which had been under the Strand Board of Works, in which there was a daily collection), the result being that the backyards of houses were frequently littered with all manner of decaying filth, among which the children played and brought it into the houses on their boots. This and the restricted supply of water made it very difficult for tenants desirous of being clean to keep their houses in a proper condition of cleanliness. Food, particularly milk, was liable to pollution, and it is not surprising that during the hot weather large numbers of children died from diarrhoea. The persistent policy of the Council in enforcing all legal requirements in its power has resulted in the abolition of houses unfit for habitation, while domestic conditions have been raised to a much higher standard of comfort and cleanliness than existed a quarter of a century ago. Statements have appeared in the Press during the last year making allegations as to the existence of slum areas and slum conditions in Westminster. It is a great help to a local authority to have the inhabitants take an intelligent interest in sanitary matters, but the object is defeated when exaggerated statements are made. Some such statements appear to be due to a misunderstanding of the facts upon which the statements are made. For instance, a quotation is given from my last Annual Report that in 6,914 houses the basements were used for dwelling purposes and V on this the suggestion is made that these basements are the only rooms occupied and that their occupation is contrary to law. In a number of instances the basements constitute the dwelling, and their use as such is legal as they comply with the requirements laid down by Acts of Parliament and By-laws made thereunder. The other half are basements which are used in conjunction with the rest of the house, most of them being mansions in Mayfair, Belgravia and Knightsbridge. As I have already stated, the number of basements found to be illegally used last year was seven. From the nature of their occupation a number of persons must live within easy access of their work and the Council early resolved that housing accommodation should be provided for such. With this object, in addition to the existing buildings in Ingestre Place and Marshall Street, they have erected Norfolk, Probyn and Jessel Buildings in Regency Street, and propose to add thereto, and Walden House. But beside these Westminster is well provided with dwellings of this class. The County Council erected buildings at Millbank, and adjoining Long Acre, giving accommodation for 4,000 persons; the Peabody Trustees have added to their existing buildings by a large block in Vauxhall Bridge Road, and in Great Peter Street in substitution for buildings in Buckingham Gate, and the Ecclesiastical Commissioners have erected a considerable number. Moreover, Westminster assists financially to a large extent towards the Housing Schemes for the rest of London. There are many people at present living in Westminster whose work takes them far away from it, and they would be glad to live nearer their work. The provision of houses in such districts is an advantage to present residents in the City. Previous to 1901 no instruction or help was given to women as to the upbringing of their children. In 1903 under the auspices of the Council the Westminster Health Society was inaugurated for this purpose. After watching its work the Local Government Board were satisfied that it was of importance, and sanctioned the appointment of Health Visitors by local authorities throughout the country. The Council then took over part of the City and appointed its own Health Visitors for that part and granted a yearly subsidy to the Health Society towards its work in the other part. I have in the body of the Report shown in some detail what has been the beneficient effects of this branch of the Council's activities. A Dental Clinic has now been added and is also doing good work among mothers and children. With regard to Tuberculosis, the Council from the first took active steps to deal with this complaint. Voluntary notification was introduced, Visitors appointed, beds secured in Sanatoria, &c., until compulsory vi notification came into force and the County Council took over the provision of institutional treatment, and in 1916 a medical officer was appointed to take charge of this branch. Details will be found in the body of the Eeport. It is difficult to show by statistics what has been the value of all this work. So far as Infantile mortality is concerned statistics may be taken as reliable, but owing to the demolition of property and the changing character of the City from a residential to a business centre, fluctuations in the population have been such that it is difficult to estimate what the population of the City may have been between the Census periods, and at the last Census which was taken at the middle of the year the population was believed to be underestimated through many of the inhabitants being away. During the last years of the War, there was a large influx into the City of workers in Government Offices and elsewhere. With these reservations, therefore, I submit a summary of the figures I have worked out for each year since 1901. At the beginning the death-rate was 16-0 per 1,000, last year it was 11-5. For males the death rate in Westminster in 1901 was 18-0 per 1,000 and for females 14-0 per 1,000, in 1924 the figures were 14-7 and 9-6, respectively. Throughout the period the death-rates for five yearly periods (last one, 4 years) are shown here:— Average Death-rates for London and Westminster from 1901 to 1924 in groups of Years. — London. Westminster. Both sexes. Both sexes. Males. Females. 1901-5 16.2 14.4 16.5 12.5 1906-10 14.1 12.4 — — 1911-15 14.7 13.2 — — 1916-20 14.8 14.1 — — 1921-24 12.3 11.7 14.4 9.6 The following table shows the death-rates at various age periods at the beginning and end of 24 years:— — Under 1*. 1-5. 5-15. 15-25. 25—45. 45-65. 65 & up. All ages. Males— 1901-2 125 25.1 2.7 4.0 10.1 24.7 110.0 18.0 1921-4 70.3 12.3 2.5 2.2 5.0 19.8 94.1 14.1 Females— 1901-2 128 22.2 2.6 1.8 5.9 21.2 107.0 14.0 1921-4 50.1 10.2 2.2 1.5 2.9 11.7 72.8 9.6 "Under 1 calculated per 1,000 births; at other ages per 1,000 estimated to be living at the respective ages. vii If the populations on which these figures are based be correct the reduction in the deaths of both sexes is very marked. It should be noted, however, that in the earlier years deaths came in of persons who had been in the Poor Law Institutions for many years and who had been admitted from areas in the City in which the houses no longer existed, for instance, it is noted in 1901 that one death was of a person who lived where the Law Courts now stand and another was of a person who had been an inmate since 1878. The same thing occurs still but to a smaller extent of persons admitted from areas more recently cleared, as in St. John's Ward, but deaths even now come in of persons who lived in the Clare Market area. Such deaths affect chiefly the higher ages. I have also worked out the death-rates for each Ward for each year, but here again the fluctuations of population make it difficult to be certain about intercensal years. I have, therefore, selected the three census years and the ones following as being more likely to give a reliable basis for calculation. Conduit. Grosvenor. Knightsbridge St. George. Victoria. St. Margaret. St. John. Ha;r.let of Knightsbridge. Pall Mail. Regent. Great Marlborough. Charing Cross. Covent Garden. Strand. St. Anne. 1901-2 9.1 10.7 10.4 16.1 14.0 23.0 8.6 9.2 16.0 19.0 10.4 17.6 25.3 13.8 1911-12 6.8 8.2 7.4 14.8 10.1 17.3 9.0 8.5 10.6 11.7 8.0 12.7 23.0 11.5 1921-22 6.5 8.2 9.1 13-3 9.8 16.9 8.5 9.2 9.5 10.3 6.8 8.2 31.0 11.2 Some explanation is required with reference to St. John and the Strand Ward figures. Both these districts suffer in the same way, first, on account of having deaths placed to their debit, the population from which they spring having gone, and secondly, all the Common Lodging Houses in the City are situated in these wards, and these add heavily to the death-rate. Thus for 1921 and 1922 the rates for males in St. Johns Ward was 19.2 per 1,000, but without Lodging House deaths it is reduced to 14 per 1,000, similarly the female death-rate would be reduced from 14.4 to 13.8. In the Strand Ward the total population has fallen to 2,116 and half of the male population (1,400) live in a common lodging house, so that the addition of deaths of old residents of the ward and of lodging house inmates tells heavily in the death-rates. Deducting these latter deaths only, the male rate is reduced from 37.8 to 20 per 1,000. Work Premises.—The Northern part of the City has and is still a great centre for tailoring and dressmaking, and regular attention has been given to the condition of the places where persons were employed in these Vlll businesses, especially as regards ventilation and overcrowding. Much of the tailoring work is given out to be done at home and constant supervision is required. Stoves for heating irons made the rooms extremely hot and polluted the air through want of proper methods for carrying off the fumes from fhe coke or gas which was used. After considerable experiments in which the officials of the Gas Light & Coke Co. lent valuable assistance the difficulty was overcome, and stoves for heating workrooms and irons are seldom now found unventilated. A woman Sanitary Inspector was appointed to deal specially with workplaces where women and girls are employed. At the last Census it was found that 318,321 persons, of whom 116,303 were females, are at work in the City daily. Food Supply.—With so many workers as well as the resident population, it is of importance that strict supervision should be kept of places where food is prepared and sold, and also the quality of the food. Great improvements have been effected in the condition of restaurants and eating houses in the 24 years. It is difficult to imagine the uncleanly way in which some of these places were conducted. Frequent and regular inspection has altered all that. The County Council after a good deal of urging on the part of the metropolitan borough authorities obtained parliamentary powers enabling the Borough Councils to deal more stringently with places where food was prepared for sale, and also where ice-creams were made. The Factory Act prohibited the further use of underground bakehouses and required such places as were then in use to be brought up to a standard. The Public Health Committee visited them all in order to decide whether or not they should be allowed to continue. It would have been well had underground kitchens of restaurants been included in the Act. Further powers for dealing with all foods to keep them free from contamination from dust and flies, &c., are still required. This country is a long way behind ou overseas Dominions in this respect. The Council early recognised the importance of taking samples of food for chemical analysis and decided that 1,800 should be taken each year, at least half of which should be of milk. Since 1905 the analysts have graded the samples of milk submitted to them into four groups:—Good quality, in which the fat was over 3.8 per cent.; fair quality, in whih the fat was between 3.3 and 3.8 per cent.; and poor 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. ix Summarised into groups of years the following results appear:— Milk. Good quality. Fair Quality. Poor Quality. Adulterated. Per cent. Per cent. Per cent. Per cent. 1902-4 — — — 14.0 1905-9 34.2 34.0 21.0 10.6 1910-14 30.6 36.3 24.3 8.8 1915-20 33.6 35.9 20.3 10.2 1920-24 44.9 36.9 15.3 2.7 For the last year the figures are— 1924 51.0 36.5 10.5 2.0 So far, therefore, as tlie chemical composition of the milk supplied to Westminster is concerned there has been a manifest improvement, especially marked in the last five years. The proportion of milk with a good percentage of cream supplied in Westminster has risen from 68 to 87-5 per cent. The figures in the 4th column contain a number of samples in which the fat content was a little below 3 per cent., but the amount being small in amount the analysts gave the vendors the benefit. If these be added to those stated definitely to be adulterated, it appears that in the years 1902-3-4 28 per cent, of the milk supply was below standard. This combined figure for the last five years works out at 7.5 per cent. The degree of adulteration when it did occur was much greater than now, 10 to 20 per cent, of added water being usual but higher amounts were found, 30, 40, and as high as 68 per cent. Deficiency in fat ran up to 26 per cent. The addition of preservatives to milk was not then forbidden (the Order forbidding its use did not come into force until 1912), but the Council, recognising the danger of having boric acid in a food largely consumed by young children and invalids, at once took steps to curtail the amount used, 40 to 70 grains per gallon were found in some samples. The bulk of the milk (97.5 per cent.), however, did not contain any, as the large dairy companies also objected to its use preferring to insist on cleanliness and prompt cooling of the milk. There is still much room for improvement at many farms, in the means of transit and distribution. Preservatives were also added to cream and a purchaser had no means of knowing whether he bought pure cream or an article heavily dosed with boric acid. The Council contended that in all cases in which preservatives were used in food disclosure should be made, and even in such cases the amount of preservative used should be small, e.g., 17½ grains of boric acid per lb. of cream. The Council successfully fought many battles in support of their view, both in the Police and higher Courts, with the result X that the trade adopted the practice of stating if the cream was fresh or preserved. The amount of boric acid used came down from an average of 36 grams to the pound so that between 1906 and 1912 in over 60 per cent, of the preserved cream the amount was under 17½ grams, and in 76 per cent, of the samples it did not exceed 22½ grams. In 1913, an Order came in force which required disclosure of the presence of preservative without any specification as to amount. Some of the trade took advantage of this and, as will be seen from the accompanying figures, the amounts found increased, some samples containing as much as 40, 50 and even 63 grains. In 1917 the Local Government Board amended the Order and specified that not more than 28 grains was allowed. This was unnecessarily high as 76 per cent, of the samples since taken have not contained as much as 22½ grains. Cream. No. of samples, Fresh. Bori- cised. Amount of Boric Acid not above 17½ grs. 17½-22½ grs 22½-25 grs. 25-28 grs. Above 28 grs. 1906-12 322 90 232 141 31 21 8 26 Percentages 27.9 72.1 60.7 15.5 9.1 3.4 11.2 1913-17 815 266 549 275 146 44 35 49 Percentages 32.6 67.5 50.0 26.5 8.0 6.3 8.9 1919-24 501 237 264 135 67 29 13 5 Percentages 47.3 52.7 51.1 25.3 10.9 4.9 1.8 Apparently the demand for fresh cream has increased considerably, and has been met by the trade without resort to preservatives, even during the summer months. Butter used to be adulterated by retaining in it considerable quantities of moisture, running up from 4 to 27 per cent. of water, in excess of what there should be, yielding a handsome profit to the vendor. It used also to be found mixed with margarine. Such conditions are very rarely found now. Preservatives were also extensively used in sausages and potted meats, and the Council called the attention of manufacturers and vendors that some manufacturers were able to put up such goods without the use of preservatives. This produced a good result but cases had to be fought in the High Courts in order to secure that the amount of preservative should be restricted. Many other articles of food, drink and drugs have been kept under supervision with beneficial results. Various foods are coloured with the idea that they will appear richer or more attractive. Thus annatto was added to milk to convey the XI impression that it was rich in cream, copper sulphate was added to tinned peas, spinach and other vegetables packed abroad for consumption in this country. As much as 10 grains has been found in some samples. This has been reduced to under 2 grains by prosecutions and by conferences with French and Italian packers. Several English firms put up such vegetables without such unnecessary colouring. There are many other matters affecting the health of the public in which the City Council has taken a leading part, as, for example, in the prevention of smoke nuisances, but I have already said sufficient to give some indication of the many activities which have engaged the attention of the Council during the 24 years I have had the privilege of being associated with it. I cannot take leave of the Council without expressing my indebtedness to the members for the consistent support I have at all times received from them in carrying out the policy and lines of action which they as a Council have laid down. Especially, my thanks are due to the members who have composed the Public Health Committee, and to the successive Chairmen of that Committee, each of whom has taken an active interest in the work of the Department, and by their advice greatly helped in the achievement of rendering the City of Westminster a healthier City both for its residents and the many who work therein, than it was. I desire also to thank my colleagues, those who are and have been the chief officers of the Council for the assistance they have given me and all those who have formed the staff of the Public Health Department upon whom has fallen the brunt of the work, for their loyal co-operation. I have the honour to be, Your obedient Servant, FRANCIS J. ALLAN, Medical Officer of Health. xii SUMMARY OF PARTICULARS REQUIRED BY THE MINISTRY OF HEALTH. 1.—General Statistics. Area (acres)—2,502-7. Population (Census 1921)—141,578. Population, June, 1924 (Registrar-General's Estimate)—143,300. „ „ „ Civilian—139,900. Number of Inhabited Houses (1924)—-27,260. Rateable value—£8,466,056 (September, 1924). Sum represented by a penny rate—£33,600. 2.—Extracts from Vital Statistics for the Year. Births— Males. Females. Total. Birth Rate. Legitimate 773 716 1,489 11.6 Illegitimate 72 63 135 ,, unregistered 2 1 3 Totals 847 780 1,627 Deaths—1,695. Death-rate—11-8. Number of women dying in, or in consequence of, childbirth:— From sepsis, 2. From other causes, 3. Number of deaths of infants under one year of age per 1,000 births—59.0. Legitimate rate, 55.0; Illegitimate rate, 101.4. Number of deaths from measles (all ages)—25. „ „ diphtheria—27. „ „ whooping cough (all ages)—4. „ „ scarlet fever—3. „ ,, diarrhoea (under 2 years of age)—2. „ ,, typhoid fever—0. Other particulars asked for are given in the body of the Report. A list of the staff of the Public Health Department is appended to the Report. PART I. A. STATISTICS. Population. Estimated Population for 1924.—The Registrar-General estimates the population to be 143,000, but for calculating the death rate he deducts the military population in Barracks and Hospitals, leaving 139,900 as representing the civil population. This is an increase on the total, but a decrease on the civilian population. The rates for infectious diseases, &c., are calculated on the larger figure, for births and deaths on the lower one. The official year on this occasion consists of 53 weeks, so that allowance has to be made for this in the calculations. The proportion of males and females in the Civil population works out at 59,467 and 80,433 respectively. Births. The number of births which took place in Westminster in 1924 was 1,447, of these the home address of 344 was elsewhere, and therefore these have to be deducted, but 521 children were born to residents of Westminster in institutions in other parts of London; adding these the net number was 1,624, a reduction of 128 on the figure for the year 1923. The fluctuations in past years are shown below. The fluctuations in past years are shown below. The influence of the opening of Maternity Wards in the hospitals is shown by the increase in registered births and in the larger deduction which has to be made for non-residents in Westminster. It is also shown in the increased number of births notified. The birth-rate was 11.6 per 1,000 persons; the London birth-rate was 18.7 and for England and Wales 18.8—the lowest recorded except during 1917-19. 2  Births Registered. Births Notified. In Westminster. Belong elsewhere. Born out of Westminster. Net. Total. Alive. Stillborn. 1909 2,520 39 270 12,751 1,612 1,571 41 1910 2,365 49 276 2,592 1,674 1,621 53 1911 2,110 60 311 2,361 1,562 1,507 55 1912 2,134 49 264 2,349 1,501 1,469 34 1913 1,992 35 276 2,233 1,462 1,424 38 1914 1,860 15 312 2,157 1,386 1,347 39 1915 1,721 71 329 1,979 1,292 1,250 42 1916 1,643 175 342 1,810 1,330 1,288 42 1917 1,325 159 378 1,544 1,020 985 35 1918 1,138 146 458 1,459 911 888 23 1919 1,210 98 480 1,592 1,004 977 27 1920 1,731 89 618 2,260 1,327 1,289 38 1921 1,418 78 579 1,919 1,049 1,032 17 1922 1,347 81 629 1,895 1,046 1,020 26 1923 1,361 194 585 1,752 1,045 1,016 29 1924 1,447 344 521 1,624 1,250 1,214 36 Divided into legitimate and illegitimate, the figures for 1924 are Legitimate— Males 711-150 +212 = 773 Females 640-133+209 = 716 Total 1,351-283 + 421 = 1,489 Illegitimate— Males 53-35+54 = 72 Females 43-26+46 = 63 Total. 96-61+100 = 135 There is a reduction of 93 in the net number of legitimate births compared with the year 1923, and of 35 in the illegitimate births. The decrease affects each of the districts into which the city is divided for maternity and child welfare work. To the above figures there should be added 3 foundlings, 2 males and 1 female, whose births were not registered. The notifications received numbered 1,250, of these 751 were received from midwives. The number of still-births notified was 36, but information was received of 15 other still-births and miscarriages. 3  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 1921 991 928 91 63 900 865 1922 945 957 68 36 877 921 1923 914 844 44 38 870 806 1924 847 780 58 38 789 742 For each 1.000 girls born, there were in— 1913 1,006 boys. 1914 1,080 boys. 1915 1,033 boys. 1916 965 boys. 1917 914 boys. 1918 1,177 boys. 1919 965 boys. 1920 972 boys. 1921 1,067 boys. 1922 987 boys. 1923 1,082 boys. 1924 1,084 boys. Maternity and Child Welfare. Expectant Mothers.—The names of 1,012 were sent in by hospitals, voluntarily notified or found by visitors, and to these 2,908 visits were paid at their homes (see Table); 163 attended the Mothercraft Classes. Ante-natal Clinics.—145 women attended for the first time in 1924. There were 306 attendances altogether of expectant mothers at the two centres. In 1923, the attendances were 247. Centre. Sessions. First Attendance. Subsequent Attendances. Total. No. of Individuals. Pimlico Road 51 70 70 140 90 Bessborough Street 50 75 91 166 65 146 women also attended the Clinic at Bessborough Street after confinement. Clinics are also held at Charing Cross, St. George's, and Westminster Hospitals. Mothercraft Classes.—These exist at each Centre and are attended by mothers both before and after confinement. Notwithstanding the decrease in the number of births, the attendances at the Council's Centres show an increased attendance by the mothers. 4 Mothercraft classes are also carried on at the Greek Street, Rochester Row and Mayfair Centres by the Health Society. These also show an increase in attendances. The total attendances at all the Centres were 4,865, compared with 4,621 in 1923, and 3,585 in 1922. Particulars relating to these classes are given below :— Mothercraft Classes. 1924. Pimlico Road. Bessboro' Street. Rochester Row. Greek Street and Mayfair. Total. Number of classes 47 48 88 126 309 Total attendances 652 689 1,892 1,632 4,865 Average attendances 13.8 14.3 21.5 12.9 15.6 Number of expectant mothers 27 32 74 30 163 Numb'-r of attendances by expectant mothers 118 166 713 404 1,401 Number of other mothers 30 46 57 48 181 Number of attendances by other mothers 534 523 1,179 1,228 3,464 Attendances of children in nurseries during classes 411 705 728 559 2,423 Materials are purchased in quantity, and sold to the mothers at cost price. The number of garments made at Pimlico Road were 226; at Bessborough Street, 199; at Rochester Row, 1,245; and at Greek Street and Mayfair, 1,210. In addition to which many renovations were carried out. Attendance during Confinement.—The Council's midwife attended necessitous women and emergency cases in the Pimlico area. Number of cases attended— 1922. 1923. 1924. As midwife 95 108 75 As emergency 7 2 — With hospital students 7 5 — With private doctor — 1 — Total 109 116 75 Number of— Pre-natal visits 527 610 570 Lying-in visits 866 1,402 920 Subsequent visits 358 172 315 Visits to infants under 1 year other than lying-in visits 215 172 266 Total number of visits .. 1,966 2,356 2,071 5 Attendances at ante-natal and other clinics:— 1, Pimlico Road 41 72 40 15, Bessborough Street 73 62 83 Total 114 134 123 In the St. John and St. Margaret's area, the Health Society has two midwives. The Society also does the out-patient maternity work of Charing Cross Hospital, and has two midwives for this object. Number of cases attended— Rochester Row. Greek Street. As midwife 67 — With hospital students 5 41 With private doctors 8 — 80 41 Midwifery visits 1,147 469 Nursing visits 114 — 1,261 469 The Greek Street midwives also attended 39 Cliaring Cross Hospital cases in Holborn. The midwives at the Rochester Row Centre attend there once a week to interview expectant mothers. The midwives at tie Greek Street Centre attend the classes at Charing Cross Hospital and an arrangement has been come to between the Health Society and Westminster Hospital for co-operation in their outdoor cases. A similar scheme is under consideration for linking up the extra cases at St. George's Hospital with the midwife employed by the Council. Maternity Wards are now available in St. George's, Charing Cross and Westminster Hospitals. By an agreement between the Council and St. George's Hospital a grant of £3 is paid for each case admitted on a recommendation from the Pimlico and Bessborough Street Centres. Confinements took place during the year in these Institutions as follows:— Charing Cross Hospital: 74, of which 24 were Westminster cases. St. George's Hospital: 223, of which 63 were Westminster cases. Westminster Hospital: 23, of which 10 were Westminster cases. (3692)Q B 6 In the Westminster Infirmary 118 confinements took place, and in Sheffield Street Hospital 23 confinements occurred during the year. Puerperal Fever and Mortality in Childbirth.—Ten cases of puerperal fever occurred with two deaths. Full inquiry was made into the circumstances in each case. Three deaths occurred from complications connected with pregnancy, one woman died from acute pleurisy during the month after confinement. There were also two deaths ascribed to abortion. At the North Centre, 60, Greek Street, 47 classes were held by Dr. Lewin for Nasal Hygiene, especially in connection with cases of adenoids and faulty nasal conditions. Infancy and Early Childhood.—The number of visits paid by the Health Visitors in the four areas into which the City was divided is shown in the accompanying table:— Pimlico. Bessborough Street. Rochester Row. Greek Street. Total. Pre-natal— First visits 244 173 254 199 870 Other visits 391 154 429 296 1,270 Children under 1 year of age— First visits 485 265 416 288 1,454 Other visits 1,338 1,157 1,161 1,009 4,665 Children over 1 and under 5 years— Visits 1,927 2,121 2,234 1,628 7,910 Death enquiries, still births, &c. 43 37 19 16 115 Infectious diseases 302 336 174 129 941 4,730 4,243 4,687 3,565 17,225 To the Pimlico and Bessborough Street figures have to be added visits paid by the midwife, viz., pre-natal, 570; children under 1, 1,266. The visits paid by the midwives at Rochester Row centre are included above. To the Greek Street centre figures have to be added visits paid by the midwives, viz., 198 pre-natal and 349 infant visits. Infant Medical Inspection.—Clinics for this purpose are held at each of the Centres and show an increased attendance at Bessborough Street, Rochester Road and Greek Street. Details of attendances are given in the accompanying table, 7 Attendances at Infant Consultations, 1924. 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 100 231 83 1,729 932 1,960 1,015 2,975 15, Bessborough Street 102 139 32 1,526 1,474 1,605 1,506 3,171 100, Rochester Row 123 240 66 1,590 1,081 1,842 1,147 2,989 60, Greek Street 49 103 15 398 159 501 174 675 1924 374 719 190 5,249 3,046 5,968 3,842 9,810 1923 357 819 101 5,282 3,194 6,022 3.434 9,456 1922 348 800 170 5,085 2,784 5,905 2,954 8,859 The average attendances per session were— 1924. 1923. 1922. 1921. Pimlico Road 29.7 26.0 27.7 31.8 Bessborough Street 31.0 29.1 29.1 40.5 Rochester Row 24.3 30.9 25.5 27.5 Greek Street 13.3 16.4 16.2 21.4 In addition to the inspections by the medical officer stated above, 106 attendances for weighing only were made at Rochester Row and 210 at Greek Street. Ante-natal Clinics and Medical Consultations in connection with theiri Maternity Department are also held by Charing Cross, Middlesex, Westminster, St. George's and York Road Lying-in Hospitals. The number of individual children medically inspected were— 1, Pimlico Road 587 15, Bessborough Street 511 100, Rochester Row 049 00, Greek Street 200 (3692)q B 2 8 District Nursing.—Under the arrangement with the Nursing Associations,* visits were paid in 1924 as follows:— Patients. Visits. Ophthalmia Neonatorum and conjunctivitis 9 133 Influenza 1 6 Pneumonia 25 334 Bronchitis 14 185 Measles 16 124 Whooping Cough 3 24 Other complaints 201 2,281 Total 269 2,787 * The Cheslsea, Pimlico and Belgravia District Nursing Association. The Metropolitan Nursing Association. The Westminster Nursing Committee. Ophthalmia Neonatorum.—23 cases were notified, four of which were treated in hospital. In addition to these instances of slight inflammation of the eyes were recorded in 27 infants and appropriate treatment secured. It is possible that some of these may be the result of infection by syphilis, gonococcus organisms having an attenuated virulence, and therefore important that in all such cases the parents should have treatment. The attention of the medical officers of the ante-natal and post-natal clinics has been called to this. Visits were paid by the Health Visitors to all the cases and by District Nurses called in to assist in 9 cases (133 visits). Ophthalmia neonatorum became notifiable in March, 1911. In the pre-war years, ophthalmia was notified in 1-2 per cent, of the infants born. It increased during the war, reaching 3 per cent, in 1918; since that year it has declined and during the last 5 years the average is 1 • 4 per cent. Until 1917, figures were not recorded of the milder cases but from that date the total of notified and mild cases gives the following rates per 100 births :— 1917 3.2 1918 3.0 1919 2.5 1920 1.5 1921 1.8 1922 2.4 1923 3.4 1924 2.4 In this connection it is of interest to compare the death rate of infants per 1,000 births from svphilis:— 1901-5 2.8 1906-10 3.2 1911-15 2.4 1916-20 4.95 1921-24 2.36 9 These rates rose during the war to 5 per cent, in 1915 and 1916; 8.4 per cent, in 1917; 6.1 per cent. in 1918; 5.6 per cent. in 1919; since when it fell to 2.6 per cent. in 1920 and 1921; and 1.2 per cent, in 1924. Dental Clinic.—The dentist, Mr. W. H. Turner, L.D.S., reports:— "The work of the Dental Clinic has shown a further marked increase during the past year. It has also been noted that the patients are coming up with increasing confidence, and that many of the mothers are themselves making the Clinics existence known and are applying for admission for other patients. The following statement gives an indication of the work done under the Maternity and Child Welfare Scheme during the last four years. 1921. 1922. 1923. 1924. Number of Sessions 62 69 70 79 New patients— First attendance 59 121 123 179 Subsequent attendances 176 463 479 522 Teeth extractions 525 942 1,056 1,349 Teeth filled 72 73 91 154 Other dental operations... 188 232 433 478 Anaesthetics administered:— Local 17 17 20 25 General 81 200 202 240 Dentures supplied 2 5 3 4 "Of the new patients in 1924, 105 were mothers and 74 were children under 5 years of age. The corresponding figures for 1923 were 73 and 50. "Patients contributed £19 8s. 0d. in small sums according to their means. "In consequence of the increasing number of patients attending, arrangements were made for additional sessions to be held. "Details relating to Tuberculous patients who attend on separate days, are given later in this Report under 'Tuberculosis.' " Convalescent Homes.—In the Soho area, facilities for convalescent treatment 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. Homes.—A grant of £100 was made to the St. John the Baptist Home, formerly in Westminster, now at Tulse Hill, and £25 to the Westminster Red Cross Day Nursery. Supply of Milk.—Grants of milk free or at reduced prices were made to expectant and nursing mothers and to children. Except in a few instances ordinary milk was granted, in the others, dried milk. The amount expended was £70 17s. 9d. 10 In addition to the above, dried milk is kept at all the Centres, and is supplied to suitable cases at cost price. The amount sold at the Council's Centres at cost and at reduced price was 2,800 lbs. Deaths. 1,745 deaths were registered in the City in the 53 weeks of 1924. After deducting 842 deaths of non-citizens in public institutions in the City, and adding those of 853 citizens who died in other districts, the corrected total is 1,695, as compared with 1,493 in 1923, and is equivalent to an annual rate of 11.8 per 1,000 persons (civilian population). The London death-rate for 1924 was 12.1 (civilians only), for England and Wales 12.2. These rates are all a little higher than 1923, but are below the average of the 5 years (1919-1923). The number of deaths and the death-rates per 1,000 for a series of years are shown below:— Year. Number of Deaths. Westminster Rate. London Rate. 1911 2,005 12.5 15.0 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 16.1 1916 1,827 13.7 14.3 1917 1,896 15.5 15.0 1918 2,062 16.3 18.9 1919 1,819 14.2 13.4 1920 1,600 10.9 12.4 1921 1,623 11.5 12.4 1922 1,796 12.9 13.4 1923 1,493 10.6 11.2 1924 1,695 11.8 12.1 The deaths of males were 913, females 782, giving rates per 1,000 for 1924, males 14-7, females 9.6. These rates are higher than those of the preceding year, but are not above the average. Divided into various age periods we get:— 1924. 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. 57 12 14 23 22 106 337 342 913 F. 39 20 25 18 24 78 220 358 782 1919 140 24 31 33 80 265 570 676 1,819 1920 167 18 21 27 53 222 517 575 1,600 1921 154 28 32 35 56 204 499 615 1,623 1922 104 26 32 41 62 211 584 736 1,796 1923 83 16 13 19 46 171 463 682 1,493 1924 96 32 39 41 46 184 557 700 1,695 ii which give rates per 1,000 estimated to be living at these periods as follows:—.. — Under 5. 5-15. 15-25. 25-45. 45-65. 65 & Up. All Ages. 1921 M. 41.0 2.8 2.4 5.2 18.8 92.0 14.6 1922 M. 34.0 2.7 2.7 5.5 21.1 100.0 15.0 1923 M. 18.2 1.4 2.0 4..3 17.6 86.0 12.6 1924 M. 27.3 3.2 1.9 5.0 21.6 98.5 14.7 1921 F. 28.8 2.0 1.1 3.0 10.6 60.0 9.0 1922 F. 22.3 3.1 2.0 3.2 13.5 80.0 10.7 1923 F. 18.0 1.3 1.4 2.7 10.7 76.4 9.1 1924 F. 26.5 2.4 1.5 2.5 11.8 74.8 9.6 Comparison of the rates at different ages shows increases over 1923 in children of both sexes and in males over 45 years of age, but females over that age show a better record and have not suffered to the same extent as males of the same age. In a Table appended to this section of the Report, the causes of death are set out. By comparison with the similar Table in the 1923 Report, it appears that among males the excess of deaths was chiefly caused by influenza, bronchitis and pneumonia, diseases of the heart and blood vessels, tuberculosis, measles and diphtheria; among females, the excess is due to respiratory diseases, influenza, accidents, diseases of the digestive organs, measles, diphtheria and scarlet fever. The deaths were distributed in the wards in the years 1921,1922,1923 and 1924 as follows:— — 1921. 1922. 1923. 1924. M. F. Total. M. F. Total. M. F. Total. M. F. Total. Conduit 8 12 20 6 18 24 11 12 23 11 11 22 Grosvenor 57 50 107 56 68 124 48 47 95 50 52 102 Hamlet 18 29 47 37 29 66 29 30 59 30 28 58 K. St. George 55 55 110 64 56 120 45 56 101 43 60 103 Victoria 234 233 467 249 283 532 217 261 478 245 282 527 St. Margaret 44 37 81 52 49 101 43 37 80 50 33 83 St. John 214 162 376 240 203 443 170 166 336 245 196 441 St. Anne 47 36 83 35 30 65 39 21 60 41 26 67 Gt. Marlborough 16 12 28 19 17 36 9 15 24 22 12 34 Pall Mall 20 11 31 24 11 35 12 12 24 33 8 41 Regent 35 37 72 27 32 59 21 30 51 35 22 57 Charing Cross 28 10 38 19 7 26 18 9 27 17 9 26 Covent Garden 38 23 61 40 28 68 34 22 56 26 25 51 Strand 57 12 69 49 13 62 42 8 50 40 7 47 Homeless 26 7 33 23 12 35 18 11 29 23 11 34 There was an increase in the number of male deaths in Victoria, St. John's, Great Marlborough, Pall Mall and Regent Wards; an increase in 12 female deaths in Victoria and St. John's Wards. The deaths correspond more nearly with those of 1922. Infantile Mortality.—The corrected death-rate of infants for Westminster was 59.0 deaths per 1,000 births. The mortality of legitimate infants was 55 per 1,000; in the Pimlico area this rate was 56.5; in the St. John's and St. Margaret's area it was 56.4; and in the Northern area 49.3. The averages for legitimate infant deaths during the preceding three years, 1921-22-23, were: Pimlico, 54.2; St. Margaret and St. John, 54.8; Northern, 49.7; and for the whole City, 53.3. It is interesting to compare the figures for the same areas in the years 1901-2-3 before systematic work was begun for Infant Welfare with the corresponding years 1921-22-23. Average death-rates of children under one year of age:— 1901-2-3. 1921-22-23. Pimlico area 131.0 57.3 Greek Street 113.0 53.3 Rochester Row 135.5 57.8 Fluctuations occur in individual years, but when the figures are grouped in five-yearly periods a steady improvement is shown, until the present low rate is obtained. With the greater attention now being given to ante-natal work and improved conditions of child birth, it is possible the rates may be still further reduced. Of the 96 deaths, 58 occurred in the first half of the year. An epidemic of measles prevailed during this period. Fortunately there was an absence of diarrhoea in the third quarter, otherwise the rate would have been higher. Respiratory complaints caused a heavier mortality chiefly in the last quarter of the year. The deaths in the four quarters occurred as follows:— 1924. Pimlico. St. Margaret and St. John. North. Unknown. Total 1924. Total. 1923. Total 1922. 1st Quarter 17 12 2 0 31 24 £1 2nd 15 3 8 1 27 20 20 3rd „ 8 4 2 2 16 18 16 4th „ 9 6 7 0 22 21 17 49 25 19 3 96 83 104 13 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 76 1921 1,729 117 67.7 190 37 194 80.2 80 1922 1,703 84 49.3 199 20 100 54.6 74 1923 .... 1,582 68 42.9 176 15 85.7 47.2 60 1924 1,489 82 55.0 138 14 101.4 59.0 69 Five-Yearly Averages. 1892-96 . 159 157 1897-1901 . . 150 159 1902-06 111 200 115 135 1907-11 92 164 96 114 1912-16 75 188 87 100 1917-21 73.8 195 88.8 90 1922-24 (3 years) 49.1 95.7 53.6 68 The reduction in the infantile death-rate in the last 24 years is remarkable. It means that 100 infant lives in every 1,000 born in Westminster are now being saved. In the three divisions into which the City is divided under the Maternity and Child Welfare Scheme, the figures (omitting the homeless) were:— 14 Legitimate. Illegitimate. Total. Centre 1922. 1923. 1924. 1922. 1923. 1924. 1922. 1923. 1924. L'irnlico and Bess- borough Births 819 773 760 92 92 66 911 865 826 Deaths 44 28 43 7 5 6 51 32 49 Death-rate per 1,000 birth's 53.7 36.2 56.5 76 54.3 91 55.9 38.0 59.3 Greek Street.- Births 372 340 304 59 54 36 431 394 340 Deaths 13 17 15 2 2 4 15 19 19 Death-rate per 1,000 births 34.9 50.0 49.3 34 37.0 111 34.5 48.2 55.3 Rochester Row. Births 512 469 425 41 23 33 553 492 458 Deaths 27 23 24 4 1 1 31 24 25 Death-rate per 1,000 births 52.7 49.0 56.4 97.5 43.4 30 56.0 48.7 54.5 The causes of death of children under 1 year of age 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:— - 1918. 1919. 1920. 1921. 1922. 1923. 1924. Diphtheria 1.4 Influenza 6.81 5.62 . . 3.6 . 0.6 Measles 0.68 1.87 2.21 . 1.0 . 5.5 Whooping cough 3.4 0.62 . 1.5 10 11 1.9 Septic diseases . . 0.44 1.4 0.5 1.7 1.2 Bronchitis and pneumonia 16.35 10.60 12.80 11.8 7.3 4.0 10.4 Stomach and bowel complaints 10.89 8.75 9.29 13.4 3.1 1.1 1.9 Syphilis 6.13 5.62 2.64 2.6 2.1 2.8 1.2 Congenital malformations 4.76 3.75 6.19 9.3 4.2 5.1 4.9 Prematurity 23.3 21.2 5.40 15.5 16.2 13.1 14.1 Neglect and injury at birth 8.17 7.50 17.07 7.3 5.7 6.8 3.1 Debility from birth and atrophy, rickets, atelectasis 8.17 11.80 11.48 11.0 4.2 6.2 5.3 Tuberculosis 6.13 2.50 1.76 1.4 1.5 1.7 1.8 Other causes 5.45 6.90 4.34 3.6 3.6 2.8 6.7 100.24 87.5 73.62 80.2 54.6 46.6 59.0 15 It will be noted in the table below that nearly half of the deaths occurred before the infants were a month old— Of the deaths over a month old, a third had not come under observation of the medical officers or health visitors at the various centres, due either to the fact that the parents were in a position to obtain skilled advice, or that the children were born elsewhere and had recently come into Westminster, or illegitimate children born outside Westminster and at once sent to homes not in the City— In the last group it frequently occurs that the child has never lived in Westminster but because the mother had been in service here before going to some institution for her confinement, the death is placed to the debit of the City— Table V——Infant Mortality, 1924— Net deaths from stated causes at 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. Tot; 1 under 4 Weeks. 4 Wreks and under 3 Mont lis. 3 Months and under 6 Months. G Monti s and under 9 —Months. 9 Months and under 12 months. Total Draths under 1 Year. Influenza — — — — — — — 1 — 1 Diphtheria — — — — — — — — — — Measles — — — 1 1 — 1 2 5 9 Whooping cough — — — — — — — 1 2 3 9 Tuberculosis — — — — — — 1 1 1 3 Syphilis — — — — — 1 1 — — 2 Meningitis — — — — — — 1 — — 1 Bronchitis — — — — — — 2 — — 2 Pneumonia (all forms) —— — — — — 3 6 4 1 14 Gastro-enteritis — — — — — — 2 1 — 3 Injury at birth — 1 — — 1 1 — — — 2 Neglect at birth 3 — — — 3 — — — — 3 Murder 1 — 1 _ — — — 1 Atelectasis 3 — — — 3 — — 3 Congenital malformations 3 1 4 3 1 — — 8 Premature birth 17 2 2 1 22 1 — — — 23 Malnutrition, marasmus debility from birth 3 1 — — 4 — 2 — — 6 Rickets — — — — — — — — — Accidents — — — — — 1 — — 1 2 Other causes 1 3 — — 4 1 1 — 2 8 Totals 31 9 2 2 44 12 18 10 12 96 16 Nett Births in the year— Males— Females— Total Legitimate 773 716 1,489 Illegitimate 74 64 138 846 780 1,627 Including 3 male and 3 female illegitimate unregistered— Nett Deaths in the year of— Males— Females— Total— Legitimate infants 49 33 82 Illegitimate infants 8 6 14 57 39 96 The causes of death of the Illegitimate were:—Broncho-pneumonia 3, bronchitis 1, syphilis 1, neglect at birth 3, murder 1, congenital malformation 1, prematurity 3, marasums 1— Table V, continued——Infant Mortality, 1924— Nett deaths from stated causes at various ages under One Year of Age in Pimlico Area, ( Victoria, Knightshridge St— George and Hamlet Wards)— CAUSES OF DEATH— Under 1 Week. j 1—2 Weeks. 2—3 Weeks. 3—4 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 One Year— Influenza — — — — — — — 1 — 1 Diphtheria — — — — — — — — — — Whooping cough — — — — — — — — — — Measles — — — 1 1 — 1 1 3 6 Tuberculosis — — — — — — 1 1 2 Bronchitis — — — — — — 2 — — 2 Pneumonia (all forms) — — — — — 1 2 3 1 7 Gastro-enteritis — — — — — — 1 — — 1 Syphilis — — — — — 1 1 — — 2 Injury at birth Atelectasis 1 — — — 1 — — — — 1 Congenital malformations 1 1 — — 2 1 — — — 3 Premature birth 9 — 2 1 12 — — — 12 Want of attention at birth — — — — — Malnutrition,marasmus and debility from birth 2 1 — — 3 — 1 — — 4 Accidents — — — — 1 — 1 2 Riokets — — — — — — Other causes 1 3 — — 4 — 1 — 1 6 Totals 14 5 2 2 23 4 10 6 6 49 17 Nett Births in the year. Legitimate 760 Illegitimate 66 Nett Deaths in the year of— Males. Females. Total. Legitimate infants 20 23 43 Illegitimate infants 3 3 6 Table V, continued..Infant Mortality, 1924. Nett Deaths from stated causes at various ages under One Year of Age in St. John and St. Margaret Wards. CACSES OF DEATH. Under 1 Week. 1.2 Weeks. 2.3 Weeks. 3.4 Weeks. Total under 4 Weeks. 1 Weeks and under 3 Months. 3 Months and under 6 Months. *5 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under 1 Year. Diphtheria . . . . . . . . . . Influenza . . . . . . . . . . Measles . . . . . . . . 2 2 Whooping cough . . . . . . 1 . 1 1 2 Sepsis . . . . . . . . 1 Tuberculosis . . . . . . . 1 1 Meningitis . . . . . .. 1 . . 1 Bronchitis . . . . . . . . . . Pneumonia (all forms) . . . . . 2 4 1 . 7 Gastro-enteritis . . . . . . 1 1 . . Syphilis . . . . . . . . . . Rickets . . . . . . . . . . Injury at birth . . . . . . . . . . Congenital malformations 1 . . . 1 2 1 . . 4 Premature birth 4 . . . 4 . . . . 4 Atrophy, marasmus . . . . . . . . . . 1 Debility from birth 1 . . . 1 . . . . Atelectasis . . . . . . . . . . Totals 6 . . . 6 5 7 3 4 25 Nett Births in the year. Legitimate 425 Illegitimate 33 Nett Deaths in the year of. Males. Females. Total. Legitimate infants 17 7 24 Illegitimate infants 0 1 1 18 Table Y, continued——Infant Mortality, 1924— Nett Deaths front stated causes at various ages under One Year of Age in the North District (Grosvenor, Conduit and Strand Borough Wards)— CAUSES OF DEATH— Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3—4 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. Influenza — — — — — — — — — — Diphtheria — — — — — — — — — — Measles — — — — — — — 1 — 1 Whooping cough — — — — — — — — 1 1 Umbilical sepsis — 1 — — 1 — — — — 1 Tuberculosis — — — — — — — — — — Bronchitis — — — — — — — — — — Pneumonia (all forms) — — — — — — — — — — Grastro-enteritis — — — — — — — — — — Syphilis — — — — — — — — — — Injury at birth — 1 — — i 1 — — — 2 Atelectasis 2 — — — 2 — — — — 2 Congenital malformations 1 — — — 1 — — — — 1 Premature birth 4 2 — — 6 1 — — — 7 Malnutrition, inanition and debility from birth — — — — — — 1 — — 1 Tonsilitis — — — — — — — — 1 i Murder 1 — — — 1 — — — — 1 Sarcoma — — — — — 1 — — — 1 Totals 8 4 — — 12 3 1 1 2 19 Nett Births in the year- Legitimate 304 Illegitimate 36 Nett Deaths in the year— Males— Females— Total— Legitimate infants 12 3 15 Illegitimate infants 3 1 4 Table V, continued——Deaths of infants with no known address, or found in streets, parks, &c.:— CAUSES OF DEATH— Under 1 Week— 1—2 Weeks— 2—3 Weeks— 3—4 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— 1 Neglect at birth 3 — — — 3 — — — — 3 Males— Females— Total— Legitimate — — Illegitimate 2 1 3 19 Mortality in Infants under one year or age from 1901 to 1924. Figures are not available before 1905, but a comparison of the ages of the deaths of children under 1 year of age shows that little improvement has taken place in the proportion of deaths which occur at birth or within the first week. The average of such deaths for the nine years 1905-13 was 23.0 per 1,000 born, but in individual years before the War it was several times below 21. During the War and up to 1920 the rate rose to 30, and since then until 1924 it has varied from 21.8 to 24.5. In 1924 the rate was 19, which is the lowest shown, and indicates that some improvement is taking place in regard to care of the mother before and at the time of confinement. It is certain that there is still room for improvement. Three-yearly Periods. Under 1 week. 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. 1905-8 23.8 41.1 21.0 16.4 15.0 11.4 1922-24 21.9 27.7 7.9 10.0 5.4 6.4 These rates are per 1,000 births. There is more improvement shown in the deaths under four weeks, while at ages 1 to 3 months, 3 to 6 months and 9 to 12 months the reduction is considerable at each period, equal in the last three years to 53 per cent, of the rates in 1905-8. The causes of death of infants under 1 year of age from 1901 to 1924 are set out below, from which it will be seen under which headings reduction has taken place. From a study of this table it appears both possible and practicable that increased efforts in various directions will effect still further improvements in the health of the infant, which will be reflected in later years in the health and longevity of the adult. 20 Infantile Mortality, 1901 to 1924— Deaths from stated causes of Infants under One Year of age with rates per 1,000 births— Causes of Death. 1901-5. 1906-10. 1911-15. 1916-20. 1921-24. Deaths. Bate. Deaths. Rate. Deaths. Bate. Deaths. Rate. Deaths.  Smallpox 3 0.1 — - - - - - 1.87 11 1.52 Measles 55 3.4 23 1.63 22 1.98 16 Scarlet fever 5 0.3 1 0.07 — — — 10 1.38 Whooping cough 72 4.4 47 3.34 46 4.14 12 1.40 Diphtheria and croup 4 0.2 7 0.49 5 0.45 2 0.23 2 0.27 Influenza — — 4 0.28 4 0.36 19 2 .22 8 1 1.11 Erysipelas 4 0.2 6 0.42 3 0.27 — 0.46 0.13 Other septic 13 0.8 23 1.63 9 0.81 4 7 0.97 Cerebro-spinal fever — — 3 0.21 2 0.18 3 0.35 1 0.13 Tuberculosis 86 5.3 66 4.68 31 2.80 28 3.27 11 1.52 Meningitis and — — — — — — 6 0.07 6 0.83 Convulsions 121 7.3 41 2.91 27 2.43 Bronchitis 156 l9.7 89 l5.7 51 l4.70 124 14.50 12 8.60 Pneumonia 164 133 112 50 Diarrhoea, enteritis 305 18.8 195 13.81 160 14.40 85 9.90 37 5.13 Other Diseases of the digestive system 43 2.6 17 1.20 15 1.35 8 0.93 1 0.13 Syphilis 46 2.8 45 3.19 27 2.43 43 5.02 17 2.36 Premature birth 306 18.8 203 21.40 233 21.03 183 21.40 108 15.00 Congenital malformation — — 78 5.54 64 5.78 47 5.48 43 6.00 Atelectasis — — — — 7 0.82 11 1.52 Injury at birth 416 25.6 36 2.56 25 2.25 21 2.46 18 2.50 Debility at birth 100 7.12 35 3.16 34 3.97 22 3.03 Marasmus 98 6.98 49 4.41 29 3.38 14 1.94 Rickets 15 1.07 11 0.90 13 1.52 7 0.97 Neglect at birth 13 0.91 23 2.07 36 4.20 16 2.22 Murder 83 51 21 1.48 14 1.26 8 0.93 4 0.54 Accidents 6 0.42 6 0.54 10 1.17 11 1.52 Kidney Disease 3 01 2 0.14 3 0.27 2 0.24 1 0.13 Other causes 63 3.7 21 1.48 27 2.34 26 3.03 8 1.08 Totals 1,940 119.0 1,391 98.6 1,004 90.6 766 89.2 437 60.6 21 Mortality of Children between the ages of 1 and 5 Years from 1901 to 1924. The accompanying table shows the causes to which death was attributed in five groups of years from 1901. Deaths of children between the ages of 1 and 5 years, with rates per 1,000, estimated to be living in the five groups of years from 1901 to 1924. Causes of Death. 1901-5. 1900-10. 1911-15. 1916-20. 1921-24. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Smallpox 3 0.06 - - - - - - - - Measles 154 3.47 86 2.19 92 2.70 37 1.35 23 1.25 Scarlet fever 32 0.71 32 0.81 14 0.41 8 0.29 3 0.16 Whooping cough 92 2.00 54 1.37 37 1.08 28 1.02 13 0.71 Diphtheria 51 1.4 52 1.2 30 0.88 33 1.20 39 2.10 Influenza 2 0.04 2 0.05 . 21 0.86 3 0.16 Erysipelas 1 0.02 - - - - - - - - Cerebro-spinal fever - - 2 0.05 3 0.08 4 0.14 1 0.05 Septic infection 1 0.02 2 0.05 3 0-08 2 0-07 1 0.05 Rheumatic fever and valvular heart disease 4 0.09 2 0.05 4 0.11 . . 1 0.05 Tuberculosis 130 3.04 107 2.72 75 2.20 44 1.60 14 0.76 Meningitis and Convulsions 45 1.00 24 0.01 16 0.47 10 0.36 8 0.43 Bronchitis 70 1.50 33 0.84 13 0.38 7 0.25 11 0.60 Pneumonia . 147 3.28 77 1.90 78 2.29 56 2.04 54 2.95 Other Respiratory diseases 33 0.84 3 0.08 1 0.03 3 0.16 Diarrhoea, enteritis 43 0.90 28 0.71 32 0.94 13 0.47 4 0.22 Other diseases of digestive system 20 0.40 13 0.33 6 0.17 7 0.25 7 0.38 Syphilis - - - - 2 0.06 1 0.03 1 0.05 Developmental disease 42 0.94 25 0.63 19 0.56 10 0.36 3 0.16 Kidney disease 8 0.18 6 0.15 2 0.06 1 0.03 1 0.05 Accidents 31 0.09 20 0.66 24 0.76 20 0.73 12 0.65 Murder 2 Other causes 39 0.91 19 0.08 17 0.50 14 0.50 15 0.82 Totals 929 22.20 624 15.9 472 13.88 318 11.00 217 11.87 The average of 22-20 per 1,000 of children living at that age period in 1901-5 has fallen in each group of years until the last which shows a slight rise, but is still about half what it was in the first period. "While improvement has taken place under most headings, the last two periods show an increase in Diphtheria deaths (to which I refer later in this Report), and in deaths from Influenza. There is no improvement in the proportion of deaths from Bronchitis and Pneumonia. To some extent this may be due to the prevalence of Influenza, but there is need for enquiry as to other factors bearing upon the causation of these affections, not only at this age, but at all age periods. The effect of smoke and fog is recognised as one (3692)q c 22 important factor, insufficient ventilation of rooms is probably another, but doubtless there are others against which it may be possible to provide protective measures. While deaths from Diarrhoea and Enteritis have largely declined, deaths from Appendicitis and other diseases of the digestive organs, which had shown a decrease up to 1916, have increased since. Combined, however, with deaths from Developmental Diseases, the decrease is regular, 1.34, 0.76, 0.73, 0.61 to 0.54. The conditions obtaining in the War and post-War years do not appear to have affected children at this group of ages. Mortality of Children between the ages of 5 and 15 Years (School age). Deaths of children between the ages of 5 and 15 years with rates per 1,000 estimated to be living in the five groups of years, from 1901 to 1924. 1901-5 1906-10. 1911-15. 1916-20. 1921-24. Causes of Death. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Deaths. Rate. Smallpox 2 0.01 — — — — — — — — Measles 6 0.05 2 0.02 10 012 6 0.08 2 003 Scarlet fever 12 0.11 19 0.20 15 0.18 3 004 7 0.12 Whooping cough 3 0-02 1 0.01 1 0.01 8 0.10 — — Diphtheria and croup 21 0-19 16 0.17 23 0.27 22 0.28 42 0.73 Influenza 2 0.01 1 001 — — 12 0.16 2 0.03 Cerebro-spinal fever — — 1 001 1 0.01 4 0.05 .— — Enteric fever 4 0.03 — 2 0.02 2 0.02 1 0.02 Tuberculosis 76 0.69 61 0.64 49 0.58 40 0.52 15 0.26 Septic diseases 5 0.04 5 0.05 11 0.13 4 0.05 — Meningitis and Convulsions 6 0.05 6 0.06 6 0.07 2 0.02 4 0.07 Other diseases of nervous system 9 0.07 7 0.07 5 0.06 3 0.04 5 0.09 Bronchitis 6 0.04 — 3 0.03 2 0.02 6 0.10 Pneumonia 6 0.05 7 0.07 17 0.20 11 0.14 8 0.14 Other Respiratory diseases 8 0.07 12 012 4 0.04 2 0.02 .. . Diarrhoea, enteritis 6 0.05 2 002 2 0.02 1 0.01 Other diseases of digestive system 11 0.10 16 0.17 10 0.12 11 0.14 6 0.10 Kidney disease 3 0.02 4 0.04 1 0.01 2 0.02 1 0.02 Rheumatio fever and valvular disease of heart 32 0.29 25 0.26 21 0.25 9 0.12 7 0.12 Other diseases of circulatory system 9 0.07 8 0.08 6 0.07 2 0.02 12 0.21 Accidents 24 0.22 22 0.23 21 0.25 20 0.26 11 0.19 Other causes 20 0.18 11 0.12 17 0.20 12 0.16 8 0.14 Totals 270 2.48 226 2.37 225 2.69 178 2.34 137 2.37 23 The death-rate for the school child (5 to 15 years) has remained practically constant throughout the whole period 1901 to 1924. Had it not been for an increase in deaths from Diphtheria in the last four years, that period would have shown a lower figure. Bronchitis and Pneumonia also give a slight increase. Rheumatic Fever and Valvular disease of the heart have decreased, but other affections of the circulatory system show a sudden rise. The drop in deaths from Tuberculosis is considerable, especially in the last four years. The death-rate at this period of life is a very low one, and is therefore not susceptible of so much improvement as the age groups already considered, but it ought to be possible to reduce to a lower level. Common Lodging House Deaths..There are now three common lodging houses in the City, licensed for 1,481 men, and one for 57 women and 2 children. The population is a fluctuating one, some are permanent lodgers, but many stay for short periods. The number of individuals passing through them in the course of a year is not known. Bruce House is in the Strand Ward, the other three are in St. John's. The death rates of these two wards are automatically increased thereby; 84 deaths of persons giving addresses in common lodging houses occurred during the year, mostly in institutions :- Bruce House (L.C.C. 16, Strutton Ground licensed for 715 men) 29 (licensed for 201 men) 14 *33, Great Peter Street 4 40, Great Peter Street (Church Army, 7, St. Ann Street licensed for 57 women (Salvation Army, and 2 children) 4 licensed for 565 men) 33 Deaths of persons who had no definite address.-Twenty-three males and 11 females died for whom no address could be traced. * This lodging houses was discontinued many years ago. Eleven of the deaths were from Tuberculosis. (3692)Q C 2 24 MALES. Table I..Causes of, and Ages at, Death during the year 1924. Causes of Death. Corrected Deaths in the City at subjoined Ages. Deaths in Wards (at all Aoes). All ages. Under 1. 1 and under 2. 2 and under 5. | 5 and under 15. | 15 and under 25. 25 and under -15. 45 and under 65. 1 | 65 and upwards. Conduit. Grosvenor. Hamlet of Knightsbridge. Knightsbridge St. George. Victoria. St. Margaret. St. John. St. Anne. Great Marlborough. Pall Mall. Regent. Charing Cross. Corent Garden. Strand. Homeless.[/####] Small-pox - - - - - - - - - - - - - - - - - - - - - - - Measles 10 65 2 2 - - - - 1 - 1 1 - 3 - 2 2 1 - - - - - - Scarlet fever - - - - - - - - - - - - - - - - - - - - - - - - Influenza 25 1 - - 1 1 2 9 11 - 2 1 4 6 1 1 2 1 3 2 1 - 1 - Whooping-cough 2 2 - - - - - - - - - - - - - 1 - 1 - - - - - - Diphtheria, Memb. croup 10 . 1 3 6 - - - - - - - - - - - - - - - - - - Cerebro-spinal meningitis - - - - - - - - - - - - - - - - - - - - - - - Poliomyelitis - - - - - - - - - - - - - - - - - - - - - - - - Enteric fever - - - - - - - - - - - - - - - - - - - - - - - - Diarrhoea, enteritis 2 - - - - - - - - - - - - - - - - - - - - - - - Erysipelas 1 - - - - - - - - - - - - - - - - - - - - - - - Puerperal fever - - - - - - - - - - - - - - - - - - - - - - - - Other sentic diseases 11 - - - - 1 - 4 5 - - 2 - 4 1 2 - - 1 1 - - - - Syphilis, &c. 4 2 - - - - - 1 1 - 2 - - 2 - - - - - - - - - - Diabetes 7 - - - - - 2 2 3 - 2 - 1 - 1 1 - 1 1 - - - - - Rheumatic fever 2 - - - - - - 1 - - - - 1 1 - - - - - - - - - - Tuberculosis of lungs 90 - - - 1 4 36 37 12 1 1 1 1 22 4 35 5 2 1 2 . 2 11 2 Non-Pulmonary Tuberculosis S 2 1 1 2 _ 2 - - _ - 3 5 _ - _ - - - - - Malignant growths 107 - - 1 - 1 8 58 39 - 4 1 7 31 8 33 5 1 1 6 2 4 4 - Congenital debility, malformation, and premature birth 26 26 - - - - - - - 1 1 2 1 7 2 4 1 2 1 2 - 2 - - Old age 24 - - - - - - - 24 1 2 1 - 9 1 7 1 - 1 - - - - 1 Meningitis and convulsions - 1 - 2 - - - -2- - - - - 1 1 - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - 25 MALES.—Table I. (continued). Causes of Death. Corrected Deaths in the City at subjoined Ages. Deaths in Wabds (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. Regent. Cbaring Cross. Covent Garden. Strand. Homeless. Loc. ataxia and general paralysis .. 12 — — - - 1 4 4 3 - — — — 3 — 6 1 — — - — 2 — — Other diseases of nervous system 23 - 1 - 2 8 3 10 4. 1 - 1 1 3 3 6 - - 3 2 1 1 2 - Valvular diseases of heart 19 — — - 2 1 2 7 7 - 1 1 2 5 1 5 2 — — — 1 1 — — Other circulatory diseases 176 — — - 2 2 7 68 97 2 15 8 11 37 11 39 13 4 6 5 6 9 5 5 Bronchitis 98 — ] - — — 2 36 59 — 2 3 3 38 1 27 4 2 3 5 1 — 7 2 Broncho.pneumonia 36 10 6 2 — — 3 7 8 1 1 — 1 11 1 16 — 2 1 — 1 — 1 - Pneumonia, other forms 41 — — 1 2 2 8 12 16 1 2 3 10 1 10 i 1 3 1 — 3 4 1 Other respiratory diseases 14 2 — — — 3 4 5 — — 1 1 4 2 3 1 — — 1 — 1 — — Alcoholism 3 — — — — 1 2 — 1 1 1 — — — — — — — — — Cirrhosis of liver 14 — — — — 2 9 3 2 1 2 4 2 1 1 — 1 — — — Appendicitis and typhlitis 6 — — — — 1 2 2 1 — — — — 2 2 1 — — 1 — — — — — Other digestive diseases 23 — — — — 1 14 8 3 1 10 1 6 — — — 2 — — — — Bright's disease, &c. 32 — — — — 1 4 16 11 — 4 1 9 2 8 — — 2 1 1 1 1 2 Cystitis, &c. 18 - — — — 1 5 12 1 1 2 3 1 5 — 1 2 1 1 — — — Accidents and diseases of parturition - - - - - - - - - - - - - - - - - - - - - - - - Deaths by accident or - - - - - - - - - - - - - - - - - - - - - - - - negligence 28 2 — 1 4 2 7 7 5 1 1 1 10 2 6 — 2 — — — 2 1 2 Deaths by suicide and - - - - - - - - - - - - - - - - - - - - - - - - murder 20 2 — — 1 5 10 2 1 2 2 5 1 1 — — 2 1 — 1 4 Other defined diseases 16 1 — — — - 4 7 4 1 1 2 2 3 — — 1 — — 2 4 Diseases, ill defined or unknown - - - - - - - - - - - - - - - - - - - - - - - - All causes 913 57 12 14 23 22 106 337 342 11 50 30 43 245 50 245 41 22 33 35 17 28 40 23 26 FEMALES. Table I.—Causes of, and Ages at, Death during the year 1924. 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. 16 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. Regent. Charing Cross. Covent Garden. Strand. Homeless. Small-pox — — — — — — — — — — — — — — — — — — — — — — — — Measles 15 4 5 5 1 — — — — — — 1 1 10 — 2 1 — — — — — — — Scarlet fever 3 — — 1 2 — — — — — — — — — — — — — — — — — — — Influenza 31 — — — — 1 2 7 21 — 3 — 4 14 2 6 1 — — — 1 — — — — Whooping-cough 2 1 1 — — — — — — — — — — — — — — — — — — — — Diphtheria, Memb. croup 17 — 3 7 7 — — — — — — — — — — — — — — — — — — — Cerebro-spinal meningitis — — — — — — — — — — — — — — — — — — — — — — — Poliomyelitis 1 — — — — — — — 1 — — — 1 — — — — — — — — — — — — Enteric fever — — — — — — — — — — — — — — — — — — — — — — — Diarrhoea, enteritis 4 3 — — — — — — — — — — — — — — — — — — — — — — Erysipelas 1 — — — — — 1 — — — — — — — — 2 1 — — — — — — — — — Puerperal fever 2 — — 1 1 — — — — — — — — — — — — — — — — Other septic diseases 13 1 — — 1 2 3 6 2 1 4 — 4 — — — — — — — — Syphilis, &c 1 — — — 1 1 — — — — — — — — — — — — Diabetes 6 — — — — — 1 2 3 — 1 1 1 1 1 1 — — — — — — — Rheumatic fever 1 — — 1 — — — — — — — — 1 — — — — — — — — — — — Tuberculosis of lungs, &c. 34 — — 1 9 16 7 1 3 2 1 17 — 4 1 — — 1 1 3 — 1 1 Non-pulmonary tuberculosis 6 1 1 — — 1 3 — 1 1 3 — — — — — — — Malignant growths 98 1 1 — — 1 5 50 40 — 5 9 7 32 7 27 2 3 1 3 1 3 — Congenital debility, malformation, and premature birth 17 17 — — — — — — — — — 1 1 11 1 — — 1 — — — — — Old age 32 — — — — -— — — 32 1 2 6 11 4 1 — — — — — — — Meningitis and convulsions 2 — — 2 — — — — — — — — — — — — — — — — — — — 27 FEMALES.—Table I. (continued). Corrected Deaths in the City at subjoined Ages. Deaths in Wards (at all Ages). Causes of Death. 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. Regent. Charing Cross. Covent Garden. Strand. Homeless. Loc. ataxia and general — — — — — — — — — — — — — — — — — — — — — — — — paralysis 2 — — — — — 1 1 — — — — — — — — 1 — — — 1 — — — — Other diseases of nervous system 16 1 — — — 2 3 7 3 1 — — — 8 1 2 2 — — — — — 2 Valvular diseases of heart 20 — — — 1 — 3 9 7 — — — 1 7 4 5 — — — — — 2 1 — Other circulatory diseases 151 — — — 1 1 5 40 104 3 16 5 13 53 7 28 3 4 1 2 2 6 3 5 Bronchitis 101 2 2 1 1 — 2 20 73 1 3 1 6 35 4 33 6 1 — 2 3 5 1 — Broncho-pneumonia 33 2 5 4 — 1 1 3 17 — 3 1 2 8 1 11 1 1 — 2 — 3 — —. Pneumonia, other forms 24 1 1 — 1 — 2 12 7 — 1 5 11 6 1 — — — — — — — Other respiratory diseases 10 1 — 1 — — 1 4 3 1 7 — 2 — — — — — — — — — Alcoholism — — — — — — — — — — — — — — — — — — — — — — — — Cirrhosis of liver 8 — — — — — 1 6 1 1 1 3 1 1 1 Appendicitis and typhlitis 5 — 1 — 1 — 1 1 1 — 1 — 1 2 1 — — — — — — Other digestive diseases 25 1 — 1 — — 4 9 10 — 2 3 1 10 1 3 1 1 — 3 — — — — Bright's disease, &c. 25 — — — — — 4 16 5 1 1 1 6 1 12 — 1 — 2 — — — — Cystitis, &c. 7 — — — — — — 4 3 — 1 — 3 — 1 — 1 — 1 — — — — — Accidents and diseases of parturition 3 _ _ — 1 2 — — — — — 2 — — — — — 1 — — — — Deaths by accident or — — — — — — — — — — — — — — — — — — — — — — negligence 36 2 — i 1 1 6 12 13 2 2 1 10 1 11 1 2 1 1 — 2 1 1 Deaths by suicide and murder 5 — — — 2 1 2 . 2 1 . 1 — 1 — Other defined diseases 25 1 — i 1 2 7 6 7 1 4 1 6 1 5 2 1 3 — — 1 Diseases, ill defined or unknown — — — — — — — — — — — — — — — — — — — — — — — All causes 782 39 20 25 18 24 78 220 358 11 52 28 60 282 33 196 26 12 8 22 9 25 7 11 28 B.- Communicable Diseases. Details respecting the notifications of infectious disease received are set out on the adjoining page. The following summary shows the number of cases which came to the notice of the Department in the last three years. 1922. 1923. 1924. 1922. 1923. 1924. Small-pox 1 ] Ophthalmia neonatorum 25 32 _ Diphtheria 285 91 237 Measles 591 131 — Erysipelas 37 34 29 German measles 11 42 34 Scarlet fever 261 129 226 Pneumonia 48 60 92 Enteric fever 12 18 15 Malaria — 1 Continued fever — — — Dysentery — —. — Puerperal fever 7 3 10 Anthrax 1 — 1 Cerebro-spinal meningitis 4 1 3 Chicken-pox 178 169 89 Mumps 25 95 147 Encephalitis lethargica 2 2 15 Whooping cough 67 35 97 Polio-myelitis 1 1 1 Smallpox.This disease continued to increase in amount in 1924 in the Midlands and the North of England. The number of cases in each of the last 8 years is given as :- 191 7 7 191 8 63 191 9 311 1920 280 1921 336 1922 973 1923 2,504 1924 3,784 The disease continues to be of a mild type with a low mortality (13 deaths only in 1924), very different from the type which has been introduced into London and elsewhere from Spain and the East on several occasions in which a third of the cases proved fatal. With a large number of persons unprotected by vaccination, if it were not for the promptness and co-operation of medical officers of health, serious epidemics would have occurred instead of which the outbreaks in London and its neighbourhood have been limited to a few cases. Cases of this disease caused some anxiety on several occasions, but one only was notified in Westminster. This was in the person of a valet whose home is in Westminster, he had been travelling in Spain and on his arrival attended and carried out his duties for a few days at a large hotel until he developed a rash which was at once diagnosed. He had been in contact at home and at the hotel with between 200 and 300 people. Fortunately nearly all had been re-vaccinated and the remainder were promptly done, and no other case occurred. A second case was that of a man, a resident of New York who had been making a tour of the world. He made the voyage from Bombay to Marseilles on board a ship in which, it was later discovered, there had been 29 City of Westminster.—Cases of Infectious Disease Notified during the Year 1924. Notifiable Diseases. Cases Notified. Cases removed to Hospital. Treated at Home. Deaths. At all Ages. At Ages—Years. At all Ages. At Ages—Years. Under 1. 1-2. 2-3. 3-4. 4-5. 5-10. 10-15. 15-20. 20-35. 35-45. 45-65. 65 and over. Under 1. 1 1-2. 2-3. 3-4. 4-5. 5-10. 10-15. 15-20. 20-35. 35-45. , 45-65. 65 and over Small-pox 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — Cholera (C). Plague (R) — — — — — — — — — — — — — — — — — — — — — — — — — — — Diphtheria 225 1 6 18 2/ 25 61 44 15 23 3 2 — 221 4 27 — 4 4 3 3 9 4 — — — — — Erysipelas 29 — — 2 — — 2 — 1 2 9 11 2 20 9 2 — — — — — — — — 1 — 1 — Scarlet fever 208 2 10 12 22 17 75 35 5 22 7 1 — 203 5 3 — — — — 1 2 — — — — — — Typhus fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — Enteric fever 15 — — — — 1 — — 4 5 1 4 — 9 6 — — — — — — — — — — — — — Relapsing fever (R) — — — — — — — — — — — — — — — — — — — — — — — — — — — — Continued fever (C) — — — — — — — — — — — — — — — — — — — — — — — — — — — — Puerperal fever 10 — — — — — — — — 6 4 — — 10 — 2 — — — — — — — — 2 — — — Cerebro-spinal meningitis 3 1 — — — — — — — — — — — — — — — — — — — — — — — — — — Polio-myelitis — — — — — — — — — — — — — — — 1 — — — — — — — — — — — 1 Encephalitis lethargica 9 — — — — — 1 — 4 2 1 1 — 5 4 6 — 1 — — — — — 2 — — 3 — Ophthalmia neonatorum 23 23 — — — — — — — — — — — 4 19 Pneumonia 92 — 1 — — 3 11 5 9 21 10 23 9 80 12 65 1 1 — — 1 2 1 1 5 6 24 23 Malaria 1 — — — — — — — — 1 — — — — 1 — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — — — — — — — — — — — — — — — — Trench fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — Anthrax 1 — — — — — — — — — — 1 — 1 — — — — — — — — — — — — — — Totals 617 27 17 32 49 46 1151 84 38 84 35 43 11 557 60 106 1 (j 4 3 5 13 5 3 8 6 28 24 Correction has been made for errors in notification or revision of diagnosis in 35 cases— Cases not notified :— Enceph— leth— 9, 57, 17,1½,, 19, 47. Polio-mvelitis 71. Scarlet fever 3½, 6, 3, 7, 40, 12, 6½, 7, 2½, 4, 3, 9, 5, 3, 6, 7, 17, 21. Diphtheria, 15, 3, 2, 9, 0, 11, 22, 5, 24, 3, 5, 2. 30 City of Westminster——Infectious Diseases, Distributed in each Ward— [###fiable Diseases. Conduit. Grosvenor. Knightsbridge St— Gerge. Victoria. St— Margaret. St— John. Hamlet of Knightsbridge. Pall Mall. Regent. Great Marlborough. Charing Cross. Co vent Garden. Strand. St— Anne. Homeless.### Small-pox — — — — 1 — — — — — — — — — — Cholera (C)— Plague (R) — — — — — — — — — — — — — — — Diphtheria — 7 7 56 12 132 — 2 3 5 1 11 — 1 1 Erysipelas — — — 14 1 9 — 1 1 1 1 — — — Scarlet fever 2 8 14 54 8 109 2 — 10 6 1 7 1 4 — Typhus fever — — — — — — — — — — — — — — — Enteric fever — 4 4 1 2 1 1 1 — — — 1 — — — Relapsing fever (R) — — — — — — — — — — — — — — — Continued fever (C) — — — — — — — — — — — — — — Puerperal fever — — — 6 — 4 — — — — — — — 1 — Cerebro-spinal meningitis — — — 1 — 1 — — — — — — — — Polio-myelitis — — 1 — — — — — — — — — — — Encephalitis lethargica — 1 2 4 3 1 — 1 — 1 — 2 — — — Ophthalmia neonatorum — 1 — 10 1 8 2 — 1 — — — — — — Pneumonia 2 6 7 25 3 37 3 1 3 1 1 2 1 — — Malaria — 1 — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — — — Trench fever — — — — — — — — — — — — — — — Anthrax — — — — — — — — — — — — 1 — — Totals 4 28 35 171 31 302 8 6 18 14 4 23 3 6 1 31 a case of smallpox. He travelled overland to London, staying in Paris a short time and stayed at an hotel in Westminster. He was absent one night on a visit to a relative in Essex and returned to the hotel feeling very ill and was seen by a doctor who found him with a high temperature which was thought to be the result of a chill. He felt better on the second day and was allowed to proceed to Southampton to embark for America. He died of smallpox two days later at sea. Until intimation of his death was received, it was not known that he had suffered from smallpox, consequently no steps had been taken to disinfect his room at the hotel which, during the week after his leaving, had been occupied by three other persons from abroad. These had returned home before the death was announced and as their home addresses were unknown communications coidd not be made to the authorities in their respective countries. It was, however, reported in the Press shortly afterwards that cases of smallpox had occurred in the country of the man who had occupied the room the night after the American had left. The staff of the hotel had been vaccinated in 1923 and no other cases occurred. A third case was that of a lady who went from Yorkshire to Italy on holiday and apparently was taken ill a week or so after in Florence. She was seen by three doctors who agreed that a rash on her forehead was due to mosquito bites. She returned to an hotel in London and was seen by a doctor who was satisfied that it was chicken pox and she was allowed to go home next day in a private motor car. On arrival at her home in Yorkshire the complaint was definitely diagnosed to be small, pox. The staff of the hotel were promptly re-vaccinated. No other cases occurred. A fourth case had been resident in a seaside convalescent home. Several cases having occurred in the Home, it was closed, and he left for his home in Sheffield, but stayed a few days with friends in Westminster on the way. He developed smallpox about a week after his arrival home, so that he was not likely to have been in a condition to infect anyone during his stay in London, although he himself had the infection in his body at the time. Besides these, information was received of persons who might have been in contact with cases abroad and elsewhere and these were kept under observation. Vaccination..The Public Vaccinators and the Vaccination Officer inform me that the following number of persons were vaccinated by them during the year :. Primary 654 Secondary 92 32 These figures do not include vaccinations and re-vaccinations done by private practitioners. No vaccination was done by the Medical Officer of Health under the Public Health (Small-pox Protection Regulations, 1917). Scarlet Fever.- There were more cases of this disease than in 1923, most of them being in the last four months ; 109 of the 237 cases occurred in St. John's Ward and 54 in Victoria Ward. Three deaths resulted, 1 at age 4 and 2 between 5 and 10 years of age, all girls, giving a mortality rate of 1.26 per cent, of the known cases. There is little doubt that a number of mild cases occur which are not detected. The number of cases equalled 1.6 per 1,000 of the total population, in England and Wales the rate was 2.16, but as the majority of the cases (80 per cent, in Westminster) occur in children and the proportion of children is lower in Westminster than in the country as a whole, there is probably little difference in the attack rate. The proportion of children under 15 and others over that age in the cases notified in 1901-5 were 76 and 24 respectively per 100 cases, in the last 5 years the proportion is 80 and 20, so that fewer cases occur in persons over 15 than formerly. Attack rate. 1901-5. 1906-10. 1911-15. 1916-20. 1921-24. Ages 0 to 15 years per 1,000 living at this age 9.0 12.6 14.1 9.3 13.3 Mortality per 100 cases at 0 to 15 years 3.25 2.82 1.7 1.1 0.8 This Table shows that while there is no diminution in the amount of Scarlet Fever, yet the number of deaths has decreased to a marked extent; that whereas in 1901-5 in every 1,000 cases, there were 32 deaths, now only 8 occur. This improvement had been going on in the 30 years before 1901, the death-rate per 1,000 of the whole population of the country having decreased from 0.97 in 1861.70 to 0.16 in 1891-1900; for last year it was 0.02. Part of this great reduction may be due to the diagnosis being better than it was in the middle of last century, part to the decrease in the number of children but the general opinion is that Scarlet Fever is a much milder complaint than it used to be. The deaths m Westminster at three groups of ages since 1901 per 1,000 living at those ages :- 1901-5. 1906-10. 1911-15. 1916-20. 1921-24. 0.30 0.07 1 to 5 years 0.71 0.81 0.41 0.29 0.16 5 to 15 years 0.11 0.20 0.18 0.04 0.12 33 It is difficult to say what effect treatment in Hospital has exercised. During the 24 years the number of cases removed to hospital has varied from 87.5 to 98 per cent, with an average of 94 per cent. Hospital isolation does not appear to have had any effect upon the prevalence, but probably has had some influence on the occurrence of complications and thereby helped to reduce the mortality. In this connection it would be of interest to ascertain whether the increased attention given to school children in recent years especially as regards adenoids, enlarged tonsils and defective teeth, has had any effect in reducing complications such as otitis, and on the number of septic cases and " return " cases. The Ministry of Health is carrying on an enquiry throughout the country on all the factors affecting Scarlet Fever. Diphtheria..This disease contributed a larger number of cases in 1924 than in the previous year, but fewer than in the years 1921 and 1922. St. John's Ward had 132 of the 237 cases and Victoria Ward 56; 27 cases ended fatally (10 males, 17 females), all in children under 15 years of age. The history of many of the cases emphasises the need for better methods of control, such as I have referred to in previous Reports. This is essentially a disease which is spread by personal contact, and if its spread is to be checked, as many persons as possible who may have been in contact with known cases should be examined and swabbings taken from their throats for bacteriological examination. This is done by the officers of the education authority in the schools, but it ought also to be done in the homes. In a number of instances the medical man attending has had the rest of the family examined, but in the majority of cases it is not carried out. In the first place the medical practitioner can hardly be expected to do it as he receives no remuneration for doing so, and in the second place it is often impracticable for him to do so, as the patient may be seen at his surgery or at a hospital. Then in a tenement house he cannot be expected to examine the members of other families There is no one on the staff of the public health department who could undertake this work systematically. The local authority might pay medical practitioners to do this and in times of epidemic might retain a medical man specially. The school medical officers co-operate as far as they can, but were they attached to the local authorities as assistant medical officers of health, they would be able to follow up suspected cases discovered in the schools and a greater check would be obtained in the dissemination of infection than we at present possess. By the use of antitoxin passive immunity can be conferred on other members of a family for 3 to 5 weeks during an outbreak. It is now possible to ascertain whether a person is susceptible or not to diphtheria by the 34 Schick method. Inmates of institutions, schools, hospital and other staffs can be tested, and those who are susceptible can be immunised, so that such institutions can be protected from outbreak of diphtheria. It often happens that a member of a family gets a slight sore throat, which exhibits none of the symptoms of diphtheria, although the diphtheria organism may be present; it is not surprising, therefore, that other members have bad throats and then, when the illness appears serious, a doctor is called in who discovers that one or more have developed typical membrane in the throat. In some persons the organism persists in the throat or nose for long periods and these become sources of danger in schools, business houses and in tenement dwellings where they are thrown into close association with others. The death rate at all ages in London was 0.12 per 1,000 living; 27 deaths occurred in Westminster giving a rate 0'18, but as all were of children under 15 years of age the heaviness of the mortality in the last four years can be better guaged by comparison of the following figures:- Death-rates of children under 15 years of age from 1901 to 1924 are :. - 1901-5. 1906-10. 1911-15. 1916-20. 1921-24. Under 1 year 0.20 0.49 0.45 0.23 0.27 1 to 5 years 1.14 1.32 0.88 1.20 2.10 5 to 15 years 0.19 0.17 0.27 0.28 0.73 Anti-toxin is provided free, and 60 bulbs were made use of, and practitioners are able to have bacteriological assistance in doubtful cases. Typhoid Fever..17 cases of this disease were notified, but 2 cases eventually proved not to be typhoid, and 3 were cases of paratyphoid fever. Ten patients contracted the disease before coming to Westminster. There was a history of shellfish (cockles, oysters) having been consumed in four cases. No deaths occurred during the year, but one case has since proved fatal. Since 1870, typhoid fever has become less and less prevalent throughout the country generally. The death rate which had been 0-90 per 1,000 in the 10 years 1861-70 has fallen until in this year it is only 0-01 per 1,000. In Westminster the average number of cases which occurred during the 10 years 1890-99 was 112 each year ; the yearly average for the last five years is 13, and most of these are imported cases. 35 Average number of cases of Typhoid Fever notified per year in WpcfminQfor in:- 1890-99 (10 years) 112 1900-1909 (10 years) 48 1910-14 (5 years) 33 1915-19 (5 years) 17 (10 years) = 26. 1920-24 (5 years) 13 The figures in the period 1910-19 included a number of infected refugees arriving in Westminster in 1914-15, otherwise the average would have been lower. To various causes has the general decline of Typhoid Fever been ascribed, such as improvements in water supply, house drainage and sewage disposal, greater control in the supply of oysters and other shellfish milk, ice creams, the introduction of deep sea fishing by steam trawlers, so that fish are not taken from polluted shallow water, the recognition that certain persons may be " carriers " of infection. Probably all the above have contributed their share and to the above list should be added the greater number of patients removed to hospitals for treatment and, especially during the war period the introduction of protective inoculation. Measles..Every second year Measles assumes epidemic forms. Thus in 1921 only 26 cases were known, in 1922, there were 591 and in 1923, 131 cases were noted. An increase in the last quarter of 1923 was remarked upon in my last Report and the suggestion was made that it was an early beginning of the 1924 outbreak and indicated more extensive and serious epidemic. This unfortunately proved correct, for 882 cases were recorded of which 852 occurred in the first four and a half months of the year, half of the cases being in the month of March. The outbreak was practically over by the end of April. In the third quarter of the year, 21 cases were recorded and 9 in the last. Information as to the cases is derived from the head masters and mistresses of schools, hospitals, medical practitioners and from the Metropolitan Asylums Board. These numbered 816, but on visiting, the Health Visitors found that 16 children were not suffering from Measles, but they discovered 82 other cases and possibly there were more cases in families above the standard usually visited. An analysis of these 852 cases shows :- Age Incidence or those Attached. Age-period 0-1 1-5 5-15 15-25 25-35 35-45 45-55 55-65 Percent 2.9 36.8 54.4 3.4 1.9 0.5 0.3 0.1 The rise and fall of the outbreak is shown below, week by week, from which it will be seen that it attained its height about the middle of March, after which it declined. 36 Weekly Incidence. January. February. March. April. May. Week 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 Per cent 1.9 7.4 1.5 3.0 4.3 3.9 5.5 8.2 7.2 16.5 15.3 13.2 3.8 2.8 1.8 2.0 0.9 0.2 Monthly percentage 13.8 21.9 52.8 10.4 11 Deaths..25 of the cases proved fatal (10 males and 15 females) ; 1 death occurred in February, 15 in March, 4 in April and the others subsequently. Three other children died, 2 from whooping cough and one from diphtheria, which supervened. With the exception of a man of 65, the deaths were confined to children under 6 years of age. These were divided thus :. Under 1. 1-2. 2-3. 3-4. 4-5. 5-6. Totals. Males 5 2 2 - - - 9 Females 4 5 2 1 2 1 15 Totals 9 7 4 1 2 1 24 While the attack rate was 15 and 69 per 1,000 children living at ages under 1 and 1 to 5, the fatality was 37 per cent, of those attacked under 1 year of age and 4.47 of those attacked between 1 and 5 years. On the estimated number of children living under 5 years of age the death rate would be 3.2 per 1,000 (males 2.9, females 3.48). Under 1, the mortality was 5.5 per 1,000 births, among children of 1 to 5, 3.0 (in this group the death-rate is estimated at 4.1 per 1,000 living between 1 and 2 years of age and 2.4 per 1,000 living between 2 and 5 years). For the whole population of Westminster, the death rate was 0.14, for London 0.29 and for England and Wales 0.12 per 1,000. In the following Table is shown the average death-rates at three groups of ages in sets of years since 1901 :- Under 1. 1-5. 5-15. 1901- 5 3.40 3.47 0.05 1906-10 1.63 2.19 0.02 1911-15 1.98 2.70 0.12 1916-20 1.87 1.35 0.08 1921-24 1.52 1.25 0.03 On these averages an improvement is shown at each period, especially in children under 5 years of age. 37 Visiting and Nursing.-820 visits were paid to families in which were one or more cases of measles by the Health Visitors. The assistance of District Nurses was called in 16 instances and 124 visits were paid. Institutional Treatment.-165 were admitted to hospitals of these 34, mostly adults, were admitted to the London Fever Hospital as paying patients; 131 patients were admitted to the Metropolitan Asylums Board, the Infirmary and other hospitals. In consequence of the occurrence of Measles amongst the children attending the Infants Departments of the 17 undermentioned schools, the County Council decided to apply the scheme for the fuller control of the disease by the special daily visitation of school nurses to schools. The co-operation thus provided led to an earlier recognition of illness among school children, thereby enabling the Health Visitors to follow up cases of measles at an earlier date and secure adequate nursing and medical attention where required :- Schools. Raneleigh Road, 18th January and 28th February. Millbank, 28th January. St. George's Road, 23rd January. St. Gabriel, 23rd January. Holy Trinity, 23rd January. Christ Church, 23rd January. St. James-the-Less, 29th January. St. Matthew's, 18th February. Pulteney, 19th February. Schools. St. Peter's, 25th February. St. Martin-in-the-Fields, (N.), 26th February. Burdett Coutts, 28th February. Brompton, 12th March. St. James's and St. Peter's, 16th March. St. Patriarchs, 21st March. Christ Church, 3rd April. St. Paul's, 14th April. Exposure of Persons suffering from Measles in Public Vehicles.. It having come to the notice of the Council that persons suffering from Measles were using taxi-cabs, omnibuses and trains and especially to a case in which a person so suffering had been sent from a convalescent home in Wimbledon to a hospital in Westminster in such manner, the attention of hospital authorities was called to the fact that Section 68 of the Public Health (London) Act, 1891 applied, along with other Sections to measles in London by an Order made by the London County Council on the 20th January, 1903, approved by the Local Government Board, whereby such exposure was forbidden and was punishable. Influenza..This was certified as the cause of 56 deaths (20 in 1923, 95 in 1922), 25 males and 31 females, giving a death rate of 0'3 9 per 1,000, the rate for London being 0'36, the difference being accounted for bv the larger proportion of older persons in Westminster : 32 of (3692) q D The term "Diarrhoea" in statistical tables includes a variety of illnesses in which diarrhoea is a prominent or final symptom. It includes infective enteritis which occurs in the third quarter of the year, illness due to improper feeding of infants, to inability to digest food from various inherent causes, and has included deaths which were due to measles, syphilis and tuberculosis. It also includes deaths in the winter months, the result of exposure to cold and damp. The reduction shown in the above Table is due to the greater attention which has been given to the feeding and care of children in the last 20 years, to improved sanitation, particularly to the daily collection of house refuse, the greater cleanliness of houses and their surroundings, better paving and cleansing of roads, Death Rates from Diarrhceal Diseases. Under 1. 1-5. 5-15. 1901- 5 18.80 0.96 0.05 1906-10 13.81 0.71 0.02 1911-15 14.40 0.94 0.02 1916-20 9.80 0.47 0.01 1921-24 5.13 0.16 38 the deaths were of persons over 65 years of age and 16 between 45 and 65 years. This complaint in a variety of forms dependent on the time of the year and the presence of different accompanying organisms crops up regularly every 33 weeks. This year, 1923, bronchitis and pneumonia were the chief features and no doubt was the cause of an increase of deaths ascribed to these causes. Research is necessary to ascertain the reason for this periodicity. Probably as with diphtheria, there may be persons who are carriers of the specific organism causing the complaint in whom it remains dormant (or ina non-virulent form until suitable conditions arise. Most outbreaks of infectious disease occur in cycles and the reasons for this have not yet been worked out. Investigation is required, but it is especially urgent in the case of Influenza, not only from the fatality it causes directly or indirectly and its after effects on the health, but also because of the serious expense it occasions by the widespread illness it produces. Diarrhoea and Enteritis..Six deaths are recorded under this heading Infective or summer diarrhoea which produces an acute illness was practically absent, chiefly on account of weather conditions. The ages at death were under 1 year, 3; 2 to 5 years, 1; 15 to 25, years, 1 ; over 65 years, 1. 39 the substitution of motors for horses and of garages for stables with their accumulation of manure. Whooping Cough.—97 cases were recorded, 50 of these being in the last quarter of the year; 4 deaths resulted, 3 of children under 1 year of age, 1 between the age of 1 and 2. Under 1. 1-5. 5-15. 1901- 5 4.40 2.06 0.02 1906-10 3.34 1.37 0.01 1911-15 4.14 1.08 0.01 1910-20 1.40 1.02 0.10 1921-24 1.38 0.71 — The death-rate for 1921 at all ages was 0-02 for Westminster; 0.11 for London ; and 0-10 for England and Wales. Health Visitors paid 130 visits to cases of whooping cough and Nurses attended to 3 children, paying 24 visits. Cerebro-spinal Fever.—-Three cases occurred; there were no deaths. Poliomyelitis.—-One case occurred and proved fatal; a female, aged 71. The attention of the Minister of Health has been directed to the lack of facilities in London for dealing adequately with the after effects of this disease in children and he has issued a circular to the Metropolitan City and Borough Councils on the subject. The Circular states, inter alia, that in view of the high proportion of cases of poliomyelitis which occur below the age of 5 years, and bearing in mind the good results of effective treatment and the serious consequences of neglect, it is important to take such steps as may be possible to secure orthopaedic treatment for these young children as part of the scheme for Maternity and Child Welfare. In ordinary circumstances the number of cases in any Metropolitan Borough is small, and would not justify the Borough Council in making independent provision for a form of treatment which is necessarily costly and elaborate. It is desirable, therefore, that the Borough Council should consider, first, what can be done to promote early diagnosis during the acute stage of the disease, and secondly, what arrangements can be made in co-operation with other authorities to send all children affected, whether the condition is slight or serious, to an institution equipped to give such special treatment as may be required to prevent avoidable muscular weakness or permanent deformity. (3692)q d 2 40 It is suggested that the Borough Council should remind medical practitioners residing within their area of the importance of early diagnosis, and a note, prepared by the Ministry, setting out the usual symptoms of the disease is enclosed with the circular, copies of which it is considered might usefully be circulated to practitioners for information. The City Council directed that copies of the note prepared by the Ministry be obtained and circulated amongst medical practitioners in the City of Westminster, and that such steps as may be possible be taken through the Council's Maternity and Child Welfare Centres to give effect to the wishes of the Ministry in the matter. Encephalitis Lethargica.—Fifteen cases occurred, with 6 deaths. In each of the two previous years 2 cases were recorded. Eight of the cases were in persons between 17 and 23 years of age, 4 at older ages (one of these, in a man of 62 who died, was a very doubtful case), 3 were in children under 10. Ten were treated in hospital. Chickenpox was less prevalent during the year, 89 cases being notified chiefly from schools. Mumps.—147 cases were recorded. In 1921, there were 263 ; in 1922, 25 ; in 1923, 95 cases. Puerperal Fever and Ophthalmia Neonatorum.—See above, under Maternity and Child Welfare. Anthrax.—A man cut his face while shaving and developed Anthrax, from which he died. The shaving brush, a cheap one, he had bought for 4\d. was submitted to the Bacteriologist, Dr. Braxton Hicks, who reported that he had been unable to identify the presence of the bacillus in it. Probably only one hair at the socket end had a few spores on it, which were liberated on use and the rest of the brush was unaffected. The consignment was traced and found to be one of a consignment of over 12,000 brushes, mixed types, said to have come from Army stores. The retailer had only one brush of the type remaining in stock and this was also examined bacteriologically and was found unaffected. In consequence of a number of cases of infection due to the use of infected brushes of Japanese origin, the Ministry of Health, by an Order in Council in February, 1920, prohibited the further importation of such brushes into this country, and a large number were collected from dealers therein and destroyed. Since when, cases arising from this cause had ceased. Plague, &c.—Intimation was received of 2 persons coming into Westminster from places where plague had occurred, 167 smallpox contacts and 21 enteric fever contacts. 41 Tuberculosis. lu 1924, 278 new cases of pulmonary disease were notified and 18 persons died who had not been notified in Westminster, a total of 296. Non-pulmonary forms of tuberculosis gave 51 new cases. Tuberculosis, 1924. Age-Periods. New Cases. Deaths. Pulmonary. Non-pulmonary. Pulmonary. Non-pulmonary. M. F. M. F. M. F. M. F. Under 1 — — 2 1 — — 2 1 1 — 1 6 2 — 1 2 1 5 4 4 9 6 — — — — 10 4 3 3 3 1 1 2 — 15 11 11 4 1 6 2 — — 20 15 23 — 4 12 6 — 1 25 36 37 3 4 20 7 — 3 35 36 23 — 1 37 9 — — 45 39 14 — 1 29 7 — — 55 15 3 — 1 10 — 2 — 65 and upwards 13 4 — — 12 1 — — Totals 173 123 27 24 90 34 8 6 In this Table all 'primary notifications are included, and also other new cases of tuberculosis coming to the knowledge of the Medical Officer of Health during the year. The increase in the number of cases of pulmonary tuberculosis was not unanticipated. The effect of unemployment in recent years was not expected to produce results in a disease such as this is, immediately. Influenza also has frequently been the starting point or has lighted up old infection which may have been dormant for years. It is gratifying, however, to note that non-pulmonary forms of the disease show a slight decrease. 42 Tuberculosis.—Notifications received during the 53 weeks from 30th December, 1923, to 3rd January, 1925. 1924. Number of notifications on Form A. Primary notifications. Total notifications, on Form A, including cases previously notified. Ago periods. 0 to 1. 1 to 5. 5 to 10. 10 to 15. 15 to 20. 20 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 and up. Total new cases Pulmonary— Casuals— Males — — — — — — 3 9 7 6 6 31 31 Females — — — — — — 1 — — — — 1 1 G-eneral— Males — — 4 3 11 15 33 26 27 6 5 130 147 Females — 1 4 3 10 22 35 22 13 3 3 116 130 Hon -pulmonary— Males 1 6 8 1 4 — 3 — — — — 23 26 Females — 2 6 4 1 2 4 1 1 — — 22 24 Total 1 9 22 11 26 39 79 58 48 16 14 323 359 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 institutions. Sanatoria. Poor Law institutions. Sanatoria. Under 5. 5 to 10. 10 to 15. Total. Pulmonary— Males — — — — — 23 129 1 83 Females — — — — — 5 51 — 33 Non-pulmonary— Males — — — — — 1 15 — 9 Females — — — — — — 9 — 10 Total — — — — — 29 204 1 135 43 Tuberculosis.—New cases coming to the knowledge of the Medical Officer of Health otherwise than by Notification under the Regulations. 1924. Number of notifications 011 Form A. Primary notifications. Age Periods. 0 to 1. 1 to 5. 5 to 10. 10 to 15. 15 to 20. 20 to 25. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 and up. Total. Pulmonary— Casuals— Males — — — — — — — — 1 1 — 2 Females — — — — — — — — — — — — General— Males — — — 1 — — — 1 4 2 2 10 Females — — — — 1 1 1 1 1 — 1 6 Non-pulmonary— Males 1 — 1 2 — — — — — — — 4 Females 1 — — — — 1 '— — — — — 2 Total 2 — 1 3 1 2 1 2 6 3 3 24 C.LH. General. Non-pulmonary Total. Notified pulmonary 32 246 45 323 Not notified in Westminster 2 16 6 24 Total 34 262 51 347 u Tuberculosis.—Table showing distribution in Wards of notified and unnotified cases, and numbers of such -persons who have been treated in Institutions. 1924. 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. Received Institutional Treatment during 1923. Pulmonary— Common Lodging-houses, &c.— Males 33 — — — — — 19 — — — — — — 13 — 1 27 Females 1 — — — — — 1 —. — — — — — — — — 1 General— Males 140 4 4 5 49 5 45 2 2 6 3 1 5 — 9 — 95 Females 122 — 6 5 43 3 25 4 1 9 3 2 11 — 7 — 76 Non-pulmonary— Males 27 — 3 1 9 — 11 — 1 — 1 — — — 1 — 24 Females 24 — i — 12 1 6 — — 1 — — 2 — — 1 22 347 4 14 11 113 9 110 6 4 16 7 3 18 13 17 2 245 Insured. Ex-Service. Army. Police. Hospital Nurses. Asylum. 111 previously. Pulmonary— Males 97 40 3 2 — 4 46 Females 45 — — — 3 7 37 Non-pulmonary— Males 4 3 — — — — 5 Females 5 — — — — — 5 151 43 3 2 3 11 93 45 The figures for a series of years are shown below Pulmonary. Non-Pulmonary. Tota of al forms. General Population. C.L.H. and no Address. Total. Males. Females. Males. Females. Males. Females. Total. 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 58 367 1921 118 114 37 2 271 19 22 41 312 1922 119 110 42 2 273 24 30 54 327 1923 111 114 42 1 268 24 32 56 324 1924 140 122 33 1 296 27 24 51 347 (Military cases which were excluded during the war were again made notifiable in 1920.) A return required by the Ministry is appended, also a table showing the distribution of the cases in the various wards of the city. Non-notified cases.—Pulmonary cases not notified in Westminster were 6 per cent. of the total, non-pulmonary 11.7 per cent. 1914. 1915. 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923.  Pulmonary 46 40 31 35 41 27 33 20 26 14 18 Non-pulmonary 13 24 21 10 14 8 7 7 12 8 6 Enquiry is made in each case as to the reason for non-notification; the majority of the pulmonary cases had been notified elsewhere, several of them came to London for treatment, some were sudden deaths, the cause being only discovered on post-mortem examination, and some were deaths in asylums. Among the non-pulmonary failure to notify was chiefly due to the shortness of the illness and difficulty of diagnosis. 46 Non-pulmonary Tuberculosis.—The parts of the body affected were:- Males. Females. Total. Meninges of brain 4 3 7 Cervical glands 8 8 16 Bones and joints 9 9 18 Skin 1 - 1 Kidneys and bladder 1 1 2 Thoracic 1 1 2 Abdomen 1 1 2 General or Miliary 2 1 3 27 24 51 Nationality of Patients.—As usual, many nationalties were represented among those notified in 1924 ; 308 were born in England, 13 in Ireland, 2 in Scotland, 1 in Wales and 2 in British Dominions ; 21 were of foreign origin:—Italian 2, Russian 3, Polish 8, Swiss 3, German 2, French, Roumanian and Japanese 1 each. The total number of cases of tuberculous disease on the Register at the end of 1924 was 1,772 as compared with 1,682 at the end of the year 1923. Pulmonary. Nonpulmonary. Total. General. Casuals. Cases on Register, 1st January, 1924 1,178 133 371 1,682 New cases, 1924 262 34 51 347 Old cases returned to Westminster 9 — 1 10 Total cases on Register during 1924 1,449 167 423 2,039 Died during 1924 122 9 14 145 Moved during 1924 104 — 18 122 Remaining at end of 1924 1,123 158 391 1,772 In addition to those who moved out of the City, 40 changed their addresses in the City during the year, casuals not being included. Home Visiting.—The Tuberculosis Medical Officer paid 421 visits during the year to patients at their homes. The number of visits paid in previous years was:— 1919 175 1921 498 1923 436 1920 257 1922 496 The Health Visitors paid 6,403 visits, 4,907 of these being to persons attending the Dispensary (in 1922, 5,278 and 4,995, and in 1923, 5,412 and 4,717 respectively); 613 visits were paid to ex-service men. 47 Extra Nourishment.—Fourteen persons have been in receipt of milk and eggs at the Council's expense. The applications were duly considered by the After Care Committee. The cost of the extra nourishment was £69 10s. 6d. Institutional Treatment.—163 pulmonary patients (89 males and 64 females) received treatment in sanatoria, hospitals or infirmaries during the year; 46 non-pulmonary patients (24 male and 22 female) were similarly treated. Dental Treatment.—Eighteen patients received dental treatment at the Council's expense, necessitating 76 attendances, at which 85 teeth were extracted, 14 teeth filled and 43 other dental operations performed. General anaesthetics were administered on 20 occasions and local on four. Dentures were provided and fitted in one case. The Council contributed £4 towards the cost. Special Treatment.—Five patients had 54 pneumo-thorax refills at a cost of £28 7s. X-Ray Examinations.—A number of cases were examined in this way at various hospitals. Bacteriological Diagnosis.—Sputum was examined in 474 instances, 232 being specimens sent from the Dispensary and 242 from private practitionors. The cost was £65 16s. Sale of Milk by -persons suffering from Tuberculosis.—The Minister of Health has issued an Order empowering Local Authorities responsible for administering the Tuberculosis Regulations to prevent infectious tuberculous persons from engaging in any occupation connected with the milk trade that would be likely to result in the milk becoming infected. Aftcr-Care.—The Committee has met regularly during the year and has done all it can with the limited powers it possesses. As regards ex-service men, arrangements have been made to secure that the local agencies of the Ministries of Labour and Pensions will actively co-operate with the local health authorities in the after-care of ex-service men suffering from tuberculosis, on their return home after a course of treatment, or treatment combined with training in a sanatorium. It has been arranged that six weeks (or as long as possible) before the tuberculous man's discharge from an institution the notification of the pending discharge will be sent to the tuberculosis officer of the man's place of residence. Thereupon special steps will be taken, on the one hand, so that, as far as possible, the patient shall not return to home conditions which are likely to prevent the satisfactory progress of the case or to cause a relapse ; 48 and at the same time, on the other hand, to do all that is possible to assist the man to obtain employment in a suitable occupation. So far as the man's home conditions are concerned, the tuberculosis officer and his staff, or the Tuberculosis Care Committee will, if these conditions are unsatisfactory, take such action as may be practicable to improve them. As regards the man's employment, if the tuberculosis officer considers that the man's occupation is unsuitable, he will furnish the Employment Exchange with a list of occupations which he considers not definitely unsuitable for the case. The employment exchanges will render all possible assistance in this matter, and special efforts will be made by the King's Roll Committee and by the chief area officer and the members of the War Pensions Committee. The departments concerned in these arrangements are satisfied that the success of after-care in cases of tuberculosis depends primarily on personal effort and individual attention, and all the local organisations concerned have been asked to co-operate actively in the work. Work of the Tuberculosis Dispensary.—The subjoined table indicates the extent to which the Dispensary has been made use of since it was started in April, 1916. Tuberculosis Dispensary. — 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1924. New Patients 553 718 779 607 582 609 421 529 603 Old Patients attending — 320 571 490 561 588 825 800 652 Contacts examined 267 286 327 139 221 281 183 245 271 Individuals who attended 553 1,038 1,350 1,097 1,153 1,197 1,246 1,329 1,255 Total Attendances 1,380 2,352 3,757 4,882 .5,267 3,695 3,275 3,133 3,292 Written Medical Reports to London County Council and Medical Practitioners 255 806 1,578 1,741 1,694 1,609 1,554 1,652 1,884 Consultations with Medical Practitioners 25 88 104 79 92 178 181 209 243 Other visits paid by Medical Officer 257 197 237 96 165 320 315 227 178 Visits by Health Visitors to Dispensary cases 1,246 2,481 3,374 4,159 4,934 4,941 4,995 4,717 4,907 Sputum Examinations 157 128 209 255 226 308 327 360 232 X-Ray Examinations — — — 12 30 28 16 5 2 The number of persons under Dispensary supervision excluding domiciliary patients at 31st December, 1924, was 662. The number of insured persons under domiciliary treatment at 31st December, 1924, was 706. References to affiliated hospital in the year were 21. 49 In addition to the above figures in non-Dispensary cases:— — 1916. 1917. 1918. 1919. 1920. 1921. 1922. 1923. 1924. Health Visitors, paid visits 3,407 1,542 1,892 2,749 2,629 1,707 283 695 1,496 Sputum Examinations for private practitioners 100 198 138 140 180 166 162 218 242 giving totals of Health Visitors 4,653 4,023 5,266 6,908 7,563 6,648 5,278 5,412 6,403 Sputum Examinations 257 326 347 395 407 474 489 578 474 Many of the present members of the City Council may not be aware of what was done before the Dispensary system came into existence, it may be useful to state shortly the preventive measures which were adopted. In 1903, the Council introduced a system of voluntary notification which was well supported until notification became compulsory.* Visitors were appointed, printed cards of information and advice were distributed, disinfection of rooms and bedding on the departure or death of patients was carried out; free examination of sputum was arranged for; sputum flasks were distributed to patients, and provision made for supplying bed, bedding and clothing in suitable cases. Sanatorium treatment for a number of patients in St. Anne's Ward was provided by the St. Henry Convalescent Fund from 1902 until the Insurance Act came into operation. The Westminster Guardians devoted their institution at Hendon for the special treatment of Consumptives, and in 1910 the Council secured beds for Westminster patients in Maitland and Fairlight Sanatoriums. Thus in 1911, 388 patients received institutional treatment, in 1914 the number was 445. In the two years before the Dispensary was opened the number of visits paid by Health Visitors was 5,085 and 6,170 respectively. Arrangements were made for the examination of "contacts" and "suspects" by hospitals, by school medical officers, by private practitioners and by the medical officers of the Children's Inspection Centres. In 1914 and 1915, 467 and 469 were thus examined. The adoption of the Dispensary system in 1916 brought in the services of medical officers of special experience in Tuberculosis, and perhaps one of the most useful of his functions has been in the increasing use which has been made of him by medical practitioners in obtaining his advice for *In 1909 notification was made compulsory for poor law cases of pulmonary tuberculosis; in 1911 it was extended to persjns using hospitals and dispensaries, and in 1913 it was made general and to include all forms of tuberculosis. 50 their patients. He also visits the houses of patients attending the Dispensary and supervises the work of the Health Visitors. The selection of suitable patients for treatment in hospital and sanatorium is another important duty, and necessitates a large number of written reports. The number of deaths from Tuberculosis which took place in Westminster in 1901 was 413, that is to say, 23 in every 10,000 of the population at that date, while last year the number was 138 or 9.6 per 10,000 of the present population. In a special report on the subject which I submitted in 1904 I pointed out that the housing conditions in parts of the City contributed excessively, thus while some areas had a rate of 5.0 only, others gave rates of 45.0, 46.3, 49.8, 51.5, and one as high as 89.5. The policy for the removal of such conditions and the improvement in general sanitary conditions was adopted by the Council and has been steadfastly carried out, although since the War it has been hampered in many ways. Notwithstanding the increase of cases caused by the War and post.War conditions in proportion to the population in 1901 and now, the reduction in the number of persons suffering from pulmonary tuberculosis is over 50 per cent. The result of the Council's action during the last 24 years has therefore been amply justified. Deaths.—In addition to the deaths in 1924 mentioned in the table above, four males died who had been notified in the past as suffering from tuberculosis : the cause of death was certified to be influenza (47), myelitis (51), broncho.pneumonia (age 28), and enlarged prostate (77). Four females died, the cause of death was certified to be bronchitis (71), sclerosis of spinal cord (38), ursemia (38), accident (58). Of the males, 45 of the deaths in the above table, and of the females 21, were new cases in 1924. The remaining deaths, 45 males and 13 females, had been notified in previous years:— 1912,3; 1916 and 1917,1 each ; 1918,4; 1919,4; 1920,3; 1921,7; 1922 10, and 1923, 25. 51 Westminster—Deaths from Tuberculosis per 100,000 civilian population. Years. Pulmonary. Non-pulmonary. 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 97 18 12 157 109 1921 „ 120 84.9 15 10.6 135 95.5 1922 „ 144 103.3 21 15 165 118.3 1923 „ 103 73.3 16 11.3 119 84.7 1924 „ 124 86.7 14 9.9 138 96.5 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 „ 163 124 27 19 190 143 1921-24 „ 123 86.9 16 11.7 139 98.7 The death-rates for males and females in Westminster for 1920, 1921, 1922, 1923 and 1924 were per 100,000 population :— Males. Females. 1920. 1921. 1922. 1923. 1924. 1920. 1921. 1922. 1923. 1924. Pulmonary 131 125.6 136.6 113.4 145.3 76.3 53.8 78.1 43.4 41.9 Non.pulmonary 9.6 11.4 19.9 6.6 12.9 14.5 9.9 11.3 14.8 7.4 Total 140.6 137.0 156.5 120.0 158.2 90.8 63.7 89.4 58.2 49.3 Subjoined are the average rates for these five years, and similar rates for the three years 1901-1903. Males. Females. 1901-3. 1920-24. 1901-3. 1920-24. Pulmonary 242.0 130.4 124.0 58.7 Non.pulmonary 49.0 12.1 29.0 11.6 Totals 291.0 142.5 153.0 70.3 These show that a reduction in death rates has taken place to the amount of :— Males. Females. Pulmonary 46 per cent. 52.6 per cent. Non-pulmonary 75.3 „ 51.0 „ 52 The death-rate from pulmonary tuberculosis in London has been falling with varying regularity since 1860 for females and from 1870 for males. For Westminster rates have been worked out from 1880. These show a steady decrease in the average death rates for pulmonary tuberculosis from 208 to 86.9 per 100,000 of population, the rate of decrease being considerably accelerated in the last four years. I have pointed out in previous Reports that not only is the incidence of the disease less among females, but the death rate is less than among males, consequently the greater proportion of females in the population results in a decrease in the total cases and in the number of deaths. This would account for a small amount of the improvement, but most of it must be attributed to the better conditions in the home and the work place. The greater drop in the last five years, notwithstanding housing difficulties and unemployment, points to the advantage of hospital and sanatoriun treatment which are now available, and to the after-care bestowed upon patients. As regards non-pulmonary deaths, improvement in the death rates is not manifest in London generally until the decennium 1891-1900 (The London Public Health Act was passed in 1891). In Westminster the average has fallen from 89 in 1881-90 to 11.7 in the last four years. Under this heading are included deaths from tuberculosis affecting the brain (meningitis), the abdomen, the spine and other bones and joints, glands, and general or miliary tuberculosis. The fatality from these is chiefly among children. I have taken out figures showing the death-rates of children under 15 years of age in five-yearly groups since 1901-5 under four headings, according to the site of the disease as registered, bat it must be kept in mind that the part of the body named may not have been the primary seat of the disease, thus meningitis may be the ultimate cause of death but there may have been some other part of the body previously affected. Still, when the rates are taken out for all deaths due to tuberculosis at these ages it is evident there has been a substantial reduction in the aggregate, whatever variations may exist in the rates from separate sites of the disease. During the War years there was a check in the falls which had been taking place, but in the last four years the improvement has been very marked. 53 Tuberculosis in children under 15 years of age. Death rates under 1 calculated per 1,000 births; between 1 and 5 years and 5 and 15 years, per 1,000 on numbers estimated to be living during those periods. 1901-5. 1906-10. 1911-15. 1916-20. 1921-24. Meningitis. Under 1 2.16 2.41 1.26 1.61 0.55 1 to 5 years 1.65 1.42 1.38 0.62 0.48 5 to 15 years 0.18 0.21 0.18 0.18 015 Abdominal. Under 1 1.54 0.78 0.45 0.58 0.55 1 to 5 years 0.42 0.48 0.32 0.18 0.10 5 to 15 years 0.07 0.06 0.04 0.04 0.03 Pulmonary. Under 1 0.37 — 0.18 0.46 0.13 1 to 5 years 0.41 0.28 0.29 0.54 0.05 5 to 15 years 0.36 0.18 0.24 0.17 0.01 Other parts of body and general tuberculosa 8. Under 1 1.23 1.49 0.90 0.58 0.27 1 to 5 years 0.54 0.61 0.20 0.25 0.05 5 to 15 years 0.18 0.19 0.12 0.13 0.01 Total from Tuberculosis. Under 1 5.30 4.68 2.80 3.22 1.52 1 to 5 years 3.04 2.72 2.20 1.60 0.76 5 to 15 years 0.69 0.64 0.58 0.52 0.26 There are two sources of infection in children, one from human sources, the other from tuberculous milk. Human infection (except in infants of tuberculous mothers, dying soon after birth) results from contact with other cases in the home, and to want of care as regards the sputum. Had there been the amount of overcrowding and bad housing conditions in Westminster which have been alleged to exist the effect would have been seen very promptly in the figures for 1921.24. Bacteriologists state that in cases in which the tubercle bacillus has entered the body by the intestinal tract, 80 per cent, were of bovine origin. In other forms of the disease infection of human origin predominates. Some reduction has been effected in the amount of tuberculous milk coming to London, but probably the improved figures for the last four years may be attributed to a considerable extent to the greater use of pasteurised milk (a large proportion of the milk coming to London has been so treated), dried milk and also of Grade A milk. If the theory be correct that the pulmonary tuberculosis of adult life is, in most instances, but the final stage of a disease begun in early childhood, the reduction shown in the above figures is one of great importance, and the future should show a progressive improvement as the children of to-day reach and pass through adult life. (3692)q E 54 Bacteriological Laboratory. Examinations were made as follows:— Swabbings from throats in suspected diphtheria 556 Blood in suspected typhoid 8 Anthrax 1 Sputum for tuberculosis 474 The expenditure on the first two was £ and for tuberculosis £65 lis. Od., including cost of outfits, postage, and telegrams in both instances. Disinfection. The number of articles treated was:— 1919. 1920. 1921. 1922. 1923. 1924. Rooms 941 1,196 1,502 1,179 742 984 Articles disinfected 50,496 49,542 31,654 28,709 21,933 23,382 Articles washed 5,759 7,185 6,766 7,355 8,679 4,862 Articles destroyed 543 70 38 105 173 198 Books disinfected 77 42 212 173 215 425 Vehicles 2 5 1 8 3 3 In addition to the above, 465 books and 3 tons of old bedding and rubbish from verminous houses were destroyed. The motor van during 1924 ran 3,458 miles and carried 3,346 cwt. of goods, the highest amount in any one day being 60 cwt. The petrol consumption was 372 gallons, equal to 9-2 miles per gallon. Cleansing of Persons.—The number of Westminster persons suffering from head and body lice treated at the cleansing station was 584. By the arrangement with the County Council, school children from Battersea, Chelsea, Holborn, Kensington, Lambeth, St. Pancras, St. Marylebone and the City of London were sent to the Station for cleansing ; these numbered 201 for head lice, 11 for body lice, and 14 for scabies, and are included in the following summary:— 1924. Head lice. Body lice. Scabies. Total. Children 768 18 26 812 Adults 9 47 5 61 777 65 31 873 All the lice cases were dealt with at the Station, but 7 of the scabies cases were treated at home. 55 Each case implies a number of attendances for treatment, and the disinfection of the clothing, besides which in the Westminster cases the bedding is removed for disinfection at the same time that the persons affected are being treated ; these amounted to 1,839 articles. The children suffering from lice and scabies had treatment at the station on 1,179 occasions. In dealing with the Westminster cases, 1,350 visits were paid to the houses by the Disinfecting Superintendent. Verminous Houses.—From 40 houses 629 articles were removed for disinfection and 3 tons of old bedding and rubbish for destruction. Mortuaries. The number of bodies removed to the Council's mortuaries under order of the Coroner, or to await burial, was 340 ; in 1 instance on account of infectious disease. Inquests were held at Horseferry Road, where the Coroner's Court is situated, in 328 cases, and there were 30 adjourned inquests. Postmortem examinations were made in 191 instances. Twelve bodies were received in the mortuary chapel to await burial. The number of dead bodies taken to the mortuaries for purposes of inquest, and to await burial during the last 20 years were :— Total. For Inquest. To await Burial. Total. For Inquest. To await Burial. 1903 396 341 55 1914 323 295 28 1904 381 322 59 1915 376 349 27 1905 368 307 61 1916 281 252 29 1906 344 283 61 1917 278 265 13 1907 358 281 77 1918 285 242 43 1908 364 298 66 1919 308 269 39 1909 291 258 33 1920 289 269 20 1910 333 281 52 1921 273 238 35 1911 383 334 49 1922 269 247 22 1912 324 284 40 1923 336 318 17 1913 328 286 42 1924 340 328 12 There are resting places for the dead at Drury Lane, Ebury Bridge, and Dufours Place, but no use was made of them during the year. The increase in the number of inquest cases appears to be due in large measure to traffic accidents. (3692)q e 2 PART II. C.—Housing, House Inspection, General Sanitation. The Housing problem has actively engaged the attention of both the Public Health and Housing Committees of the Council during the year. The opening of Walden House enabled the Council to provide accommodation for 40 families, many of whom were living in an overcrowded condition. Several sites considered to be suitable for the erection of dwelling houses have been enquired into, but so far arrangements have not been able to be come to for acquirement. The County Council has decided to offer accommodation in houses which they are erecting to the metropolitan boroughs for families who are living in a state of overcrowding or special hardship. Westminster's proportion is 8 per 1,000 houses available for letting during the year. The only County Council Housing Estates on which it is anticipated accommodation may be available during the next 12 months are at Becontree, Essex, and Grove Park, near Bromley, Kent, both a considerable distance from Westminster. The County Council's offer is being brought to the notice of persons living in the most overcrowded conditions in Westminster and who have applied to the City Council for other accommodation. Unless employment could be found in the neighbourhood of these estates (as one man has done) the cost of travelling to Westminster would be prohibitive. Dangerous Structures.—The County Council has arranged that district surveyors shall notify borough councils where notices have been served involving the demolition or partial demolition of dwelling houses in order that the borough council concerned may take such action as it deems necessary to prevent any unnecessary hardship to occupiers of such houses. Conversion of Houses into Flats.—Section 27 of the Housing, Town Planning, &c., Act, 1919, provides that where it is proved to the satisfaction of the County Court on an application by the local authority or any person interested in a house that, owing to changes in the character of the neighbourhood in which such house is situate, the house cannot readily be let as a single tenement but could readily be let for occupation if converted into two or more tenements, and that, by reason of the provisions of the lease or of any restrictive covenant affecting the house or otherwise, such conversion is prohibited or restricted, the Court, 57 after giving any person interested an opportunity of being heard, may vary the terms of the lease or other instrument imposing the prohibition or restriction so as to enable the house to be so converted subject to such conditions and upon such terms as the Court may think just. Application was made to the Courts under this section in respect of a large house in Princes' Gate, but permission was refused on the ground that the difficulty in letting the premises, as a single residence, was not due to changes in the character of the neighbourhood. It will be noticed below, under heading " Plans," that 13 houses have been converted into flats and 5 stables into dwellings during the year. An attempt was made by the Council to lease the old Peabody Buildings, Buckingham Gate, for the temporary housing of families who were overcrowded or living in unsatisfactory conditions. Only a portion of the Buildings could be so used, the rest being unfit for occupation and the amount asked for rent together with the sum necessary to be expended rendered the suggestion impracticable. One block is now being converted into flats by the purchaser, and the remainder is to be utilised as shops and offices. New Peabody Buildings.—The Trustees have at last been able to obtain possession of the ground for the remaining block of their dwellings in Horseferry Boad, and are clearing the site. Restriction of Rents Acts.—Nine applications for certificates were asked for and were granted. Houses let in Lodgings.—At the end of 1924 there were 1,120 houses on the register, 4,062 visits were paid to such houses, and notices were served with reference to 229 defects, 9 being for overcrowding. Statutory notices were served in 17 instances. No police court proceedings had to be taken to enforce them. 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. The by-laws drawn up by the County Council under the Housing and Town Planning Act are, unfortunately, still in abeyance. Number of new houses erected during the year :— Tenements. (a) Total 40 (ib) With State assistance under the Housing Acts, 1919, 1923, or 1924— (i) By the Local Authority 40 (ii) By other bodies or persons 0 58 1. Unfit dwelling-houses. Inspection—(1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 3,752 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 6 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 5 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 1,117 2. Remedy of defects without Service of formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 103 3. Action under Statutory Powers. A.—Proceedings under Section 28 of the Housing, Town Planning, &c., Act, 1919. (1) Number of dwelling-houses in respect of which notices were served requiring repairs 0 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 0 (b) By Local Authority in default of owners 0 (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close 0 B.—Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 1,014 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 995 (b) By Local Authority in default of owners 0 (c) Closed voluntarily and demolished 4 59 C.—Proceedings under Sections 17 and 18 of the Housing, Planning, &c., Act, 1909. (1) Number of representations made with a view to the making of Closing Orders 0 (2) Number of dwelling-houses in respect of which Closing Orders were made 0 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwellinghouses having been rendered fit 0 (4) Number of dwelling-houses in respect of which Demolition Orders were made 0 (5) Number of dwelling-houses demolished in pursuance of Demolition Orders 0 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 premise! parts of which were occupied as workshops:— 1924. 1924. Complaints received and dealt Sanitary Work completed:— with 979 Drains:— Premises inspected on complaint, &c. 996 Cleansed and sealed off from sewer 51 House to house inspection 3,752 Gully traps fixed 903 Subsequent visits 19,180 Defective traps abolished 81 Premises (registered), visits to 4,062 Manholes built 641 Overcrowding found 9 „ repaired and cleansed 272 Other infringements 220 Sanitary "Work completed:— „ covers fixed or repaired 647 Houses:— Cleansed throughout 324 Tested by smoke 64 „ partially 778 „ chemical 321 Overcrowding 66 „ water 663 „ remedied 49 „ air 24 Light or ventilation improved 211 Fresh air inlets fixed or repaired 296 Eoofs repaired 392 Soil Pipes:— Floors and staircases repaired .. 312 Fixed 419 Ventilated 287 Underground rooms:— Repaired 142 Illegal use 7 Tested by smoke 129 Closed 2 Tested by chemical 281 Yards, areas, paved or repaired 340 „ water 125 „ air 210 Damp walls remedied 220 Offensive refuse removed 163 Water-closets:— Constructed 1,323 Keeping of animals discontinued 20 Repaired 314 Verminous premises cleansed 151 Ventilated and light improved 378 Filthy or unwholesome bedding, &c. 3 tons Cleansed or lime washed 535 Drains:— Ventilated - lobbies' vided 238 Constructed 389 Unstopped 102 Amended and repaired 121 Ventilated 300 Traps ventilated 1,007 Unstopped and cleansed 141 Flushing cisterns fixed 1,187 Interceptor traps fixed 189 „ „ repaired 282 60  1924. 1924. Sanitary Work completed:— Sanitary Work completed: — Waste Pipes:— Water Supply:— Constructed 1,179 Cisterns fixed 159 Eepaired 190 „ cleansed 147 Unstopped 108 „ covered 156 Trapped 2,092 Cisterns defective, abolished 11 Yentilated 1,680 Taps off main provided 714 Disconnected from drain 305 Pipes repaired 184 Rain water Pipes:— Dust Bins:— Fixed or repaired 608 Movable, provided 246 Disconnected from drains 146 „ repaired 10 Urinals:— Fixed, abolished — Constructed 237 Stables:— Eepaired or improved 34 Drained 2 Cleansed 86 Paved 3 Water Supply:— Cleansed 17 Provided 764 Dung receptacles provided 1 ,, additional in tenement houses 27 Dung accumulations removed 34 Cut off 14 Garages constructed 28 Eeinstated 21 Petrol interceptors provided 6 1,098 intimations of nuisances (exclusive of smoke nuisances), &c., and 41 statutory notices relating to 30 premises were issued ; 1,028 letters were written in addition. Police Court proceedings had to be resorted to in respect of 2 properties for want of supply of water. In each case the summonses were withdrawn on payment of costs, the water having been re-instated before the hearing. Plans.—602 sets of plans were submitted during 1924. Of these 80 were plans of new buildings. The corresponding figures for 1921 were 383 and 22, for 1922, 468 and 39, and for 1923, 551 and 73 respectively. Ten plans were disapproved, and three others were withdrawn or not proceeded with. Orders for "Combined Drainage" were made in 33 cases. In 13 instances the plans related to houses wholly or partially being converted into flats, and in 5 instances to stables being converted into dwellings. Failure to give notice occurred in 23 instances, and to send in plans 15 instances. Sixteen builders were cautioned. Two builders were summoned for this, having been previously cautioned, and were fined : one £2 and £3 3s. costs, one £3. Two summonses are outstanding. Water Supply.—14 notices of withdrawal of water supply were received from the Metropolitan Water Board. The reasons given for cutting 61 off the supply were: Defects, 1; non-payment of rates, 13. Proceedings were taken in two instances as mentioned above. Additional water supply to the upper floors of tenement houses was provided in 27 instances. Removal of Offensive Refuse.—Four summonses for removing refuse in improper vehicles or receptacles, and eight for removing it in prohibited hours. Fines were inflicted in each case, amounting in all to £20. Rat Repression.—The campaign against rats was continued throughout the year; 35 specific complaints were investigated and steps taken to destroy the vermin and to remove the source from which they came. In the majority of instances the invasion of houses was due to defects in the drains or sewers ; 27 examinations of sewer connections were made, faulty ones were remedied and disused connections were bricked off; in 5 instances defects in sewers were found and remedied. Care was taken during re-construction of premises to see that disused drains were taken out or properly filled in and sealed off from the sewer. In some instances rats had been brought from the docks in packages of fruit. In the week commencing 1st November a united attack was again made throughout the country. During the week 20,000 baits were laid in 247 of the Council's sewers and approximately 13,000 baits were taken, but the actual number of dead rats seen was only 64, probably the dead bodies were carried away in the sewers. Baits to a limited extent are now put down in the sewers periodically throughout the year. Removal of Human Remains.—The reconstruction of the premises known formerly as Poland Street Workhouse necessitated the removal of a large quantity of human bones, as the open space inside the buildings had been used as a burial ground from about 1690, when it was acquired to supplement the burial accommodation by the St. James', Piccadilly, parochial authorities. No burials appear to have taken place in the ground for over 100 years. Under licence of the Home Office the remains disturbed were removed to the City's Cemetery at Hanwell under my supervision. The remains consisted entirely of bones weighing 31 tons, 8 cwts. During excavations in connection with rebuilding of premises on the site of 48, Palace Street, a small quantity of human bones was found and the Home Office granted licence for their removal to Brookwood Cemetery. Filtration Plant, Great Smith Street Baths.—After consideration of reports by the City Engineer and the Medical Officer of Health the Council decided to adopt a system whereby the water of these Baths could be purified by filtration and the addition of a disinfectant. The " Turnover " 62 system was selected and was installed during the year. The plant has not been in use long enough to enable a full report to be made on its working, but from results obtained up to the present time it is evident that considerable saving in water and fuel is being effected, and the continual supply of clear, bright aerated water is very much appreciated by the bathers, as is shewn by a marked increase in their number since August last. In order to test the purity of the water which has been in use in the Second-class Swimming Bath for nearly three months, samples have been taken for analysis and examination by the Chemical Kesearch Association. The results show that the standard of purity required under the contract (which standard was fixed after consultation with the Medical Officer of Health) has been reached. No B. Coli were detected in the water in quantities varying from 0-01 to 200 cc. The advantage to the bathers in having always a pure clean water in which to swim needs no comment. I suggested the adoption of some such system before the War. Pulverisation of Refuse.—Another innovation is the erection of plant whereby the refuse of the City is converted into a powder resembling loam. I brought this question to the notice of the Highways Committee also in pre-war days, but it was not then proceeded with. Difficulties of removal from Westminster and disposal of the refuse in suitable dumps on the banks of the Thames in its lower reaches led the Council to seek some other method of disposing of the City refuse and very elaborate apparatus has been installed and promises to be a success. Cleansing of Telephone Instruments.—The Council had brought to its notice by one of its members that telephone instruments and telephone boxes were not kept in a properly sterilised and sanitary condition. On enquiry it was found that the complaint did not refer to public call stations, which are cleaned, and the transmitter mouth pieces and receiver caps disinfected by a special staff of the Post Office at intervals of three days, but to private installations in blocks of residential and office flats, which the public are allowed to use. It was, therefore, suggested to the Postmaster-General that where a telephone box is allowed to be used by the general public, he should make it a condition of the licence, that such telephone and appurtenances should be kept in a sanitary condition. To this the Postmaster-General replied that in those cases where an exclusive line subscriber elects to exhibit a sign " You may telephone from here," only a hiring agreement is entered into. As no restriction can be placed on the use of a telephone in a subscriber's house and members of the public can always, if they prefer, use a telephone at a Post Office or at other premises where an official call 63 office is installed, the Postmaster-General regrets that he is not in a position to impose such a condition as the Council suggests. Where an official Call Office is provided by the Post Office under the care of an attendant, as is frequently the case with Call Offices at shops which are not Post Offices, it is a condition of the attendants' agreement that he shall keep the cabinet and telephone in a clean condition to the satisfaction of the Postmaster-General, and it is stated in the instructions issued to Call Office attendants that the mouthpieces and earpieces of telephones should be wiped out every morning with a clean cloth moistened with disinfectant fluid. The question of the need for regular cleansing of the call boxes and apparatus was the subject of some enquiry between the years 1905 and 1910. Numerous examinations failed to reveal the presence of the tubercle bacillus except in one case (Lancet, June 27th, 1908), but the agitation resulted in improvements both in the construction of call boxes and in their cleanliness. No examination appears to have been made as to the presence of other organisms, but unless the person using the telephone allows his mouth to come in contact with the receiver, the risk of infection is probably small as organisms in the receiver would in many instances be in a moist condition. Still, even if the risk be small, it is desirable that the instruments should be regularly cleansed, not only those to which the public have access but also those in common use in business firms and offices. It is of interest to note that in the Public Health Act of the Province of Alberta, Canada, it is required that those in charge of all public pay telephone stations shall either at least twice daily disinfect the transmitter or mouthpiece with formalin or shall provide a supply of carbolized vaseline and a sponge, in which case it shall be the duty of all persons immediately before using the telephone to wipe out the mouthpiece with the sponge and vaseline. The same requirement is to be observed in hotels, public houses and boarding houses. Smoke Prevention. The following is a summary of the work done in connection with smoke prevention:— — 1921. 1922. 1923. 1924. Complaints received 30 31 12 40 Observations taken 1,838 1,795 600 2,309 Notices issued— Preliminary 1 80 8 42 Statutory 52 2 2 - Summons - - 1 - 64 We are reminded every winter by the occurrence of fogs that there is room for still further improvement if London is to be protected from the evil effects of the pollution of the atmosphere by smoke. If the public generally appreciate that it is a direct cause of illness and death, that it lowers industrial output besides throwing an additional charge for artifidial illumination and that it could be prevented, steps would be taken to have the law made more stringent. A Bill for this purpose has been promised. It has been estimated that domestic fires in London caused about 2-|- times as much pollution as factory and furnace fires. D.—Occupations and Workshops. The following shorn the state of the register of work premises at the end of 1924:— Work Premises. Total Number. Tailors, outfitters, shirt makers, hat, cap and helmet makers 1,694 Dressmakers, milliners, embroiderers, lace makers, blouse makers, costumiers, lingerie makers, children's outfit makers, feather dyeing, corset makers, furriers, &c. 947 Leather workers, boot and shoe makers, harness makers, &c. 55 Carpentry, upholstery, carvers, gilders, &c. 56 Surgical and dental instrument makers 4 Tobacco manufacturers 20 Wig makers and hair workers 45 Printing, bookbinding, lithographers, envelope making, stationers, relief stamping, &c. 51 Jewellers, silversmiths and burnishers, diamond cutters and polishers, engravers, &c. 55 Metal workers 7 Miscellaneous—Basket making, fancy work, shoe ornaments, hat pins, stamp sorters, postcard tinters, fan makers, artificial flower makers, &c. 61 Florists 26 Laundries 51 Bakehouses 80 Photographers 20 Jewel case makers 10 Cinema film workplaces 60 New workshops are always being discovered, at the same time the occupation of premises on the register is constantly changing. The use of 292 workshops was discontinued, and 320 additions were made to the register during the year. 65 Inspection.—1924. Premises. Number of Inspections. Reinspections. Defects Found. Intimation Notices. Statutory Notices. Prosecutions Factories 132 60 17 12 — — Workshops 1,485 2,224 583 269 2 — Workplaces (Excluding restaurant kitchens, &c.) 981 1,708 542 141 — Total 2,598 3,992 1,142 422 2 — Defects found. Particulars. Number of Defects. Number of Prosecutions. Found. Nuisances under the Public Health Acts :— Want of cleanliness 435 Want of ventilation 83 Want of ventilation of gas stoves 46 Overcrowding 30 Want of drainage of floors 22 — Sanitary accommodation— Insufficient 62 Unsuitable 77 Defective 116 Not separate for sexes 36 — Other defects 235 — Total 1,142 — Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouses — — Breach of special sanitary requirements for — — bakehouses (included above) Other offences — — Other Matters. Class. Number. Visits to Out-workers' premises Matters notified to H.M. Inspector of 1,143 Factories:— Failure to affix Abstract of the Factory and Workshop Act 172 Absence of means of warming I Matters referred by H.M. Inspectors 110 310 Visits of Enquiry re Employment of Women 83 „ „ Outworkers 273 Underground bakehouses in use at the end of the year 59 66 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 hon es, 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 employers who neglected to send in returns, and those who failed to reply were visited by an Inspector. No further proceedings had to be taken. The handling of 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. They in their turn send names of persons living in Westminster receiving work from employers in their districts. 67 City of Westminstcr. Outworkers—1924. 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. Bootmaking 383 6 354 35 402 7 371 38 Corset-making 1 — 1 — 1 — 1 — Cutlery repairing — 1 — ] — 1 — 1 Dressmaking 325 69 293 101 336 77 289 124 Dyeing and Cleaning 4 2 2 4 6 2 4 4 Embroidery 32 2 22 12 35 1 26 10 Engraving — 1 — 1 — 1 — 1 Farriers 38 5 32 11 27 4 24 7 Hair Working — 2 — 2 — 1 — 1 Hatmaking — 2 — 2 2 5 2 5 Lingerie, &c. 167 14 160 21 159 16 149 26 Shirtmaking, Hosiery, &c. 133 9 110 32 145 8 104 49 Tailoring 3,274 122 1,506 1,890 3,744 123 1,760 2,107 Theatrical costumes 7 — 4 3 8 — 5 3 Toys, fancy goods, &c 106 4 87 23 83 22 75 10 Waterproofing 1 3 1 3 1 1 1 1 Totals 4,471 242 2,572 2,141 4,949 249 2,811 2,387 Number of lists received during the year, 875—(February, 411; August, 464). 68 The large number of persons employed as outworkers indicates an improvement in these trades during the year. After adjusting the lists, it appears that the actual number of outworkers resident in Westminster is 1,403 (in 1922 the number was 1,311 and in 1923, 1,278); this is less than the apparent number shown on the accompanying table, as more than one employer may send work to the same person. The number of houses in which out-work is carried on was 748. These premises 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 (Sees. 109, 110). Factories Bill.—A Bill to amend and consolidate the enactments relating to factories and workshops was introduced into Parliament, but further consideration was adjourned. While in some respects it is an advance on existing legislation, in one respect at least it introduces a retrograde proposal to centralise all the work and to make the provisions enforceable by the Factory Inspectors, except that in any factory in which mechanical power is not used, and which forms part of a dwellinghouse or shop, certain provisions in Part I are to be enforced by the sanitary authority ; and in the case of any other factory in which mechanical power is not used the Secretary of State may make arrangements for the enforcement of the provisions by the sanitary authority instead of the Factory Inspector. The Public Health (London) Act, 1891, gives power to the sanitary authority to deal with " Any premises " which includes all factories and workshops, and any attempt to take away this power should be opposed. It is desirable that similar power should be given to local authorities in the rest of the country. There are other proposals in the Bill which are unsatisfactory, thus in Parts III and IV there are certain provisions which ought to be enforced by the sanitary authority, viz., Clause 38 (supply of drinking water), Clause 39 (washing facilities), Clause 41 (facilities for sitting), Clause 42 (accommodation for keeping and drying clothing), Clause 47 (prohibition of spitting), Clause 54 (night work in bakehouses), Clause 58 (underground rooms), Clause 60 (laundries). In Part V, notification of cases of industrial poisoning has to be sent to the Factory Inspector. He should be required to furnish copy of same to the local sanitary authority. 69 Clause 91 (3) deals with the examination of young persons as to fitness for employment, and the Secretary of State may transfer this duty to County Councils. In London it should be the Borough Councils. The present arrangements, so far as Westminster is concerned, are not satisfactory in so far as neither of the certifying surgeons are resident within a reasonable distance of Westminster. Clause 94.—The owner of a tenement factory is to be responsible instead of the occupier. Both ought to be made responsible. The occupier may not be the owner, and may be the person infringing provisions relating to overcrowding, failure to maintain ventilation, fixing of abstracts, &c. Clause 99.—The provisions of Part I with respect to sanitary conveniences in building operations should be carried out by the sanitary authority. The provisions contained in the fourth Schedule, relating inter alia to bakehouses, should be administered by the sanitary authorities. The City Council made representations to the Home Secretary, the Minister in charge of the Bill, with a view to the amendment of the Bill on the lines suggested above, and other metropolitan authorities have taken similar action. E.—Food Supply. During 1924, 4,915 visits have been paid to the various classes of business by the District Inspectors, beside which there was the regular inspection of street markets, Covent Garden Market, and other places selling food, by the Food Inspectors. 115 notices were served in respect of defects found. Restaurants.—The kitchens of hotels and restaurants are inspected regularly, and a number of notices were served in respect of defects found. In only one instance had a statutory notice to be served. Ice-cream Premises.—There were during the year 148 places where this commodity was made or sold, and these were kept under supervision ; 240 visits were paid. (3692)q f 70 Bakehouses.—At the ei)d of 1923 there were 21 above-ground and 59 underground in use. During 1924 two underground were reported to be not at present used. All the bakehouses were inspected, and cleansing carried out twice a year. Milkshops.—At the end of 1924, 494 names of persons selling milk were upon the register. These include 8 persons selling milk on rounds, who had no shop or store. 1,730 visits were paid during the year to premises in which milk is sold. Proceedings were taken against 1 itinerant vendor of cream and milk for not having his own name and address on his barrow. Fined 40s. and 20s. costs. Cowhouse.—There is only one remaining, licensed for 6 cows, but none have been kept during the past year. There are no slaughter-houses in Westminster. % 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 :— Articles of Food Submitted. Tons. Cwt Lb. Tons. Cwt. Lb. Apples 17 7 30 Kale 1 9 0 Apricots 1 12 58 Lettuce 0 7 10 Artichokes 4 8 0 Lemons 3 14 0 Asparagus 0 13 30 Melons 0 19 15 Bananas 14 4 40 Onions 1 6 0 Cauliflower 5 3 5 Oranges 10 9 0 Cherries 2 10 64 Peaches 0 2 20 Chicory 0 1 3 Pears 12 17 84 Currants (Red) 0 0 10 Pineapples 2 9 0 Endive 0 2 60 Plums 0 14 66 Gooseberries 0 9 56 Potatoes 3 9 7 Grapes 1 7 8 Spinach 1 10 0 Greens 2 5 0 Tomatoes 8 13 35 60 lbs. Corned Beef, 158 Rabbits, 4 Hams, 86 lbs. Plaice, 10 lbs. Halibut, 6 cwt. Peppers in Vinegar, 28 lbs. Dried Milk. Certificates to enable articles of food to be exported to the United States and Canada were granted in 8 instances. 71 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 1924. #]Number. Article of Food. Number of samples purchased. Genuine. (Inferior in brackets.) Adulterated. Prosecutions. Convictions. Withdrawn or dismissed. Fines. Costs. £ s. d. £ s. d. I Vlilk 994 926 (49) 19 12 8 4 8 0 0 19 19 0 2 Do. separated 8 6 2 2 2 — 3 0 0 2 17 0 3 Do. condensed 29 28 1 1 — 1 — — 4 Cream 65 60 5 1 — 1 — — 5 Do. preserved 62 43 19 1 1 — — 2 2 0 6 Do ice 2 2 — — — — — — 7 Do. cheese 1 1 — — — — — — 8 Do. Do. (preserved) 23 22 1 — — — — — 9 Cheese 3 3 — — — — — — 10 Butter 152 150 (1) 1 2 1 1 2 0 0 — 11 Buttered rolls 1 1 — — — — — — 12 Do. scone 3 3 — — — — — — 13 Coffee 14 14 — — — — — — 14 Sponge cake 46 44 2 2 2 — 5 0 0 1 0 0 15 Mrat pies (various) 38 25 13 — — — — 16 Sausages 120 91 29 3 3 — 15 0 0 17 Meat and Fish Paste (various) 52 48 4 — — — — 18 tirawn 1 1 — — — — — 19 Dripping 1 1 — — — — — — 20 Peas 42 18 24 4 4 — 12 10 0 3 13 G 21 Beans 13 4 9 1 1 — — 2 2 0 22 Spinach 4 1 3 — — — — — 23 Tomatoes 2 2 — — — — — — 24 Fruit (tinned) 20 13 7 — — — — — 25 Whiskey 60 49 11 6 5 1 8 0 0 7 7 0 26 Bum 14 6 8 5 5 — 12 0 0 13 13 0 27 Brandy 3 3 — — — — — — 28 Olive oil 11 11 — — — — — — 29 Lime water 6 6 — — — — — — 30 Camphorated oil 10 10 — — — — — — Totals 1,800 1,592 (50) 158 40 32 8 65 0 0 52 13 6 Refusal to sell.—For refusing to sell a tin of pears to the Inspector a shopkeeper was fined £5 and £1 Is. costs. Milk.—994 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 officiai 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 beiow the official standard of 3 per cent, for fat and 8*5 for solids not fat. (3692) F 2 72 District. Total. Good Quality. Fair Quality. Poor Quality. Adulterated. No. Per cent. No. Percent. No. Per cent. I No. Per cent. North 459 248 54.0 146 31.8 54 J11 .7 11 2.30 South 535 259 48.4 217 40.5 51 j 9.5 8 1.40 1924 994 507 51.0 363 36.5 105 j10.5 19 1.90 1923 997 458 45.9 368 36.9 149 | 14 .9 22 2 .2 1922 998 493 49.4 338 33.8 138 13.8 29 2.9 1921 987 321 32.5 400 40.5 236 23.9 30 3.0 1920 977 449 45.9 362 37.0 131 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 ll.2 1917 920 329 35.7 304 33.0 162 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 28.0 343 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 The quality of the milk shows a still further improvement, not only in the amount of adulteration but also in the amount of milk supplied of the best quality. Twelve prosecutions were taken with regard to adulteration—7 for fat abstracted (17, 14, 9, 8, 7, 5 and 4 per cent.) and 5 for added water (17, 14, 10, 9 and 5 per cent.). The roundsman in a number of cases is responsible. In one case the man admitted having added separated milk. Warranties were successfully proved in four instances. For selling separated milk to which had been added water, two vendors were fined: one £2 and £2 2s. costs, the other £1 and 15s. costs. Sunday Samples.—83 of the samples of milk were taken on Sundays during the year, two of which were reported adulterated, 3 per cent, fat abstracted and 9 per cent, added water. One vendor was prosecuted and ordered to pay £2 2s. costs, the other was cautioned. Samples taken in course of Delivery— On Delivery at Shops, &c.—8 samples of milk were taken as it was being delivered by wholesale firms to retail customers, including shops, hotels and hospitals. Of these samples, 6 were good, 2 fair. These samples were taken in consequence of previous samples having been found below the limit (including cases where a warranty defence was set up). The Public Health (Condensed Milk) Regulations.—29 samples were examined and 28 were reported to comply with the Kegulations. In the remaining case proceedings were taken, but as doubt was raised as 73 to whether the milk in the tin had been properly mixed by the Inspector the case was dismissed. Milk (Special Designation) Order.—Under the provisions of this Order the Council issued licences for the sale of— Certified Milk 27 Grade A (Tuberculin-tested) 9 Samples for baceteriological examination were taken under the directions of the Ministry and were reported to be satisfactory. The demand for this class of milk is steadily increasing. The Public Health (Milk and Cream) Regulations.— Samples analysed during the Year 1924. Article. Number of samples examined for preservative. Number containing preservative and percentage of preservative found in each sample. Milk 994 No preservative found. Separated Milk 8 No preservative found. Cream 65 Five contained preservative (18.0, 17.5, 13.0, 7.0, and 4-0 grains of boric acid per lb. respectively). The person who sold the cream to the vendor of the first sample was fined £2 and £1 costs. With regard to the 13 grains sample the vendor's roundsman was prosecuted and ordered to pay £1 1s. costs for infringing Article 5 (2). Satisfactory explanations were received in respect of the remaining samples but the vendors were cautioned. Preserved Cream. Number examined. Without preservative. Preservative under amount stated on label. (0-4 per cent.) Preservative over amount stated on label. Milk fat in preserved cream. Above 35 per cent. Below 35 per cent. 62 4 57* 1 62 Nil. * Samples contained respectively 35.0, 26.0, 26.0, 25.2, 24.5, 24.5, 23.8, 23.5, 23.1, 23.0, 22.4, 22.4, 21.0, 20.3, 19.6, 19.6, 19.6, 19.6, 19.0, 18.9, 18.7, 18.2, 18.2, 18.2, 18.0, 18.0, 17.3, 17.0, 16.8, 16.5, 16.1, 16.0, 14.8, 13.8, 13.4, 13.3, 13.0, 13.0, 13.0, 12.0, 11.5, 11.4, 11.2, 11.0, 10.0, 10.0, 10.0, 9.0 grains of boric acid per lb. The remaining samples contained only small amounts o{ boric acid. Action taken. The vendor of the sample containing 35 grains was prosecuted and ordered to pay £2 2s. costs. No action was taken with regard to the remaining samples. Infringements under Article 5 (1)—Nil. Infringements under Article 5 (2)—Two. One defendant fined £2 and £1 costs ; the other ordered to pay £1 Is. costs. 74 Butter.—In one case in which a sample was found to contain sodium carbonate and an excessive amount of water, the vendor admitted that the butter had gone rancid and he had tried to render it saleable by mixing with it a solution of soda. He was fined £2. Sponge Cakes.—46 purchases of sponge cakes and sponge-fingers were made to ascertain whether the arrangement not to use preserved liquid eggs in their manufacture was being adhered to. In only two instances was it found that boric acid (19 grains and 11 grains respectively) was present. The two bakers concerned had each to pay £3 by order of the magistrate. Spirits.—Complaints having been received that spirits were being sold containing more water than is allowed, the Public Health Committee ordered samples to be taken (60 whiskey, 14 rum, 3 brandy), 11 of whiskeys and 8 rums were found to be below standard. In some instances the vendor sought to protect himself by exhibiting a notice that he did not guarantee the quality of the spirits sold. Some of these notices were held to be valid, but others were not so. Proceedings were taken against 11 vendors who either exhibited no notice or in which the notice was deemed to be insufficient, and were successful in 10 cases. Food Preservatives.— The Committee appointed by the Minister of Health to enquire into the use of preservatives and colouring matters in food after hearing evidence from medical officers of health and public analysts, physicians, pharmacologists, chemists and a great number of persons connected with the trades which would be affected, has issued a lengthy report of which the following is a summary of its conclusions and recommendations :— (1) Preservatives* should be prohibited in all articles of food and drink offered or exposed for sale, whether manufactured in this country or imported, except that for the present the use of sulphur dioxide and benzoic acid may be permitted in definite and specific cases to a limited amount, viz. :— (A) Sulphur dioxide only should be permitted— (i) In sausages in amounts not exceeding 3 grains per pound ; (ii) in jam in amounts not exceeding 0-3 grain per pound ; (iii) in dried fruit in amounts not exceeding 7 grains per pound ; (iv) in preserved (but not dried) whole fruit or fruit pulp in amounts not exceeding 5 grains per pound ; * The Committee does not include in the word " preservative " such substances as salt, saltpetre, sugar, vinegar, acetic acid, alcohol or spices, or the minute quantities of preservative agents introduced by the process of curing known as "smoking" or substances such as saccharin. 75 (v) in beer and cider, whether in bottle or in cask, in amounts not exceeding 5 grains per gallon ; (vi) in alcoholic wines, non-alcoholic wines and cordials, and fruit juices, sweetened and unsweetened, in amounts not exceeding 3 grains per pint; (B) Benzoic acid only should be permitted— (i) in coffee extract in amounts not exceeding 3 grains per pound ; (ii) in non-alcoholic wines and cordials, and sweetened and insweetened fruit juices (as an alternative to sulphur dioxide) in amounts not exceeding 5 grains per pint; (iii) in sweetened mineral waters and in brewed ginger beer in amounts not exceeding 1 grain per pint. The method of estimating the foregoing preservatives should be prescribed by the Minister of Health. (2) The sale of any preparation as a food preservative or for use in such circumstances that it may be introduced into food should be declared illegal unless such preparation (a) bears a description clearly indicating its composition and strength ; (b) is free from impurities, and in particular contains not more than 1/100th part of 1 grain of arsenic per pound or more than 1 /7th part of 1 grain of lead per pound. (3) Disclosure of use of Preservatives.—The use of preservatives so far as they are permitted should be upon the condition that the nature and quantity of the preservative present in the article of food should be declared in a manner prescribed by the Minister of Health. It is possible that there may be some cases in which the declaration of the preservative used might be difficult to enforce or which might result in undue harm to the industry without compensating advantage to the consumer. If this be so, exceptions might be made in their favour, but the exception should in no circumstances apply to sausages. (4) The employment of a copper salt to colour or preserve the colour of peas and other vegetables should be prohibited. (5) A schedule should be issued by the Minister of Health of ing matters the use of which in foods may be considered non-injurious to health, and thereafter the use of any other colouring matter should be prohibited. 76 (6) Before the prohibition of preservatives or of colouring matters in food a period of grace should be allowed to allow manufacturers and importers to adjust their methods and processes and to allow stocks to be cleared. (7) Improved methods in the storage and transport of food by rail, road and water, especially as regards the use of refrigeration and cool air storage are urgently required. (8) It shoidd be provided by law that any regulations or statutes prohibiting or limiting the use of preservatives and colouring matters should bind the Courts in proceedings taken in respect of their use. (9) An amendment of the law is required to render more expeditious the prosecution of a person actually responsible for offences under the Sale of Food and Drugs Acts, where a warranty defence is pleaded. (10) Further powers of control by registration, licensing or tion should be given to Local Authorities in relation to all places concerned in the production, sale, storage and distribution of food. The Committee considers this especially important as regards sausage making, and that permission to use sulphur dioxide cannot safely be accorded unless greater power be given to Local Authorities to inspect the places where such articles are prepared, together with the methods of preparation and the materials used. The Minister of Health has promised to issue at an early date draft regulations designed to give effect to the majority of these recommendations which could be carried out without legislation. F.-STAFF OF THE PUBLIC HEALTH DEPARTMENT. I reported during the year that an additional Sanitary Inspector was required and the Council agreed to this being done. In my report I stated:— " The City is divided into eight districts, to each of which a Sanitary Inspector is appointed to attend to complaints of nuisances, supervise new drainage work, and, as time permits, to systematically inspect the houses in his district . In addition, the Woman Inspector, whose principal work is the inspection of workshops where women are employed and outworkers' premises, also visits houses let in lodgings which are registered. The Health Visitors also report insanitary and unsuitable conditions which they discover in the course of their visiting. " The work of the Inspectors varies considerably in different districts. For example, those in districts including Regent Street and the Strand 77 are largely occupied with new buildings and reconstruction, while in Pimlico and St. John's the work is chiefly attending to insanitary conditions. During and since the war the number of insanitary conditions in Pimlico especially have increased, partly due to the degeneration of this district which has been gradually taking place over a considerable number of years, by reason of the breaking-down of houses previously let to one family into flats and tenements. Pimlico has always been a difficult district to deal with on account of so many of the houses being leased by persons who make their living through sub-letting their houses, which for many is their sole source of income. As a result of the higher cost of living and of all works of repair, these people, in many instances, have not had the funds to expend in keeping up their houses to a pre-war standard, while others have spent their savings in so doing. In some cases the leaseholders, having only a few years to run, have had to surrender their leases through inability to do what is necessary. The Restriction of Rents Acts have prevented the getting rid of careless and dirty tenants, whose conduct leads to an increase for renovations in excess of the amount of the authorised increase of rent, which, moreover, is frequently not paid. " From these causes the work of an Inspector in this district has become much more onerous, and the difficulty in getting work carried out necessitates more visits to properties on which notices have been served than was formerly the case. He is thus unable to give the time to systematic house-to-house visiting. I am of opinion that, in this district particularly, the need for an additional Inspector is required, in order that such systematic visiting should be carried out." During the year the Council lost the services of one of its Sanitary Inspectors, Mr. J. W. Whipp, who was obliged to retire on account of illhealth. Mr. Whipp, who was originally appointed by the Vestry of St. George's, Hanover Square, and was taken over by the Council on its formation, was a very experienced and conscientious officer. Mr. John Smith was apointed temporarily during his illness and continued in that position on Mr. Whipp's retirement pending the appointment of a successor. Mrs. Watkinson, Health Visitor, also retired on account of ill-health and was replaced by Miss M. M. Scott. In the same Report I also reminded the Council that the work of the Department was much hampered by the insufficiency of the clerical staff which threw a considerable amount of clerical work on the Medical Officer of Health, but I recognised that until the additional office accommodation is provided, for which arrangements have been made, there is no room in the present office for more clerks or for the proper storage of records. It is also desirable that the Medical Officer of Health should have the assistance of a medical man to enable him to deal with various matters, for example, Diphtheria (see remarks ante). With the decreasing 78 amount of work at the Tuberculosis Dispensary, it might be possible to utilise the services of the Tuberculosis Officer as an Assistant for general work. The staff of the Department during the year was made up as follows :— Medical Officer of Health and Administrative Tuberculosis Officer: Qualifications. Francis J. Allan M.D., D.P.H., etc. Assistant Medical Officers: Andrew J. Shinnie M.D., D.P.H. (Tuberculosis and Maternity and Child Welfare.) *Ethel M. Vernon M.D., B.S. (Maternity and Child Welfare.) Bacteriologist: *J. A. Braxton Hicks M.D., M.R.C.P., D.P.H. Dental Clinic: *W. H. Turner L.D.S. *T. Graham Scott (Anaesthetist) M.R.C.S., L.R.C.P. Public Analysts: *Cecil H. Cribb B.Sc., F.I.C. *P. A. Ellis Richards F.I.C. Clerical Staff: A. Wise. F. W. Lake. A. J. Manhood. W. Jenkins. Miss M. MacFarlane (Tuberculosis Dispensary). Sanitary Inspectors: F. A. Aris R.S.I. C. J. Dee S.I.E.B., R.S.I., and Meat and Food Cert. F. J. Haigh S.I.E.B. H. R. Hardy R.S.I., M.I. San. Eng. E. J. Martinson R.S.I. J. Sanderson R.S.I., San. Sc. Cert., Gold Medallist Carpenters' Company. A. L. Ware S.I.E.B. and R.S.I., R.P.C. J. W. Whipp (retired 30th June, 1924) R.S.I. C. Ratcliff (Food & Drugs, &c.).. S.I.E.B., Meat Cert. F. E. Siddle (Food & Drugs, &c.) S.I.E.B., Meat Cert., R.S.I. J. Smith (Temporary) S.I.E.B. Miss C. Hughesden S.I.E.B., R.S.I., H.V., C.M.B. * Part time Officers. 79 Midwife: Qualifications. Miss A. J. Irving C.M.B., Hosp. Nursing. Health Visitors: Miss A. Sanders (Supt. Centre) .. H.V. Miss J. G. Alexander (Supt., H.V., C.M.B., Hosp. Nursing. Centre) Mrs. M. Watkinson (retired, 30th C.M.B., Nursing. June). Miss D. H. M. Walding (Tubercu- S.I.E.B., Dipl. Nat. Health Soc., losis). Nursing. Miss Howell Evans S.I.E.B., Dipl. Nat. Health Soc., Nursing, Y.A.D. Miss M. M. Scott (appointed, 1st S.I.E.B., H.V., C.M.B. July). *Mrs. Coleman (Mothercraft Classes) Red Cross Cert. 1st cl., and gold medal. Other Staff: A. E. Birch, Keeper of Mortuary and Coroner's Court . R. Watling, Mortuary Assistant. A. Wheal, Superintendent of Disinfection. W. Slattery, Engineer. J. Atkins, Disinfector. E, C. Powell, Disinfector. S. C. West, Disinfector. E. Bridger, Drain Tester. P. W. Attwater, Motor Driver. A. T. Steward, Assistant to Inspectors. P. C. Neck, Messenger. Mrs. Wheal, Attendant, Verminous Children. Mrs. W. Jenkins, Caretaker, 15, Bessborough Street. Mrs. Ash and Mrs. Flanagan, Cleaners. In addition to the above, there are the following employed by the City of Westminster Health Society (subsidised by the City Council):— Medical Officers: *Octavia Lewin M.B., B.S., Maternity and Child Welfare. *N. Olivier Richards M.D., M.R.C.P., Maternity and Child Welfare. * Part time Officers. 80 Health. Visitors : Miss Cove (Supt., Centre) Nat. Health Diploma. Miss Callaghan (Supt., Centre) H.Y., San. Insp. Cert. Domestic Economy, &c. (With assistants, paid and voluntary, holding H.V. certificates, and nursing experience. Four Midwives. Mrs. Shanks (Supt., Mothercraft Classes, Reg. Teacher, &c.). Mrs. Steffens (Assistant, Mothercraft Classes). ANNUAL REPORT BY THE TUBERCULOSIS MEDICAL OFFICER, 1924. The number of new patients examined shows again an increase over the previous year. In 1922 the number was 421, in 1923 it was 529. and in 1924 it has increased to 603. The new patients examined in the infirmary have largely contributed to the growing numbers, making a proportion of 130, while in the previous year they amounted to 60. The period which is represented by the smaller number was, however, not a full year, as my appointment as consultant in tuberculosis to the infirmary dated from the beginning of May, 1923. In last year's report I referred at some length to the usefulness of the Tuberculosis Officer being attached to the infirmary, and I pointed out that in many instances patients who ordinarily would have been unwilling to enter that institution went in without raising objection when they realised that the Tuberculosis Officer would visit them there. The fact that it was possible for them to be transferred to sanatoria subsequently also had a favourable influence. There is no doubt that many patients who were suffering at home from the lack of skilled nursing, insufficient food and unfavourable surroundings derived lasting benefit from treatment in the infirmary. It might be of interest to note the types of the disease which one meets with in the tuberculosis wards of the infirmary. Firstly, there are the acute cases, many of them being young adults between the ages of 25 and 35. Very often the reason for their admission has been a haemorrhage or 81 acute pleurisy ; but in other cases no such critical occasion has occurred and the disease may have developed insidiously but gained rapidly in intensity over periods so short as two or three weeks. The illness usually continues to a fatal ending within a short time, and treatment seems to be without effect in influencing the downward course. This type of pulmonary tuberculosis has been observed more frequently in women than in men and closely corresponds to that described by Brownlee as phthisis of the young adult. A second type of case met with most commonly in middle-aged men is that of chronic phthisis associated with chronic bronchitis, and cases of this sort make up fully half of the sufferers from tuberculosis in the infirmary. The age period in this group is between the years 45 to 55 and the disease, although very disabling in foggy and wintry weather, is slow in its progress. Many of the patients enjoy fairly good health in summer, and some of them leave the institution to resume such occupations as street hawking, newsvending, etc. The fogs of the late autumn, however, aggravate their sufferings and they are glad to return to the shelter and comfort of the infirmary. The type of disease from which they suffer has been called middle-age phthisis. It is worthy of note that although the condition continues a slow and chronic course through middle age, it may assume an acute and rapid phase when patients reach old age. In those of 60 or 70 years of age, phthisis may present all the features belonging to the speedily fatal disease of young adult life. The infirmary also affords treatment for patients who have experienced prolonged periods in sanatoria but have failed to respond to all known methods employed on their behalf. A certain number of cases have been transferred to the infirmary from sanatorium and have not returned to their homes. They are thus afforded nursing and comfort which are not available in their homes and at the same time they are removed from being a further source of infection to other members of their families. With regard to cases showing the disease in an early stage or in whom the diagnosis of tuberculosis was doubtful, 13 were admitted to the infirmary for observation or pending vacancies in sanatoria and were subsequently dealt with by the London County Council. The following table shows the age periods and the diagnosis in 130 new patients examined in the infirmary during 1924 :— Males. Years: 0-5 5-10 10-20 20-30 30-40 40-50 50-60 Over 60 Tuberculous 3 0 3 1 2 0 2 2 13 Non-Tuberculous 0 0 3 5 11 16 21 5 61 Total 3 0 6 6 13 16 23 7 74 82 Females. Years: 0-5 5-10 10-20 20-30 30-40 40-50 50-60 Over 60 Tuberculous 0 0 3 13 8 5 2 0 31 Non-Tuberculous 3 1 3 9 5 1 1 2 25 Total 3 1 6 22 13 6 3 2 56 As mentioned in last year's report, a considerable proportion of the male infirmary patients have been inmates of common lodging-houses, and it has been possible to obtain a good deal of useful information concerning them. Four of them were considered suitable for sanatorium treatment and are included in the 13 patients recommended to the London County Council for sanatorium treatment. It is doubtful whether the expenditure in sanatorium treatment for those common lodging-house cases is justifiable. They usually have no dependants and possess no sense of responsibility. On discharge from sanatorium they disappear into the unknown and cannot be traced, or probably come to light again in the infirmary of another district. During 1924 no newly devised method of treatment was considered worthy of investigation at the infirmary. Almost every week a specific cure for tuberculosis is discovered, advertised as such, usually supported by much Continental testimony, and rapidly fades into the region of forgotten things. One preparation, patented and manufactured in London, died very hard. It figured on the boards of the omnibuses for some years. It was thrust on the medical profession and on the public by intensive advertising methods and its virtues have been extolled by the credulous of all classes. It proved to have no specific value and one cannot help feeling pity for those who could ill afford, but were deluded into spending money in the confident hope of receiving the benefits boldly asserted in the advertisements. At the present time there is no known specific for consumption. When the secret of what constitutes natural immunity or resistance to tuberculous infection is discovered, we shall be on the high road towards the cure. Most individuals at some time in their lives have been infected with tubercle in varying degrees. In some there is evidence of fairly extensive infection, but they may live long lives and never show " illness " of a tuberculous nature. Others, infected less extensively perhaps, may develop tuberculous disease given some predisposing cause such as over work, anxiety, under nourishment or the extremely debilitating condition following influenza, diabetes, &c. Tuberculosis is an infectious disease, but the question as to whether the infection will cause active disease depends upon the natural resistance of the individual exposed and to a lesser degree on the amount of the infective agent. From certain observations it would appear that 83 there is a relationship between natural resistance to tuberculosis and the state of the function of certain ductless glands such as the thyroid and ovary. In the case of women suffering from active pulmonary tuberculosis I have noted in several cases that at the period of middle age, when profound changes are in progress in those glands, the condition of tuberculosis tends to become either very acute or rapidly quiescent. I have known cases described as almost hopeless steadily to put on flesh and the disease in the lungs to become almost unrecognisable to the stethoscope. It is well known that most women tend to put on adipose tissue about middle age, but in those who show the wasting associated with tuberculosis those changes are remarkable. It has also been noted that in young adults, both male and female, those showing derangement of thyroid function often prove when they develop tuberculosis to be cases of rapidly progressive nature. The suggestion that there is a definite relationship between resistance to tuberculosis and the functioning of the glands of internal secretion seems worthy of investigation. The total number of new cases certified to the Medical Officer of Health during the year numbered 348, of which 223 were dealt with directly through the tuberculosis dispensary. The gross total of 348 includes a number of cases which could not have come within the purview of the dispensary, for example, 30 patients were not certified before death, 6 were notified from asylums and had been resident there for a number of years, and finally there were some 10 patients for whom private arrangements for treatment were made. If this number, 46 in all, be deducted from the total 348 it will be noted that the dispensary dealt with 73-8 per cent, of all the cases which might ordinarily come within its sphere. The following table shows the classification of cases and the proportion of the total which passed through the dispensary. Notifications and Deaths (unnotified), 1924. Notified by dispensary. Notified from other sources. Per cent, of Total. Pulmonary 177 67 87 264 Non-Pulmonary 26 52 24 50 Common lodging-house cases 20 58.8 14 34 Total 223 64.8 125 348 In 1923, 60.8 per cent, of total new cases of tuberculosis were examined by the Tuberculosis Officer, 84 The increased proportion, namely, 64.8 per cent., shows that Tuberculosis Dispensary tends year by year to widen the scope of its activities and is playing its part in the administration of tuberculosis in the city to an ever increasing extent. Patients came under the care of the Tuberculosis Officer at the instance of:— Insured. Uninsured. Total. Males. Females. Males. Females. Boys. Girls. Medical Practitioners 63 57 8 33 13 22 196 Health Visitors 8 8 5 28 66 74 189 St. Stephen's Hospital (formerly (Citv of Westminster Infirmary) 55 30 18 13 6 8 130 Ministry of Pensions 13 0 2 0 0 0 15 School Medical Officers 0 0 0 0 8 9 17 Hospitals 6 1 1 1 0 0 9 Friends, Charitable Societies, British Red Cross Society, Jewish Board of Guardians, &c. 5 4 4 9 13 12 47 150 100 38 84 106 125 603 Recommendations for Institutional Treatment to London County Council. Hospitals. Sanatoria Insured patients— Males 38 39 Females 11 16 Uninsured Patients— Males 3 5 Females 5 7 Boys 3 3 Girls 2 4 62 74 Andrew J. Shinnie.