(a) t S '> City of Westminster. REPORT of the MEDICAL OFFICER OF HEALTH FOR THE YEAR 19 2 5 ANDREW J. SHINNIE, M.D., D.P.H. (Lond.), Medical Officer of Health and Administrative Tuberculosis Ojficer. Printed by Order of the Council. LONDON: HARRISON AND SONS, LTD., PRINTERS IN ORDINARY TO HIS MAJESTY, ST. MARTIN'S LANE, W.0,2. City of Westminster. "REPORT of the MEDICAL OFFICER OF HEALTH FOR THE YEAR 1925 ANDREW J. SHINNIE, M.D., D.P.H. (Lond.), Medical Officer of Helth 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. iii CONTENTS. page Introductory remarks v Census Statistics viii Population I Births 2 Deaths 5-11 Infantile Mortality 12 Common Lodging-Houses 19 Tables 5-8 Communicable Diseases 21 Smallpox 21 Vaccination 21 Scarlet Fever 24 Diphtheria 24 Schick Test 25 Anti-toxin 7 Bacteriological Diagnosis 27 Typhoid Fever 27 Measles 28 Influenza 29 Diarrhoea and Enteritis 29 Deaths from 30 Whooping-Cough 30 Cerebro-spinal Fever 31 Poliomyelitis 32 Encephalitis Lethargica 32 Chickenpox 33 Mumps 33 Plague 33 Anthrax 33 Puerperal Fever 33 Ophthalmia Neonatorum 34 Bacteriological Laboratory 34 Tuberculosis 35 Non-notified deaths 40 Non-notified cases 40 Deaths from 41 Tuberculosis Scheme 44 Tuberculosis Dispensary Work 52 Report by Tuberculosis Officer 53 (6375)q A 2 ; iv page Housing 56 Survey Report 56 Housing Act, 1925 61 Housing Consolidated Regulations, 1925 61 Specimen of Form (card index) to be kept 62 Houses let in Lodgings 63 By-laws 63 Register of 64 Restriction of Rents Acts 64 House inspection—defects remedied 67 Removal of house refuse 68 Removal of offensive refuse 68 Nuisances—Intimation and Statutory Notices 68 Rat repression 69 Water Supply 69 Artesian Wells 69 New building work, &c., Plans Submitted 70 Combined drainage orders 71 Failure to deposit plans or give notice 71 Smoke prevention 71 Workshops 72 Occupations and number of workers 72 Inspections and defects found 74 Outworkers List 75 Disinfection 76 Mortuaries 77 Maternity and Child-Welfare 78 Food—Inspection and Supervision 91 Registration of Dairymen, &c 92 Certified Milk—Licenses 93 Milk and Cream Regulations 93 Milk and Dairies (Consolidation) Act, 1915 94 Quality of Milk 96 Legal Proceedings 97 Arsenic in Apples 99 Meat Regulations 100 Ice-cream premises 101 Bakehouses 101 Food condemned 102 Spirits—Adulterated samples 103 Preservatives in Food Regulations 105 Staff 107 V Annual Report on the Health and Sanitary Condition of the City of Westminster* 1925. Mr. Mayor, My Lords, Ladies and Gentlemen, I have the honour to present my Annual Report for 1925. * It includes Returns required by the Ministry of Health and the Home Office. It was intimated in Circular 510 of the Ministry in December, 1924, that the Annual Report of the Medical Officer of Health for 1925 should be a Survey Report dealing comprehensively with the measure of progress in the improvement of the public health during the preceding five years, and also with any changes which had taken place in the sanitary conditions of the area, together with any alterations in the character and extent of public health services such as [Housing, Water-supply, Maternity and Child-Welfare and Tuberculosis Schemes. My predecessor in his final Annual Report, which was issued last year, presented a comprehensive survey of the changes which had taken place in the sanitary conditions of the City during his long tenure of office. I have, therefore, in this report dealt briefly with developments which have occurred during the past five years. In most instances statistical data relating to each year of the quinquennial period are shown for the purpose of comparison. In dealing with certain subjects such as Maternity. and Child-Welfare I have attempted to explain the methods of working and the objects which it is our purpose to achieve. The state of the general health of the City is reviewed and allusion is made to measures for the prevention of sickness and mortality. The Ministry have required detailed information under certain specified headings in several sections of the report, which is in consequence somewhat more lengthy than usual. VI The question of housing is discussed and a brief retrospective note is made of the various proposals which the Council have explored during the past five years in endeavouring to find a solution of the difficulties which are known to exist. It is highly satisfactory to record that the year 1925 has seen definite progress in housing. Before another year has passed it is hoped that an addition to the Council's dwellings capable of housing some five hundred individuals will have been completed. The Health of the City during the year has been satisfactory. With regard to Infectious Diseases, Diphtheria and Whooping Cough showed a higher incidence, while Measles and Scarlet Fever were notably less prevalent. There was a definite decrease in new cases of Tuberculosis and also in the number of deaths from that disease. Cancer and Diseases of the Heart and blood vessels claimed more victims than in 1924. The fall in the birth-rate has continued and was lower in 1925 than in previously recorded years, with the exception of 1918. With a view to the prevention of outbreaks of Diphtheria the Council, having obtained the approval of the Ministry of Health, have resolved to institute the Schick method of immunization in connection with the Maternity and Child-Welfare Centres. Samples of food taken throughout the year for the purpose of analysis show that adulteration is continuing to decrease. Spirits received particular attention and, as a result of the policy adopted by the Public Health Committee, it has become evident that "dilution" to the prejudice of the purchaser is being practised on a much smaller scale. In September the Public Health Department was transferred into new offices, or what was formerly the first floor of the St. Martin's Lane Library. The rooms are large, airy,'and admit plenty of sunlight; a marked contrast to the old quarters. I have to record with regret the death of Messenger P. C. Neck. He died in September, 1925, after a long illness. He served the Council with faithfulness and regularity for twenty-two years. The names of the Stall of the Department are set out elsewhere as required by the Ministry. In July Dr. Ian S. Thomson was appointed Tuberculosis Officer and Assistant Medical Officer of Health and to act as deputy in the absence of the Medical Officer of Health. He was formerly Assistant Medical Officer of Health in charge of the Isolation and Tuberculosis Hospital of the County Borough of Southampton. vii Dr. Ethel Vernon, a part-time officer of the Council, engaged in Maternity and Child-Welfare duties, was appointed in April to undertake additional sessions at the Pimlico Road Centre. Those sessions were formerly conducted by myself when Assistant Medical Officer of Health. In April, Mr. Wm. French, Sanitary Inspector in the Borough of Fulham, was appointed Sanitary Inspector under the City Council. In October, on the resignation of Mr. John Smith, temporary Sanitary Inspector, Mr. Jackson, of the Works Department, who had become qualified as a Sanitary Inspector, was appointed to succeed him. In conclusion I should like to express my appreciation of the consideration which has been shown to me by the Chairman and Members of the Public Health Committee and my gratitude to all members of the Staff for their loyal and willing service. I have the honour to be, Your obedient Servant, Andrew J. Shinnie. May, 1926. vx11 SUMMARY OF PARTICULARS REQUIRED BY THE MINISTRY OF HEALTH. 1.—General Statistics. Area (acres)—2,502.7. Population (Census 1921)—141,578. Population, June, 1925 (Registrar-General's Estimate)—142,600. „ „ „ Civilian—139,600. Number of Inhabited Houses (1924)—27,352. Rateable value—£8,558,820 (March, 1926). Sum represented by a penny rate—£35,662. 2.—Extracts from Vital Statistics for the Year. Births— Males. Females. Total. Birth Rate. Legitimate 722 696 1,418 10.7 Illegitimate 61 56 117 Totals 783 752 1,535 Deaths—1,728. Death-rate—12-3. Number of women dying in, or in consequence of, childbirth:— Puerperal mania, 1. From other causes, 5. Number of deaths of infants under one year of age per 1,000 births—69.0. Legitimate rate, 62-0; Illegitimate rate, 153.8. Number of deaths from measles (all ages)—1. „ „ diphtheria—17. „ „ whooping cough (all ages)—17. „ „ scarlet fever—0. „ „ diarrhoea (under 2 years of age)—9. „ „ typhoid fever—4. 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. STATISTICAL, INCLUDING REMARKS ON THE NATURAL AND SOCIAL CONDITIONS. A summary of particulars required by the Ministry of Health are set forth on the preceding page and further reference to certain points mentioned will be found in other parts of the report. The estimated population of the City of Westminster for the year 1925 is given by the Registrar-General as 142,600 (the population as enumerated at the 1921 Census was 141,578). The civilian population, which excludes those belonging to the military forces in barracks and hospitals, numbered 139,600, and for the purpose of calculating the death-rate this number is taken. Both gross and net totals show a decrease on the corresponding figures for 1924, which were 143,300 and 139,900 respectively. The City of Westminster occupies an area in Central London bounded on the north side by Oxford Street, on the east by a portion of Chancery Lane and proceeding as far asTemple Gardens, and in the west it extends in one direction as far as the Broad Walk in Kensington Gardens. The Royal Albert Hall and Imperial Institute are contained within its borders. South of the latter institution, however, the western boundary of the City runs east of Sloane Street, Chelsea, and continues to the river along Chelsea Bridge Road. Throughout part of its course the Thames forms a boundary to the City. Westminster is rich in historical associations and its claim to antiquity may be gathered from the fact that according to the schedule issued by the Office of Works there are to be found in the City a greater number of ancient monuments than in any area in the British Isles. It contains the residences of the Sovereign and of the Heir-Apparent, the Houses of Parliament and the chief administrative departments of central government. The City of Westminster is of the nature of an administrative, business and social centre. There is no industry in which the inhabitants are engaged which is sufficiently large in itself to afford grounds from which deductions may be made regarding the influence of a particular occupation on the health of the inhabitants. It must be remembered that of all the occupied males and females in Westminster by far the greater proportion do not reside in the City. In this respect there is a close comparison with the City of London. The day population of Westminster (Census 1921) 2 is given as 385,984, while the night population, which include all whose homes are in the city, numbers 141,578, and of the latter a certain proportion are engaged in occupations outside Westminster. During 1925, unemployment showed a tendency to decrease and this was reflected in the amount of outdoor relief. The Guardians have been good enough to supply the following figures : £9,849 16s. was the amount expended in outdoor relief during the year. The corresponding expenditure in 1924 amounted to £11,097 5s. Births. The births registered in Westminster during 1925 numbered 1,519, but of these the homes of 481 were in other districts and have therefore to be deducted from the total. There were, however, 497 children belonging to Westminster parents born in institutions outside the City, and these must be added. This gives a net total of 1,535, which is 89 less than the similar figure for 1924. The increase in births registered which was noted last year has been maintained, but a greater deduction has to be made for infants born in the City although not belonging to it. The net result shows a continued fall in the births in Westminster, but it shows a greater use of the maternity beds available in the City by women from other districts. As compared with 1924 there was also a reduction from 521 to 497 in the number of children belonging to Westminster parents born in other districts. Although the number of maternity beds in the hospitals of the City are not numerous, yet a considerable number of confinements, including a large proportion from other districts, take place annually in those institutions, and this is possible because as a rule the duration of the mother's stay in hospital does not exceed ten or twelve days. There are 14 maternity beds in Charing Cross Hospital, 12 in St. George's Hospital and 4 in Westminster Hospital. In-patient facilities for mothers residing in the City are, however, not restricted to those institutions, as quite a number arrange to have their babies in the large maternity hospitals which are within easy reach, namely, Queen Charlotte's Hospital and the General Lying-in, York Road. Some also take advantage of the large maternity departments of the Middlesex, St. Thomas's and Royal Free Hospitals. The birth-rate was 10.7 per 1,000; that for the County of London being 18.0. The birth-rate for England and Wales Was recorded as 18.3. 3 Table I. Births Registered. Births Notified. In Westminster. Belong elsewhere. Born out of Westminster. Net. Total. Alive. Stillborn. 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 1,402 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 1925 1,519 481 497 1,535 1,435 1,385 50 The legitimate and illegitimate births are distributed as follows:— Table II. Legitimate. Males 713 - 195 + 204 = 722 Females 702 - 210 + 204 = 696 1415 - 405 + 408 = 1418 Illegitimate. Males 60 -44 + 45= 61 Females 44 - 32 + 44 = 56 104 - 76 + 89 = 117 The legitimate births are 71 fewer than in 1924 and the illegitimate show a decrease of 18. As shown in Table I, 1,435 notifications of births were received by the Department for 1925 as compared with 1,250 in 1924. Of the total of notifications, 761 were sent by midwives, of whom 45 were practising in the City during 1925. The following Table shows the number of male and female children born since 1913, and those who did not survive the first year of life with the number of the surviving children at the end of the first year of life:— 4 Table III. 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 1925 783 752 57 49 726 703 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 1,086 boys. 1925 1,041 boys. Still-births.—Fifty still-born children were notified to the Department during the year. 5 MALES. Table IV.—Causes of, and Ages at, Death during the year 1925. Causes of Death. corrected deaths in tub city at subjoined Ages. Deaths in Wards (at all Ages). All ages. Under 1. 1 and under 2. 2 and under 5. 5 and under 15. | 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Conduit. Grosvenor. Hamlet of Kniglitsbridge. Kniglitsbridge St. George. Victoria. St. Margaret. St. John. St. Anne. Great Marlborough. Pall Mall. Regent. Charing Cross. Corent Garden. I Strand. Homeless. Small-pox — — — — — — — — — — — —— — — — — — — — — — — — — Measles 1 — 1 — — — — — — — — — — — — — — — — — — — — — Scarlet fever — — — — — — — — — — — — — — — — — — — — — — — — Influenza 13 — — — — — 3 7 3 — 2 — — 4 1 2 — — — 1 1 1 1 — "Whooping-cough 11 5 — 6 — — — — 1 — — — 1 7 — 3 — — — — — — — — Diphtheria, Memb. croup 0 1 2 4 2 — — — — — — — 1 4 — 4 — — — — — — — — Cerebrospinal meningitis 1 1 — — — — — — — — — 1 — — — — — — — — — — — — Poliomyelitis 1 1 — — — — — — — — — — — 1 — — — — — — — — — Enteric fever 3 — — — — — 3 — — — — — — — — — — — — — — — — — Diarahoea, enteritis 9 6 1 2 — — — — — — 1 — — 5 — 2 — — — — — 1 — — Erysipelas 2 — — — — — — 2 — — — — — — — — — — — — — — — — Other septic diseases 6 1 — — 1 — — 2 2 — — — — 2 — 2 — — — 1 — — 1 — Syphilis, &c 6 2 — — — — — 2 — — — — — — — 3 1 — — — — — — 1 Diabetes 4 — — — — — 1 1 2 — — — 1 2 — — — — — — — — 1 — Rheumatic fever — — — — — — — — — — — — — — — — — — — — — — — — Tuberculosis of lungs 78 — — 1 — 7 28 36 0 — 3 1 2 28 2 26 2 — 2 2 1 3 6 1 Other forms of tuberculosis 7 3 — — 1 — 2 1 — — — — 4 1 1 — — — — 1 — — — Malignant growths.. 114 — — — — 1 4 49 60 2 15 5 4 32 3 27 3 1 1 2 2 4 S> 4 Congenital debility, malformation, and premature birth 19 19 — — — — — — — — — — 1 11 — 2 1 — — — — 2 3 — Old age 24 — — — — — — — 24 — 1 — 3 7 — 8 — — — 1 1 — — 5 Meningitis and convulsions 6 1 2 — — 1 1 — — — 1 — — 1 — 4 ~— — — — — ~~~ — — 6 Causes op Death. corrected deaths in the City at subjoined ages. Deaths in Wards (at all Ages). All ages. Under 1. I 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 10 — — — — 2 3 4 1 — — — 1 1 2 2 — — — — 1 1 2 — Other diseases of nervous system 11 — — — 1 1 1 4 4 1 — — 1 1 1 4 — — 1 — — 1 1 — Valvular diseases of heart 28 — — — — 2 3 9 14 5 — 3 8 1 6 1 — 1 1 2 — Ot her circulatory diseases 106 1 — — — 2 9 59 125 2 18 5 15 47 13 41 9 3 3 9 2 6 18 5 Bronchitis 93 2 — — — — 7 24 60 1 8 3 6 25 2 27 3 1 1 1 1 b 8 1 Bronclio-pneumonia 39 6 7 1 — — 3 13 9 — 2 2 4 14 — 10 1 2 1 1 1 — 1 — Pneumonia, other forms so 2 — — — 3 5 21 19 — 4 — 3 12 2 11 3 — 4 2 — 3 4 2 Other respiratory diseases 6 — — — — — — 4 2 1 2 — — 1 — 1 — — — 1 — — — — Alcoholism 5 — — — — — 3 2 — — 1 — — 1 — — 1 — — 2 — — — — Cirrhosis of liver 12 — — — — — 6 4 — 3 1 — 5 — — — — 1 1 — — 1 — Appendicitis and typhlitis 2 — — — — — 1 — 1 — — — 1 1 — — — — — — — — — — Other digestive diseases 29 2 1 — — — 4 16 6 — 2 — 1 9 2 4 4 — 1 1 1 1 2 1 Bright's disease, &c. 38 — — — — — 4 13 21 1 5 — — 12 3 13 2 — — — 1 — 1 — Cystitis, &c. 17 — — — — —. — 5 12 1 — — 2 6 2 2 — — 1 — 1 1 — 1 Deaths by accident or negligence 36 3 — — 1 4 6 10 12 — 5 3 2 10 — 8 2 — 2 — 2 1 — 1 Deaths by suicide and murder 19 — — 5 6 7 1 1 3 — 6 3 — 2 1 — — — — 1 — 1 Other defined diseases 21 1 1 — 2 1 3 4 9 1 — 2 — 6 1 6 .3 — — — — — — 2 Diseases, ill defined or — — — — — — — — — — — — — — — — — — — — — — — — All causes 925 67 16 13 8 29 102 303 398 11 80 23 58 275 37 221 37 7 19 27 16 31 60 23 7 FEMALES Table IV. (continued)—Causes of, and Ages at, Death during the year 1925. Causes of Death. Corrected Deaths in the City at subjoined AGes. / Deaths in Wards (at all Ages). All ages. Under 1. 1 and under 2. 2 and under 5. 5 and under 15. ' 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Conduit. Grosvenor. Hamlet of Knightsbridge. Knightsbridge St. George. Victoria. St. Margaret. St. John. St. Anne. Great Marlborough. Pall Mall. Regent. Charing Cross. Covent Garden. Strand. Homeless. Small-pox — — — — — — — — — — — — — — — — — — — — — — — — Measles —- — — — — — — — — — — — — — — — — — — — — — — — Scarlet fever — — — — — — — — — — — — — — — — — — — — — — Influenza 24 1 1 — 1 1 3 4 13 — 3 1 3 6 2 6 1 1 — — — — 1 — Whooping-cough 6 2 3 1 — — — — — — — — — — — — — — — — — — — — Diphtheria, Memb. croup . 8 — 1 2 4 1 — — — — — — 1 6 — 1 — — — — — — — — Cerebrospinal meningitis 1 — — — — — — — — — — — — — — — — — — — — — — — Poliomyelitis — — — — — — — — — — — — — — — — — — — — — — — — Enteric fever 1 — — — — — — — — — — — — — — — — — — — — — — — Diarrhoea, enteritis 4 2 — — — — — — — — — — — — — — — — — — 1 — — Erysipelas — — — — — — — — — — — — — — — — — — — — — — — — Puerperal fever 1 — — — — — 1 — — 1 _ — — — — — — — — — — Other septic diseases 7 — — 1 — 1 1 1 3 — 1 — — 4 — 1 — — — — — 1 — — Syphilis, &c — — — — — .— — — — — — — — — — — — — — — — — Diabetes 5 — — — 1 — 2 1 1 — — — — 2 — 2 — 1 — — — — — — Rheumatic fever —— — — — — — — — — — — — — — — — — — — — — — — — Tuberculosis of lungs, &e 37 — — — 2 9 18 8 — — — — 1 16 1 11 2 — — 3 — 3 — — Other forms of tuberculosis 7 — 1 2 — 2 1 1 — — — — 1 — 1 4 — — — 1 — — — — Malignant growths 116 — — 2 1 13 68 42 — 9 3 13 43 9 24 4 3 2 3 1 — 1 1 Congenital debility, malformation, and premature birth 24 24 — — — — — — — 1 1 — 1 14 — 3 — 1 — 2 — — — 1 Old age 44 — — — — — — — 44 — 1 2 7 16 3 10 — — — 1 1 1 — 2 Meningitis and convulsions 5 2 — — — 1 — 2 — — — — — 4 — 1 — — — — — — — — 8 FEMALES.—Table IV. (continued). Causes of Death. Corrected Deaths in the City at subjoined Aoes. Deaths in Wards (at all Ages). All ages. Under 1. 1 and under 2. 2 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Conduit. Grosvenor. Hamlet of Knightsbridge. Knightsbridge St. George. Victoria. St. Margaret. | St. John. St. Anne. Great Marlborough. Pall Mall. Regent. Charing Cross. Covent Garden. Strand. Homeless. Loc. ataxia and general paralysis 2 — — — — — — — — — — — — — — — — — — — — — 1 — Other diseases of nervous system 15 — — 1 1 4 4 3 2 — 3 — — 5 1 2 1 — — 2 — 1 — — Valvular diseases of heart 27 — — — — 2 2 8 15 — 4 — 8 2 9 1 — — — 1 1 — 1 Other circulatory diseases 100 — — — 1 — 10 27 122 1 14 7 13 02 9 29 4 6 — 4 2 6 — 3 Bronchitis 83 3 1 — — — 1 20 58 — 1 — 1 30 3 28 7 3 — 3 — 4 — 3 Broncho-pneumonia 41 11 2 1 1 — 1 4 21 — 1 2 2 20 1 12 — 1 — — 1 1 — — Pneumonia, other forms 33 1 1 1 1 1 0 6 10 — 1 1 4 11 3 10 2 — 1 — — — Other respiratory diseases 7 — — — — 1 1 4 I — — 1 1 1 — 1 — — 1 — — 1 — 1 Alcoholism 2 — — — — — 1 1 — — — — — — — — — — — — — — 1 Cirrhosis of liver 4 — — — — — 1 2 1 — — 1 — 2 — 1 — — — — — — — — Appendicitis and typhlitis 9 — 1 — — 2 2 3 1 — — — 1 2 — 2 — — 1 — 1 2 — — Other digestive diseases 26 — — — 1 1 6 9 9 1 2 — 3 7 1 7 1 — 1 — — 3 — — Bright's disease, &c. 40 — — — — 2 5 14 19 — 4 ~ 3 10 1 8 2 1 — 2 1 1 — 1 Cystitis, &c. 2 — — — — — — 1 1 — 1 — 1 — — — — — — — — — — — Accidents and diseases of parturition 5 — — — -— 3 2 — — — — — — 2 1 2 — — — — — — — Deaths by accident or negligence 32 — 1 — 1 2 4 10 14 2 1 1 13 1 7 3 1 1 — — 1 1 Deaths by suicide and murder 13 2 — — — 1 9 1 1 — — 2 4 1 3 — — — — — 1 — 1 Other defined diseases 12 1 1 — 1 1 2 2 4 — 1 — 1 5 — 2 1 1 — — 1 — — — Diseases, ill defined or unknown — — — — — — — — — — — — — — — — — — — — — — — — All causes 803 49 13 9 17 36 90 193 390 4 49 20 61 305 42 189 29 20 7 21 9 28 3 16 9 Deaths. 1,835 deaths were registered in the City in the 52 weeks of 1925. After deducting 987 deaths of non-citizens in public institutions, etc., in the City, and adding those of 880 citizens who died in other districts, the corrected total is 1,728, as compared with 1,695 in 1924, and is equivalent to an annual rate of 12.3 per 1,000 persons (civilian population). The London death-rate for 1925 was 11.7 (civilians only), for England and Wales 12.2. These rates are a little lower than 1924 as regards London, but a little higher for Westminster. The figure is constant for England and Wales. The number of deaths and the death-rates per 1,000 for the past fifteen years are shown below:— Table V. (From 1911 to 1925.) 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 1925 1,728 12.3 11.7 The deaths of males were 925, females 803. Table VI. Divided into various age periods we get:— 1925. 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 15 13 8 29 102 303 398 925 F. 49 13 9 17 36 96 193 390 803 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 1925 106 28 22 25 65 198 496 788 1.728 B (6375)Q 10 The causes of death are set out in Table IV, and those which .have mainly contributed to the increase in deaths as compared with 1924 are, for males, whooping cough, enteritis, cancer, pneumonia, diseases of the heart and blood vessels, digestive organs, kidneys and accidents. In the case of females, whooping cough, diseases of the digestive system and kidneys, cancer, pneumonia, and deaths by violence seem to have contributed to the greatest extent. The distribution of deaths in the various wards of the City are shown in the following table, and may be _ compared with the similar figures during the four preceding years:— Table .VII. - 1921. 1922. 1923. 1924. 1925. m. f. Total. 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 11 4 15 Grosvenor 57 50 107 56 68 124 48 47 95 50 52 102 80 49 129 Hamlet 18 29 47 37 29 66 29 30 59 30 28 58 23 20 43 K St. George 55 55 110 64 56 120 45 56 101 43 60 103 58 61 119 Victoria 234 233 467 249 283 532 217 261 478 245 282 527 275 305 580 St. Margaret 44 37 81 52 49 101 43 37 80 50 33 83 37 42 79 St. John 214 162 376 240 203 443 170 166 336 245 196 441 221 189 410 St. Anne 47 36 83 35 30 65 39 21 60 41 26 67 37 29 66 Gt. Marlborough 16 12 28 19 17 36 9 15 24 22 12 34 7 20 27 Pall mall 20 11 31 24 11 35 12 12 24 33 8 41 19 7 26 Regent 35 37 72 27 32 59 21 30 51 35 22 57 27 21 48 Charging Cross 28 10 38 19 7 26 18 9 27 17 9 26 16 9 25 Covent Garden 38 23 61 40 28 68 34 22 56 26 25 51 31 28 59 Strand 57 12 69 49 13 62 42 8 50 40 7 47 60 3 63 Homeless 26 7 33 23 12 35 18 11 29 23 11 34 23 16 39 It will be noticed that there is an increase in the male deaths in Grosvenor, Knightsbridge St. George, Victoria, Covent Garden and Strand Wards. St. Margaret, St. Anne, Great Marlborough and Covent Garden Wards show increased deaths among females. There was a marked increase in the deaths in Victoria Ward, notably in the age group of 65 years and upwards. Cancer continues to claim an increasing number of victims each year; accounted for rather more than one-seventh of the total deaths in 1925, or 13-31 per cent. The figures since 1921 are shown below:— 1921 201 1922 225 1923 237 1924 205 1925 230 11 By far the greater number of deaths occur after middle life. Among males the age period 65 years and upwards furnishes more than half the deaths from this disease, but among females the greater number of deaths occur between 45 and 65 years. It is now generally accepted that the increase in deaths from cancer can be only partly explained by more accurate diagnosis and consequent correct death certification. There is also the factor that as cancer is mainly a disease of late middle age or old age it follows that since people tend now to live longer, but must eventually die of some cause, thev survive until they reach the period of life where cancer holds sway. Many theories have been advanced as to the probable cause of cancer, some of those postulate excess in certain forms of diet, others, deficiency in particular elements of foodstuffs. It is now beyond doubt that irritation of the skin or mucous membranes can give rise to malignant disease of those tissues. The instances which occur among workers in paraffin shale and substances of a tarry nature are definitely associated with the use of those materials in industry. Industrial cancer is now regarded as a definite cause of disablement by the medical authorities of the Home Office. On the other hand, it has been put forward that workers in lead are remarkably immune from cancer. It is of significance that in Liverpool remarkable cures have been effected by the use of lead compounds. The treatment, however, is of the nature of a doubleedged weapon because of the highly toxic nature of the drug employed, and it requires special experience and careful judgment in its administration. The public have been asked to focus their attention on the investigation of the causes of cancer, and as a result considerable sums of money have been raised and are being administered by such bodies as the Imperial Cancer Research Fund and the British Empire Cancer Campaign for the use of a large body of workers who are directing their entire energies towards the solution of this problem. In July the efforts of Dr. Gye and Mr. Barnard held the attention of the entire scientific world. They claimed that they had discovered the existence of a virus which could be isolated from cancerous material and which, given suitable conditions, was capable of reproducing cancer experimentally. The virus was demonstrable by means of an ultra-microscope specially devised by Mr. Barnard. This discovery is of the utmost importance, and no evidence has been forthcoming with which to controvert the findings of those workers. A considerable amount of confirmatory work, however, (6375)<j u 2 12 will have to be done by other workers before this discovery is accepted as the foundation stone on which to build all future researches. Infantile Mortality.—The corrected death-rate of infants for Westminster was 69.0 per 1,000 births. The mortality among legitimate infants was 62 per 1,000; that of illegitimate 153.8. The average rates of mortality for the five year period 1921-25 work out at 55.38 for legitimate and 126.98 for illegitimate, giving a total rate for the period of 62.0 per 1,000 for Westminster as compared with 70.0 for London as a whole. The death-rates for infants under one year of age as applied to the districts in which the City is divided for Maternity and Child Welfare purposes are as follows:— Table VIII. Death-rates of children under one year of age for 1925 Legitimate. Illegitimate. Pimlico area 71.5 153.8 Greek Street 50.3 88.2 Rochester Row 53.2 111.1 Table IX shows the deaths as they occurred during the four quarters of the year and allocated according to the districts already mentioned. Table IX. 1925. Pimlico, St. Margaret and St. John. North. Unknown. Total 1925. Total 1924. Total. 1923. 1st Quarter . 20 11 3 1 35 31 24 2nd „ 10 3 1 0 14 27 20 3rd „ 12 3 7 2 24 16 18 4th „ 20 7 6 0 33 22 21 62 24 17 3 106 96 83 Of the 106 deaths, 35 occurred in the first quarter of the year and 33 in the final quarter. In the former period an epidemic of whoopingcough, which lasted from January to April, exacted a severe toll of infant life; 205 cases were notified during this quarter, when 6 deaths out of a total of 7 under one year occurred. Enteritis and prematurity also accounted for more deaths than in 1924. Table X shows the births and deaths of infants, legitimate and illegitimate, since 1902 onwards, with the corresponding infantile mortality rates for Westminster and for London:— 13 Table X. Year. Legitimate. Illegitimate. Total Rate, Westminster. Total Bate, 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 40 298 118 146 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 95 163 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 41 200 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 1925 1,418 88 62.0 117 18 153.8 69.0 67 Five yearly average rate per 1,000 births. Legitimate 55.38 Illegitimate 126.98 Total Westminster rate 62.0 Total London rate 70.0 In Table XI are shown the legitimate and illegitimate births and deaths of infants under one year as they occurred in the three districts of the City. The corresponding death-rates are shown and the data from the two previous years are given for comparison. 14 Table XI. Centre Legitimate. Illegitimate. Total. 1923. 1924. 1925. 1923. 1924. 1925. 1923. 1924. 1925. Pimlico and Bessborough— Births 773 760 727 92 66 65 805 826 792 Deaths 28 43 52 5 6 10 32 49 62 Death-rate per 1,000 births 36.2 56.5 71.5 54.3 91 153.8 38.0 59.3 78.2 Greek Street— Births 340 304 278 54 36 34 394 340 312 Deaths 17 15 14 2 4 3 19 19 17 Death-rate per 1,000 births 50.0 49.3 50.3 37.0 111 88 48.2 55.3 54.4 Rochester Row— Births 469 425 413 23 33 18 492 458 431 Deaths 23 24 22 1 1 2 24 25 24 Death-rate per 1,000 births 49.0 56.4 53.2 43.4 30 111.1 48.7 54.5 55.6 Table XII shows the causes of death of children who died under one year of age. Figures under the same grouped causes are given from 1919 onwards, with the proportion per 1,000 births applicable under each heading:— Table XII. 1919. 1920. 1921. 1922. 1923. 1924. 1925. Diphtheria - - 1.4 - - - 0.65 Influenza 5.62 _- - 3.6 - 0.6 0.65 Measles 1.87 2.21 - 10 - 5.5 - Whooping Cough 0.62 - 1.5 1.0 1.1 1.9 4.5 Septic diseases - 0.44 1.4 0.5 1.7 1.2 - Bronchitis and pneumonia. 10.60 12.80 11.8 7.3 4.0 10.4 16.2 Stomach and bowel complaints 8.75 9.29 13.4 3.1 1.1 1.9 5.2 Syphilis 5.62 2.64 2.6 2.1 2.8 1.2 1.3 Congenital malformations 3.75 6.19 9.3 4.2 5.1 4.9 3.2 Prematurity 21.2 5.40 15.5 10.2 13.1 14.1 16.9 Neglect and injury at birth. 7.50 17.07 7.3 5.7 6.8 3.1 0.65 Debility from birth and atrophy, rickets, tasis 11.80 11.48 11.0 4.2 6.2 5.3 7.1 Tuberculosis 2.50 1.76 1.4 1 .5 1.7 1.8 1.9 Other causes 6.90 4.34 3.6 3.6 2.8 6.7 10.4 87.5 73.62 80.2 54.6 46.6 59.0 69.0 15 Table XIII shows nett deaths from various causes at several age periods during the first year of life in the City of Westminster:— Table XIII.—Infant Mortality, 1925. causes of death. Under 1 Week 1—2 Weeks. 2—3 Weeks 3—4 Weeks. Total under 4 Weeks. 4 Weeks a.nd under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Monti s. 9 Months and under 12 month*. Total Deaths under 1 Year. Influenza — — — — — — — — 1 1 Diphtheria — — — — — — — 1 — 1 Measles — — — — — — — — — — Whooping Cough — — — — — 1 3 2 1 7 Sepsis — — — — — — — — — — Tuberculosis — — — — — — — — 3 3 Syphilis — — — 1 1 1 — — — 2 Meningitis — — 1 — 1 1 — 1 — 3 Bronchitis — — — .— — 1 2 2 — 5 Pneumonia (all forms) — — — 1 1 6 6 4 3 20 Gastro.enteritis — — — — — 3 4 1 — 8 Injury at birth — — — — — — — — — — Neglect at birth — — — — — — — — — — Murder 2 — — — 2 — — — — 2 Atelectasis 3 — — — 3 — — —. — 3 Congenital malformations — — 1 — 1 1 1 2 — 5 Premature birth 18 2 1 — 21 4 1 — — 26 Malnutrition, marasmus debility from birth 3 1 — — 4 1 2 1 — 8 Rickets — — — — — — — — — — Accidents 1 — — * — 1 — — — 1 2 Other causes 3 1 — — — 1 1 1 7 Polio encephalitis — 1 — — 1 — — — — 1 Want of attention 1 — — — 1 — — — — 1 Cerebro spinal meningitis — — — — — 1 — ~~ — 1 Totals 31 5 3 2 41 20 20 15 10 106 Table XIIIa. Nett Births in the year— Males. Females. Total. Legitimate 722 696 1,418 Illegitimate 61 56 117 783 752 1,535 Nett Deaths in the year of— Males. Females. Total. Legitimate infants 48 40 88 Illegitimate infants 9 9 18 57 49 106 The causes of death of the Illegitimate ivere:—Bronchitis 1, neglect at birth 1, murder 2, prematurity 6, marasmus 2, enteritis 3, mastoiditis 1, meningeal hemorrhage 1, accident 1, 16 Table XIV. Infant Mortality, 1925.—Nett Deaths from stated causes at various ages under One Year of Age in Pimlico A rea ( Victoria, Knightshridge St. George and Hamlet 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 One Year. Influenza — — — — — — — — 1 1 Diphtheria — — — — — — — — — — Whooping Cough — — — — — 1 2 2 1 6 Measles — — — — — — — — — — Tuberculosis — — — — — — — — 2 2 Bronchitis — — — — — 2 — — — 2 Pneumonia (all forms) — — — — — 3 2 3 2 10 Gastro-enteritis — — — — — 4 — — — 4 Syphilis — — — — — — — — — — Injury at birth — — — — — — — — — — Atelectasis 2 — — — 2 — — — — 2 Congenital malformations — — — 1 1 — 1 1 — 3 Premature birth 14 — — — 14 3 — — — 17 Want of attention at birth — — — — — — — — — — Malnutrition, marasmus and debility from birth 2 — — — 2 1 1 — — 4 Accidents — — — — — — — — 1 I Rickets — — — — — — — — — — Other causes 3 — — — 3 — — — 1 4 Polio encephalitis — 1 — — 1 — — — — 1 Cerebro spinal gitis — — — — — — 1 — — 1 Meningitis — — 1 — 1 1 — 1 — 3 Murder 1 — — — 1 — — — — 2 Totals 22 1 1 1 25 15 7 7 8 62 Table XIVA. Nett Births in the year- Legitimate 727 Illegitimate 65 Nett Deaths in the year of— Males. Females. Total. Legitimate infants 27 25 52 Illegitimate infants 6 4 10 17 Table XV. Infant Mortality, 1925.—Nett Deaths from stated causes at various ages under One Year of Age in St. John and St. Margaret Wards. causes of death. Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3—4 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. Totnl Deaths under 1 Year. Diphtheria — — — — — — — 1 — 1 Influenza — — — — — — — — — — Measles — — — — — — — — — — Whooping Cough — — — — — — 1 — — 1 Sepsis — — — — — — — — — — Tuberculosis — — — — — — — — — Meningitis — — — — — — — — — — Bronchitis — — — — — — 1 1 — 2 Pneumonia (all forms) — — 1 — 1 2 4 1 1 9 Gastro-enteritis — — — — — — 1 — — 1 Syphilis — — — 1 1 1 — — — 2 Rickets — — — — — — — — — — Injury at birth — — — — — — — — — — Congenital malformations — — — — — 1 — — — 1 Premature birth 2 — — — 2 1 — — — 3 Atrophy, marasmus 1 — — — 1 — — — — 1 Debility from birth — — — — — — — — — — Other causes 1 — — — 1 1 — 1 — 3 Totals 4 — 1 1 6 6 7 4 1 24 Table XVA. Nett Births in the year— Legitimate 413 Illegitimate 18 Nett Deaths in the year of— Males. Females. Total. Legitimate infants 13 9 22 Illegitimate infants 0 2 2 18 Table XVI. Infant Mortality, 1925. Nett Deaths from stated causes at various ayes under One Year of Age in the North District (Grosvenor Conduit and Strand 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 — — — — — — — — — — Whooping Cough — — — — — — — — — — Umbilical sepsis — — — — — — — — — — Tuberculosis — — — — — — — — 1 1 Bronchitis — — — — — — 1 — — 1 Pneumonia (all forms) — — — — — 1 — — — 1 Gastro-enteritis — — — — — — 3 — — 3 Syphilis — — — — — — — — — — Injury at birth — — — — — — — — — — Atelectasis 1 — — — 1 — — — — 1 Congenital malformations — — — — — — — 1 — 1 Premature birth 4 — — — 4 — 1 — — 5 Malnutrition, inanition and debility from birth 1 — — — 1 — — 1 — 2 Accidents 1 — — — 1 — — — — 1 Want of attention 1 — — — I — — — — 1 Totals 8 — — — 8 1 5 2 1 17 Table XVIA. Nett Births in the year— Legitimate 278 Illegitimate 34 Nett Deaths in the year— Males. Females. Total. Legitimate infants 8 6 14 Illegitimate infants 2 1 3 19 Table XVII. 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. Prematurity 1 — — — 1 — — — — l Murder 1 — — — — — — — — l Marasmus — — — — — — 1 — — l Table XVIIA. Males. Females. Total. Legitimate — — — Illegitimate 1 2 3 Common Lodging House Deaths. Reference has been made in former reports to the shifting population which inhabits the four common lodging houses which are licensed in the City. Some of the residents are permanent, but a greater proportion are birds of passage. Deaths among the latter class of people tend to increase the death-rates of the Wards in which those lodging houses are situated; 96 deaths of persons giving addresses in common lodging houses occurred in 1925. They were mostly in institutions:— Table XVIII. Deaths. Bruce House (L.C.C.) (licensed for 715 men) 42 *33, Great Peter Street 2 10, Great Peter Street (Salvation Army) (licensed for 565 men) 27 16, Strutton Ground (licensed for 201 men) 18 40, Great Peter Street (Church Army) (licensed for 57 women and 2 children) 7 96 * Discontinued many years ago. 20 HOSPITALS IN WESTMINSTER. The following is a list of Hospitals in the City:— All Saints' Hospital, 49, Vauxhall Bridge Road. Genito urinary diseases. Charing Cross Hospital, Agar Street, W.C. Gordon Hospital, 126, Vauxhall Bridge Road. Rectal diseases. Grosvenor Hospital for Women, Vincent Square, S.W. Infants' Hospital, Vincent Square. King Edward VII Hospital for Officers, 17, Grosvenor Crescent, S.W. London Lock Hospital, 91, Dean Street, W. Royal Dental Hospital, 32, Leicester Square, W.C. Royal Ear Hospital, 43, Dean Street, W. St. George's Hospital, Hyde Park Corner, S.W. St. John's Hospital, Leicester Square, Disease of the Skin. St. Peter's Hospital, Henrietta Street, W.C. Diseases of the bladder, etc. Sheffield Street Hospital, Clare Market (Female). Under the control of the Metropolitan Asylums Board. Westminster Hospital, Broad Sanctuary, S.W. Royal Westminster Ophthalmic Hospital, King William Street, W.C. St. Stephen's Hospital (City of Westminster Infirmary) under the control of the Guardians of the City of Westminster is situated at 369, Fulham Road, S.W. Dispensaries:—City of Westminster Tuberculosis Dispensary, 1, Pimlico Road. A well equipped dispensary under the control of the Guardians is held at the Union Offices, Princes Row, S.W. Public Dispensary, 122, Drury Lane, W.C. Western Dispensary, 40, Rochester Row, S.W. Westminster General Dispensary, 9, Gerrard Street, W, 21 PREVALENCE OF AND CONTROL OVER INFECTIOUS DISEASES. The following table shows the number of cases of infectious disease which came to the notice of the department during the period 1921-1925. Details respecting the notifications of infectious disease received are set out on the adjoining page. Table XIX. 1921 1922 1923 1924 1923 Smallpox — — 1 1 — Diphtheria 248 285 91 237 286 Erysipelas 53 37 34 29 44 Scarlet Fever 681 261 129 226 214 Enteric Fever 10 12 18 15 17 Continued Fever — — — — — Puerperal Fever 10 7 3 10 6 Cerebro-spinal Meningitis — 4 1 3 3 Encephalitis lethargica — 2 2 15 7 Polio-myelitis — 1 1 1 3 Ophthalmia neonatorum 25 25 32 23 21 Measles 26 591 131 852 117 German Measles 9 11 42 34 117 Pneumonia 62 48 60 92 58 Malaria 1 — — 1 1 Dysentery — — — — 3 Anthrax — 1 — 1 — Chicken-pox 119 178 169 89 149 Mumps 278 25 95 147 120 Whooping-cough 133 67 35 97 255 Smallpox—No cases of this disease were notified in Westminster during the year. Information was received from the various Port Sanitary Authorities of 146 contacts. Some of these were direct contacts. All, however, were visited directly on arrival in the City and every precaution taken. On several occasions the assistance of the Medical Officer of Health was asked for by Medical Practitioners in cases where a doubt existed as to the nature of the disease. The majority of these contacts were people coming to this Country on holiday, and who had been in contact with a fellow passenger or member of the crew, stricken with this disease ; and a large number were officers and men of H.M. Forces who were coming home on leave to this Country from some foreign station where smallpox is usually prevalent. Vaccination.—The Vaccination Officer informs me that the following number of persons were vaccinated by the Public Vaccinators during the year Primary 1,278 Secondary 37 22 Table XX. City of Westminster.—Cases of Infectious Disease Notified during the Year 1925. Notifiable Diseases. At all Ages. Cases Notified. Cases removed to Hospital. Treated at Home. At all Ages. Deaths. At Ages—Years. 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. 1-2. 2-3. 3-4. 4-5. 5-10. 10-15. 15-20. 20-35. 35-45. 45-65. 65 and over. Small-pox — — — — — — — — — — — — — — — — — — — — — — — — — — — — Cholera (C). Plague (R) — — — — — — — — — — — — — — — — — — — — — — — — — — — — Diphtheria 253 12 12 17 15 26 92 34 9 25 6 5 — 249 4 17 1 3 1 1 4 4 2 1 — — — — Erysipelas 44 — — — — — — 2 3 3 10 20 6 33 11 2 — — — — — — — — — — 2 — Scarlet fever 193 1 3 6 15 14 80 46 13 11 2 2 — 190 — — — —— — — — — — — — — — — Typhus fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — Enteric fever 17 — — — — — — 1 2 6 4 3 1 13 4 4 — — — — — — — — 1 2 — 1 Relapsing fever (R) — — — — — — — — — — — — — — — — — — — — — — — — — — — — Continued fever (C) — — — — — — — — — — — — — — — — — — — — — — — — — — — — Puerperal fever 6 — — — — — — — — 5 1 — — 6 — 1 — — — — — — — — — 1 — — Cerebro-spinal meningitis 3 1 — — — — — — — 1 — 1 — 2 1 2 i — — — — — — — — — 1 — Polio-myelitis 2 — — 1 — 1 — — — — — — — 1 1 1 i — — — — — — — — — — — Encephalitis lethargica 7 — — — — — 2 — — — — 4 1 6 1 4 — — — — — 1 1 — — — 1 1 Ophthalmia neonatorum 21 21 — — — — — — — — — — — 12 9 — — — — — — — — — — — — — Pneumonia 58 — 3 — 1 — 3 1 3 13 7 18 9 49 9 83 4 — — — 1 1 — i 4 10 27 35 Malaria 1 — — — — — — — — — 1 — — — 1 — — — — — — — — — — — — — Dysentery 3 — — 1 — — — 1 — — 1 — — 1 2 — — — — — — — — — — — — — Trench fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — Totals 608 35 18 25 31 41 177 85 30 64 32 53 17 562 46 114 7 3 1 1 5 6 3 2 5 13 31 37 Correction has been made for errors in notification or revision of diagnosis in 56 cases. Cases not notified:— Polio-myelitis, 7 days. Scnriet fever, 1, 2, 2, 2, 3, 3, 4, 4, 4, 4, 5, 6, 8, 10, 11, 12, 17, 17, 20, 24, 48. Diphtheria, 1, 1, 1, 1, 1, 3, 3, 3, 4, 4, 4, 4, 6, 5, 6, 6, 6, 7, 7, 8, 10, 11, 12, 12, 14, 16, 16, 20, 20, 21, 23, 25, 28. Table XXI. City of Westminster.—Infectious Diseases, Distributed in each Ward. XOTIFIAIILK DlSKASKS. Conduit. Groevenor. Knishtsbridtre St. George. Victoria. i St. Margaret. St. John. Hamlet of Knightsbridge. Pall Mall. Regent. Great Marlborough. Charing Cross. Co vent Garden. Strand. St. Anne. Homeless. Small-pox ' Cholera (C). Plague (R) — —- — — — — — — — — — — — — — Diphtheria — 8 16 127 4 02 4 — 9 2 — 6 — 16 2 Erysipelas .... — 1 4 11 1 19 2 1 2 — — 1 1 — 1 Scarlet fever .... .... .... — 18 10 52 20 70 3 — 4 12 2 5 2 10 — Typhus fever — — — — — — — — — *— — — — — — Entcric fever — 3 — g 1 — 2 1 1 — — 1 2 — — Relapsing fever (R) — — — . — — — — — — — — — — — — Continued fever (C) — — — — — — — — — — — — — — — Puerperal fever — 1 — — 1 2 — — 1 — — — — — 1 Cerebro-spinal meningitis , — — — 2 — 1 — — — — — — — — — Polio-myelitis — • — — 1 — 1 — 1 — — — Encephalitis lethargica — 1 1 1 — 3 — . 1 — — — — — — — Ophthalmia neonatorum — — 2 12 — 6 1 — Pneumonia 1 6 4 15 2 18 — 2 1 1 — — 3 4 1 Malaria — — — — — — — — — — — 1 — — — Dysentery — — — 1 — 1 — — ■ — __ — 1 — Trench fever — — — — — Anthrax • .... — — — — — — — — — — — — — — Totals .... 1 38 37 928 2!) 21!) u 5 10 15 2 14 8 32 ! 5 11 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 fewer cases of this disease than in 1924; 76 of the 214 cases occurred in St. John's Ward and 52 in Victoria Ward. . The disease was mostly contracted by children between the ages of 5 and 15. No deaths occurred. There is little doubt that a number of mild cases occur which are not detected. The number of cases equalled 1.5 per 1,000 of the total population. In England and Wales the rate was 2"36, but as the majority of the cases (84.5 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. Of the total cases 98.6 per cent. were moved to hospital. There is now considerable evidence in support of the view that Scarlet Fever is a streptococcal infection, but so far it has not been possible to identify a particular strain of the organism as the causal factor. Varieties of this type of germ have been found in various cases, different types seeming to vary according to the virulence of the infection. A test for immunity to Scarlet Fever based on a skin reaction, somewhat similar to the Schick test in Diphtheria and named after its discoverers—the two doctors Dick—is now being investigated in this country. A method of immunization against Scarlet Fever has also been devised. Neither the Dick test nor the method of immunization has been practised so far in Westminster Diphtheria.—A larger number of cases occurred than during any other year of the five-year period. This was largely accounted for by two definite outbreaks. There were 286 cases, of which 92 occurred in St. John's Ward and 127 in Victoria Ward. There were 17 deaths (9 males, 8 females), all in patients under 17 years of age. The first outbreak began in November, 1924, in connection with a residential school in St. John's Ward and the cases continued to- occur until the end of February, 1925. There was one death in this outbreak, which involved 21 cases. Although 21 cases were notified, only 13 were considered to be genuine sufferers from clinical diphtheria. The remaining eight were found to show the presence of diphtheria germs in their throats. The difficulty in dealing with carriers is shown by the fact that one scholar gave negative results in December, positive at the end of the same month, and was returned from hospital on 10th January as having been found "not to be suffering from diphtheria"; on 19th January was again found positive on swabbing, and removed to hospital. On 17th February, this 25 same boy was discharged for the second time from hospital as not suffering from diphtheria. It became evident th??? the clinical cases which kept occurring were being caused by contact with carriers of the type described. Those of the boys who were susceptible developed diphtheria, while the immune individuals carried the germs, intermittently, in their throats and proved positive or negative to swabbing according to the degree of contact with the carriers which they were experiencing at the time. It seemed that the most practicable method of dealing with those recurring cases was to immunise the susceptible scholars by the Schick method. Dr. Monckton Copeman, of the Ministry, very kindly gave the benefit of his experience and advice. He and Drs. Letham and Scott, of the Ministry, performed the preliminary testing of the scholars, at which the Medical Officer of Health and Medical Officers of the L.C.C. assisted; material for the purposes of immunization was very graciously supplied by Burroughs Wellcome & Company free of charge. 72 individuals including the staff of the school were tested and 13 were found to be susceptible. The process of administering three successive weekly injections of toxin-antitoxin (immunising mixture) to each susceptible scholar was then undertaken. The Schick test, and the method of immunization associated with it, are now practised as a preventive measure against diphtheria by certain sanitary authorities in this country, and the results so far achieved have been very satisfactory. It has been extensively used in Edinburgh, and in the fever hospitals of large towns such as Manchester and Birmingham, in the Metropolitan Borough of Holborn and in many residential schools throughout the country. A sanitary authority, in considering the adoption of this method of prevention, is advised that it is particularly applicable to children under school age, as they are the most susceptible to diphtheria and are most affected by the mortality of this disease. It would, therefore, appear appropriate that this work should be carried out at the Welfare Centres. It would be necessary to interest the parents and to obtain their co-operation and assent to the Schick work being carried out, and also to enlist the sympathies and efforts of all officials and others engaged in child welfare work in the area. A preliminary report dealing with the Schick test and immunization in its relation to the prevention of outbreaks of diphtheria was presented to the Public Health Committee in November, and it was decided that the question of adopting this method of prevention in the City should be considered. The second outbreak, which occurred in Victoria Ward, began in September and involved 74 cases. As in the former case, the outbreak was due to a carrier, a child attending St. Gabriel's School. The infection (6375)Q c 26 spread amongst the scholars throughout the school, and was also conveyed to children living in the same tenement houses as those from the affected school. In some instances, cases arose through the children playing together in the streets, although there was no history of close contact, such as is possible in school or in the same dwelling house. There were four deaths in school children, aged 4, 5, 5| and 11 years, and in one of those instances the death might have been prevented, had medical aid been sought at an earlier stage of the illness. While the outbreak was being controlled, there was the closest co-operation between the officers of the London County Council School Medical Service and those of the City Council. The Assistant Medical Officer of Health personally visited each home from which a case of diphtheria was notified, examining and swabbing the throats of all contacts. Those visits were additional to those of the Sanitary Inspectors, who paid repeated visits of inquiry to infected households. He also kept closely in touch with the school medical officers when they paid their daily visits to the school for the purpose of examining and swabbing suspicious throats. In this way several carriers of infection were discovered, and the interchange of information regarding the infection from the sources at school and in the homes proved of the greatest use in dealing with the outbreak. The virulence tests which were carried out by the school authorities were of the utmost value. Several of the carriers, who were apparently healthy, proved to be harbouring virulent germs in their throats and noses, and although in these cases it was not always easy to persuade parents that their children were in a highly infectious state, yet isolation in hospital was effected in every instance of a virulent carrier. The matter of isolation and treatment of carriers is still in a very unsatisfactory state. It frequently happens that carriers who show germs intermittently when swabbed are discharged from the fever hospitals after a few days' stay—say, after three negative swabs have been taken. They are not regarded by the hospital authorities as " suffering from " diphtheria, but on return home they may again prove positive on swabbing. The vital question is, whether the strain of germ which they possess is virulent or non-virulent. One is glad to record that in every case where a known virulent carrier was sent into hospital, that patient was retained for a period sufficient to permit of the infection being cleared up or its virulence destroyed. It is generally accepted that most carriers show some abnormalities of the throat or nasal passages; and septic tonsils or chronic inflammation of the mucous membrane of the nose offer favourable lodgment for diphtheria germs. Those conditions can frequently be remedied by surgical treatment. It is very desirable that provision should be made in the hospitals of the Metropolitan Asylums Board for the services of a surgical specialist to deal with those cases. By this means many sources of infection through carriers 27 could be eradicated, and the incidence of return cases of diphtheria avoided. At the present time it is extremely difficult to obtain surgical treatment for these cases, as, being of an infectious nature, they cannot properly be treated in the throat departments of general hospitals. The County Council have made arrangements for dealing with a limited number of carriers occurring among school children, and this should prove of the greatest value in clearing sources of infection in this particular group of the community. Anti-toxin, for use in cases of diphtheria, is provided free of charge for medical practitioners attending patients residing in the City. The supply is available on application at the City Hall, and at the Council's Mortuary in Horseferry Road. It is apparent, however, from the small amount used (36 bulbs, each containing 8,000 units), that practitioners prefer to send their patients at once into the fever hospitals, where anti, toxin is administered on admission to all cases of clinical diphtheria. In times of epidemic, however, when the capacity of the fever hospitals is greatly taxed, there tends to be delay in admitting cases, and it is then that practitioners make full use of the anti-toxin supplied by the Council. Bacteriological Diagnosis.— Swabs from suspected cases among those residing in the City can be examined by the Council's bacteriologist free of charge to the practitioners attending. The materials for swabbing are supplied by the Council, and reports are in the first instance telephoned or telegraphed to the doctor concerned, and written reports follow. The number of throat swabs examined by the Council's bacteriologist during each year since 1921 were :— 1921 1922 1923 1924 1925 431 456 281 556 674 Typhoid Fever.—The number of cases notified during the five yearly period are as follows:— 1921 1922 1923 1924 1925 10 12 21 17 17 of which the following proved to be:— 1921 1922 1923 1924 1925 Paratyphoid 3 2 7 3 5 Not typhoid 0 2 2 2 .0 Confirmed as typhoid 7 8 12 12 12 In 13 cases out of a total of 71 cases of Typhoid and Para typhoid during 1921-1925, there was a history of shellfish having been consumed previous to the onset of illness. In the remainder, infection seems to have been contracted outside Westminster, mainly abroad; three were (6375)Q c 2 28 inmates of asylums and in one the infection was conveyed from an existing case. The death rate at all ages in London was 0.11 per 1,000 living; 17 deaths occurred in Westminster giving a rate 0.12. In 1925, 17 cases of this disease—11 males and 6 females, were notified— five cases eventually proving to be para typhoid. Four cases proved fatal. Two cases of persons who have since recovered and two fatal cases could be traced to the eating of shellfish. Of the remaining 13 cases, 12 contracted the disease whilst on holiday abroad, or before coming to this country, and one was a nurse who had been assisting at an abdominal operation on a woman who was subsequently found to be suffering from typhoid. In the cases where the consumption of shellfish was alleged to be the cause of the disease, every enquiry was made to discover its source of origin. The case rate of the disease for England and Wales was 0.07 per 1,000 living and for Westminster, 0.12. The death-rate for England and Wales was 0.01, for London 0.01, and for Westminster 0.02. Measles.—The year 1925 was not a 'measles' year. The disease assumes epidemic form every second year, and attacks large numbers of children who escaped the infection at the previous outbreak in addition to susceptible infants who have arrived at the age at which they seem to become vulnerable to attack. The following table shows the number of cases notified by head teachers of schools, the Metropolitan Asylums Board, Hospitals and private practitioners during the last five years:— 1921 1922 1923 1924 1925 26 591 131 852 117 All cases of measles do not come to our knowledge, but the above figures give a fair idea of the proportion of cases from year to year. In towns and cities, the attack rate is higher in the third, fourth and fifth years of life, and these years are mostly covered by the information forwarded by the school authorities. During the years 1916-1919, measles was a notifiable disease and figures could be calculated with a greater degree of accuracy, but after four years' experience the Regulations were revoked by a Rescission Order made by the Ministry of Health, as from 31st December, 1919; it was concluded that compulsory notification was not the best method of solving the problem. The majority of these cases must be treated at home, but many cases occur where it is absolutely necessary that hospital assistance should be sought, owing to the severity of the case, the bad home surroundings, or the inability to isolate the patient from the other members of the family 29 in the limited accommodation at their disposal. Measles is often followed by a more or less prolonged period of ill-health, which can be ameliorated by good food and fresh air, and seeing that the greater proportion of cases are drawn from the poorer classes in the congested areas of cities and towns, the inability to obtain these two vital necessities points to the desirability of the establishment of convalescent homes, where patients recovering, not only from measles but from other infectious diseases, can have a better chance of recovery. Deaths.—One of the cases proved fatal. For the whole population of Westminster, the death rate was 0.07 for London 0.08 and for England and Wales 0.13 per 1,000. Visiting and Nursing.—44 visits were paid to families in which were one or more cases of measles by the Health Visitors. The assistance oi District Nurses was called in three instances and 32 visits were paid. Table XXII. Influenza.—The deaths certified from this cause during the fiveyearly period are as follows :— 1921 1922 1923 1924 1925 Males 14 43 9 25 13 Females 16 52 11 31 24 30 95 20 56 37 The death-rate in 1925 was 0.26 per 1,000, the rate for London being 0.23. Last year the corresponding rates were higher, being 0.39 for Westminster and 0.36 for London. Of the 37 deaths in 1925, 16 were in individuals over 60 years of age and 11 in those between 45 and 65 years. This disease affects all ages and all classes of society, and although there were a considerable number of cases, they seem generally to have been of a mild type. When accompanied or followed by conditions such as cardiac or kidney disease, bronchitis or pneumonia, this affection tends to end fatally and, as is to be expected, the deaths mostly occur among people beyond middle age. The population of Westminster contains more than the average number of elderly people and consequently influenza causes a somewhat higher death-rate here than in London generally. Diarrhoea and Enteritis.—These terms include the diarrhoea which is frequently a terminal symptom in certain exhausting diseases; for example, marasmic infants who are unable to assimilate any sort of nourishment may suffer from intractable diarrhoea which eventually 30 causes death. This should be contrasted with summer or infective diarrhoea, which strikes even the most healthy and well nourished babiesThis disease is generally conveyed by flies which contaminate milk, if improperly kept, and thus infants who are fed on cow's milk become infected. The educative influences of Welfare Centres have played a large part in eliminating this infection. Mothers are taught how to pasteurise milk and how to keep it chilled and free from contamination. Of the 13 deaths, none were due to diarrhoea of the summer or infective type. There were eight under 1 year; one between 1 and 2 years; two between 2 to 5 years and two over 65 years. Table XXIII. Deaths from Diarrhcea and Enteritis. Under 1 year. Other ages. Total. 1921 26 7 33 1922 8 4 12 1923 2 — 2 1924 3 3 6 1925 8 5 13 47 19 66 The eight deaths under 1 year of age were distributed over the quarters of the year :— Table XXVI. 1st quarter. 2nd quarter. 3rd quarter. 4th quarter. 2 0 3 3 The average death rate from diarrhoea and enteritis for all ages during the five-year period was 0.09 per 1,000. The average from this cause under 1 year of age was 5.37 per 1,000 births for the same period. The death rate under one year for 1925 from the same cause was 5.21 per 1,000 births. Whooping Cough.—An outbreak occurred in the early spring which accounted for 205 of the total 255 of cases recorded. The former number of cases were all during the first quarter of the year. The cases coming to the knowledge of the department in 1925 and in previous years were :— Table XXV. 1921. 1922. 1923. 1924. 1925. 133 67 35 97 255 31 This outbreak was the most severe of any since 1921, and resulted in 17 deaths. During its course leaflets were distributed through the Welfare Centres for the information of mothers and others in chafge of children. In cases where the patients could not be adequately nursed at home by reason of severity of the illness or the presence of complications, admission to hospital was arranged by the department, and 52 cases were thus removed. Many parents are inclined to take a light view of this infection, but there is no zymotic which exerts such a baleful influence on the health and progress of infants and young children as whooping cough. The causal organism has not been isolated, but there is reason to believe that it belongs to the group of ultra visible viruses among which may be found the causes of smallpox and rabies. The poisons germinated . by this infection affect the nervous system and induce debility of the whole constitution. Its effects on the lungs are such that broncho-pneumonia is frequently set up which unfortunately often ends in death. The deaths from whooping cough during the five years are thus set out:— Table XXVI. Under 1 year. At other ages. Total. 1921 3 6 9 1922 2 3 5 1923 2 3 5 1924 3 1 4 1925 7 10 17 17 23 40 In 1925 there were seven deaths under one year, nine between the ages of 1 and 5 years and one in a person of 65 years. The average death rate for the five-year period at all ages was 0-05 per 1,000 and average death rate of infants under one year was 1-94 per 1,000 births. For 1925 the death rate of infants under one year was 4-5 per 1,000 births. 272 visits were paid by Health Visitors to cases of whooping cough. Cerebro-spinal Fever.—There were three cases, two of whom died. The incidence in the preceding years was :— Table XXVII. 1921. 1922. 1923. 1924. 1925. 2 4 1 3 3 of which the following were fatal 13 10 2 32 Poliomyelitis.—Three cases occurred, one of whom, a male infant of seven days, died. The incidence and mortality since 1921 were:— Table XXVIII. 1921. 1922. 1923. 1924. 1925. 0 0 1 1 3 Deaths:— 0 0 0 1 1 This disease became notifiable in 1912, and increasing attention has been drawn to the crippling effects which result from this infection, effects which may cause serious and permanent deformity. Efforts are being made to secure earlier diagnosis, so that appropriate treatment may be applied at a stage in the illness when deformities may be prevented. The London County Council have made arrangements for the reception of patients at Queen Mary's Hospital, Carshalton. These cases in the stage immediately following the fever may be admitted, and also those later ones in which "infantile paralysis" has definitely developed. Encephalitis Lethargica.—Seven cases occurred, with four deaths. Of the remaining three one moved away from the district, one died from cirrhosis of the liver. The third died from cerebral haemorrhage, and it is probable that in this case the original diagnosis was mistaken. The incidence in Westminster during the past five years is given below, but these figures must necessarily be inexact, as a certain amount of doubt existed as to the diagnosis in some cases, while it is more than likely that other cases were missed. The disease was made compulsorily notifiable in 1919, and investigations into its epidemiology and characteristics have been proceeding under the auspices of the Ministry of Health and Medical Research Council. The first outbreak was noted in London in 1918, and was said to be associated with food poisoning. Since then its occurrence has been studied in various parts of the country. It attacks all classes and at all ages. Its mortality is roughly estimated at about 50 per centof those attacked. It is suggested that indoor workers and those undergoing mental strain are specially susceptible. Public attention has been drawn to this infection from the fact that it has caused the death of several eminent personages during the past year, and its after effects on those who survive are such that in some it causes mental deterioration. In cases of mental delinquency those effects have been pleaded as a defence to charges of petty theft. The London County Council have initiated an inquiry into the after effects in sufferers who are of school age and they desire that the medical officers of metropolitan boroughs should supplement these records by supplying information concerning patients of pre-school age and adults. It is requested that data should be furnished at 35 half-yearly intervals on such cases as merit inquiry. The most prominent after effects which have come to the notice of the school medical authorities are those associated with sleep, intelligence (e.g. apathy and drowsiness), conduct and physical condition (e.g. paralysis). The Metropolitan Asylums Board have made arrangements in the Northern Hospital for 100 beds to be reserved for the treatment of suitable cases among sufferers from those after effects in children up to 15 years of age. Table XXIX. 1921. 1922. 1923. 1924. 1925. Cases notified:— 3 2 2 15 7 Deaths:— 1 1 2 6 4 Chickenpox.—149 cases were notified, chiefly from the schools. The corresponding figures from 1921 were: 1921, 119; 1922, 178; 1923, 169; 1924, 89. The Medical Officer of Health was requested to see three cases—one adult and two children—who were suffering from moderately severe attacks and who were at first suspected to be suffering from smallpox. Mumps.—120 cases were recorded. In 1921 there were 263 ; in 1922, 25 ; in 1923, 95 cases ; and in 1924, 147. Plague, &c.—Intimation was received of one person coming into Westminster from a place where plague had occurred. Anthrax.—There were no cases in 1925 nor in 1921, 1 in 1922, none in 1923, 1 in 1924. Puerperal Fever.—6 cases were notified during the year, with one death. All cases were removed to hospital. One of these cases came from Willesden, one was due to improper medical arrangements, one case of abortion, one puerperal mania, and two other cases. Inquiry is made into every case, where practicable, by the Health Visitors, and strict attention is also paid to this disease by the Medical Staff of the London County Council, especially where a midwife was in any way connected with the case. The following table shows the number of births for the last five years, together with the number of cases of puerperal fever and deaths :— Year. No. of births. No. of cases. Deaths. 1921 1,919 10 2 1922 1,895 6 4 1923 1,752 3 - 1924 1,024 10 2 1925 1,535 6 1 34 Special facilities both for nursing and medical treatment have been arranged by the Metropolitan Asylums Board, whereby cases of puerperal fever will be concentrated, as far as possible, in three of their Institutions, namely, the Eastern Hospital, Homerton, the North Western Hospital, Hampstead, and the South Western Hospital, Stockwell, where special wards have been set aside and special medical and nursing staff provided. An obstetric consultant has also been appointed at these Institutions. A circular letter has been sent to each of the medical practitioners in Westminster expressing the hope that full use will be made of the accommodation provided by the Metropolitan Asylums Board for cases in this City. Ophthalmia Neonatorum.—Twenty-one cases were notified during 1925—10 males and 11 females. Twelve were admitted to hospital and nine treated either at home or as out-patients of hospitals. In addition to these notified cases, 11 cases of slight inflammation of the eyes came to the knowledge of the Department. Cases of ophthalmia neonatorum (and puerperal fever also) cannot be grouped together in tables to serve any useful purpose, as each case must be regarded in its own light—governed by the health of the parents or the conditions under which the confinement took place. Facilities are afforded for the treatment of this disease by the Metropolitan Asylums Board at St. Margaret's Hospital, Kentish Town, N.W. Mothers are also admitted, and, if necessary, receive treatment. The following details in tabular form are required by the Ministry of Health of the cases notified in 1925:— Cases. Vision unimpaired. Vision impaired. Total blindness. Deaths. Notified. Treated. At home. In hospital. 21 9 12 14 1* Nil. — * This child was born in and received treatment at hospital. At present it has a film over right eye. Four children moved away soon after notification and two died— one from lobar pneumonia and the other from bronchitis. No cases were notified by midwives during 1925. Bacteriological Laboratory. The examination of specimens for bacteriological investigation is carried out by Dr. Braxton Hicks at the laboratory of Westminster Hospital. The facilities provided by the Council apply only to patients 35 who are residents in the City. A charge, however, is made for work done on behalf of individuals whose place of occupation is in Westminster, but who may be attended by Westminster practitioners. The following is the summary of bacteriological work performed:— Swabbings from throats in suspected diphtheria .. 674 Blood in suspected typhoid 9 Sputa for investigation of T.B. 443 Expenditure on first two was £96 17s., and for the third £60 15s. 8d., including cost of outfits, postage and telegrams. TUBERCULOSIS. In 1925, 223 new cases of pulmonary tuberculosis were notified and 5 moved into the City who had been notified elsewhere—a total of 228. Non-pulmonary forms of tuberculosis gave 54 cases. Table I. Tuberculosis, 1925. Age-Periods. New Cases. Deaths. Pulmonary. Non-pulmonary. Pulmonary. Non-pulmonary. M. F. M. F. M. F. M F. Under 1 — — — — — — 3 — 1 1 1 3 5 1 — — 3 5 4 3 5 3 — — 1 — 10 2 1 3 4 — 2 — — 15 8 9 1 7 3 4 — 2 20 12 10 3 1 4 5 — — 25 39 33 5 4 15 11 — — 35 32 18 1 3 13 4 3 1 45 19 11 — 2 19 8 — 1 55 13 4 1 2 18 3 — — 65 and upwards 5 3 1 — 5 — — — Totals 135 93 23 31 78 37 7 7 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. 36 The total number of new cases notified during 1925 was the lowest recorded since the Tuberculosis Regulations came into force. The primary notifications for 1925 show a decrease of 65 on those of 1924. The reason for this large reduction can only be a matter of conjecture; it may be that tuberculosis is on the decline in Westminster—a condition earnestly to be desired—or it may be that there are many people, as instanced by the following tables, who are suffering from this disease in a far more advanced stage than they imagine, and who refrain from consulting a doctor—fearing that a medical examination would make into a certainty that which they had for some time dreaded. Out of the total cases notified in 1925, 46 died, and the following table shows the period between notification and death of these cases. Weeks. Months. 1—2 2—3 3—4 1—2 2—3 3—4 4—5 5—6 6—7 7—8 8—9 9—10 15 5 3 8 4 2 3 1 1 2 1 1 There are considerable grounds for believing that the incidence of tuberculosis in 1925 has shown a genuine fall. Reference has been made to sufferers who delay seeking medical advice until an advanced stage in their illness which results in those cases being notified to the Medical Officer of Health so late that death ensues before such means of treatment as is in the hands of the public authority can be usefully applied for their cure or relief. On comparison it is found that in the four preceding years, the number of cases which died during the same year as they were notified was as follows:— Table II. 1921 1922 1923 1924 1925 New eases notified 312 327 324 347 282 Number included in above who died during the year 83 (26.6%) 100 (30.5%) 44 (13.5%) 66 (19.0%) 46 (16.3%) Total Tuberculous Deaths 135 165 119 138 129 Death Rates per 100,000 95.5 118.3 84.7 96.5 92.4 While there has been a considerable reduction in the number of cases diagnosed as tuberculous, there have also been fewer deaths from this disease and a smaller proportion of cases found in an advanced stage, i.e., diagnosed within a year of death. 37 Table III. Tuberculosis.—Notifications received during the period from 4th January, 1925, to 2nd January, 1926. 1925. Number of notifications on Form A. Primary notifications. Total notifications, on Form A, including cases previously notified. 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 new cases. Pulmonary— Males — 1 4 2 8 12 37 31 19 13 5 132 147 Females — 1 3 1 9 10 31 18 11 14 3 91 100 Non.pulmonary— Males — 3 5 3 1 3 5 1 — 1 1 23 27 Females — 4 2 3 6 1 3 3 2 2 — 26 32 Total — 9 14 9 24 26 76 53 32 30 9 272 306 Number of notifications on Form B. (School medical inspection.) Number on Form C. Admissions to Primary notifications. Total notifications, including cases previously notified. Poor Law institutions. Sanatoria. Under 5. 5 to 10. 10 to 15. Total. Pulmonary— Males — — — — — 20 117 Females — — — — — 1 86 Non -pulmonary— Males — — — — — — 12 Females — — — — — — 17 Total — — — — 21 232 38 Table IV. Tuberculosis.—New cases coming to the knowledge of the Medical Officer of Health otherwise than by Notification under the Regulations. (Forms A and B.) 1925. Age Periods. 0 to 1. 1 to 5. 6 to 10. 10 to 16. 15 to 20. 20 to 26. 25 to 35. 35 to 45. 45 to 55. 55 to 65. 65 and up. Total. Pulmonary— Males — — — — — — 2 1 — — — 3 Females — — — — — — 2 — — — — 2 Non-pulmonary— Males — — — — — — — — — — — — Females — 1 1 1 1 — 1 — — — — 5 Total — 1 1 1 1 — 5 1 — — — 10 C.L.H. General. Non-pulmonary. Total. Notified pulmonary 28 195 49 272 Not notified in Westminster — 5 5 10 Total 28 200 54 282 39 Table V. Tuberculosis.—Table showing distribution in Wards of notified and unnotified cases, and numbers of such persons who have been treated in Institutions. 1925. All Ages. Conduit. Grosvenor. Knightebridge 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 dining 1925. I'ulmonary— Males 135 — 1 7 36 7 43 1 1 2 3 5 6 15 8 — 98 Females 93 1 12 4 28 1 32 2 2 2 2 4 3 — — — 62 Non-pulmonary— Males 23 — 1 2 11 — 7 — — 1 — 1 — — — — 14 Females 31 — 5 4 4 2 9 — — 2 — 2 — 2 1 — 23 282 1 19 17 79 10 91 3 3 7 5 12 9 17 9 — 197 40 Table VI. The figures for a series of years are shown below:— Pulmonary. Non-Pulmonary. Total of all 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 1925 108 92 27 1 228 23 31 54 282 (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 Deaths.—There were 23 deaths from Tuberculosis (15 males and 8 females) during 1925 of persons who had not been notified in Westminster. The majority of these had been notified elsewhere, some were sudden deaths of visitors to this country, and the cause of death in some cases was only discovered on post-mortem examination. These 23 non-notified deaths gave a percentage of 17.8 on the total deaths from Tuberculosis for the year. Non-notified cases.—Previous to the year 1925, the non-notified cases of pulmonary and non-pulmonary tuberculosis bore a fair percentage to the total cases notified. In 1924, the percentage for pulmonary was 0, and for non-pulmonary 11.7. In 1925, there were no non-notified cases. This was mainly due to the Public Health (Tuberculosis) Regulations, 1924, which came into operation on the 1st day of January, 1925. These Regulations require, inter alia, that where an admission to or discharge from hospital is received by the Medical Officer of Health of a person suffering from Tuberculosis who has not been previously notified a Form A should be sent to the Medical Officer of the Institution from 41 whom the notification was received, at the same time informing him of the circumstances and asking that a notification on that Form may be furnished. In all cases where it was found necessary to ask for a notification under the above Regulations, Form A was returned, duly filled in, together with an apology or letter of explanation as to why the case had not formally notified, thereby obviating the necessity of any further proceedings being taken. The total number of cases of Tuberculosis on the Register at the end of 1925 was 1,805, as compared with 1,758 at the end of the year 1924. Table VII. Pulmonary. Non-Pulmonary. Males. Females. Males. Females. Number of cases on Register at beginning of year 1925 794 573 183 208 Notified for the first time during year 135 93 23 31 929 666 206 239 Removed from the Register on account of death or removal from Westminster 118 88 16 13 811 578 190 226 Of the 235 cases removed from the Register during the year 1925, 111 were on account of death, and 124 persons suffering from Tuberculosis moved from the City. Of the 111 deaths mentioned above, 6 died from causes other than Tuberculosis. Deaths from Tuberculosis.—The total number of deaths from Tuberculosis for 1925 (all forms) was 129—Males 85, Females 44. This gives a death-rate for this disease of -92 per 1,000. The following table shows the number of deaths from Tuberculosis for the last 5 years, together with the death rate. Year. Deaths. Rate per 1,000. 1921 135 .95 1922 165 1.16 1923 119 .84 1924 138 .98 1925 129 .92 The average five-yearly rate per 1,000 was .97. The following table shows Deaths per 100,000 of civilian population since 1916, and the average for the period 1921-25. (6375)Q d 42 Table VIII. 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 „ 191 147 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 1925 „ 115 82.3 14 10.0 129 92.4 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 1921-25 „ 121 860 16 11.3 137 97.4 The following Regulations and Orders dealing with Tuberculosis came into force during the year:— 1. The Public Health (Tuberculosis) Regulations, 1924, made by the Minister of Health came into operation on 1st January, 1925. They amend the Regulations of 1912 and 1921 in regard to certain matters of notification. In his circular letter the Minister points out that discrepancies have been. noted in the past. Cases have not been notified until after death, and the Minister does not consider that these should be regarded as coming within the terms of the Regulations, and therefore do not entitle the practitioner to notification fees. He attaches great importance to inquiry being made where deaths occur in cases which have not been previously notified. Where there was apparent neglect to notify, an explanation should be required of the practitioner certifying the death. Three cases of this nature were inquired into, and satisfactory explanations were received from the practitioners concerned. The Tuberculosis Officer is now required to notify every case in which he diagnoses tuberculosis unless he has definite knowledge that the practitioner attending has notified or will notify the case. It has occasionally happened that each left it to the other to notify, with the result that the case remained unnotified. New cases have sometimes been notified from institutions on Forms C. and D. (admission and discharge forms), instead of on the primary Form A. This is liable to cause confusion in estimating the number of new cases in the year. In each case a Form A. is sent to the notifying doctor at the institution, with a request for its completion and return. This plan has worked satisfactorily, as mentioned heretofore in this report. It has been found that there is sometimes a divergence between the numbers of notifications of tuberculosis sent in the weekly returns of Infectious Diseases to the Registrar-General and those in the total of primary notifications sent to the County Medical Officer. It is now asked that only the number of primary notifications on Forms A. or B. should be sent to the Registrar-General in the weekly return. 43 It is suggested that the local authority should obtain from the local Registrar, on payment of prescribed fees, returns of the particulars registered concerning deaths from tuberculosis, in order that the Medical Officer of Health may obtain early information regarding those deaths. An arrangement by which weekly returns of the copies of Certificates of Births and Deaths registered are sent to the Medical Officer of Health has been in force in Westminster for many years. The Regulations themselves deal with methods of keeping the notification register, the elimination of arrested cases and removals from the district, and of appropriate returns to be made to the County Medical Officer. 2. The Public Health (Prevention of Tuberculosis) Regulations, 1925. The object of these Regulations, which came into force on 1st August, 1925, is to prevent the contamination and infection of milk from human sources. Until the issue of these Regulations there has been no effective means of dealing with persons who suffer from infectious forms of tuberculosis, and are engaged in the handling of milk. If methods of persuasion failed to deter an individual, so affected, from continuing his occupation and remaining a potential source of infection, he had every legal right to keep to his occupation because he was protected by the Tuberculosis Regulations of 1912. Under Article 16 of the 1912 Regulations no individual need be prejudiced in regard to his occupation by reason of his being notified to the Medical Officer of Health as suffering from tuberculosis. The notification remained a private and confidential document so far as the individual was concerned. It is not anticipated that the confidential nature of notification need be disturbed, but the fact that the sanitary authority is now armed with legal powers should, in itself, be sufficient to effect the end in view when methods of persuasion seem likely to fail. The Regulations consist of seven articles and a schedule. In the definition, " dairy " does not include a shop or other place in which milk is sold for consumption on the premises only. The local authority shall enforce these regulations and make any necessary inquiries. . • No person who is aware that he is suffering from tuberculosis of the respiratory tract shall enter upon any employment in a dairy which would involve the milking of cows. the treatment of milk, or the handling of vessels used for containing milk. A local authority, if satisfied on a report by their Medical Officer of Health that a person residing in their district engaged on dairy work is suffering from tuberculosis, and is in an infectious state, may by notice in writing, signed by the Clerk or Medical Officer of Health, require such person to discontinue his occupation as from a specified date, not less than seven days after service of the notice. Such person shall comply with the notice. The form of notice is given in the schedule. If the person feels aggrieved by the notice he may appeal within fourteen days to a court of summary jurisdiction, and shall inform the clerk of his intention to appeal, and the grounds thereof. The court may make an order in the matter and may award costs, and the order shall be binding. The court may direct appellant to be examined by a medical practitioner nominated by the court, and only with his consent. Compensation for damage sustained by the operation of these Regulations may be applied for by the person concerned, not being himself in default, and he is entitled to full compensation from the local authority. It may be taken for granted that only in cases where tubercle bacilli are present in the sputum would the Medical Officer of Health be prepared to report the ease to his local authority for action to restrain an individual from following his occupation. (6375)q d 2 44 One case requiring action under the Regulations came to the notice of the Medical Officer of Health. The patient voluntarily discontinued his connection with the milk trade when he was informed that there were legal powers for compelling him to do so. There is nothing in the Regulations to prevent waitresses and others employed in small restaurants, who may be suffering from tuberculosis, from handling milk to be consumed on the premises. It is extremely important that sufferers from infectious or open tuberculosis should not be permitted to prepare or distribute not only milk but also other articles of food for use by the public. No doubt the experience gained in the practice of these Regulations will pave the way for future measures of a more comprehensive nature. 3. Milk and Dairies Consolidation Act, 1915, contains certain provisions for prohibiting the sale of milk which is infected with tuberculosis. This Act came into force on 1st September, and its provisions are mentioned in the Food Section of this report. 4. Tuberculosis Order of 1925 made by the Minister of Agriculture and Fisheries. The Order is a lengthy document consisting of twenty-three articles, the provisions of which will be administered, so far as London is concerned, by the London County Council. As cows are no longer kept in the City of Westminster, nor are there any slaughter-houses, the Order is not of immediate application. This Order revoked the Tuberculosis Order of 1914. Tuberculosis Scheme. The constitution of the Tuberculosis Scheme of the City Council is similar to that described in the survey report of 1920. I.-—(1) The dispensary is situated at 1 Pimlico Road, S.W. (2) Tuberculosis Officer : Dr. Ian S. Thomson. He is also Assistant and Deputy Medical Officer of Health. His duties are mainly concerned with the tuberculosis scheme, but a proportion of his time is devoted to general public health work. (3) The visiting of patients in their homes, whether in connection with the dispensary or in regard to visiting on notification under the Tuberculosis Regulations, is performed by four Health Visitors, three of whom divide their duties between tuberculosis and maternity and child welfare. (4) The City Council is not the authority for providing residential treatment, and has therefore no beds under its control. The large voluntary hospitals admit cases for observation and also in emergency but do not make any established provision of beds for cases of tuberculosis other than the sufferers from non-pulmonary disease who by custom are treated by surgeons in surgical wards. Those cases, when convalescent, are generally transferred to institutions administered by the public authority. The Guardians of the City of Westminster provide wards in their St. Stephen's Hospital for the purpose of treatment of patients suffering 45 from consumption, as tuberculosis of the lungs is called. There are 30 beds for males and 20 for females. The benefits to the community which arise from the special accommodation which the Guardians provide has been the subject of comment in the annual report for many years. Immediate admission can be obtained for acute and emergency cases, while patients who are no longer fit for work and are in an advanced stage of the disease may receive rest and treatment for an indefinite period, and, at the same time, are prevented from being a source of infection to their families. In 1923 the City Council suggested to the Guardians that the services of their Tuberculosis Officer would be available as consultant on cases of tuberculosis in the hospital. The Guardians readily accepted the offer, and appointed the Tuberculosis Officer to visit the hospital at regular intervals and to consult with the Medical Superintendent as to the diagnosis and treatment of cases in the hospital. The arrangement has now been in force since May 1923, and has added the link which was lacking in the Council's tuberculosis scheme—continuity of observation and treatment. This is the most important development which has taken place since the scheme was established in 1916. The Tuberculosis Officer is now enabled to obtain accurate observations of cases difficult of diagnosis and can pursue his own investigations. II.—Applies to County Councils. III.—The tuberculosis dispensary is affiliated by official agreement with Westminster Hospital. This agreement was entered into when the dispensary was established in 1916, and has been renewed annually. Under its terms patients may be referred to the hospital for the purposes of further diagnosis and special treatment. The number of cases thus referred is as follows :— 1921 1922 1923 1924 1925 37 37 32 21 16 The majority of patients sent to Westminster Hospital are referred for the purposes of special treatment of non-pulmonary tuberculosis (disease of the bones and joints and glandular affections requiring surgical treatment) and conditions not tuberculous in nature, but which have been found to require treatment when the patients have been examined at the dispensary. With regard to " chest" cases an arrangement has been made with the hospital by which a report by the radiographer and the film taken are supplied to the Tuberculosis Officer who may refer patients for the purpose of X-ray examination. The sum of 12s. 6d. for a report and film is payable to the hospital by the Council. Two cases were examined in this way at the hospital in 1925. The co-operation which exists between the Tuberculosis Officer and the staff of Westminster Hospital has always been of a close and cordial 46 nature, and has extended to other branches of public health work in which the two authorities are mutually interested. Relations with the other hospitals in the City and with those elsewhere, although not so intimate, have been equally cordial. The scheme of co-operation between the school medical service and the dispensary which was organised by the County Council in 1920 continues to work smoothly. Particulars concerning children who are suspected of suffering from tuberculosis are forwarded by the School Medical Officer, and those children are taken in charge at the dispensary. Should the suspicious signs pass away, they are transferred back to the care of the school doctor; otherwise they become dispensary patients, and may require in course of time sanatorium treatment. Similarly the Tuberculosis Officer informs the School Medical Officer of children whom he has examined as contacts, and so an interchange of information is kept up which is helpful to the work of the dispensary, in that it reduces the number of children attending who no longer require the expert supervision of the Tuberculosis Officer, but for whom it is necessary that occasional medical examination at the schools should be carried out. The Tuberculosis Officer has referred in his report to the Sunlight treatment which is available in the City at the centre organised by the British Humane Association in Tufton Street. A number of patients have been referred to this institution, and courses of treatment have been carried out at very moderate cost to the patients; in some cases no charge has been made. IV.—The good will which was extended to the dispensary by the medical practitioners when it was established ten years ago has grown as time went on. Roughly, one-third of the total new patients who are examined each year are sent by practitioners. It is recognised that the dispensary in no way exists for the purpose of displacing the private doctor in his relations with his patient, but rather as a centre where expert aid is available in doubtful cases, where the practitioner can consult r.s to the progress of his cases, and where information relating to the various activities of the anti-tuberculosis campaign can readily be obtained. Figures relating to the number of patients sent for the opinion of the Tuberculosis Officer are appended, and at the same time may be noted the number of occasions during the past five years on which he has been called by practitioners in consultation at the bedside. While the co-ordination between insurance practitioners and the Tuberculosis Officer can hardly be improved, there has been no great disposition 47 on the part of practitioners to make use of the forms of report devised in Memorandum No. 286. V.—The diagnosis of doubtful cases has always been regarded as one of the chief functions of the dispensary, and if diagnosis cannot be established at the first attendance, the patient is instructed to attend at frequent and regular intervals—say bi-weekly, or once a week. Careful records are kept, and examinations are made with a view to arriving at a definite diagnosis as early as possible. Visits are paid to the homes by the Health Visitors, who instruct patients in the use of the clinical thermometer, and it is their duty to report to the Tuberculosis Officer on the home conditions generally, and on any probable source of infection there. If diagnosis has not been established within a period of four weeks' regular observation, recourse is made to the facilities provided by the London County Council in Brompton and other chest hospitals. Certain figures relating to the disposal of doubtful cases are included in Form R of the Ministry of Health, which is appended. VT.—The examination and supervision of contacts is the foundation of the anti-tuberculosis effort of a dispensary. On visiting cases of tuberculosis notified to the Medical Officer of Health, the Health Visitor suggests examination, where practicable, of all home contacts. A considerable proportion of adult cases notified in Westminster are single individuals—domestic servants, persons living in hostels, clubs, etc.— who are without home contacts in the family sense. Cases, however, occurring in families are visited by the Tuberculosis Officer in their homes after their first attendance at the dispensary. He is thus in a position to visualise the surroundings, which is of great use in considering the progress of the patient afterwards. The Health Visitor arranges for the home contacts to be examined at this visit, or for their subsequent attendance at the dispensary for this purpose. Negative results from first or single examination of contacts are sometimes misleading and may engender a sense of security which future events often fail to justify in those who are constantly exposed to infection. Those who live or work in close touch with an " open " case of tuberculosis should be examined from time to time over a period of years. It would be impossible for a single tuberculosis officer to keep under review all the contacts of all notified cases in the City, but for school children the need is met by the periodic school medical examinations. As regards the insured classes, the attention of the insurance authorities might be directed to considering the possibilities of routine examinations of insured lives, with special reference to the effects which may be looked for in cases where there is a family history of tuberculosis. 48 VII.—No special methods of diagnosis or treatment have been investigated at the dispensary during the period under review. Experience has shown that it is necessary to have patients under closer personal observation than is possible at their visits to a dispensary in order to investigate accurately the value of many diagnostic methods and the remedies which appear from time to time. The facilities for X-ray diagnosis at Westminster Hospital have already been alluded to, and there remains the special forms of treatment which are available by arrangement with the City Council for Westminster patients at certain hospitals. Artificial pneumothorax treatment is carried out at Brompton Hospital on the recommendation of the Tuberculosis Officer. This arrangement has been in force since 1921, and there is no doubt that in suitable cases this form of treatment has a greater effect in restoring patients to working capacity than any other—and it is noteworthy that the good health gained is maintained, which is not always the case when sanatorium treatment only has been given. In order to obtain the best results artificial pneumothorax treatment should be given while the patient is in a sanatorium, so that its good effects may be assisted by the building up afresh of his constitution. All the Westminster cases have done well, and some of them have been undergoing this treatment for three or four years. Those under treatment numbered 1921 1922 1923 1924 1925 No. of patients 2 1 5 5 4 No. of refills 10 4 54 54 21 The cost to the Council is 10s. 6d. for each refill. Arrangements for the X-ray and radium treatment of cases of lupus and other tubercular skin conditions at the London and St. Thomas' Hospitals have existed since 1921. VIII.—The results of such forms of special treatment as are available have been indicated in the preceding paragraph. IX.—Denial Treatment.—A scheme of dental treatment for tuberculous patients was established in 1920. The clinic is conducted at the -Western Dispensary in Rochester Row under the care of Mr. AV. II. Turner, L.D.S., assisted by the sister-in-charge, Miss A. St. Leger, who is attached to the school treatment centre. The scheme is run in combination with that organised for mothers and children under maternity and child welfare, a special session being held once a fortnight for tuberculous patients. Extractions requiring gas are performed once a month, Dr. Graham Scott acting as anaesthetist. 49 Eight new patients received dental treatment at the Council's expense, necessitating 40 attendances, at which 70 teeth were extracted, 23 teeth filled, and other dental operations performed. General anæsthetics were administered on 14 occasions. Reference to dental treatment is also made under the heading of maternity and child welfare, a brief report by the dental surgeon being appended. The importance of dental treatment is becoming widely recognised, but the public require a very great deal of persuasion to appreciate that a sound appearance and absence of pain may nevertheless conceal an active process of progressive disease in the roots of teeth and in the gums. There is no doubt that concealed dental disease poisons the blood, and so renders a patient liable to dangerous maladies. The association between the condition of diabetes and dental disease is now accepted, and improvement in sufferers from this disease when dental disease has been eradicated has been observed and noted by many authorities. So in tuberculosis, which, like most infections, results in a certain degree of blood poisoning, the presence of dental disease aggravates the primary infection and lowers the patient's resisting power. The Council have made provision for the supply of dentures at the clinic, and in necessitous cases contribute a half, or even two-thirds, of the cost. No tuberculous patients required assistance in this way in 1925. In the four previous years 1921 (5 persons), 1922 (8 persons), 1923 (2 persons), and 1924 (1 person) were provided with dentures at a total cost of £11. X.—Nursing and Extra Nourishment.—Up to the present time expenditure on nursing has not ranked for grant in the Council's tuberculosis scheme. There are very few bedridden cases of tuberculosis at home, as advantage is widely taken of the beds which are provided for advanced cases by the County Council and by the Guardians. The District Nursing Associations, of which there are three, have always been glad to lend their aid in such cases. They make a small charge, not exceeding Is. 6d. per visit, where it can be afforded, but a good deal of gratuitous service is also given. It would add to the completeness of the tuberculosis scheme and would confer welcome benefits on the sulferers if an arrangement similar to that in the maternity and child welfare scheme were made with the Nursing Associations for cases of tuberculosis. Extra nourishment, in the form of milk and eggs, is granted by the Council on the recommendation of the Tuberculosis Officer to suitable cases. These are mainly patients who have returned from sanatoria and find difficulty in accommodating themselves to the changed conditions 50 of diet and environment. It assists them in lessening the strain of taking up their work again after a period of rest and helps to maintain the good derived from sanatorium treatment. The grants are made really on medical grounds, but each case is considered in its economic aspects by the Tuberculosis Care Committee. In the survey report of 1920 comment was made on the difficulty in obtaining extra food from the Insurance Committee. In those days all insured consumptives were under the impression that they were entitled to milk and eggs as part of sanatorium benefits. The demand was considerable, and in some instances grants were made to unsuitable cases, whilst they were discontinued in others who required them. Since the Council was given the power to provide extra nourishment there has been no difficulty and no case of hardship. The suggestion that the extra food is required comes from the medical officer and not from the patient. The amount spent in 1925 was £38, and 9 patients received grants. Since 1921 the number benefited and the money spent for this purpose are as follows :—1921 (6 persons : cost £35), 1922 (9 persons: cost £55), 1923 (15 persons: cost £49), and 1924 (14 persons: cost £69). XI.—Arrangements for the treatment of cases of non-pulmonary tuberculosis have been considered when describing the measures of cooperation existing between the dispensary and the general hospitals with particular reference to Westminster Hospital, with which the dispensary is affiliated. It would be appropriate here to mention with appreciation the services of the surgeon in charge of the orthopoedic department of the hospital, whose advice and skill are always so generously given. The supply of surgical apparatus is usually arranged at the hospitals with such bodies as the Invalid Children's Aid Association and the Surgical Aid Society. XII.—Care and After-Care.—A Tuberculosis Care Committee, which is formed under the auspices of the Council, meets once a month alternately at the City Hall and at the Tuberculosis Dispensary. The Committee consists of individuals representing bodies interested in the various aspects of tuberculosis work, such as the Guardians, School Medical Service, School Care Committees, British Red Cross Society, United Services Fund, London Insurance Committee, Charity Organization Society, Invalid Children's Aid Association and Westminster Health Society. The almoners of Bromptori and the general hospitals in the City are members, and the Medical Officer of Health is Chairman. The Health Visitors are exofficio members, and bring forward reports on cases in which questions of after-care arise. The chief matters which occupy the business of the Committee are those affecting families while a parent is in a sanatorium— measures for safeguarding the health of the patient on his or her return from 51 sanatorium ; also questions as to future employment, decisions as to Applications for dental treatment and extra nourishment, and assessment of contributions towards payment for sanatorium treatment provided by the County Council. Although the Committee has no funds at its disposal to administer for matters of after-care, assistance has been rendered in various other ways, and much good has resulted from the discussion of individual problems and the interchange of views which take place at its meetings. XIII.—The question of employment of tuberculous patients, is and always will be, a most difficult one. As regards ex-service men, a scheme of co-operation between the War Pensions Committee, the local Labour Exchange, and the Tuberculosis Officer and the Care Committee has been drawn up by the Ministries of Labour and Pensions. The object of the scheme is to ensure that the patient will not return from sanatorium to home conditions likely to retard his progress, and also if possible to secure suitable employment for him. The Tuberculosis Officer's advice is available for the guidance of the officials of the Labour Exchange in discriminating between occupations which are suitable and those which are not. The scheme for the treatment and training of ex-service pensioners for tuberculosis has resulted in two or three patients being placed in suitable employment, but it is limited in its application to those who have recovered full earning capacity. The services of the Junior Advisory Committee of the Education Authority have also been called upon in the finding of employment for patients who are about to leave school. The Care Committee have given much consideration to the problems of employment, and have explored many avenues when dealing with individual cases. Their efforts have not been entirely without success, but greater perseverance must be practised in dealing with this baffling situation if much headway is to be gained. XIV.—Shelters.—As Westminster is situated right in the heart of London, vacant space, attached to dwellings of the working-class type, on which to place shelters is almost unknown. There are a number of houses with back yards, but as a rule they are much shut in and overlooked by high buildings. The use of shelters is therefore not practicable in the City. XV.—Occupational Incidence of Tuberculosis.—As stated in the preliminary remarks of this report, there is no evidence to show that any particular occupation has an influence on the health of the inhabitants. This area is not in any sense industrial, but there are large numbers, both males and females, who find employment in the Government offices, in those of public administrative bodies, of large business concerns, banks. 52 &c. Many residents are also employed as hotel, club, and domesti^ servants. The tailoring and dressmaking industry also provides work for a goodly proportion of the adult population. In the northern area of the City (Soho) those chiefly engaged in making clothes are of foreign nationality, and they work in their homes finishing garments for the large . shops. In the southern area a large number of Westminster residents are employed at the Army Clothing Depot. It is not unexpected to find, therefore, that of the occupations of male and female adult sufferers from tuberculosis, clerks are the most numerous; next come hotel, club) restaurant servants and waiters, and then those engaged in the making of clothing. XVI.—Special Methods adopted or proposed for the Prevention of Tuberculosis.—The preventive methods used in connection with the Tuberculosis Scheme were sketched in the survey report of 1920, and no addition of any importance has been made to them. The free examination of specimens of sputum is widely taken advantage of by medical practitioners; the distribution of cards of information and instruction and the provision of sputum flasks is carried out. Early diagnosis of cases, the examination of contacts, and the isolation of advanced cases have already been described as prominent activities of the scheme. Subsequent reference is made to the administration of laws and regulations relating to tuberculosis which have come into force. during the year. XVII.—Any difficulties which have been encountered in dealing with the prevention and treatment of tuberculosis have arisen from the social circumstances of unemployment and inadequate housing. The former shows signs of declining, and progress has been made in overtaking the shortage of accommodation which is always a factor to be reckoned with in trying to combat the spread of this infection. The following figures relate to the work performed at the Tuberculosis Dispensary during the year as compared with similar data since 1921:— Table IX. Tuberculosis Dispensary. 1921. 1922. 1923. 1924. 1925. New Patients 609 421 529 603 395 Old Patients attending 588 825 800 652 474 Contacts examined 281 183 245 271 150 Individuals who attended 1,197 1,246 1,329 1,255 809 Total Attendances 3,095 3,275 3,133 3,292 2,637 Written Medical Reports to London County Council and Medical Practitioners 1,009 1,554 1,652 1,884 1,280 Consultations with Medical Practitioners 178 181 209 243 90 Other visits paid by Medical Offiecr 320 315 227 178' 87 Visits by Health Visitors to Dispensary Cases 4,941 4,995 4,717 4,907 5,636 Sputum Kxaminations 308 327 300 232 443 X-Ilay Examinations 28 16 5 2 2 53 The number of persons under dispensary supervision excluding domiciliary patients at 31st December, 1925, was 484. The number of insured persons under domiciliary treatment at 31st December, 1925, was 757. References to affiliated hospital in the year were 16. In addition to the visits paid to dispensary cases, the Health Visitors paid 1179 visits to non-dispensary cases. It will be noted that there is a sharp decline in the work performed by the Tuberculosis Officer as compared with last year. The reason is that a full-time permanent Tuberculosis Officer was not appointed until July and did not take up his duties till 13th October. From 1st January to October, the work was carried on by Dr. Saxby Willis, who has so ably acted in the past during the summer vacation. He was, however, unable to devote all his time to the work and was appointed to attend at the dispensary on certain days in the week. Much of the home visiting during that period was not overtaken and the examination of contacts in consequence fell somewhat in abeyance. Westminster Tuberculosis Dispensary. Annual Report of Tuberculosis Officer, 1925. Dr. Ian S. Thomson, Tuberculosis Officer and Assistant Medical Officer of Health, has made the following report:— The number of new patients examined during the year was 395, as compared with 421 in 1922, 529 in 1923, and 603 in 1924. This decrease may be to a large extent ascribed to the fact that the total number of cases notified in Westminster in 1925 was 65 less than in 1924. There were thus not only fewer cases in Westminster, but also a resultant decrease in the number of contact cases available. The examination of contacts is a large and important part of the work of the Dispensary, and frequently a whole family is examined subsequent to the notification of one member. The following table shows the sources from which new cases were recommended, and a comparison with the numbers of similar cases in 1924 Table X. 1925 1924 Practitioners 136 196 Health Visitors (contacts, etc.) 91 189 St. Stephen's Hospital 76 130 Ministry of Pensions 12 15 School Medical Officer 44 17 Hospitals 4 9 Friends, Charitable Societies, Jewish Board of Guardians, etc.. 32 47 395 603 54 It will be noted that the greatest decrease proportionally is in the contact cases. The fact that the proportion cases recommended by general practitioners is well maintained suggests that the Dispensary continues to play its useful part in the health work of the City. This is supported by the fact that 58 per cent. of the total number of cases notified in Westminster during the year have been examined in connection with the work of the Dispensary, as compared with 64.8 per cent. and 60.8 per cent. in the last two years. The decrease in the number of contacts examined may be in some degree due to the fact that in 1925 the work was carried on for the first three-quarters by a part time Tuberculosis Officer and in the last quarter by a new Officer, but the decrease in notification is largely responsible. There has been no radical alteration in the work of the Dispensary which has been described elsewhere. Advantage has, however, been taken of two new schemes started during the year for the treatment of tuberculous subjects and contacts, and it may be of interest to refer to these briefly. In April, 1925, the London County Council started a scheme for the boarding out of children from heavily infected and overcrowded homes during the terminal stages of a case of Pulmonary Tuberculosis in the family, and of children who have been discharged from sanatoria, to prevent the necessity of returning home if the conditions there are unsuitable. There can be no doubt that, to have such a scheme available for suitable cases, is a most valuable thing for the Dispensary and it is satisfactory to note that the scheme is to be continued although on restricted lines. The other agency referred to is the Artificial Sunlight Clinic recently started in Tufton Street by the British Humane Association. A number of school children attending the Dispensary have had a course of treatment at this Clinic on the recommendation of the Tuberculosis Officer or through some other agency. The most suitable cases appear to be those of the rachitic type, with enlarged cervical glands and of poor nutrition. Many of these children appear to derive a marked tonic effect from this treatment and rapidly improve in weight and general condition. No pulmonary cases have been recommended for Sunlight treatment by the Dispensary, but a few cases have been examined who have been treated in this way. In none of these was anything found to suggest that the lung condition had been improved by the treatment and in several cases activity appeared to have been increased. The following table shows the number of cases recommended for institutional treatment to the London County Council:— 55 Table XI. Insured patients— Hospitals. Sanatoria. Males 10 32 Females 12 18 Uninsured patients— Males 5 5 Females 9 7 Boys 4 10 Girls 1 3 41 75 Table XII.— Showing copy of return made to the Ministry on Form R (revised). Metropolitan. Borough of Westminster. , Return as to work carried out in connection with the Tuberculosis Dispensary for the year 1925. (The return should relate only to persons residing in the area which is served by the Dispensary, under the scheme of the Metropolitan Borough Council.) Number of Under observation at the Dispensary on Jan. 1st pending diagnosis. Examined for the first time during the year. Total. Found to be Under observation at the Dispensary on Dec. 31st pending diagnosis. Ceased attendance before completion of diagnosis. Suffering from Tuberculosis. Not suffering from Tuberculosis. Pulmonary. Non- Pulmonary. (a) All persons (including " Contacts.") Adults— Males 0 134 134 92 4 37 1 0 Females 0 126 126 60 6 60 0 0 Children under 15— Males 0 70 70 12 16 42 0 0 Females 0 65 65 3 8 54 0 0 Total 0 395 395 167 34 193 1 0 (6) " Contacts " (included in (all- Adults— Males 0 32 32 19 3 10 0 0 Females 0 54 54 26 0 28 0 0 Children under 15— Males 0 30 30 4 7 19 0 0 Females 0 34 34 1 2 31 0 0 (c) Insured persons (included in (a)). Males 0 104 104 67 3 33 1 0 Females 0 62 62 41 2 19 0 0 56 1 Number of patients under treatment or supervision (excluding persons under observation or domiciliary treatment) on the 31st December* 484 2. Total number of attendances of patients at the Dispensary during the year— Insured 1,309 Uninsured 1,328 3. Number of persons placed during the year under observation at the Dispensary for the purpose of diagnosis 41 4. Number of cases in which the period of observation at the dispensary exceeded two months 6 5. Number of insured patients under domiciliary treatment on December 31st ‡ 757 6. Number of reports received from Insurance Practitioners in respect of insured patients under domiciliary treatment during the year 1 7. Number of persons referred to affiliated hospital for consultation 16 8. Number of consultations with medical practitioners at the homes of patients— Insured 54 Uninsured 36 9. Number of other visits paid by Tuberculosis Officers to the homes of patients 87 10. Number of visits paid by Nurses or Health Visitors to the homes of patients for dispensary purposes 5,636 11. Number of specimens of sputum, examined in connection with the work of the Dispensary 443 * Insured persons under domiciliary treatment by Insurance practitioners should be excluded, even though they may attend the dispensary at intervals for examination or consultation. Such cases should be included under Head 5. ‡ All insured persons in the dispensary area who are actually receiving domiciliary treatment from Insurance practitioners should be included, irrespective of the date upon which they were placed under domiciliary treatment and of any attendance at the dispensary. (Signed) Ian S. Thomson, Date 1st February, 1926. Medical Officer of the Dispensary. HOUSING. During 1925 the Council have continued to prosecute their policy for easing housing difficulties in the City. The Council are fully aware of the shortage of accommodation which exists, and also of the fact that many are living in dwellings which, although they cannot be classified as uninhabitable, are still far below the standard of those erected by the Council during the past twenty years. The Housing Committee were engaged throughout the year in making investigations of sites suitable for housing purposes, and in preparing schemes for the erection of dwellings, while the Public Health Committee were dealing with defects in existing houses and in endeavouring to mitigate overcrowding and other unhealthy conditions of living. In certain districts of London the problem of housing has seized the imagination of groups of individuals who have interested themselves in it. They have set themselves the task of stimulating local authorities to exercise without delay the powers conferred by the various Housing Acts. The suggestions put forward and the advice tendered sometimes 57 reveal a lack of discrimination or unfamiliarity with practical considerations ; but criticism which is helpful and information which is likely to lead to measures for the improvement of unsatisfactory conditions are acceptable. References, somewhat vague in character, have been made to slum areas in Westminster. There are no areas such as would have come under the provisions of Part I of the Housing of the Working Classes Act, 1890, according to the usual criteria adopted; abnormally high deathrate, high incidence of infectious disease, tuberculosis and epidemic enteritis ; absence of modern drainage, inadequate water supply, deficiency of light and air, and structural decay. In an old city such as Westminster there are sure to be found old houses where improvements, although very desirable, would be extremely costly. The leases on such old dwellinghouse properties are often within a few years of expiry. In many instances schemes of development for the erection of large buildings for business and administrative purposes are in contemplation, but are held up owing to the difficulty of rehousing the inhabitants of those out-of-date properties, which would otherwise be ripe for demolition. The scheme of the London County Council for providing suitable homes on their housing estates for those residents in Westminster who are living in insanitary or overcrowded conditions proceeded during 1925 : 3 i families were offered homes, and 15 accepted vacancies on the Becontree and Downham estates. It seems almost unnecessary to repeat that in a number of instances where the vacancies were not accepted the reasons given were either inability to pay the rent of the new houses or inaccessibility to place of work of the wage earner, and the expense of travelling. In every case of a removal from conditions such as mentioned above measures have been taken to secure as far as possible that the rooms in question will not be re-let as formerly. It is the intention of the City Council in considering housing schemes, to provide homes for Westminster workers, many of whom are occupied at hours of the day and night which are not convenient for travelling to outlying suburbs. Reference to the occupational statistics of the 1921 Census shows that there were then 85,797 occupied males and females residing in the City. Of those 56,859 worked in the City, 18,916 worked in other districts and for the remainder definite details were not available (see Table IV). Some of the congestion in Westminster could be eased if those who are living in unsatisfactory conditions, but work in distant suburbs, could be induced to move there. To give point to this suggestion the case may be cited of a man employed at works in a northeastern district who was living in the City. He spent almost three hours daily in travelling, and fares cost him 7s. per week. He and his family were housed in a basement room, but it had not occurred to him that (6375)q K 58 they would all derive benefit by living in a County Council house in the suburb where his work was situated. There ?s much of a constructive nature that those who are interested in housing might do—for example, advice could be given in a case such as the one cited. Much good could be done by spreading information among the people as to how to keep their homes clean and maintain them in good order. Miss Octavia Hill, Some years ago, practised this form of propaganda with very beneficial results. In the annual report of 1922 there was mention of special inspections having been made in respect of houses in certain streets. Many of those houses were old cottages which had fallen into considerable disrepair. In order that the inspections should be undertaken on a more extensive scale, and the work of repair and renovation of similar properties in other areas proceeded with as speedily as possible, the Council appointed an additional sanitary inspector, who took up his duties in May. The Victoria Ward, in which are housed almost a third of the total private families living in the City was considered to be requiring closer sanitary supervision. The fall in population in this ward between the Census of 1911 and 1921 amounted only to 1 per cent. In the same period the population of the Strand, Covent Garden and Charing Cross Wards has fallen 30 per cent. Two inspectors were allocated to the former area where previously there was one. This has resulted in very satisfactory progress in the improvement of the sanitary conditions of the houses of this district, many of which are let in lodgings. The majority are large houses, probably at one time each was entirely occupied by one family: now they are let in floors or in rooms, furnished and unfurnished. They are structuralfy sound, but the internal fittings, woodwork, etc., in many are worn out, and require frequent repairs. Nearly all contain basements, only a small proportion of which are let separately from the ground floor, and in all cases the back rooms are not underground, but open at the level of the back yard. In several instances of overcrowding, difficulties were due to families having grown up while house space had not increased. Rooms which the young adults of working age could use for sleeping purposes were found in the neighbourhood and this alleviated the situation. In a few instances it was found that the presence of a lodger caused the other rooms to be overcrowded. The removal of the lodger put an end to the overcrowding. The more apparent defects in the housing accommodation of the City are to be seen among the groups of old cottages which still remain in various parts. Their faults are easily appreciated by the interested spectator, because the whole structure including the roof, can usually 59 be viewed from the street or yard. The late medical officer of health, when making a survey of cottages in 21 streets which were alleged to be insanitary, pointed out that in many cases the owners themselves had intended to demolish them, but were unable to proceed owing to lack of accommodation for the rehousing of the tenants and to the expense of rebuilding. In certain streets some of the properties mentioned are scheduled to be demolished to make way for street improvement schemes. During 1925 progress was made towards this end, and houses in the following streets were demolished or closed with a view to demolition : 2 in Wood's Place, 4 in Wood Street and 3 in Tufton Street. The conditions at St. George's House have received considerable attention from the Press. This building, the old casual wards of the workhouse, was adapted to house temporarily the tenants displaced from Chadwick Street when the new Peabody Buildings were erected on the Horseferry Road site. The conditions were not ideal, the chief defect being the dark badly ventilated corridor which runs throughout the length of the upper floor, but it was a temporary improvisation devised to meet urgent circumstances. Most of the tenants have not been in haste to leave their much abused quarters where the rents are conveniently low. Originally 28 families were lodged there. In March, 1925, there were 13, and in December, 6. The owners have assisted all the tenants who have found other homes, and have held out monetary inducements to the others to encourage them to do likewise. Before anything on a considerable scale can be done in the way of clearing old and dilapidated houses new houses must be built. Although Westminster in relation to its population contains a larger number of industrial dwellings than any other borough in London—there are 6,089 tenement flats in 70 blocks of buildings—there is still need for further housing accommodation. There are those who consider that block dwellings are undesirable, and allege that they are deficient in light and air. They would prefer to see modern cottages with gardens in the City. The area of the City cannot be extended, and there are consequently no suburbs capable of development. In order to find sufficient space therefore even to house 40 or 50 families it is necessary to build upwards. No blocks of industrial dwellings were completed during the year, but the additional block to the Peabody Estate which will have a frontage to Horseferry Road was well advanced. This block will complete the new estate, and will contain 25 flats with a total of 75 rooms. The total number of tenements on this estate when the new block is completed will be 120 ; "the rents vary from 7s. to 18s., exclusive of rates, for one (6375)q E 2 60 to four rooms. A separate W.C. and scullery, with sink and copper are provided to each tenement; baths and laundries are for common use. The Housing Committee, in July last, in view of certain criticisms which had been made from time to time thought it well to remind the citizens of Westminster of their efforts to obtain suitable sites for working class dwellings in the years following the war. They drew up and circulated a report which by courtesy of the late Chairman is summarized below. It traces the course of various inquiries and negotiations, and gives reasons why schemes which they prepared were reluctantly abandoned. Some of the sites were too small to permit of any adequate housing scheme, and the cost of the land was often out of proportion to its utility. Schemes for the conversion of existing large buildings into working class flats were also drawn up, but later set aside for financial reasons laid down by the Ministry. The success of the scheme for Walden House was largely due to the generosity of the Duke of Westminster, who gave a 99 years' lease of the land at a ground rent of £1 per annum. This block of 40 tenements, housing 285 persons, was opened in 1924. The cost of this structure was approximately £26,000, and although the land is free there is an annual deficit of between £600 and £700 on the scheme. During 1923 and 1924 other sites were considered, and among them may be mentioned a small area with frontages on Willow Street and Greencoat Place. This was found to be awkward in shape and had insurmountable difficulties in other directions. Another fronting on Vauxhall Bridge Road possessed similar drawbacks. A site owned by the London County Council extending almost to the Embankment and bounded on one side by Pulford Street, was rejected because of general inaccessibility. Interest has revived, however, in regard to this site in view7 of the opinions expressed by the agents of the Duke of Westminster, who is the freeholder of the Pulford Street side of the area. There is a prospect that the Westminster Estate might be willing to co-operate in clearing away the buildings which render the site inaccessible, thus making a large open space worthy of consideration for housing purposes. In the concluding paragraph of the report, attention is drawn to the fact that the City of Westminster has already contributed up to March, 1925, £156,430 to the County Rate for housing schemes for the County of London, the present annual rate of contribution being approximately £33,500. Among the many sites which have been considered by the Housing Committee the only one concerning which it has been possible to 61 proceed with definite proposals is that adjoining the Council's dwellings in Regency Street on the Esher Street aspect. The land has been offered by the Duke on very reasonable terms, and plans were drawn up for a block of dwellings similar from an architectural point of view to those which were erected by the Council in 1902-1903. They were, however, to contain considerable improvements such as self-contained bathrooms. The original intention was to provide 83 fiats capable of housing approximately 500 individuals. Certain objections were raised by the Ministry of Health as to possible obstruction to light and air which might be caused by the addition of another high block to those already existing. The Council were, however, eager to proceed with this scheme after so many disappointments and they requested the Minister to receive a deputation to plead for its reconsideration. The Minister consented to discuss the difficulties with the Council, and a deputation consisting of members of the Housing Committee and certain officers of the Council attended in November. It was subsequently arranged that the Esher Street scheme, with certain modifications, would again be submitted to the Minister. Housing Act, 1925.—The Housing Act, 1925, which is an Act consolidating all the housing measures which have been placed on the Statute Book since 1890, came into force on the 1st July, 1925. It repeals wholly the Housing of the Working Classes Acts, 1890 (except for one sub-section), the Acts of 1894, 1900 and 1903. The Housing and Town Planning Acts of 1909 and 1919 are partly repealed, so also the Housing Acts of 1921-1924 which relate more to matters concerning the administration of financial provisions. Regulations were made under the Act of 1925 which cover a wide field. They are called the.Housiiig Consolidated Regulations 1925 and consist of six parts. The first three deal with designations, compulsory purchase, issue, interest, and transfer of local bonds. Part IV deals with the Inspection of District, and re-enacts the Inspection of District Regulations made under the 1909 Act: it is of direct application to the Public Health Department. Parts V and VI relate to rates of interest on expenditure of local authorities, and restrictions on the acquisition of certain lands. New forms of record were drawn up in order to comply with the requirements of Part IV of these regulations. These are kept in card index form, a specimen of which is indicated on the following page. Information obtained by the sanitary inspectors relating to dwelling houses which they visit on complaint, or in the course of routine inspections, is entered each day on those record cards. 62 CITY OF WESTMINSTER. Housing Consolidated Regulations, 1925. Inspection of Houses. Article 28 requires that the Inspecting Officer shall consider specially the following mailers :— (1) Arrangements for preventing contamination of water supply. (6) Arrangements for the deposit of refuse and ashes. (2) Water-closet accommodation. (7) Existence of any room which would by virtue of sub-section (1) (3) Drainage. of Section 18 of the Act be a house so dangerous or injurious (4) Condition of house in regard to light, free circulation of air, damp- to health as to be unfit for human habitation. ness and cleanliness. (8) Any defects in other matters which may tend to render the (5) Paving, drainage and sanitary condition of any yard or out-houses house dangerous or injurious to the health of an inhabitant. belonging to or occupied with the house. Name and Address of Owner : No. of Rooms Character of Letting . (single family, furnished or unfurnished lodgings, etc.). Date of Inspection. Reason for Inspection. State of house at date of Inspection in reference to matters set out above. Action taken by Medical Officer of Health. Result of any action taken. Any further action required. . Remarks, references as to incidence of infectious diseases, etc. • 63 Houses Let in Lodgings.— The revised by-laws for Louses let in lodgings, which have been under consideration by the London County Council since 1920, are shortly to be submitted to the Minister of Health for his confirmation. A conference was convened at the County Hall in July for the purpose of considering the amendments suggested by the Metropolitan borough councils while the by-laws were in draft form. Representatives from all the boroughs attended, those from Westminster being the Chairman of the Public Health Committee, the Town Clerk and the Medical Officer of Health. The chief points which distinguish these by-laws from those made by the various borough councils under the Housing and Town Planning Act 1909, and now in force in the respective boroughs, are as follows :— (1) The new by-laws apply to all tenement houses occupied by the working classes, irrespective of the rent charged for the rooms (under the existing by-laws such houses are exempt where the rent exceeds 15s. unfurnished, and 18s. furnished). (2) The amount of cubic space required for each person occupying a room used wholly or partly as a sleeping apartment is increased to 400 cubic feet, both for adults and for children (the existing standard is 300 cubic feet for persons over 10 years of age, and 200 for those under that age in the case of a room used exclusively as a sleeping apartment, and 400 and 200 respectively where the room is not used exclusively for that purpose). (3) The tenant (person receiving rents) is prohibited from letting rooms which are in a verminous state, and is required, in cases where beds and bedding are supplied by him, to provide them in a clean and wholesome condition. (4) The lodger is required to keep clean and free from vermin all parts of the house used exclusively by him, to keep clean windows, walls, floors and paintwork, and to keep open for at least one hour a day the windows of sleeping apartments. • (5) The owner is required to provide for each family, where ably necessary, separate water-closet accommodation, and accommodation for the washing of clothes and the storage, preparation and cooking of food. (6) The owner is required to provide windows to all habitable rooms, and handrails to all staircases. (7) The owner is required to pave all courts and courtyards adjoining the premises, where necessary for the prevention or remedy 64 of insanitary conditions, and to provide natural and artificial lighting to common staircases. (8) The tenant (person receiving rents) is required to remove accumulations of soot from all chimneys once a year. Items Nos. 2, 5 and 7 above-mentioned do not come into operation until six months after the expiration of the Rent Restrictions Acts, 1920 and 1923. It will he noted from the foregoing summary of the chief points that the proposed by-laws deal with the properties in question in a more comprehensive manner. It is desired that a uniform standard of administration should be in operation for the whole of London, but until the Rent Restrictions Acts have lapsed many of the most important requirements which involve structural alterations will remain in abeyance. The register kept under the present by-laws of the City Council shows that at the end of the year 1925 there were 1,103 houses of this description. In 1924 there were 1,120, and for the years 1921, 1922 and 1923 the numbers were 1,150, 1,150 and 1,144. The gradual diminution in the number from year to year is largely accounted for by the fact that in a district such as Soho a steadily proceeding transformation is in progress—old dwelling-houses are being converted into business premises. During the year 4,317 visits of inspection were paid to those houses. Intimation notices were issued in 205 instances for sanitary defects, and in 8 for overcrowding. Statutory notices were required in 20 cases. No legal proceedings were necessary. Restriction of Rents Acts.—Two certificates were granted on application by tenants. The numbers granted since 1921 were : 1921, 4 ; 1922, 5 ; 1923,10; 1924,9. The following table required by the Ministry of Health is set forth in detail:— Table I. Number of new houses erected during the year:— Tenements. (а) Total25 (б) With State assistance under the Housing Acts, 1919, 1923, or 1924— (i) By the Local Authority .. 0 (ii) By other bodies or persons .. .. .. 0 Table I. Number of new Louses erected during the Year:— Tenements. (a) Total .. 25 (6) With State assistance under the Housing Acts, 1919, 1923, or 1924— (i) By the Local Authority 0 (ii) By other bodies or persons 0 65 1. Unfit dwelling-houses. Inspection—(1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 3,668 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910, or the Housing Consolidated Regulations, 1925 20 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 0 (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 1,013 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 72 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 963 (2) Number of dwelling-houses in which defects were remedied after sendee of formal notices:— (a) By owners .9.16 {b) By Local Authority in default of owners 0 66 C.— Proceedings under Sections 17 and 18 of the Housing, Town 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 houses 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 ance of Demolition Orders 0 General Sanitary Conditions. The table given below shows in considerable detail matters relating to the genera] sanitary condition of the City. The work of the district sanitary inspectors is performed under several main headings : inspection of nuisances and other insanitary conditions, whether on complaint or otherwise; supervision of all new sanitary fittings and drainage in old and new buildings, which includes reporting on plans of proposed sanitary construction in respect of requirements laid down in the by-laws under the Metropolis Management Acts and the Public Health (London) Act, 1891; inquiries into cases of infectious disease; routine inspection of bakehouses, milk shops, restaurants and workshops and workplaces. The observation of smoke nuisances is undertaken by the two inspectors whose duties are otherwise taken up in the administration of the Sale of Food and Drugs Acts. 67 Table II. Inspection of premises :— Stables:— Cleansed 20 Dung accumulations removed 31 Complaints received and dealt with 942 Sanitary work supervised :— Premises inspected on plaint, &c. 959 House to house inspection 3,668 Subsequent visits 20,613 Drains:— Houses let in lodgings, visits to 4,317 Constructed 466 Overcrowding found 8 Amended and repaired 192 Other infringements 205 Ventilated 291 Nuisances and other matters dealt with:— Interceptor traps fixed 166 Sealed off from sewer 62 Gully traps fixed 953 Defective traps abolished 106 Manholes built 676 Houses, cleansed throughout 420 ,, repaired 306 „ „ partially 812 ,, covers fixed or repaired 736 Overcrowding found 43 Light or ventilation improved - 205 Tested by smoke 97 Roofs repaired 453 ,, chemical 431 Floors and staircases repaired 399 „ water 849 Underground rooms:— » air 38 Illegal use 12 Fresh air inlets fixed or Closed 2 paired 372 Yards, areas, paved or repaired 421 Soil Pipes :—- Fixed 477 Damp walls remedied 246 Ventilated 228 Offensive refuse removed 194 Repaired 229 Keeping of animals discontinued 15 Tested by smoke 148 „ chemical 481 Verminous premises cleansed 247 „ water 186 Filthy or unwholesome bedding, &c. „ air 324 Water-closets:— Drains unstopped 170 Constructed 1,634 Waste-pipes „ 106 Repaired 377 Urinals cleansed 89 Traps ventilated 1,249 Water-closets:— Flushing cisterns fixed 1,471 Cleansed or limewashed 715 ,, ,, repaired 279 Unstopped 108 Waste Pipes:— Ventilated and light improved 290 Constructed 1,717 Repaired 249 Ventilated lobbies provided 240 Trapped 2,574 Dust-bins provided 288 Ventilated 2,327 „ repaired 6 Disconnected from drain 322 Water supply:— Rainwater Pipes:— Provided 1,118 Fixed or repaired 639 „ additional in tenement houses 55 Disconnected from drains 125 Urinals:— Cut off 9 Constructed 175 Re-instated 20 Repaired or improved 24 Cisterns fixed 198 Stables:— ,, cleansed 178 Drained — ,, covered 189 Paved — ,, abolished 37 Dung receptacles provided — Taps off main provided 590 Garages constructed 48 Pipes repaired 266 Petrol interceptors provided 20 68 Removal of Refuse.—This is in charge of the Highways Department, whose chief officer is the City Cleansing Surveyor, and the following particulars are supplied by his courtesy. There are no earth closets or privies in the area, the water carriage system being universal throughout the City. The refuse which requires removal comes from domestic premises, clubs, hotels and other similar buildings. A charge is made for the removal of other than house refuse from trade premises, such examples being fruit and vegetables, builders' refuse, etc. There is a daily collection of house refuse, the removal of trade refuse being subject to special arrangements; 80,000 tons of the former were collected during the year and 1,000 tons of the latter. Refuse, after collection, is disposed of in two ways; in one it is sent down the river in barges to be finally deposited on waste land in Essex ; in the other it is sorted in a salvage plant at one of the Council's depots. This plant was installed in 1923, and is similar to a coal washing plant in design and mode of working. By the latter method quantities of materials of a saleable value, such as paper, rags, bones, metal, cinders, etc., are recovered from the bulk. The residual product, largely free from organic debris, is disposed of in a pulverised form, for the purposes of agriculture, etc. During 1925, 66,000 tons were sent away in barges and 15,000 tons were treated at the salvage plant. The use of sanitary movable dustbins is general in the City, and is . required under the by-laws. By-laws as to Removal of Offensive Refuse.—Four cases were reported of removal in unsuitable vehicles and in inadequate receptacles. Including those there were 12 instances of removal during prohibited hours. A summons was ordered in each case, the proceedings resulting in fines amounting to £27. Nuisances.—Intimation notices were served in 980 instances and 1,592 letters were sent dealing with those notices or kindred matters. Statutory notices authorised by the sanitary authority numbered 27 and related to 22 premises. Police court proceedings were taken in 5 instances in order to enforce comoliance with the reouirements of statutory notices. The following are the comparative figures since 1921:— — 1921. 1922. 1923. 1924. 1925. Intimation Notices 1,780 1,344 1,373 1,098 980 Letters 1,305 1,445 1,141 1,028 1,592 Statutory Notices 113 01 38 41 27 Legal Proceedings 9 6 2 2 5 69 In the five instances of legal proceedings the cases were: failure to remedy defects or to cleanse premises; absence of water supply to a water-closet; and failure to abate a nuisance arising from the keeping of animals. Abatement orders were made in two cases and a prohibition order, with £2 2s. costs, in the case of the keeping of animals. One summons was adjourned for 21 days on the owner undertaking to carry out the work, and was eventually withdrawn. One summons against an occupier was dismissed, the owner being ordered to abate the nuisance. Rat Repression.—Forty-two complaints of rats were received and in each case an inspector investigated as to the cause of the complaint. Steps were taken to abolish their portal of entry into premises and advice was given as to the best methods of destroying them. In 15 instances it was found that they had entered through faulty or defective drains and sewers. Forty-seven connections were examined by the City Engineer's staff at the request of the Public Health Department on account of complaints of rats. During rat week, beginning in November, a special circular dealing with the causes of rat invasion and the means of getting rid of rats was drawn up in the department and distributed to householders and to business firms. During that week 14,000 baits were laid in the Council's sewers, which number 247. This is about twice the number of baits which are normally laid each week in the sewers. Water Supply.—The Metropolitan Water Board sent nine notices of withdrawal of water supply to premises. The reason for the action of the Board in each case was failure to pay water rate. Considerable progress was made in improving the water supply to the upper floors of tenement houses, and it is anticipated that when the new by-laws come into force still further improvements will be achieved. Power to effect this provision is given under Section 48 of the Public Health (London) Act, 1891, and under Section 78 of the London County Council (General Powers) Act, 1907. The number of cases in which this action was taken since 1921 is as follows :— 1921. 44 1922. 53 1923. 36 1924. 27 1925. 55 Artesian Wells.—There are approximately 25 artesian wells in the City, and analysis of the water obtained shows it to be of a wholesome character. The wells which have been sunk during the past few years have been bored more and more deeply into the chalk underlying the London clay. It has been found that as the number of wells increased the level of the underground water has fallen, and it is now necessary to go down 500 to 550 feet or more before an adequate supply can be reached. 70 The older and more shallow wells—those of 200-300 feet—have suffered in consequence, and in many the water supply has steadily diminished, while in others it has ceased, the water level having sunk below the boring. Many hotels and large blocks of flats are supplied with water from artesian wells. If the wells are deep enough to secure a constant supply the scheme is economically advantageous, as the premises are exempt from the 7 per cent. rate on the annual rateable value levied by the Metropolitan Water Board. In very large buildings this may mean a saving of several thousand pounds per annum. In some cases the water supply has required to be supplemented from the Water Board's mains, while in others the supply from the wells is used only for heating and washing purposes, that from the Board being specially provided for drinking and cooking. New Sanitary Construction.—Plans relating to work of'this description numbered 658, of which 102 represented sanitary provisions in entirely new buildings. The corresponding figures since 1921 are as follows :— — 1921. 1922. 1923. 1924. 1925. Plans 383 468 551 602 658 Plans of work in new buildings included in above 22 39 73 80 102 A glance at these figures indicates the great activity in building which has been in progress in the City during the past five years. These developments are rapidly taking place, as even the most casual observer must have noticed; the transformation of Regent Street and the vast new buildings in Piccadilly are examples of the extensive changes which are making the face of the City unfamiliar to the old-time Londoner. It need hardly be added that the supervision of the sanitary requirements in such vast undertakings has greatly increased the responsibilities of the officers of the department. In 19 instances the plans related to houses wholly or partially being converted into flats, and in 7 instances to stables being converted into dwellings. Of the total of plans submitted, 10 were not approved, as the work proposed did not comply with the by-laws. In 5, the proposals were withdrawn. 71 Combined drainage orders were made in 46 cases. Infringements of the by-laws were reported to the Public Health Committee in 29 instances. In 17 there was failure to give notice of intention to construct, and in 12 there was neglect to deposit plans. Four builders were cautioned and five were summoned in respect of these offences and were convicted, fines and costs amounting to £13. During the year very strong representations were made by architects and others holding favourable opinions of the methods of sanitary arrangement in vogue in buildings in America. They urged that in one particular large block of residential flats they should be permitted to override the by-laws of the London County Council by placing w.c.s in rooms without external walls, and without natural ventilation to the outside air. They alleged that mechanical ventilation had every advantage over the natural method. The proposals were, however, rejected as being contrary to the spirit and the letter of the by-laws. Smoke Prevention.—The need for the adoption of more stringent measures to abate the nuisance from smoke has been voiced in all quarters, and the matter has now engaged the attention of Parliament. In Central London, at any rate, it would appear that domestic coal fires are the chief contributory factors in polluting the atmosphere, and play a large part in creating the fogs which continue, although less frequently and less completely than in years gone by, to inflict their depressing influences. Fogs are very ill-borne by sufferers from lung and heart affections, and there is good reason to suppose that many deaths from these causes are attributable to the effects which the impurities of the air seem to set up in elderly people who are afflicted with these maladies. A measure is being introduced into Parliament which, it is hoped, may lead to considerable improvement in dealing with smoke nuisances. It extends Sec. 24 of the Public Health (London) Act, 1891, to include any type of smoke, and not only " black smoke " : soot, ash and grit are included in the term " smoke " as defined. The emission of black smoke will be an inexcusable offence, although evidence relating to suitable plant and proper use thereof for the prevention of other kinds of smoke will be accepted as exonerating the offenders. Power to make by-laws prescribing standards of smoke, and for the limitation of periods during which it may be emitted, is proposed in the bill. By-laws are also suggested for regulating the construction of heating apparatus in new buildings other than private houses, so as to ensure that there will be little or no smoke from such apparatus. The bill, unfortunately, leaves untouched the difficult and ever present problem of smoke from private houses. 72 Some interesting figures are found in the Report of the Royal Commission on the Coal Industry published a few weeks ago. The work of the Departmental Committee who reported in 1921 is quoted. " The gross wastefulness of present methods of consuming coal in domestic grates is commented upon, and also the ill-effects on health from pollution of the air. There is 20 per cent. more sunlight in the country than in towns because of their smokiness. Two and a half million tons of potential fuel from domestic fireplaces and half a million tons from industrial furnaces escape annually into the air. In terms of money this annual waste is computed at £6,000,000. Smoke makes things dirty. It has been estimated that in Manchester the increased cost of household washing alone on account of smoke is over £290,000 a year." The following table shows the extent to which smoke has been a cause of complaint to the sanitary authority during the past five years, and also a summary of the measures taken in mitigation :— Table III. — 1921. 1922. 1923. 1924. 1925. Complaints received 30 31 12 40 80 Observations taken 1,838 1,795 600 2,309 1,999 Notices issued— Preliminary 1 80 8 42 23 Statutory 52 2 2 — — Summons ~ ~~ 1 ~ It has not been found necessary during the year to serve any statutory notices, and it is satisfactory to record that in every instance the party responsible for the nuisance has been anxious to do everything possible to prevent a recurrence of it. Occupations and Workshops. In this report previous comment has been made on the fact that the City of Westminster is a great administrative, business and shopping centre, and that by far the greater proportion of those whose occupations are in the City live in other districts. The following table extracted from the data supplied by the Registrar-General in his report on the 1921 Census, and reproduced from the report of the late Medical Officer of Health for the year 1923, may. be of interest in this survey report of the previous five years:— 73 Table IV. Total resident population enumerated Males. Females. Totals. 61,380 80,198 141,578 Occupied persons enumerated 45,041 40,756 85,797 Do. do. with workplace in City 23,717 33,142 56,859 Do. do. with no fixed workplace 5,698 1,240 6,938 Do. do. workplace not stated 2,189 895 3,084 Do. do. with workplace outside City 13,437 5,479 18,916 Occupied persons working in the city but living elsewhere 170,414 81,026 251,440 Total occupied persons in City during day 207,018 116,303 323,321 In the following tables are shown in detail the number and variety of work premises on the register at the end of 1925 ; the number of inspections made, and the results of such inspections; and a summary of the work of the lady sanitary inspector whose duties are confined to supervision of premises where women are employed and to those occupied by outworkers :— Table V. Work Premises. Total Number. Tailors, outfitters, shirt makers, hat, cap and helmet makers Dressmakers, milliners, embroiderers, lace makers, blouse makers, costumiers, lingerie makers, children's outfit makers, feather 1,424 dyeing, corset makers, furriers, &c. 1,141 Leather workers, boot and shoe makers, harness makers, &c. 64 Carpentry, upholstery, carvers, gilders, &c. 59 Surgical and dental instrument makers 9 Tabacco manufactures 16 Wig makers and hair workers 52 Printing, bookbinding, lithographers, envelope making, stationers, relief stamping , engravers,&c. 55 Jewellers, silversmiths and burnishers, diamond cutters and 57 Metal workers 14 Miscellaneous—Basket making, fancy work, shoe ornaments, hat pins, stamp sorters, postcard tinters, fan makers, artificial flower makers, &c. 88 Florists 24 Laundries 29 Bakehouses 77 Photographers 26 Jewel case makers 10 Cinema film workplaces 59 The use of 295 workshops was discontinued, and 254 additions were made to the register during the year. (6375)Q F 74 Table VI.—Inspection. Premises. Number of . Inspections. Reinspections. Defects Found. Intimation Notices. Statutory Notices. Prosecutions Factorirs 107 81 16 2 ~ ~ Workshops 1,666 2,325 632 260 1 ~ Workplaces (Excluding restaurant kitchens, &tc.) 1,445 1,929 649 143 ~ ~ Total 3,218 4,335 1,297 405 1 ~ Table VII.—Defects found. Particulars. Number of Defects. Number of Prosecutions. Found. Nuisances under the Public Health Acts :— Lack of cleanliness 484 — Insufficient ventilation 77 — Unventilated gas stoves 59 — Overcrowding 36 — Floors without means of drainage 25 — Sanitary accommodation— Insufficient 81 — Unsuitable 98 — Defective 157 — Not separate for sexes 46 — Other defects 234 — Total 1,297 — Offcnces under the Factory and Workshop Act;— Illegal occupation of underground bakehouses — — Breach of special sanitary requirements for bakehouses (included, above) — — Other offences — — Table VIII.—Other Matters Class. r. Visits to Out-workers' premises other than workshops 149 Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act 213 Absence of means of warming .. — Matters referred by H.M. Inspectors 132 Workrooms measured 290 Visits of Enquiry re Employment of Women 150 „ „ Outworkers 454 Underground bakehouses in use at the end of the year 56 A copy of a table relating to outworkers required by the Home Office under the Factory and Workshop Act, 1901, and giving information under the headings of Sees. 107. 108, 109 and 110 is appended. 75 (6375)Q Table IX. Outworkers Lists, Section 107. Outwork in unwholesome premises. Section 108. Outwork in infected premises, Sections 109 & 110. Trade. Lists received from employers. Addresses of Outworkers. Notices served on occupiers as to keeping or sending of lists. Prosecutions. Instances. Notices served. Prosecutions. Instances. Orders made (Section 110). Prosecutions (Sections 109, 110). Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of lists. Failing to send lists. Outworkers. Outworkers. Received from other Councils. Sent to other Councils. Lists. Contractors. Workmen. Lists. Contractors. Workmen. Wearing apparel 1,007 1,777 8,744 64 43 139 472 6,024 109 — — — — — 15 — — Linens, etc. 4 26 51 — — — — 55 1 — — — — — — — — Furriers 10 18 23 1 — 1 12 32 3 — — — — — — — — Umbrellas, toys, artificial flowers, etc 4 76 98 — — — — 162 — — — — — — — — — Engraving, metal work, etc. — — — — — — 6 — —— — — — — — — — — Total 1,025 1,897 8,916 65 43 140 490 6,273 113 — — — — — 15 — — v 2 75 Outworkers.—The total number of lists received during the year amounted to 1,090, an increase of 215 compared with the previous year. This increased figure is due mainly to systematic visits having been paid by the lady sanitary inspector to firms engaged in certain businesses, principally the sale of wearing apparel, whose names did not appear on the list of those employing outworkers. No legal proceedings had to be taken in respect of failure to send lists, but reminder notices were sent to 113 firms. The lists received contained 10,996 names and addresses, of which 6,273 belonged to other districts. The number of individual outworkers in Westminster is 1,737, of whom 1,465 are registered as occupying workshops. The number of premises in which outwork is carried on is 874. Disinfection. Disinfection of rooms from which patients suffering from notifiable infectious disease have been removed is carried out by means of the. formaldehyde spray. For other non-notifiable infectious conditions disinfection is carried out on request, and a charge is made according to the circumstances of the case. Bedding and wearing apparel are removed to the Disinfecting Station, and are there submitted to steam disinfection. The apparatus used is of the type manufactured by Manlove and Elliot, and the steam pressure employed varies between 180 to 250 lbs., according to the nature of the articles. Books are treated with formalin. The cleansing of persons and of premises in a verminous state has occupied a considerable proportion of the time of the Disinfecting StafE. Visits were paid to 36 houses and 2,071 articles of clothing, bedding etc. were removed for disinfection. Individuals numbering 117 (98 men and 19 women) were given medicated baths at the Disinfecting Station, which necessitated their making 874 attendances. Notices from the London County Council in regard to school children affected with vermin numbered 399, and the Disinfecting Superintendent paid 1,190 visits of investigation to their homes. By agreement with the London County Council, arrangements are in force for the treatment at the Westminster Disinfecting Station of school children from the boroughs of Battersea, Chelsea, Holborn, Kensington, Lambeth, St. Pancras, St. Marylebone and the City of London. 77 There were among Westminster children, 537 cases of head lice treated, 11 of body lice and 38 of scabies. In all these cases the clothing was disinfected together with the bedding from their homes, amounting in all to 2,401 articles. Children from the above-mentioned boroughs treated for similar conditions were as follows: 324 for head lice, 2 for body lice and 16 for scabies. The number of attendances of these children for baths at the station was 1,559. The following table shows the total number of individuals treated at the station for verminous conditions:— Table X. 1925. Head lice. Body lice. Scabies. Total. Children 861 13 56 930 Adults *117 10 9. 136 978 23 65 1,066 * The large number of adult cases of head lice is due in a great measure to the cleansing necessary before admission to the hostel in Grosvener Road organised by the St. Martin's Church authorities. All the lice cases were dealt with at the station, but 4 of the scabies cases were treated at home. Table XI. 1921. 1922. 1923. 1924. 1925. Rooms 1,502 1,179 742 984 1,081 Articles disinfected 31,654 28,709 21,933 23,382 22,833 Articles washed 6,766 7,355 8,679 4,862 5,142 Articles destroyed 38 105 173 198 265 Books disinfected * 212 173 215 425 454 Vehicles „ Offices and business premises 1 8 3 3 8 — — — — 21 * School books, 413; library books, 30; private books, 11. The motor van during 1925 ran 3,663 miles and carried 3,361 cwt. of goods, the highest amount in any one day being 36 cwt. The petrol con. sumption was 406 gallons, equal to 9.0 miles per gallon. Mortuaries. The number of bodies removed to the Council's mortuaries under order of the Coroner, or to await burial, was 332—in one instance on account of infectious disease. 78 Inquests were held at Horseferry Road, where the Coroner's Court is situated, in 317 cases, and there were 10 adjourned inquests. Postmortem examinations were made in 184 instances. Seventeen 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 23 years were :— Table XII. Total. For Inquest. To await Burial Total. For Inquest. To await Burial. 1903 396 341 55 1915 376 349 27 1904 381 322 59 1916 281 252 29 1905 368 307 61 1917 278 265 13 1906 344 283 61 1918 285 242 43 1907 358 281 77 1919 308 269 39 1908 364 298 66 1920 289 269 20 1909 291 258 33 1921 273 238 35 1910 333 281 52 1922 269 247 22 1911 383 334 49 1923 336 318 17 1912 324 284 40 1924 340 328 12 1913 328 286 42 1925 334 317 17 1914 323 295 28 There are resting places for the dead at Ebury Bridge, Dufours Place and Drury Lane. The latter was used on two occasions. MATERNITY AND CHILD WELFARE. The Maternity and Child Welfare scheme of the Council embraces both municipal and voluntary organisations. Until 1918, with the exception of the assistance rendered by one whole-time health visitor who was appointed by the Council on the adoption of the Notification of Births Act (1907), this work was carried out for the whole City by a voluntary body, the Westminster Health Society, which received financial aid from the Council. The Society was founded in 1904, and is thus one of the pioneer bodies in the country to engage in the campaign for the preservation of infant life. As a result of the appreciation of the work of this Society, similar bodies were founded in other parts of London, and they have profited by the experience of the early efforts of this body of enthusiasts in Westminster. Among its moving spirits were Miss Margaret Horn, who remains the Hon. Organiser of the Society, and Dr. Allan, the late Medical Officer of Health of the City. The Society built up the system of child welfare in Westminster. They taught mothers that mothercraft came not always by intuition, and that rule-of-thumb methods sometimes gave disappointing results. They organised clinics where mothers could receive free advice on infant feeding from qualified doctors, and this was supplemented by printed leaflets. Instruction in 79 garment-making and cookery was given, and information concerning all those various activities was brought into the homes by trained health visitors. We live in days when maternity and child welfare is a term in common currency, and remote indeed must be the township which does not possess its welfare centre. But in the early days of the Society it required high courage to break down the defensive barriers of those who felt it an indignity to be told how to bring up their own children. In 1918 the Society gave up the work in that part of the city comprising the wards of Victoria, Knightsbridge St. George and Hamlet of Knightsbridge, and the Council took over their duties. The same premises at No. 1, Pimlico Road were used as a centre, and the health visiting was reorganised, an additional visitor being appointed to the Council's staff. The scheme was enlarged in 1920 by the opening of another centre at 15, Bessborough Street. The City is thus served by two centres administered by the Council in the area mentioned above, and in the remaining and larger portion by two centres organised by the Westminster Health Society. Of the latter, one is situated in Soho at 60, Greek Street, and the other at 100, Rochester Row, in St. John's Ward. The Society have felt for some years that the work at the Rochester Row centre is being seriously hampered by lack of accommodation. The building is an old dwelling-house, the ground floor of which was formerly a shop. The building is high, the stairs are narrow and steep, and the rooms are small. A scheme to build a new centre in the neighbourhood is in contemplation, and it is hoped to put into this project all the modern notions of what a maternity and child welfare centre should be. The Society, faced with the end of the lease of their northern centre at 60, Greek Street, came reluctantly to the conclusion that they ought to concentrate all their energies and resources on the scheme for a new centre in place of that at Rochester Row. Accordingly, in December they intimated to the Council their intention to discontinue the work in the northern area when the lease of 60, Greek Street, ends in June, 1926. Ante-natal Work.—Expectant mothers are brought in touch with the centres by introduction from mothers who already attend : they may be recommended by the health visitors or by the almoners of hospitals to which the women have applied for assistance in their confinements. Some arc sent by midwives. Thus 817 became known to the centres, and 796 primary visits were paid to them in their homes by the health visitors; subsequent visits numbered 1,169. Ante-natal clinics are held once a week at each of the Council's centres by Dr. Ethel Vernon, who 80 also conducts the clinics for infants. The number of mothers who attended during the year and the total attendances are given below. Table I.—Ante-natal Clinics. Centre. Sessions. First Attendance. Subsequent Attendances. Total. No. of Individuals. Pimlico Road 52 55 52 107 82 Bessborough Street 51 88 65 153 103 The object of ante-natal supervision is to ensure that the mother will be protected as far as it is possible from the preventable maladies which sometimes render the period of pregnancy a time of illness and distress. Many of the difficulties and dangers of labour can be foreseen and guarded against. There are still too many women who die as a result of pregnancy or of conditions connected with it. In 1924 there were 2,847 deaths in England and Wales from causes directly connected with childbirth, 1,018 of these being due to sepsis. It would appear that a proportion, probably amounting only to a third of the total deaths, could have been prevented by ante-natal measures. Not until the very eve of labour, or sometimes not until it has actually begun, is it possible to comprehend certain dangers which may jeopardise the life of the mother or infant. Ante-natal supervision can do a great deal in safeguarding the general health of the mother and in providing against certain natural difficulties, but it is clear that the weight of our efforts should be directed towards the actual state of labour and its premonitory symptoms. In first pregnancies it would appear that modern conditions of life tend to vary what should be a natural process to one approaching the pathological. In those cases it is most desirable that patients showing any deviation from what may be considered normal should be placed at the very first signal of distress in the institutions devoted to this special purpose. Comment has already been made in the first section of this report that in Westminster there is an increasing tendency for mothers to enter hospitals for their confinements. At Charing Cross, St. George's, and Westminster Hospitals expectant mothers who have made arrangements for their confinements with these hospitals may attend in the special departments at regular intervals during the period preceding labour to receive advice and treatment. Molhercraft.—The teaching of mothercraft has always occupied a very prominent place in the activities of the Westminster Health Society, and the Society have received well-merited honour for their 81 achievements in this branch. Mothercraft is also taught at the Council's. centres on principles similar to those which were first introduced by the Society. The teaching of mothercraft consists of demonstrations in everything connected with the culture of the young child : its requirements in clothing and feeding, its daily habits and general nurture of mind and body. Health talks are also given on these matters and on such others as the prevention and treatment of childish ailments, the methods of maintaining the purity of milk and its importance in infant dietary. Classes were held once a week at the Council's centres and at those of the Society. Figures are submitted of the attendances and of the work done in the making of children's garments by the mothers. Table II.—Mothercraft Classes. 1924' Pimlico Road. Bessboro' Street. Rochester Row. Greek Street and Mayfair. Total. Number of classes 47 48 78 114 287 . Total attendances 622 912 1,712 1,387 4,633 Average attendances 13.2 19.0 21.9 12.1 16.2 Number of expectant mothers 19 49 63 32 163 Number of attendances by expectant mothers 108 307 677 230 1,322 Number of other mothers 27 66 47 45 185 Number of attendances by other mothers 514 605 1,035 1,228 3,382 Attendances of children in nurseries during classes 241 920 699 454 2,314 Materials are purchased in quantity, and sold to the mothers at cost price. The number of garments made at Pimlico Road were 182; at Bessborough Street, 263 ; at Rochester Row, 1,140 ; and at Greek Street and Mayfair, 1,090. In addition to those, many renovations were carried out. Midwifery Services.—Midwifery is practised in the City by doctors, midwives, and by the in-patient and out-patient services provided by the hospitals. The Council felt in 1919 that there was a lack of home midwifery service for those who could not afford the attendance of private midwives, and they appointed a midwife to attend necessitous cases in the Victoria, Knightsbridge, and Hamlet "Wards. A fee, which varies according to ability to pay, is assessed by the Maternity and Child Welfare Commitee, and is payable to the Council for the midwife's services. The Council's midwife, in addition to attending her own cases, is available for assistance as maternity nurse in cases being attended by private doctors, and also in those attended from the hospitals. The following table shows a record of the midwife's work since 1921. 82 Table III. Number of cases attended— 1921. 1922. 1923. 1924. 1925. As midwife 103 95 108 75 73 As emergency 13 7 2 — — With hospital students 2 7 5 — — With private doctor 1 — 1 — — Total 119 109 116 75 73 Number of— Pre-natal visits 919 527 610 570 779 Lying-in visits 880 866 1,402 920 939 Subsequent visits 115 358 172 315 335 Visits to infants under 1 year other than lying-in visits 158 215 172 266 234 Total number of visits 2,072 1,966 2,356 2,071 2,287 Table IV. Attendances by midwife at ante-natal and other clinics :— 1921 1922 1923 1924 1925 1, Pimlico Road 83 41 72 40 54 15, Bessborough Street 105 73 62 83 75 Total 188 114 134 123 129 The Westminster Health Society provide midwives for a similar object in the areas of the City under its organisation. Until the middle of the year four midwives were employed, two working in St. John and St. Margaret wards, and two in the northern area (Strand, Covent Garden, Soho, etc.). In the former area the midwives co-operate with Westminster Hospital by nursing the outdoor cases of that institution. In the northern area the two midwives performed the duties concerned with all the outdoor cases of Charing Cross Hospital, for which a grant was paid to the Society by the hospital. This arrangement was discontinued in July, when the Society relinquished all midwifery practice in this area. The hospital then became responsible for the attendance on their own outdoor maternity cases and employed midwives on the staff of the hospital for this purpose. The table which follows summarises the work of the Society in this sphere. It has been the custom in both areas for the Society's midwives to attend the ante-natal clinics at each hospital concerned, bringing for advice cases in which there were elements of doubt or difficulty. 83 Table V. Number of cases attended— St. John and St. Margaret Wards (Rochester Row). Northern area (Greek Street). As midwife 56 — With hospital students 13 17 With private doctors 3 — 72 17 Midwifery visits 1,113 236 Nursing visits 165 — 1,278 236 There is a growing tendency among doctors to give up the practice of midwifery. Perhaps this may be partly due to the exigencies of panel and private practice and the fact that the remuneration offered is not always proportionate to the time and trouble expended. An aspect of the situation which should be considered is that some cases requiring skilled medical aid have already become difficult before such aid is summoned. In many, difficulties might be avoided if medical skill were at hand from the very beginning. During the quinquennium considerable progress has been made in the provision of maternity beds at the general hospitals. Reference to the annual report of 1920 reveals the fact that no beds were then available for ordinary maternity cases, although specially difficult cases were admitted for operative treatment. The Council at that time considered that a Lying-in Home was urgently required, and contemplated establishing an institution in conjunction with the Women's Section of the Comrades of the Great War. They were deterred from embarking on this scheme by reason of the very considerable annual expenditure which was proposed. The need, however, has been met owing to the initiative of the voluntary hospitals and the increased accommodation which has been provided at St. Stephen's Hospital; 15 beds were opened at Charing Cross Hospital in 1924, followed by 11 at St. George's Hospital, and when Westminster Hospital was partly reconstructed and enlarged in the same year 4 beds were set aside for maternity cases. It is important that the public should be made aware of the maternity department at St. Stephen's Hospital. A ward of 28 beds is devoted to maternity. The excellence of the work which is performed may be judged from the fact that this department is recognised as a training school for midwives by the Central Midwives Board. Fully qualified and experienced midwives are in 84 charge of the cases, and the medical staff undertake the treatment of those requiring operative measures. Several operations of major degree, such as Cesarean sections, have been performed most successfully. There are also wards for patients suffering from septic conditions of the puerperium. Those cases should be handled at home as little as possible. If the case happens to be one of accident to an early pregnancy there is always present the risk of sepsis, which sometimes proves fatal. Thorough treatment is immediately necessary to prevent this risk, and the patient should be removed to hospital at once. A further remark about the facilities at St. Stephen's Hospital might be made. Women may be admitted many days before labour has begun— in some instances weeks before. This is possible because of the ample accommodation which the Guardians have provided, and is of immeasurable benefit to patients when there are organic complications present. A period of rest before labour lessens the strain of the confinement. Patients are also kept in the hospital for two or three weeks afterwards. Most women appreciate this extension of the usual puerperium, which should certainly diminish any tendencies to subsequent complications. The following table shows the number of confinements in Westminster institutions:— Table VI. Charing Cross Hospital: 226, of which 63 were Westminster cases. St. George's Hospital: 260, of which 76 were Westminster cases. Westminster Hospital: 123, of which 61 were Westminster cases. St. Stephen's Hospital: 122. Sheffield St. Hospital: 28. In order to link up the ante-natal work of the centres with the maternity service provided in hospitals the Council in 1924 entered into an agreement with St. George's Hospital for the reception of maternity cases recommended by the Medical Officer of the Ante-natal Clinic : cases in emergency may also be admitted at the request of the Council's midwife. This arrangement is in operation for the area in which the Council are responsible for maternity and child welfare. A grant is payable by the Council to the hospital for each case admitted on recommendation, and the number treated in 1925 was ten, and in 1924 ten. Puerperal Fever and Mortality in Childbirth.—Six cases occurred with one death. The results of inquiries showed that in one instance fatal sepsis followed an abortion. Two other patients died who were normally resident out of the City: they had made inadequate arrangements for confinement. Infancy and Early Childhood.—At the four centres in the City 7 weekly clinics are held for the purpose of giving medical advice. The health 85 visitors attached to those centres visit the homes for the purpose of supplementing the instructions of the medical officers, and of advising as to how those instructions should be carried out. Home visiting is of prime importance in maternity and child welfare, and its place cannot be taken by teaching groups of mothers at the centre. In the home the visitor, by seeing the actual conditions, can appreciate any difficulties with which the mother may be contending, and much can be cleared up in the course of a quiet talk. Visits of inquiry are necessary in cases of ophthalmia, measles, and other infectious diseases. The following table shows the number of visits paid in connection with the four centres:— Table VII. —- Pimlico. Bessborough Street. Rochester Row. Greek Street. Total. Pre-natal— First visits 235 174 244 147 800 Other visits Children under 1 year of age- 357 147 426 239 1,169 First visits 417 265 327 277 1,286 Other visits Children over 1 and under 5 years— 1,174 840 1,124 862 4,000 Visits 2,058 1,911 1,923 1,298 7,190 Death enquiries, still births, &c. 57 32 25 19 133 Infectious diseases 410 220 138 4 772 4,708 3,589 4,207 2,846 15,350 The Council's midwife paid 779 visits before, and 234 after, confinements which are not included in the Table VII. This also applies to the Greek Street centre of the Westminster Health Society, where the midwives paid 103 visits before confinement and 185 to infants under 1 year of age. At the North Centre, 60, Greek Street, 15 classes were held by Dr. Lewin for Nasal Hygiene, especially in connection with cases of adenoids and faulty nasal conditions. Infant Clinics.—These are held at the following centres at the times mentioned:— Council's Centres— 1, Pimlico Road—2 p.m. Wednesday. 2 p.m. Friday. 15, Bessborough Street—2 p.m. Thursday and 10 a.m. Friday (combined with ante-natal clinic). Westminster Health Society— 60, Greek Street—2.45 p.m. Thursday. 100, Rochester Row—2 p.m. Tuesday. 2 p.m. Friday. It will be noted from the following table of attendances that in spite of considerably fewer births in the City there are a greater number of new infants being brought to the centres. The average attendance per session has increased, as also have the total attendances. The comparative totals since 1921 are also shown :— 86 Table VIII. Attendances at Infant Consultations, 1925. Centre. Number of Sessions. First Attendances. Subsequent Attendances. Total. . Under 1 year. Over 1 year. Under 1 year. Over 1 year. Under 1 year. Over 1 year. 1, Pimlico Road 102 233 67 1,847 1,144 2,080 1,211 3,291 15, Bessborough Street 101 166 63 1,597 1,574 1,763 1,637 3,400 100, Rochester Row 94 239 73 1,566 1,108 1,805 1,181 2,986 60, Greek Street 50 116 7 701 126 817 133 950 1925 347 754 210 5,711 3,952 6,465 4,162 10,627 1924 374 719 196 5,249 3,646 5,968 3,842 9,810 1923 357 819 161 5,282 3,194 6,022 3,434 9,456 1922 348 800 170 5,085 2,784 5,905 2,954 8,859 1921 318 900 243 5,980 2,665 6,895 2,908 9,803 The average attendances per session were— 1925. 1924. 1923. 1922. 1921. Pimlico Road 32.2 29.7 26.0 27.7 31.8 Bessborough Street 33.6 31.0 29.1 29.1 40.5 Rochester Row 30.7 24.3 30.9 25.5 27.5 Greek Street 19.0 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 138 at Greek Street. Ante-natal clinics and medical consultations in connection with their 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 580 100, Rochester Row 578 15, Bessborough Street 495 60, Greek Street 207 87 Infant clinics in connection with the maternity departments of Charing Cross, Westminster, St. George's, Middlesex, and the General Lying-in Hospitals are held weekly in those institutions. They do not come within the maternity and child welfare scheme of this Council, but Westminster mothers whose confinements have been conducted within or in connection with those hospitals may, if they so desire, attend with their infants. Mention should also be made of the valuable work which is being carried out at the Infants' Hospital, Vincent Square. Not only does this institution exist for the treatment of infantile diseases, but its influence as a centre for research and for the training of doctors and infant welfare workers is becoming widely known and appreciated. Nursing.—In 1917, under the powers conferred by the late Local Government Board, the Council made arrangements with the three District Nursing Associations which work in the City for the home nursing of measles and ophthalmia neonatorum. With the advent of the Maternity and Child Welfare Act of 1918, the Council were of opinion that the agreements should be extended to cover all diseases of children and this action was accordingly approved by the ' late Board in 1919, and has been in operation ever since. The table submitted below shows the number of visits paid and the nature of the conditions for which visits were made. The request for a patient to be visited as a rule comes through the welfare centre on the information of the health visitors. The rules of the nursing associations, however, make it obligatory that a medical practitioner must be in attendance on any case where their nursing services are required, and so it is necessary that the medical officer of the centre or medical practitioners in the district should authorise nursing visits. In each case the requisition for nursing services requires to be sanctioned by the Medical Officer of Health. There is no doubt that this provision for home nursing has exercised an extremely beneficial effect in diminishing the after-effects and dangers of certain illnesses—notably, measles and ophthalmia. In cases where medical attendance at home cannot be continued, the daily visit of the district nurse ensures that no neglect can occur. She keeps in close touch with the welfare centre and reports as to the progress of her cases, so that should the need arise for removal to hospital this can be effected without delay. 88 Table IX. Ophthalmia neonatorum and conjunctivitis Patients. Visits. 14 329 Influenza 3 33 Pneumonia 20 278 Bronchitis 22 252 Measles 3 32 Whooping cough 1 13 Other complaints 199 2,059 Total 262 2,996 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. From 1921 the total of notified and mild cases gives the following rates per 100 births 1921 1.8 1922 2.4 1923 3.4 1924 2.4 1925 2.0 There are a number of cases in which inflammation develops in the eyes of recently born infants, and if the discharge remains watery in nature and pus does not form the condition need not be classified as ophthalmia. The infection, nevertheless, may be gonococcal in origin. Those are necessarily mild cases, but it is important that they should be recognised and treated at an early stage, because if neglected genuine purulent ophthalmia might ensue. Twenty-one cases were notified during the year, 12 of those being treated in hospital. There were also 11 instances of watery discharge from the eyes which were brought to the notice of the health visitors. All cases of ophthalmia neonatorum are visited as soon as possible after notification in order to see that adequate treatment is being provided. Treatment by the district nurses was carried out in 14 cases, 329 visits being paid. The case rate of notified and mild (non-purulent) cases since 1921 is as follows, showing a decline in 1925 :— 89 Table X. Cases (notified). Rate per 100 births for both classes of cases. 1921 21 1.8 1922 24 2.4 1923 30 3.4 1924 23 2.4 1925 21 2.0 With regard to the incidence of venereal disease the following table, showing the death rates of infants per 1,000 births certified to have died from syphilis, is reproduced from the report of last year, with the inclusion of the year 1925. This makes complete the five-yearly period 1921-25, which was given last year as 1921-24 :— 1901-5 2.8 1906-10 3.2 1911-15 2.4 1916-20 4.95 1921-25 1.7 It will be seen that there is a notable decline in infant deaths from this cause during this period. During the war period the high death-rate among infants would appear to indicate that infectious venereal disease was unduly prevalent, and the fall in the quinquennium under review is evidence that this infection has largely lost its power to transmit affliction and death to the innocents. Dental Treatment.—A scheme for dental treatment in connection with maternity and child welfare was inaugurated in 1920. Reference has already been made to its working in relation to the tuberculosis scheme of the Council. Cases requiring treatment among expectant and nursing mothers and among children up to five years of age are eligible for treatment on the recommendation of the medical officer of the centre or health visitors. The part which pathological dental conditions play in interfering with normal health has already been fully discussed, and it only remains to add that knowledge of these dangers is now becoming fully appreciated by expectant and nursing mothers. The work of the dental clinic has shown very satisfactory progress. Mr. W. II. Turner, L.D.S., adds the following remarks with a table showing the work during the past five years:— "I have pleasure in stating that the clinic has had another successful year with a continued increase in its work. (6375)Q G 90 "The additional fortnightly session authorised has been a great boon in providing a little more time needed for the extension of conservation work, i.e., fillings, scalings, etc. "The necessity was becoming more marked as many of the earlier patients retunred voluntarily for further treatment in order to remain dentally healthy. " The following statement gives an indication of the work done under the Maternity and Child Welfare Scheme during the last five years:— Table XI. 1921. 1922. 1923. 1924. 1925. Number of Sessions New patients— 62 69 70 79 92 First attendance 59 121 123 179 205 Subsequent attendances 176 463 479 522 613 Teeth extractions 525 942 1,056 1,349 1,278 Teeth filled 72 73 91 154 167 Other dental operations 188 232 433 478 616 Anæsthetics administered— Local 17 17 20 25 38 General 81 200 202 240 255 Dentures supplied 2 5 3 4 6 "Of the new patients in 1925, 122 were mothers and 83 were children under 5 years of age. The corresponding figures for 1924 were 105 and 74. "Patients contributed £21 1s. 0d. in small sums according to their means." Convalescent Homes.—There are many charitable agencies throughout the City which are always ready to answer the call for convalescent treatment for mothers and children. Among them may be mentioned the Friends of the Poor and the St. Henry Fund. The Medical Officer of Health is ex officio a trustee of the latter, the benefits of which are available only to residents of the parish of St. Anne's, Soho. Homes for Unmarried Mothers, etc.—The Council make an annual grant of £100 to the Home of St. John the Baptist at Tulse Hill. This home was formerly in the City, and cases from Westminster are eligible for admission. Unmarried mothers are received some months before confinement, which takes place in the home and they usually remain with their infants for about six months afterwards. The matron and sisterin-charge are trained midwives, and the confinements are conducted under their charge. During their period of residence the women are trained in various branches of useful service, and so far as possible employment is found for them on leaving the home. There are two other homes in the City which exist for a similar purpose. 91 Day Nursery.—There are two nurseries in which mothers who work away from home may place their young children during working hours. There the children are cared for by a trained staff, and a visiting medical officer examines all children on entry, pays regular visits, and is available for cases of sudden illness. The homes are situated in the districts where the need for them is greatest. The Council make an annual grant of £25 towards the expenses of the nursery organised by the British Red Cross Society. Supply of Milk.—Fresh and dried milk is supplied to certain cases recommended by the medical officer of the Maternity and Child Welfare centre. Before the grants are made a standard of income laid down by the Ministry must be proved. In some instances the weekly income does not justify an award of free milk, but those cases may come within the scale for milk at half price. The applications are considered by a meeting of the ladies of the Maternity and Child Welfare Sub-Committee, which takes place once a month at each centre. Grants are made for a period of one month and are reconsidered for continuation at each meeting. Preparations of dried milk are sold at cost price in connection with the centres, 1,224 pounds being disposed of during the year. The amount expended by the Council for fresh milk as extra nourishment for mothers and infants amounted to £89 1s. 11d.; the figures since 1921 are as follows:— £ s. d. 1921 260 16 1 1922 142 0 6½ £ s. d. 1923 78 16 7 1924 70 17 9 INSPECTION AND SUPERVISION OF FOOD. The importance of food, its sources of production, methods of preparation and storage are subjects which continue to attract increasing public attention. History shows that as the culture and wealth of a nation develop, the simpler elements of diet tend to become more and more elaborated. It is not only that the public have become fastidious, but rather that the part which diet plays in human economy is studied with ever widening knowledge. The relative values of the various foodstuffs as sources of energy, heat and tissue repair, continue to engage the study of the physiologists, while a newer aspect, that of food as a factor in the growth of the organism and its influences in the prevention and causation of disease, has opened up an entirely new aspect of inquiry. There are good grounds for the belief that rickets is largely due to a deficiency of calcium and phosphorus in the body. In order to obtain improvement in this condition, the output from the body of those substances must be adjusted in relation to the (6375)Q G 2 92 intake of foods containing calcium and phosphorus in considerable amount. Cod Liver Oil has been found to have a controlling influence on this adjustment by virtue of containing an as yet unidentified substance (Vitamin A). Experiments seem to show that sunlight, both natural and artificial, also exercises control on these phenomena. The place of importance which cow's milk occupies as the substitute for the natural food of infants and also the preponderating part which it takes in the dietary of children and invalids, has justified the attention which has been paid to it in so many quarters. It is recognised that, although an invaluable food, it possesses vast potentialities for transmitting disease. The need for a clean milk supply has called forth propaganda from voluntary societies, which have been founded with the object of instructing the public in everything concerned with the production of milk and its value as a food when pure. Reforms in methods of production and supply have been urged by official, professional, and technical bodies for many years and they have been constant in asking for legislative measures to fulfil their demands. The various statutes and regulations dealing with the supply and sale of milk, are given more or less in chronological order as headings, under which an account of the administrative activities is mentioned. Dairies, Cowsheds and Milkshops Orders, 1885 to 1899. Registration of Dairymen, etc.—At the end of the year the register contained the names of 492 persons who were engaged in the selling of milk, either in or from shops, and including those itinerant vendors who have neither shops nor stores, but sell milk from street barrows. Ten new applications to be registered during the year were received. Of those, six concerned the transfer of business to another proprietor, while the premises continued to be used for the same purpose. Two applications were refused, on the grounds that the premises were unsuitable for the sale of milk. These were small general shops without proper facilities for the storage of milk and for the cleansing of milk vessels. The sanitary inspectors paid 537 visits to premises in which milk is sold, but no defects were found which required the service of a notice. In one instance an assistant to a milk roundsman was stopped from continuing his occupation because of having been in contact with a case of infectious disease. He was permitted to resume when all danger of infection had been removed. Six names were removed from the register as the persons concerned had given up business as milksellers. 93 The Register of milk shops contained the following number of names in the five years:— 1921 1922 1923 1924 1925 477 478 490 494 492 At the end of 1924 there was one cowhouse in Westminster. No cows had been kept there for several years and the premises had become unsuitable for the purpose. On the representation of the Public Health Committee, the renewal of the license was refused by the London County Council in November, 1925. Milk and Dairies Amendment Act, 1922. Under the Milk (Special Designation) Order made under this Act the Council issued licenses for the sale of:— Certified milk 28 Grade A (Tuberculin tested) milk 16 Grade A milk 2 Pasteurised milk 12 18 samples were taken for bacteriological analysis. None were found to contain B Coli. The quality of the milk samples taken under this Order was found to be good and the bacteriological standard satisfactory. Pasteurisation of milk is not undertaken at any premises in the City. Public Health (Milk and Cream) Regulations, 1912 and 1917. The following table shows the results of work done under these regulations. With regard to cream only two samples were found to contain Preservative. In 1924 there were 5; in 1923, 2; in 1922, 12; and in 1921, 5. In the 68 samples of Preserved Cream there were none which showed an excess of preservative over the amount permitted (28 grs. per lb.). In fact 18 showed no preservative at all and the remainder of the total contained amounts below the allowed standard. These results are much in accordance with those of the five previous years and they show that although it was at one time stoutly affirmed that it was impossible to keep cream fresh without preservative it has now been found practicable to produce even "preserved cream" without this addition. Generally speaking, amounts much below the generous standard laid down by the 1917 regulations are found sufficient for the purpose. In the foreword to his last annual report the late Medical Officer of Health dealt in some detail with the progress made in the past towards the elimination of preservatives in cream. He showed that the amount of Boric Acid 94 in samples had fallen considerably as a result of the legal actions taken by the Council prior to 1912. After this date, however, the Regulations permitting preservative in cream, so long as it was disclosed, having come into force the amounts became much larger. The trade no doubt regarded this regulation as a moral sanction for putting in still larger quantities and as much as 50 grs. of Boric Acid have been found per lb. The Regulations of 1917, however, rectified this and fixed a limit of 28 grains per pound in preserved cream which, as indicated above, would seem to be in excess of the amount required. Table I. The Public Health (Milk and Cream) Regulations, 1912 and 1917. Samples analysed during the Year 1925. Article. Number of samples examined for preservative. Number containing preservative and percentage of preservative found in each sample. Milk 970 No preservative found. Separated milk 7 No preservative found. Cream 74 Two contained preservative (28 and 16.1 grains of boric acid per lb. respectively). The vendor of the sample containing 28 grains was prosecuted and fined £2. A satisfactory letter of explanation was received in respect of the remaining sample. Preserved Cream. Number examined. Without preservative. Preservative under amount stated on label (0.4 percent.). Preservative over amount stated on label. Milk fat in preserved cream. Above 35 per cent. Below 35 per cent. 68 18 50* Nil. 68 Nil *Samples contained respectively 24.5, 21.7, 21.7, 21.7, 21, 21, 21, 21, 20.3, 20, 20, 20, 18.6, 18.6, 18.5, 18.2, 18, 17.8, 17.7, 17.7, 17.5, 17, 17, 17, 17, 17. 16.8, 17.5, 16.8, 16.8, 16.5, 16.4, 161, 161, 15, 15, 14.8, 14.7, 14, 13, 13, 13, 13, 13, 12, 11.6, 10.8, 7.7, 4.9, 4.5 grains of boric acid per lb. Action Taken—nil. Infringements under Article 5 (1)—Nil. Infringements under Article 5 (2)—Nil. Milk and Dairies Consolidation Act, 1915. This Act, which consists of twenty-one sections and five schedules, came into force on 1st September, 1925. It was originally intended that it should be put into force not later than one year from the 95 termination of the war, but its operation was postponed by the Milk and Dairies (Amendment) Act, 1922, Section 1. The Act gives effect to the universally expressed movement of public opinion in favour of a wholesome milk supply and it should be noted that during the ten years since the Act was passed there has been a steadily growing improvement in the methods of milking, milk storage, handling and delivery. Within the milk trade itself it has been recognised that there are advantages in the production of a cleaner and more wholesome milk, and efforts have not been spared towards this end. The chief features of this statute are directed towards maintaining a high sanitary standard in cowsheds, dairies, milk stores, methods of transit and distribution. It aims at requiring that both the individuals who are engaged in the milk trade and the cows shall be clean and healthy. The milk itself shall be kept clean and free from infection from the time it leaves the cow until it reaches the consumer. The varieties of milk shall be kept clearly defined and described for the guidance of purchasers and this will apply also to milk products. No additions, or abstractions, will be permitted unless under strict regulation. An important provision of this measure is the authority given to the Minister to make orders which when they come into force will amplify and supersede the Dairies, Cowsheds and Milkshops Order, 1885-99. Among the orders which are to be made under this Act is one dealing with the registration of dairy premises. This will be an important advance, as at the present time only the dairyman requires to be registered. Other orders will deal with such important features of the milk industry as inspection of persons engaged in handling milk, the conveyance and distribution of milk, labelling and sealing of churns, and many other matters. The Act also contains sections dealing with the prevention of tuberculosis similar to those of the London County Council General Powers Act, 1907, which, after one year, it will supersede. Under Section 8 a sample of milk may be taken at any time before it is delivered to the customer. Formerly a sample could be taken in course of delivery but only at the place of delivery. Under Section 9 the warranty defence cannot be pleaded when the sample is taken from mixed milks from more than one consignor. A warranty may hold good only if the purveyor has requested within sixty hours a sample to be taken by the sanitary authority from the consignor. This sample must be from a corresponding milking. If the sanitary authority do not accede to the purveyor's request to take a sample from his consignor they cannot take proceedings against the former. There is an important definition of "dairy"; it does not include a shop from which milk is not supplied otherwise than 96 in the properly closed and unopened receptacles in which it was delivered to the shop. Shops and other places where milk is sold lor consumption on the premises only do not come within the definition. The Act which came into force on September 1 has not been in force long enough to enable one to estimate the effect, of its provisions. Up to the end of the year eight milksellers, having had samples of milk taken by the inspectors under the Sale of Food Drugs Acts, made written requests for samples to be taken from their consignors at the place of delivery. All those eight samples proved to be genuine. Milk and Dairies (Consolidation) Act, 1915.—For selling milk from a can which had no name and address inscribed thereon, a vendor was fined 7s. 6d. under the above Act. Milk.—During the year 970 samples of milk were taken for analysis. The analysts have graded samples in four standards of quality as stated below. The legal standards below which milk is regarded as adulterated are for fat, 3 per cent., and for non-fatty solids, 8.5 per cent.:— Good quality, over 3.8 per cent. of fat. Fair quality, between 3.3 per cent. and 3.8 per cent. of fat. Poor quality, between 3 per cent. and 3.3 per cent. Adulterated, below 3. per cent. of fat and 8.5 per cent. non-fatty solids. The following table shows the total number of samples taken since 1910 and their classification into the grades as defined with the percentage proportion of the total which each grade represented. In the year 1925 the samples taken in each of the two districts of the City are given. Table II. District. Total. Good Quality. Fair Quality. Poor Quality. Adulterated. No. Per cent. No. Percent. No. Per cent. No. Percent. North 448 252 56.2 150 33.4 37 8.2 9 2.0 South 522 237 45.4 218 41.7 61 11.6 6 1.0 1925 970 489 50.4 368 37.9 98 10.1 15 1.5 1924 994 507' 51.0 363 36.5 105 10.5 19 1.90 1923 997 458 45.9 368 36.9 149 14.9 22 2.2 1922 998 493 49.4 338 33.8 128 13.8 29 2.9 1920 987 321 32.5 400 40.5 236 23.9 30 3.0 1921 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 11.2 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 97 It will be noted that the improvement in the quality of the milk supplied in the City which has been taking place during the past fifteen years is well maintained. Slightly more than half of the total samples were well above the legal standard and were ranked as of good quality. Only 10.1 per cent. were as low as the legal standard or slightly above it in fat content, and the proportion of adulterated samples was only 1.5 per cent. of the total. This represents a smaller proportion of adulteration than has yet been recorded, and is significant of the progress in the methods of production and distribution of milk which has been made in recent years. Legal Proceedings for Adulteration.—Six prosecutions were undertaken against vendors for the following offences:—10, 9, 5 and 3 per cent. of fat abstraction, and 6 and 5 per cent. of added water. A warranty was successfully proved in one instance; this was before September 1, when the Milk Act (1915) came into force. The fines and costs imposed as a result of proceedings were as follows:— Milk— Fine. Costs. 10 per cent. fat abstraction Warranty proved, summons dismissed. 9 per cent. fat abstraction — £3 3s. 5 per cent. fat abstraction £1 — 3 per cent. fat abstraction — £2 2s. 6 per cent. added water £1 10s. — 5 per cent. added water £3 — Separated Milk.—In this instance the sample was sold as separated milk. It contained 18 per cent. of added water. The vendor was fined 5s. with £2 costs. Of the total of 970 samples of milk taken during the year, 100 were obtained on Sundays. One of the latter showed 10 per cent. of fat abstracted. This was the case where a warranty was proved, the summons being dismissed. Samples taken in course of Delivery.—Four samples were taken as the milk was being delivered by consignors to retail purveyors at shops. Three of the samples were of good quality, the remaining one being " poor " but not adulterated. 98 Table III. Sale of Food and Drugs Acts. Samples purchased under the Sale of Food and Drugs Acts, showing results of Analysis and subsequent Proceedings for year 1925. Number. Article of Food. Number of samples purchased. Genuine. (Inferior In brackets.) Adulterated. Prosecutions. Convictions. Withdrawn or dismissed. Fines. Costs. £ s. d. £ s. d. 1 Milk 970 889 (64) 17 6 5 1 5 10 0 5 5 0 2 Do. separated 7 6 1 1 1 — 5 0 2 0 0 3 Cream 74 72 2 1 1 — 2 0 0 — 4 Do. (preserved) 68 68 — — — — — — 5 Do. cheese 1 — 1 — — — — — 6 Butter 145 144 (1) — — — — — — 7 Buttered rolls 1 1 — — — — — — 8 Tea 1 1 — — — — — — 9 Cakes 27 25 2 — — — — — 10 Mincemeat 1 1 — — — — — — 11 Marmalade 1 — 1 — — — — — 12 Meat pies (various) 55 45 10 — — — — — 13 Sausages 75 62 13 1 1 — 5 0 0 — 14 Meat and Fish Paste (various) 60 56 4 — — — — — 15 Brawn 2 2 — — — — — — 16 Galantine 1 1 — — — — — — 17 Suet (chopped) 1 1 — — — — — — 18 Asparagus 1 1 — — — — — — 19 Olives 1 1 — — — — — — 20 Peas 30 16 14 4 3 1 2 0 0 11 11 0 21 Beans 5 2 3 1 1 — 2 0 0 5 5 0 22 Spinach 2 — 2 1 1 — 1 0 0 3 0 0 23 Tomatoes 2 — 2 — — — — — 24 Apples 6 — 6 — — — — — 25 Lemon squash 7 — 7 — — — — — 26 Do. Syrup 1 — 1 — — — — — 27 Fruit juices 5 1 4 — — — — — 28 Lime juice 6 — 6 — — — — — 29 Beer 26 26 — — — — — — 30 Whiskey 143 112 31 14 14 — 27 0 0 37 1 0 31 Brandy 20 18 2 — — — — — 32 Rum 39 33 6 2 1 1 2 0 0 5 5 0 33 Gin 16 11 5 2 — 2 — 9 9 0 Totals 1,800 1,595 (65) 140 33 28 5 46 15 0 78 16 0 The following list shows in detail the results of analysis of individual samples other than milk, cream and spirits, which were adulterated and the decision taken in each with the result of any legal proceedings ordered by the Council:— Apples.—6 samples were taken and found to contain arsenic in the following quantities:—1/180, 1/500, 1/500, 1/900, and 1/1000 grain per lb., the remaining sample had 1 part of arsenic per 2 million parts of apple. A special note, on this subject, is made below. 99 Cakes.—27 samples were taken and 2 only contained preservative—14 and 10 grains boric acid respectively. The Vendors were cautioned. Cream Cheese.—1 sample was taken and contained 16 grains boric acid per lb. A notice was displayed and no further action taken. Meat Pies.—55 samples were taken and 10 contained boric acid. (15.4, 10.5, 9.8, 9.1, 9.0, 6, 6, 5.6, 4 and 2 grains per lb. respectively). Cautionary letters were sent in two eases and in the remainder the vendors' attention was called to the result of analysis. Sausages.—75 samples of sausages of various kinds were examined, 12 contained preservative in small quantities and 1 had 14.7 grains of boric acid per lb. No notice being given and the vendor, having been cautioned for a similar offence, was fined £5. Meat and Fish Paste.—60 samples were taken and 4 contained boric acid in the following quantities:—5, 1.4, 1.4 grains per lb., and the remainder contained a trace. A cautionary letter was sent in the first case. Peas.—30 samples were taken and 14 were found to contain preservative—10, crystallised copper sulphate in quantities varying from .17 to 3 grains per lb., and 4 zinc in quantities varying from .2 to 1.75 grains per lb. Summary proceedings were taken in three cases with respect to sulphate of copper—3 grains (£2 fine and £5 5s. costs), 1.73 grains (warranty proved; summons dismissed), and 3.04 grains (dismissed with £3 3s. costs) and in one containing zinc 1.75 grains per lb. (dismissed with £3 3s. costs). Beans.—5 samples were taken and 3 were found to contain preservative (2, crystallised copper sulphate, 1¼ and 1 grain respectively; and 1, .7 of a grain of zinc per lb. The vendor of the sample in which was found 1¼ grains of copper sulphate, no notice having been given, was fined £2 and £5 5s. costs. Spinach.—2 samples were taken and both contained preservative—5.4 grains crystalised copper sulphate and .7 grain of zinc per lb. respectively. The vendor of the first sample was fined £1 and £3 costs. Tomatoes.—2 samples taken and each contained 1 grain of tin per lb. No action was taken. Lime Juice Cordials, &c.—19 samples were taken and 18 contained small quantities of Salicylic Acid, Sulphur Dioxide or Benzoic Acid. In every case a notice was printed on the label which was on the bottle. No action was therefore taken. Arsenic in Apples.—As a result of the occurrence of two cases of illness in Hampstead alleged to be due to the presence of arsenic in apples, samples were taken by that authority and were found to contain arsenic in appreciable amount. Proceedings were instituted and were successful. It has been known for many years that in various parts of the world where the codlin moth is the cause of blight , insecticides containing arsenic are used to prevent its ravages. These insecticides are generally used in the spring season while the blossom is out, but they are not applied as a rule when the fruit has formed. The season of 1925 abroad happened to be particularly dry, and, apparently, these arsenical preparations had to be applied again at a later stage to the maturing fruit while the rainfall proved insufficient to wash it of!. The result was that many consignments of an early brand of apples (Jonathans) coming from Canada and the United States were found to contain arsenious oxide varying in amount from 1/100 gr. to 1/10 gr. per pound. Samples from many 100 ments arriving at Covent Garden were examined, and the amounts of arsenic found varied from 1/500gr. to 1/150 gr. per pound. In each case where there was suspicion of a substantial amount of the drug being present the sale and distribution were delayed until the results of analyses became known. In no case was it found necessary to restrict the sale of the apples. Samples from retail shops showed even smaller amounts. A conference was held in December at the Ministry of Health at which the medical officers of the City and Port of London and Westminster were present together with representatives of the wholesale trade in these areas. It was pointed out that there was a real danger to health arising from the presence of a foreign and poisonous ingredient in apples which being a product of nature should be entirely free from such contamination. There were possibilities, even if small amounts were permitted, of injury to health from the effects of taking very small doses over prolonged periods. It was agreed that importers should take steps to ensure that all apples from abroad should be entirely free from arsenic or other foreign substance. Meat Regulations, 1924.—These Regulations came into force on 1st April, 1925. They were made under the Public Health (Regulations as to Food) Act, 1907, and contain provisions relating to slaughtering, slaughterhouses, meat marking, stalls and shops, stores, transport and handling. The definition of "meat" as laid down in the Regulations includes bacon and ham, and the raw and untreated edible parts of the carcases of cattle, swine, sheep and goats, but does not apply to rabbits, poultry, fish, butter, margarine and cheese. Cooked meat, lard, sausages and other preparations containing meat are outside the scope of the Regulations. As many of the reasons for which the Regulations were made apply to the conditions of sale of those articles which have been excluded, it is not clear why they have been left out from its purview. There are no slaughterhouses in Westminster, and so it is therefore the articles which deal with the retail trade of butchers which are of application to the City of Westminster. Provision is made for the stalls to be legibly inscribed with the name and address of the stallholder. The stalls shall be suitably covered and screened ; cleanliness of knives and counters is required, and meat must be protected from dirt and flies. All trimmings and rubbish must be kept separately. With regard to shops no sanitary apparatus or drain shall be in or directly communicate with any room where meat is sold or exposed for sale or deposited for the purpose of sale, etc. No such room shall be used for sleeping purposes. There are provisions against accumulations 101 of rubbish, for cleanliness of walls and ceilings, and for the protection of meat against contamination by flies and for keeping it free from mud and filth blown in from the street. The Public Health Committee gave instructions that two months before the Regulations were to come into force, copies of the Regulations and a printed circular embodying and explaining the provisions, so far as they affected retail shops, should be delivered to each retail butcher by the sanitary inspector of the district concerned. A certain amount of doubt subsequently arose as to whether it was compulsory for butchers to put in glass fronts to their shops. A further circular was issued by the Minister in June explaining that it was not intended to make the provision of glass fronts compulsory for all butchers' shops. This reservation has in some degree weakened the effectiveness of the Regulations, but there has been a general desire among the traders to comply with them. The requirements generally as regards shops have been adequately met, and so also have those referring to stall". Many butchers constructed new stalls when the Regulations came into force. The three sides of these stalls consist mainly of glass while the tops arc composed of wood or waterproof canvas. In no case has it been necessary to take proceedings for non-compliance with the regulations; verbal warnings have proved sufficient, except in one case where a warning letter was sent. This had the desired effect. During 1925, 3,614 visits were paid by the sanitary inspectors to premises where food is prepared for Sale, deposited for sale, or sold, These premises include milkshops, bakers' shops, butchers shops, greengrocery and fruit shops, eating places, eats and restaurants. Street markets and the large wholesale fruit market of Covent Garden were regularly visited. Notices referring to defects in sanitary conditions were served in 61 instances. There were 739 visits paid to restaurants and hotels in the City, the kitchens and arrangements for washing dishes and utensils receiving particular attention. Ice Cream Premises—During 1925 were 139 premises where ice cream was prepared or sold. The inspectors paid 108 visits for the purpose of supervision. It is particularly necessary, that there should be a high standard of cleanliness in the methods of preparation of this article and in the premises where it is made. Ice cream has been Known to convey germs of Typhoid Fever and is stated also to have contained the bacillus of Tuberculosis. Bakehouses.—At the end of there were 77 bakehouses in the City, of which 59 were underground. During the year 245 visits of 102 inspection were made and in all instances the cleansing which is required to be done twice a year was carried out. In the case of one underground bakehouse it was found that, owing to the breakdown of the system which had been in use, the day temperature had risen to 109 degrees Fahr., and movement of air was practically non-existent. The firm were required to instal a new plant and the results have been most satisfactory, the temperature falling to 72 degrees Fahr. The number of underground bakehouses during the preceding five years decreased from 61 to 59 in 1923, and this number has remained. Inspection of Food.—Food exposed for sale has received regular inspection by the food inspectors, who have carried out this work daily including Sundays. The following table shows the nature and amount of food voluntarily surrendered or submitted. Two instances occurred when food exposed for sale, was seized by the inspectors and condemned by the magistrate. Prosecution was authorized in one case, that of bottled herrings and a fine of £3 with £5 5s. costs was inflicted. In the other, a caution was administered to the vendor after all the circumstances relating to the incident had been explained. Table IV. A rticles of Food submitted. Tons. cwts. lbs. Tons. cwts. lbs. Apples 1 10 100 Horseradish — 2 10 Apricots 1 19 50 Limes — — 40 Aubergins — — 30 Medlars — 14 110 Bananas 1 3 63 Melons — — 82 Beans — — 76 Oranges 1 7 110 Cranberries 2 7 26 Pears 20 2 11 Cauliflower — — 30 Pineapples — 7 16 Cabbage — 19 62 Peaches — 6 48 Cherries — 4 32 Plums — 10 80 Gooseberries — 1 68 Potatoes 1 7 91 Grape Fruit — 2 101 Red Currants — — 50 Globe Artichokes — 3 84 Tomatoes — 8 40 Grapes — 9 15 Walnuts — 4 14 Haddocks 48 lbs., Soles 1 cwt., Chickens 48 lbs., Beef 3 lbs., Kippers 40 lbs., Chocolates 1 lb. Certificates enabling the export of certain articles of food to the United States of America and Canada, were granted in three instances. Spirits.—218 samples of whiskey, rum and gin were taken during the year. In 44 cases it was found that the spirits were diluted below the standard strength of 35 degrees U.P. It is generally held that spirits are not sold to the prejudice of the purchaser, if a notice is displayed in the bar warning him, that the spirits are so diluted. A good deal depends on the nature of the notice. Four prosecutions for "dilution" offences 103 undertaken in 1924, were adjourned until a ruling had been given in the High Court on cases in another district where the notices were of somewhat similar charactcr. The Lord Chief Justice held that the notice*, in each of the latter cases, was ambiguous and misleading, and referred the cases back to the magistrate to convict. The notices in the Westminster cases, however, were not precisely similar, and in the opinion of the City Solicitors did not afford sufficient grounds for appealing to the High Court in the event of the magistrate dismissing the summons. Proceedings in these cases, which were dilutions of 48, 41.5, 40.5, and 47.4 degrees U.P., were accordingly withdrawn. As a result of the High Court proceedings the Trade issued a circular to all its members advising them not to sell spirits below 35 degrees U.P. and presented a form of notice which they recommended for adoption. They advised their members that they (the Trade) would not hold themselves responsible for undertaking the expenses of defence for members who did not adopt this form of notice. Many, however, have not acted on this advice and use a notice on which it might be advisable to have a High Court ruling. This is to the effect that "All spirits sold in this bar are diluted below 35 degrees U.P." By this the purchaser is made aware that he is buying diluted spirits but he is prejudiced in so much that he is not informed how weak the spirits are. He may be asked to pay an excessive price for very weak spirits. The following table shows the samples of spirits on which action was taken, and the nature of the notice if any Table V. Sale of Food and Drugs Acts. Spirit Samples, 1925. No. Article. Result of Analysis. Notice or No Notice. Action taken and Result. Degrees U.P. 70s Whiskey 41.7 N. Solicitors advised No Action. Inspectprs verbally told that all Spirits were diluted below 35 degrees u.p. Notice in Bar:—Notice to purchasers of Spirits—All Spirits sold in this compartment are diluted below 35 degrees up All spirits sold in this establishment are of the same superior quality as heretofore hot to meet the requirements of the Sale of Food and Drugs Acts, they are now sold as diluted spirits, no alcoholic strength being guaranteed. 104 No. Article. Result of Analysis. Notice or No Notice. Action taken and Result. Degrees U.P. 71s Whiskey 44-6 N. Solicitors advised No Action. Notice in Bar:—"Notice—All Spirits sold at this establishment are reduced, but not below half-proof strength, proprietary brands excepted." This sample was served from a plain bottle. 65n „ 44.4 N. Solicitors advised No Action. Two Notices in Bar:—(1) "Notice to purchasers of Spirits—All Spirits sold in this compartment are diluted below 35 degrees u.p., unless specials are ordered(2) "All Spirits sold in this establishment are of the same superior quality as heretofore, but. in order to meet the requirements of the Food and Drugs Adulteration Act, they are now sold as 'Diluted Spirit,' no alcoholic strength, being guaranteed." 171n „ 37.9 N. No Action. Notice in Bar:—"Notice to Purchasers of Spirits—All spirits sold in this compartment are diluted below 35 degrees under proof." 295s „ 35.9 N. No Action. 300s „ 37.15 N.N. Caution. 301s „ 38.7 N.N. Proceedings, £1 fine and £2 2s. costs. 426s „ 36 N.N. No Action. 275n „ 45.6 N.N. Proceedings, £4 4s. costs. 277n „ 37 N.N. Caution. 278s „ 45.4 N.N. Proceedings, £4 is. costs. 311n „ 39 N. Notice invisible (in another bar). Proceedings, £4 fine. 339n „ 47 N. Notice invisible (when examined, unsatisfactory). Proceedings, £3 fine. 340n „ 48.6 N.N. Proceedings, £5 fine. 383N „ 50 N.N. Proceedings, £3 fine. 385n „ 42 N. Notice unsatisfactory. Proceedings, £3 3s. costs. 596s „ 39.4 N. Notice unsatisfactory. Proceedings, £2 fine, £5 costs. Notice in Bar:—"All spirits sold at this establishment are 35 under proof." 597s „ 52.7 N.N. Proceedings, £2 fine, £5 costs. 599s „ 41.7 N. Notice unsatisfactory. Proceedings, £2 fine, £5 costs. Notice in Bar:—"Strength not below 35 u.p." 613s „ 38 N.N. Proceedings, £5 costs. 465n „ 41 N. Caution. Notice:—"All spirits in this compartment are diluted below 35 degrees u.p." 696n „ 37.5 N.N.. Caution. 697N „ 38.8 N.N. Proceedings, £4 4s. costs. 700n „ 38.6 N. Call attention of Vendor to result. Notice in Bar as to spirits sold being diluted. 815n „ 44.9 N.N. Proceedings, £4 is. costs. 868n „ 36 N. Caution. Notice in Bar:—"All spirits sold at this Establishment are of the same superior quality as heretofore, but in order to comply with the requirements of the Food and Drugs Adulteration Acts they are now sold as Diluted Spirits, no alcoholic strength being guaranteed. 776s „ 35.6 N. Caution. Notice in bar as to strength of spirits sold not considered satisfactory. 105 No. Article. Result of Analysis. Notice or No Notice Action taken and Result. Degrees U.P. 779s Whiskey 35.8 N.N. Caution. 783s „ 35.8 N. Caution. (Notice unsatisfactory.) Notice in bar as to strength of spirits sold not considered satisfactory. 784s „ 36.4 N.N. Caution. 785s „ 36.8 N.N. Caution. 549s Brandy 37 N.N. Caution. 762N „ 35.5 N.N. Caution. 168s Rum 45.2 N.N. Proceedings, £2 fine, £2 2s. costs. 172N „ 48.3 N. No Action. Notice in Bar:—"Notice to Purchasers of Spirits—All spirits sold in this compartment are diluted below 35 degrees under proof." 664s „ 37.9 N.N. Caution. 546N „ 51.7 N. Notice unsatisfactory. Proceedings, £3 3s. costs. 812N „ 35.5 N.N. Caution. 871s „ 35.6 N.N. Call attention of Vendor to result. 724N Gin 36.5 N.N. Caution. 793N „ 38.9 N.N. Proceedings, £7 7s. costs. 862s „ 36 N. Caution. (Notice unsatisfactory.) 863s „ 35.6 N.N. Call attention of Vendor to result. 673s „ 38.3 N.N. Proceedings, £2 2s. costs. Public Health (Preservatives in Food) Regulations, 1925. These Regulations, made under the Public Health (London) Act, 1891, Public Health Act, 189G, the Public Health (Regulations as to Food) Act, 1907 and the Butter and Margarine Act, 1907, come into force on 1st January, 1927, with the exception of those made in reference to butter and cream which operate from 1st January, 1928, and those relating to preservatives used in the preparation of preserved bacon, ham, margarine which operate as from 1st July, 1927, and, in the case of preserved butter, as from 1st July, 1928. The Regulations consist of five parts and fifteen articles with two schedules. They were issued after consideration of the report drawn up by a committee of experts appointed by the Minister. They heard-evidence from many who were qualified to speak on the subject of preservatives in food including witnesses from interested trades. The recommendations of the committee were discussed in detail in the annual report of last year and they have, with certain exceptions, been embodied in the Regulations. One of those concerned a recommendation that any prohibitions or limitations imposed by the Regulations should bind the Courts in proceedings taken under the Sale of Food and Drugs Acts. (6375)q h 106 By this means the traders and the public would know what was permissible and what was not, the only point at issue being whether the preservative or colouring matter used or the amount of it was contrary to the Regulations. The Minister, while agreeing with the recommendation found it impracticable to introduce legislation to give effect to it. He suggests that Local Authorities should not take proceedings under the Sale of Food and Drugs Acts in respect of the addition of preservatives to food except where such addition would be contrary to the Regulations. A considerable period of time is allowed from the issue of the Regulations in August, 1925, to the date when they will become operative, in order to permit of time in which adjustments in methods and processes may be overtaken and existing stocks cleared. The only preservatives which are permitted are sulphur dioxide and benzoic acid and these only in certain specified foods and not exceeding stated amounts. Preservative is not permitted in cream nor must any thickening substance be added. A list of prohibited colouring matters is set forth in the first schedule of the Regulations and among them may be mentioned copper compounds, arsenic, lead and zinc. There are also provisions for labelling articles of food as to the presence of preservative. The operation of these Regulations will doubtless cause many changes in the methods now adopted in this country for preserving focd. Experience has shown that much can be achieved by improved methods of preparation and cold storage. As remarked when discussing preserved cream, it was found that certain samples contained an amount of boric acid far below that legally permitted, while a goodly propo rtion were put on the market without its aid. 107 STAFF of the PUBLIC HEALTH DEPARTMENT. Medical Officer of Health and Administrative Tuberculosis Officer: Andrew J. Shinnie M.D., D.P.H., etc. Assistant Medical Officers: †Ian S. Thomson (appointed 30th July, M.D., D.P.H. 1925). (Tuberculosis Officer and Asst. Medical Officer of Health.) †*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 R.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.L †C. J. Dee S.I.E.B., R.S.L, and Meat and Food Cert. †W. L. French (appointed 1st April, S.I.E.B., Meat Cert. 1925). †F. J. Haigh S.LE.B. †H. R. Hardy R.S.L, M.L San. Eng. †E. J. Martinson R.S.I. †J. Sanderson R.S.L, San. Sc. Cert., Gold Medallist Carpenters' Company. †A. L.Ware S.I.E.B. and R.S.I., R.P.C. †C. Ratcliff (Food & Drugs, &c.) S.I.E.B., Meat Cert. (Now District Inspector.) fF. E. Siddle (Food & Drugs, &c.) S.I.E.B., Meat Cert., R.S.L †T. H. Jackson (Food & Drugs, &c.) S.I.E.B. (appointed 15th October, 1925). †J. Smith (Temporary) (appointment S.I.E.B. ended 20th September, 1925). †Miss C. Hughesden S.I.E.B., R.S.L, H.V. * Part time Officers. † The Council receives Exchequer grant towards the salaries of these officers. 108 Health Visitors: †Miss A. Sanders (Supt. Centre) H.V. †Miss J. G. Alexander (Supt., Centre) H.V., Certified Midwife, Hosp. Nursing. †Miss D. H. M. Waldino( Tuberculosis) S.I.E.B., Dipl. Nat. Health Soc., Nursing, Dipl. Board of Education. †Miss Howell Evans S.I.E.B., Dipl. Nat. Health Soc., Nursing, V.A.D. †Miss M. M. Scott (appointed 1st July) S.I.E.B., H.V., Certified Midwife, Dipl. Board of Education. †*Mrs. Coleman (Mothercraft Classes) Red Cross Cert. 1st cl., and gold medal. Midwife: †Miss A. J. Irving Certified Midwife, Hosp. Nursing. 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 (deceased 21st September, 1925). W. H. Smith (Messenger and Cleaner). (Temp. appt.. 4th May, 1925.) (Permanent appt., 26th November, 1925.) Mrs. Wheal, Attendant, Verminous Children. †Mrs. W. Jenkins, Caretaker, 15, Bessborough Street. †Mrs. Hawthorn and Miss Mates, Cleaners. In addition to the above, the following are the staff of 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. Health Visitors: Miss Cove (Supt., Centre) Nat. Health Diploma. Miss Callaghan (Supt., Centre) H.V., 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). * Part time Officers. † The Council receives Exchequer grant towards the salaries of these officers. 123 RZ 170