WES 37 City of Westminster. REPORT of the MEDICAL OFFICER OF HEALTH FOR THE YEAR 1927 ANDREW J. SHMNIE, M.D., D.P.H. (Lond.). Medical Officer of Health and Administrative Tuberculosis Officer. Printed by order of the Council. LONDON: HARRISON AND SONS, LTD PRINTERS IN ORDINARY TO HIS MAJESTY, ST. MARTIN'S LANE, W.C.2. III. CONTENTS. PAGE Introductory Remarks v Census Statistics x Meteorological 1 Population 1 Births 2 Deaths 7-15 Infantile Mortality 15 Common Lodging-Houses 21 Tables 7-20 Communicable Diseases 23 Smallpox 23 Vaccination 23 Scarlet Fever 26 Diphtheria 26 Schick Test 27 Anti-toxin 30 Bacteriological Diagnosis 30 Typhoid Fever 31 Measles 33 Influenza 33 Diarrhœa and Enteritis 33 Deaths from 34 Whooping-Cough 34 Cerebro-spinal Fever 36 Poliomyelitis 36 Encephalitis Lethargica 36 Chickenpox 36 Mumps 36 Plague 36 Anthrax 36 Puerperal Fever 36 Ophthalmia Neonatorum 37 Bacteriological Laboratory 37 Tuberculosis 38 New cases (notified) 38 ,, ,, ,, Tables 38-43 Deaths and non-notified deaths 43—15 Tuberculosis Dispensary 45 Dental Treatment 47 Returns (Ministry of Health table) 48 Housing 50 New Schemes, etc. 50-54 Conditions generally 54-57 Register of Houses let in lodgings 57 Underground Bedrooms 57 Restriction of Rent Acts 57 Table I (Required by Ministry) 58 (9616)q a 2 IV PAGE Housing—contin ued. General Sanitary Conditions 59 „ „ „ (Statistical table) 60 Removal of Offensive Refuse 60 Removal of Refuse 61 Nuisances—Intimation and Statutory Notices 61 Unfit Dwellings and Rooms 61 Rat Repression 62 Water Supply 62 New Sanitary Construction 62 Smoke Prevention 63 Nuisance from Pigeons 64 Fouling of Footways by Dogs—By-law 65 Public Health Act, 1925 (useful provisions) 65 Lighting of Staircases of Tenement Buildings 66 Draft Revised Drainage By-laws Under Sec. 39, P.H. (London) Act, 1891 67 Local By-laws and Regulations 68 Factories, Workshops and Workplaces 69-71 Ventilation in Workshops 69 Outworkers' Lists 72-73 Disinfection 73 Mortuaries 74 Maternity and Child-Welfare 75-77 Widows and Orphans Contributory Pensions Act, 1925 77 Births and Deaths Registration Act, 1926 77 Ante-natal Work 77 Maternity and Mothercraft 78-80 Infancy and Early Childhood 80-84 Nursing 81-85 Dental Treatment 85-86 Convalescent Homes 86 Homes for Unmarried Mothers 87 Day Nursery 87 Supply of Milk 87 Inspection and Supervision of Food 87 Sale of Food and Drugs Acts 88-89 Other Acts and Regulations relating to Food, etc. 89-90 Milk and Dairies Order, 1926 90 Registration of Dairymen 90 Milk and Dairies Amendment Act, 1922 91 Public Health (Milk and Cream Regulations), 1912 and 1917 92-96 Public Health (Preservatives in Food) Regulations, 1925, 1926 and 1927 96 Samples Taken 97 Meat Regulations, 1924 98 Regulation of Street Trading—Storage of Food 98 Food Premises 99 Food Condemned 100 Spirit Samples 101 Staff 102 V Annual Report on the Health and Sanitary Condition of the City of Westminster. 19 2 7. Mr. Mayor, My Lords, Ladies and Gentlemen, I have the honour to present my Annual Report for the year 1927. This report is, in accordance with the instructions of the Ministry of Health, submitted as an ordinary report. The fuller survey reports are required at the end of each quinquennium. These Annual Reports are generally published about the end of May, and the lateness of this year's publication requires some explanation. The report is compiled normally during the first three months of the year following the one to be considered, but on this occasion this period was fully occupied owing to the work which fell to the lot of the Department in consequence of the disastrous flooding of the Thames on the night of January 6th-7th. Even in June there still remains a considerable amount to be done. On that night there was a large volume of flood water in the river following an unusually heavy snowfall at Christmas. The existence of very full tides urged by strong easterly winds from estuarial regions, caused a condition whereby the abnormally swollen river could not be contained within its banks. The embankment walls gave way at the weakest points. Reliable eye-witnesses state, that the torrent—some 7 or 8 feet in height—rushed through the breaches with a loud roar and at the speed of an express train. In several districts riverside houses were inundated. In Westminster a large part of St. John's Ward suffered very greatly. The area affected VI is bounded by Grosvenor Road, Horseferry Road, Regency Street and Vauxhall Bridge Road. There were considerable areas further afield where much damage was done owing to back flooding from the sewers. This was due to the over-pressure on the sewers from the enormous volume of surface water which had been deposited and was seeking outlet; the sewer pumping station at Grosvcnor Road was also flooded and was soon put out of action. All basements in the area were flooded beyond ceiling level, and houses without basements had 4 or 5 feet of water on the ground floor. Unfortunately ten individuals lost their lives. The question was raised at the time as to whether there was not some responsibility for permitting basement rooms to be used for sleeping purposes. It should be made clear that there are no legal powers for preventing 'persons sleeping in basement rooms so long as such rooms, if habitually used for sleeping purposes, comply with the Regulations made under the Housing Act. As regards the fatalities, only one occurred in a basement room illegally occupied, and in this case the character of the whole letting had recently changed. Previously a wholly occupied private dwelling, it had been sublet as a boarding-house. On the morning of the flood an appeal for relief funds was issued by the Mayor, and with the willing help of members of this Department an emergency relief depot was opened at the Council's Coroner's Court in Horseferry Road. Temporary shelter, and the distribution of food, clothing and blankets were organised. The personal assistance of members of the Westminster Philanthropic Society and the gifts of coal and food which they provided, proved of inestimable value in obtaining comfort for the distressed. The development of the relief services and an account of the wonderful voluntary effort exerted during the period of stress will be recorded elsewhere and require no further mention. The insanitary conditions resulting from the flow involved much extra work for the staff, and this was cheerfully undertaken. The inspection of flood damage in the 722 affected houses, the examination of goods and household effects removed either for cleansing or destruction, the inventories which had to be taken for the purpose of grants from the Mayor's Fund, and the disinfection of premises after the peculiarly unpleasant effluvium from the Thames silt, continued for fully three weeks without remission. Relief work was of necessity closely bound up with remedying insanitary conditions, and the Health Visitors bore a large share of the efforts to alleviate the distress which prevailed throughout the area. Then there VII followed the house-to-house inspection of the district to ascertain the fitness of the affected houses, special vists in connection with the Mayor's Relief Fund (structure sub-committee), and finally the survey of the whole of the Millbank area with the view to the preparation of an Improvement Scheme to be promoted in a private Bill. These brief allusions simply mention the outlines of the various fields of work which, even in June, has not been completed. So great were the demands made on the staff, that I was glad to avail myself of the services of two sanitary inspectors very kindly lent by Dr. Fenton, Medical Officer of Health, with the authority of the Council of the Royal Borough of Kensington. As they could not remain with us indefinitely three temporary sanitary inspectors were appointed for varying periods, and one still remains. A temporary clerk was engaged for a period of four months. The following figures in connection with the flood work may prove of interest:— Flooded houses, 451. Houses where back flooding from drains occurred, 271. Separate dwellings—ground floors, 86 ; basements, 46.* Houses from which damaged furniture and household effects were removed, 619. Some 6,000 visits were paid by sanitary inspectors and health visitors to houses and families affected by the flood. Over 2,000 tins of disinfectant were distributed for use in flooded premises. Reference has already been made to the detailed housing survey of the flooded districts, which is still in progress. Many houses in this district were old, frequent repairs being necessary to maintain them reasonably fit for habitation, and the damage wrought by the flood has in a number of cases precipitated their decline. It is anticipated that the housing conditions in this district will be dealt with in due course in an improvement scheme. It is gratifying to note that there was no outbreak of infectious disease in consequence of the flood, and in fact there were fewer notifications than usual in this particular area during the three months following. In a few instances, however, sufferers from chronic ailments, such as rheumatism and bronchitis, were caused considerable discomfort and required treatment in hospital. It *Twelve were found to have been illegally occupied. VIII was anticipated that the health of the children in the area might suffer from the disturbing circumstances of the flood. Many parents were therefore very glad to take advantage of the arrangements made by the Mayor's Fund and various charitable bodies, notably the Invalid Children's Aid Association, by which a large number of children were sent into the country for a few weeks. The health of the City has remained satisfactory throughout the year. There is still a further decline in new cases of tuberculosis and in deaths from this disease. There were very few cases of measles, while those of whooping cough were more numerous. Scarlet fever had increased, while diphtheria had diminished. The enteric group has furnished more cases than usual, chiefly owing to a small outbreak of paratyphoid, which receives special notice in the report. The birth-rate has fallen again, while the death-rate has risen, diseases of the circulatory system and cancer having taken a greater toll among elderly people. The infantile mortality rate has risen slightly, and the number of women who lost their lives owing to childbirth is unfortunately two more than last year. Housing continues to engage serious attention, and the duties connected with it increase year by year. It. is certainly second to none in importance among the public health issues of the present day. Allusion has been made to the comprehensive housing policy which the Council has initiated. The proposed schemes will, when completed (unless there should occur an increasing influx from other districts), go a very long way to solving the problem of overcrowding, illegally occupied separate basement dwellings, and other insanitary conditions associated with housing shortage. Staff.—During the year there were two retirements among the sanitary inspectors: Mr. E. J. Martinson, who had been appointed under the Strand Board of Works in 1893, retired in 1927, having reached pensionable age. He had completed 34 years of faithful and efficient service, and was esteemed highly on all hands for his high character and proved capabilities. Mr. F. Aris the senior sanitary inspector, broke down in health after sustaining an accident, and unfortunately did not recover sufficiently to enable him permanently to resume his duties. He had served the Council, and previously the Vestry of St. George, Hanover Square, for more than 34 years. I have with great regret to record his death while this report is in the press. Mr. John Sanderson, who has completed 30 years, was appointed senior sanitary inspector, and in virtue of this position certain special duties were assigned to him. Mr. II. E. White, sanitary inspector to the County Borough of Croydon, and Mr. W. G. J. Sutton, sanitary IX inspector to the Urban District Council of Barnes, were appointed to fill the vacancies caused by these retirements. I have also to report with regret the death of Mr. A. E. Birch, mortuary keeper, He had held a joint appointment with his wife, who predeceased him only twelve months. His service dated from 1890. The assistant mortuary keeper, Mr. K. Watling, was promoted to fill Mr. Birch's place. The appointment is no longer a joint one, assistance for cleaning being obtained from part-time employees. Two deaths occurred among the disinfecting staff—E. Bridger, pensioned in 1926 owing to ill-health, died in 1927; E. C. Powell, with 23 years' service, died very suddenly in September, 1927. Both were capable and trustworthy servants of the Council. To fill the vacancies thus created A. W. Nicholls was appointed assistant mortuary keeper, and J. R. Doyle to the disinfecting staff. In conclusion, I wish to thank the past and present Chairmen and the members of the Public Health Committee, also the Chairman and members of the Maternity and Child Welfare Committee, for their constant support and encouragement, and to acknowledge with gratitude the assistance given by the staff of the Department. I wish to put on record my appreciation of the self-denying efforts of the staff in connection with the flood. A great deal of the work was entirely voluntary, and although often involving exceedingly long hours, was cheerfully carried out. I have the honour to be, Your obedient Servant, Andrew J. Shinnie. July, 1928. (9616)q a 3 X SUMMARY OF PARTICULARS REQUIRED BY THE MINISTRY OF HEALTH. 1.—General Statistics. Area (acres)—2,502.7. Population (Census 1921)—141,578. Population, June, 1927 (Registrar-General's Estimate)—139,300. „ „ „ Civilian—136,500. Number of Inhabited Houses (1921)—25,321. Number of Families or Separate Occupiers (1921)—33,946. Rateable value—£9,583,241 (March, 1928). Sum represented by a penny rate—£38,000. 2.—Extracts from Vital Statistics for the Year. Births— Males. Females. Total. Birth-rate. Legitimate 638 617 1,255 10.0 Illegitimate 74 70 144 Totals 712 687 1,399 Deaths—1,682. Death-rate—12.3. Number of women dying in, or in consequence of, childbirth:— Puerperal fever, 1 1 5. 7 per 1,000 births. From other causes 7 Number of deaths of infants under one year of age per 1,000 births—68.6. Legitimate rate, 64.5; Illegitimate rate, 104.1. Number of deaths from measles (all ages)—0. „ „ diphtheria—9. „ „ whooping cough (all ages)—7. „ „ scarlet fever—1. „ „ diarrhoea (under 2 years of age)—16. „ „ typhoid fever—1. 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 is set forth on the preceding page and further reference to certain points mentioned will be found in other parts of the report. Meteorological. The rainfall during the year was considerably in excess of the average for the whole country and was particularly pronounced in London and "the Home Counties. In London there were 182 wet days in the 365, which is 19 days more than the average. The holiday month of August proved very disappointing for those who hoped for re-invigoration from open air and sunshine. There were only ten days free from rain during this month. The month showing the heaviest rainfall was September, which, however, had a larger proportion of dry days than August. As a climax to a season in every way disastrous to outdoor sports, a blizzard swept over the country on Christmas Day, the Southern districts of England being most severely affected, even to a depth of 6 or 7 feet of snow in some places. Not since the winter of 1881 had such a snowstorm been experienced in these districts. December, with a maximum mean air temperature of 39.5° F., was the coldest month, while August was the warmest, with a corresponding figure of 71.7° F. The hottest day of the year occurred on June 16th (shade max. 85° F.), the coldest on December 19th (shade minimum 18° F.). The maximum temperature for June, July and August were 85° F., 81° F., and 78° F., compared with 79° F., 89° F., and 84° F. in the corresponding months of 1926. The barometric readings in millibars varied from 1,003.5 in March to 1,014.7 in May, the average for the year being 1,009.8. There was most bright sunshine in May, with a daily mean of 6.54 hours, and least in November, with .96 hours. Fog was noted on 41 days throughout the year. the month of February having the largest number (12), while in November there were only 5. Population. The estimated population of the City of Westminster for the year 1927 is given by the Registrar-General as 139,300 (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 136,500, and for the purpose of calculating the death-rate this number is taken. Both gross and net totals show a large decrease on the corresponding figures for 1926, which were 141,800 and 138,400 respectively. 2 It will be noted that the decrease in the civilian population was 1,900, while that in the military, which includes soldiers living in barracks or in dwellings under the control of the War Office, numbered 2,500. The former figure is largely accounted for by the movement of families from overcrowded conditions in the City to houses on the L.C.C. suburban estates, details of which are given in the Housing Section of the report. The latter figure was no doubt influenced by the movements of troops both at home and overseas. The Guardians have again been good enough to supply figures dealing with outdoor relief, and from them it would appear that unemployment is, fortunately, still decreasing in the City. In 1925 the amount expended in outdoor relief was £9,849 16s., in 1926 £8,222 3s. 8d., and in 1927 £6,360 13s. 3d. Births. The births registered in Westminster during 1927 numbered 1,375, but of these the homes of 532 were in other districts and 20 were registered under the Legitimacy Act, and have therefore to be deducted from the total. There were, however, 576 children belonging to Westminster parents born in institutions outside the City, and these must be added. This gives a net total of 1,399, which is 207 less than the similar figure for 1926. The birth-rate throughout the country generally and in the County of London shows a continued decline, the figures being 16.7 and 16.1 per 1,000 respectively. From the considerable reduction which has taken place in the total population it naturally follows that births will also be fewer. The outward movement of the military, among whom are a large number of young married couples, has had an appreciable effect in lowering the birth-rate. Throughout the whole country the birth-rate continues to decline, and has now fallen below the lowest recorded rate, which was in 1918, the last year of the war, when so many of the male population were overseas. The following figures show that London has not shared to the same extent in the decline below the 1918 figure:— Birth-rate. England and Wales. London. 1918 17.7 1927 17.8 1928 16.7 15.8 17.1 16.1 3 The various causes which had been put forward to account for the falling birth-rate were discussed in the report of last year. It might also be noted that the facilities now provided for the emigration of young adults of both sexes to lands of more hopeful opportunities carry away annually from our shores some 60,000 potential parents. When this country has recovered a measure of its former industrial prosperity it is not unlikely that the birth-rate will cease to decline and may possibly advance considerably beyond the 1918 rates. A similar fall in the birthrate is being experienced in Germany and in some other European States. It will be observed from Tables I and II that the registered births are 207 fewer than last year; the legitimate births were 194, and the illegitimate 13 fewer. The percentage reductions may be expressed as follows:— Per cent. Legitimate 13.4 Illegitimate 8.3 The comparative totals are:— Males Females 1926. Legitimate. 723 726 1927. Legitimate. 638 617 Males Females Illegitimate. 74 83 1,606 Illegitimate. 74 70 1,399 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 1,462 1,424 38 1914 1,860 15 312 2,157 1,386 1,347 39 1915 1,721 71 329 1,979 1,292 1,250 42 1010 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 8S8 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 1.3S5 50 1926 1,635 600 571 1,606 1,402 1,355 47 1927 1,375 552* 576 1,399 • 1,205 1,169 36 *20 of this number are registrations under the Legitimacy Act, and cannot be classified as births. 4 The legitimate and illegitimate births are distributed as follows:— Table II. Legitimate. Males 665 - 261 + 234 = 638 Females 626 - 237 + 228 = 617 1,291 - 498 + 462 = 1,255 Illegitimate. Males 39 - 25 + 60 = 74 Females 45 - 29 + 54 = 70 84 - 54 + 114 = 144 The legitimate births show a decrease of 194 and the illegitimate 13 on the figures of 1926. As shown in Table I, 1,205 notifications of births were received by the Department for 1927 as compared with 1,402 in 1926. Of the total of notifications, 608 were sent by midwives, of whom 31 were practising in the City during 1927. The following Table shows the number of male and female children born since 1914, 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:— Table III. Number Born. Number of Deaths under 1 year. Number remaining at end of year. Boys. Girls. Boys. Girls. Boys. Girls. 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 7S0 58 38 789 742 1925 783 752 57 49 726 703 1926 797 809 48 48 749 761 1927 712 687 52 44 060 643 5 For each 1,000 girls born, there were in— 1914 1,080 boys. 1921 1,067 boys. 1915 1,033 boys. 1922 987 boys. 1916 965 boys. 1923 1,082 boys. 1917 914 boys. 1924 1,086 boys. 1918 1,177 boys. 1925 1,041 boys. 1919 965 boys. 1926 985 boys. 1920 972 boys. 1927 1,036 boys. Still-birlhs.—36 still-born children were notified during the year, 15 of this number being born to non-residents of Westminster. The corresponding figure for 1926 was 47. Under the Births and Deaths Registration Act, 1926, which came into force on 1st July, 1927, all stillbirths must be registered. Inquiries into 10 of these cases elicited that in 2 ante-partum ha?morrhage from Placenta Prævia caused the death of the infant; protracted labour from mal-presentation accounted for 4. In 3 there was a history of fall, fright and accidents, and in 1 there was the possibility of venereal disease being present. The Ministry of Health is desirous that certain figures supplied by the Registrar-General, and statistics based thereon, should, for the purpose of comparison, be included in this Report. In making these comparisons one thing must not be forgotten—-the difference between notified cases of infectious disease as supplied by the Registrar-General, and upon which figures are based not only the case rates, etc., for Westminster, but for London and the County as a whole; and the return of cases of infectious diseases as compiled by the Medical Officer of Health. As statistics must, to a certain degree, portray the health of a community, every effort is made in Westminster to confine figures to cases in which the diagnosis has been confirmed. During 1927, 40 cases, or roughly 12 per cent. of the diphtheria and scarlet fever cases, were discharged from hospitals as not suffering from these diseases—these figures are not supplied to the Registrar-General. Another important factor is the number of infectious disease cases for which certificates are not submitted, and therefore cannot be forwarded to the Metropolitan Asylums Board, from which source the Registrar-General obtains his figures. Obviously the totals of cases and case rates must be seriously affected if the same conditions prevail among other Metropolitan Boroughs and the various Councils throughout the country. 6 The following statistics are forwarded by the Registrar-General for the information of the Medical Officer of Health in connection with paragraphs 6 and 7 and Appendix II of the Circular 834, dated the 15th December, 1927, addressed to Local Authorities from the Ministry of Health. A summary of the vital statistics for England and Wales, London, and the respective aggregates of the Great and Smaller Towns for the year 1927 :— Birth-rate, Death-rate and Analysis of Mortality during the year 1927. (Provisional figures. The rates have been calculated on a population estimated to the middle of 1927. The mortality rates refer to the wholo population as regards England and Wales, but only to civilians as regards London and the groups of towns. As the registration of stillbirths did not come into operation until 1st July, 1927, no stillbirths are included.) - Birthrate per 1,000 Total Population. Annual Death-rate per 1,000 Population. Rate peii 1,000 Births. Percentage of Total Deaths All Causes. Enteric Fever. Smallpox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Violence. Diarrhoea and Enteritis (under two years). Total Deaths under one year. Certified by Registered Medical Practitioners. Inquest Cases. Certified by Coroner after P.M. No Inquest. Uncertified Causes of Death. England and Wales 16.7 12.3 0 .01 0. 00 0. 09 0.01 0.09 0.07 0.57 0.51 6.3 69 91.7 6.6 0.7* 1.0 107 County Boroughs and Great Towns, including London. 17.1 12.2 0.01 0.00 0.12 0.01 0.10 0.08 0.49 0.46 8.3 71 91.9 6.6 0.9* 0.6 155 Smaller Towns (1921 Adjusted Populations 20,000-50,000). 16.4 11.3 0.01 0.00 0.07 0.01 0.08 0.05 0.58 0.41 5.0 68 92.7 5.8 0.3* 1.2 London 16.1 11.9 0.01 0.00 0.04 0.01 0.12 0.09 0.39 0.51 7.5 59 90.3 7.9 1.8* 0.0 * The Coroners (Amendment) Act, 1920, which came into operation on the 1st May, 1927, provided for the registration of deaths on a certificate of the Coroner after P.M. without inquest. These percentages relate, therefore, to 8 months of the year only. 7 Causes of Death at different Periods of Life in the City of Westminster. Causes of Death. Sex. All Ages. 0— 1— 2— 5— 15— 25- 15— 55— 75— All Causes M. 909 53 7 11 17 23 87 328 228 155 F. 781 44 6 11 7 20 93 211 185 204 1. Enteric fever M 2 - - - - - 1 1 - - F. - - - - - - - - - - 2. Smallpox M. — — — — — — — — — - F. - - - - - - - - - - 3. Measles M. 1 - - - 1 - - - - - F. - - - - - - - - - - 4. Scarlet fever M. 1 - - - - - - - 1 - F. - - - - - - - - - - 5. Whooping cough M. 3 - 2 1 - - - - - - F. 4 2 1 1 - - - - - - 6. Diphtheria M. 5 2 - - 3 - - - - - F. 4 — 1 1 1 — — 1 — - 7. Influenza M. 24 - - - - - 3 14 5 2 F. 41 — — — — 2 9 14 7 9 8. Encephalitis lethargica M. 2 - - - - - 1 1 - - F. - - - - - - - - - - 9. Meningococcal meningitis M. 2 - 1 1 - - - - - - F. - - - - - - - - - - 10. Tuberculosis of respiratory system M. 67 - - - - 8 17 38 3 1 F. 32 - - — — 8 13 9 2 — 11. Other tuberculous M. 14 2 1 2 2 2 2 2 1 - diseases F. 5 1 - 2 — 1 1 — — — 12. Cancer, malignant disease M. 118 - - - - - 5 53 41 19 F. 127 — — 1 — — 13 51 35 27 13. Rheumatic fever M. 2 - - 1 - - 1 - - - F. 3 - - - 2 - - 1 - - 14. Diabetes M. 5 - - - - - - 3 1 1 F. 7 - - - - - - 3 2 2 15. Cerebral hemorrhage, etc. M. 27 - - - - - 1 8 14 4 F. 44 - - - - - 3 9 18 14 16. Heart disease M. 173 - - - 1 2 6 51 57 56 F. 136 — — — — 3 5 27 38 63 17. Arterio-sclerosis M. 43 - - - - - - 16 15 12 F. 31 - - - - - - 7 11 13 18. Bronchitis M. 51 2 - - - - - 18 17 14 F. 42 - - - - - 1 6 12 23 19. Pneumonia (all forms) M. 64 6 1 1 2 1 12 20 14 7 F. 59 1 2 2 1 — 11 23 12 7 20. Other respiratory diseases M. 7 - - - - - 1 9 1 3 F. 7 — — 1 — 2 — 2 1 1 8 Causes of Death. Sex. All Ages. 0— 1— 2 5— 15— 25— 45— 65— 75— 21. Ulcer of stomach or duodenum M. 16 - - - - - 3 12 i - F. 3 - - - - - 1 1 l — 22. Diarrhoea, etc. M. 8 7 - - - - 1 - - - F. 6 5 - - - - - - - 1 23. Appendicitis and typhlitis M. 7 - - - - 2 1 - 1 - F. 4 — — — — 2 - 1 1 — 24. Cirrhosis of liver M. 4 - - - - - 1 1 2 - F. 6 - - - - - - 3 2 1 25. Acute and chronic nephritis M. 32 - - - - - 9. 16 9 5 F. 29 1 — — 1 — 1 9 7 10 26. Puerperal sepsis M. - - - - - - - - - - F. 2 - - - - - - - - - 27. Other accidents and diseases of pregnancy and parturition M. - - - - - - - - - - F. 8 — — — — — 7 1 — — 28. Congenital debility and malformation, premature birth M. 24 23 1 - - - - - - - F. 22 22 - - - - - - - - 29. Suicide M. 20 - - - - 2 8 4 4 2 F. 9 - - - - - 4 3 2 - 30. Other deaths from violence M. 42 - - 2 7 3 8 10 7 5 F. 24 1 — 1 — 1 3 4 7 7 31. Other defined diseases M. 145 11 1 3 1 3 13 55 34 24 F. 126 11 2 2 2 1 19 36 27 26 32. Causes ill-defined or unknown M. - - - - - - - - - - F. - - - - - - - - - - A statement showing the number of cases of certain infectious diseases in the above-named area during the 52 weeks ended 31st December, 1927:— Westminster, City of, Met. B. Number of Cases of Infectious Diseases Notified (Civilians). Smallpox. Scarlet fever. Diphtheria. Enteric fever. Puerperal pyrexia. Puerperal fever. Erysipelas. — 156 172 23 26 6 36 (The case rates of these diseases for England and Wales per 1,000 living are respectively as follows:—Smallpox, 0.38; scarlet fever, 2.16; diphtheria, 1.33; enteric fever, 0.09; puerperal pyrexia, 014; puerperal fever, 0.05; and erysipelas, 0.38.) 9 MALES. Table IV.—Causes of, and Ages at, Death during the year 1927. causes of Death. Corrected Deaths in thb 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. Strnnd. Homeloss. Small-pox - - - - - - - - - - - - - - - - - - - - - - - - Measles - - - - - - - - - - - - - - - - - - - - - - - - Scarlet fever 1 - - - - - - - 1 - - Influenza 24 — - — — — 3 14 7 1 1 - 2 4 2 8 1 - 1 1 — 1 1 1 Whooping-cough 3 — 2 1 - - - - - - - - - - - - - - - - - - - - Diphtheria, Memb. croup 5 2 - — - - - - - - - - - - - - - - - - - - - - Cerebrospinal meningitis 1 — 1 - - - - - - - - - - - - 1 - - - - - - - - Poliomyelitis - - - - - - - - - - - - - - - - - - - - - - - - Enteric fever 1 - - - - - 1 - - - - - - - 1 - - - - - - - - - Diarrhœa, enteritis 10 10 - - - - - - - - - - - 3 - 3 1 1 - - - 1 - - Erysipelas — — — — — — — — — - — — — — - — — - - — — — - — Other septic diseases 12 1 — — — 2 1 4 4 - 1 - 2 5 1 — 1 — 1 — 1 - - Syphilis, Ac. 8 2 1 — — — — — 0 — - — — — 2 — 1 — 1 1 1 — — 2 — Diabetes 4 — — — — — - 2 2 - 1 - 1 1 - - - - - - - - - - Rheumatic fever 4 - - - - - - - - - - - - - - - - - - - - - - - Tuberculosis of lungs 67 — — — — 8 17 38 4 - 4 1 2 16 — 25 3 — 1 3 1 3 6 2 Other forms of tuberculosis 11 2 1 2 3 1 1 — 1 - - - 1 4 - 4 1 - - 1 - - - - Malignant growths 111 — — — — — 6 48 57 - 10 - 9 26 10 16 5 3 3 9 2 8 8 2 Congenital debility, malformation, and premature birth 22 21 1 - - - - - - - 3 1 1 10 - 3 1 - - 1 - 1 - 1 Old age 13 — — — - - - — 13 - - - - 6 1 2 - - - - - - - 2 Meningitis and convulsions 2 1 — 1 - - - - - - - - - - - - - - - - - - - (9616) b 10 MALES—Table IV. (continued). Causes or Death. Corrected Deaths in the Citt 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 Knishtsbridge. 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 13 - - - - - 4 5 4 - 1 - 2 2 1 3 - - - - - - - 2 Other diseases of nervous system 14 - - - - 2 3 5 4 - - 1 2 5 — 5 - — - — - 1 - - Valvular Deases of heart 27 - - - 1 1 2 5 18 - - 1 4 14 4 3 — — - — - — 1 - Other circulatory diseases 186 2 - 1 - 1 6 72 104 — 14 6 13 50 6 44 11 6 6 4 4 4 10 8 Bronchitis 105 1 - - - - 3 29 72 — 6 2 9 20 4 37 4 4 — 4 3 2 9 1 Broncho-pneumonia 27 5 1 1 1 - 4 4 11 - - 3 3 8 1 6 1 — 1 — — 2 1 1 pneumonia, other forms 37 1 - 1 1 1 8 14 11 — 2 — 5 9 3 8 3 1 1 3 — — 1 1 Other respiratory diseases 2 - - - — - — 1 1 - — — — — — — — — 1 — 1 — - Alcholism 2 - - - - - - 2 — - — — — 1 1 - - - - - - - - - Cirrhilism of liver 9 - - - — - 1 3 5 — 1 2 1 — — 2 — — 1 — 2 — — - Appendicitis and typhitis 8 - - - - 2 1 4 1 1 — — — 2 — 3 1 — — 1 — — — - Other digestive diseases 35 3 1 1 - - 5 20 5 - 2 2 1 13 2 6 - 1 2 1 — — 3 2 Bright's disease, &c. 47 - - - - - 4 21 22 1 3 3 5 10 1 13 1 — — 2 — 1 5 2 Cystitis, &c. 23 - - - - - - 2 21 - 3 1 5 7 2 3 1 — — — 1 — — — Deaths by accident or negligence 46 - 1 2 7 3 10 11 12 - 4 2 3 11 - 13 4 1 3 — - 2 1 2 Deaths by suicide and murder 19 - - - - 2 7 5 5 - 1 - 3 4 — 3 1 — — 1 — 2 - 2 Other defined diseases 9 — — — 1 — 1 7 — 1 — — — 4 1 2 1 - - - - - - - Diseases, ill defined or unknown - - - - - - - - - - - - - - - - - - - - - - - - All causes 908 51 8 10 17 23 88 324 387 4 58 25 74 245 42 217 44 18 21 35 15 29 52 29 11 FEMALES. Table IV (continued)—Causes of, and Ages at, Death, during the year 1927. 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. Simall-pox - - - - - - - - - - - - - - - - - - - - - - - - Measles — - - - - - — — — - - - — — - — - - - - - - - - Scarlet fever - - - - - - - - - - - - - - - - - - - - - - - - Influenza 37 - - - - 1 8 12 16 - 4 - 1 11 5 5 3 1 1 - - 3 - - Whooping-cough 4 2 1 1 - - - - - - - - - - - - - - - - - - - - Diphtheria, Memb. croup 4 - 1 1 1 - - 1 — - — - — 1 1 - — - - - - - - - Cerebro-spinal meningitis - - - - - - - - - - - - - - - - - - - - - - - - Poliomyelitis - - - - - - - - - - - - - - - - - - - - - - - - Enteric fever - - - - - - - - - - - - - - - - - - - - - - - - Diarrhoea, enteritis 6 6 - - - - - - - - - 2 1 2 — 1 — - - - - — - - Erysipelas 2 — - - - - — 1 1 - - - - - - - - - - - - - - - Puerperal fever 1 — - - - - 1 — — - — — — 1 — — — - - - - — - - Other septic diseases 8 — — 1 2 — 2 — 3 — — 1 2 2 — 1 — - - - 1 - - 1 Syphilis, &c. 2 2 - - - - - - - - - - - - - - - - - - - - - - Diabetes 5 - - - - - - 1 4 - — 1 1 — — 3 — - - - - — - - Rheumatic fever 6 - - - - - 1 1 4 - 3 1 — 1 — 1 — - - - — - - Tuberculosis of lungs 33 - - - - 8 14 9 2 - 4 — 3 12 — 11 1 1 - 1 - — - - Other forms of tuberculosis 3 1 - 1 — 1 — — — - — — — 3 — — - - - - - — - - Malignant growths 125 — — — 12 50 03 13 7 8 52 8 10 4 3 2 4 2 6 - - Congenital debility, malformation, and premature birth 24 24 - - - - - - - - - 2 1 12 - 8 - - - - - 1 - - Old ape 17 - - - - - - - 17 - 1 — 1 9 — 4 1 1 - - - - - - Meningitis and convulsions 2 2 - - - - - - - - - - - - - - - - - - - - - - (2016) h 2 12 FEMALES—Table IV (continued). 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 i». 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. Conduit. Grosvenor. Hamlet of Knightsbridge. Knightsbridge St. George. Victoria. St. Margaret. St. John. St. Anne. Great Marlborough. Pall Mall. Regent. Charing Cross. Covent Garden. Strand. Homeless. Loc. ataxia and general paralysis 2 - - - - - 1 - 1 - - - - 1 - 1 - - - - - - - - Other diseases of nervous system 14 - - - - 1 4 6 3 - 1 1 3 2 1 1 - 1 1 2 - 1 - - Valvular diseases of heart 10 - - - - 1 1 9 8 - 3 1 1 8 — 4 — 1 - 1 - - - - Other circulatory diseases 166 1 - - 1 3 13 30 118 - 17 4 22 55 10 29 3 - 3 9 1 9 2 2 Bronchitis 87 — 1 - - - 3 19 64 - 2 2 8 35 4 20 8 2 - 1 1 2 - - Broncho-pneumonia 30 2 2 2 1 — 2 10 11 - 2 1 4 11 1 5 2 2 — - - 2 - - Pneumonia, other forme 37 - - - - - 6 18 13 - — 1 9 14 1 2 2 — 1 — - 4 1 2 Other respiratory diseases 3 — — 1 - — 1 1 — - 1 1 — 1 — — — — — — - — — — Alcoholism — — — — - — — — — — — — — — - - - - - - - - - - Cirrhosis of liver 6 — — — - — 1 2 3 - — — — 3 1 1 - - - - - 1 - - Appendicitis and typhlitis 4 — — — - 2 — 1 1 - 2 — — 1 — — 1 — — — - - — — Other digestive diseases 20 1 — — - — 2 8 9 - 5 1 1 5 1 3 2 — — — - 1 - 1 Bright's disease, &c. 45 1 — 1 2 — 1 17 23 — 5 1 5 16 5 8 - - - 2 - - - 3 Cystitis, &c. 3 — — — — — — 1 2 - — 1 — 1 — — — — — — - 1 — — Accidents and diseases of parturition 7 - - - - - 7 - - - - - - 2 - 1 1 1 1 - - 1 - - Deaths by accident or negligence 30 2 - 1 - - 5 6 16 - 4 - 3 12 - 5 - 2 - - 2 1 - 1 Deaths by suicide and murder 10 - - - - 1 4 3 2 - - - - 3 2 - 4 - - - - 1 - - Other defined diseases 10 — — 1 — 1 1 3 4 - — — — 5 2 2 1 - - - - - - - Diseases, ill defined or unknown 1 1 — — — — — — — — — — — — — — — — — — — — — 1 All causes 774 45 6 10 7 19 91 209 388 — 67 | 30 74 286 42 138 33 15 9 20 7 35 5 13 13 Deaths. 1,817 deaths were registered in the City in the 52 weeks of 1927. After deducting 1,015 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 1,682, as compared with 1,608 in 1926, and is equivalent to an annual rate of 12.3 per 1,000 persons (civilian population). The London death-rate for 1927 was 11.9 (civilians only), for England and Wales 12.3. These rates are a little higher than in 1926 for the country as a whole. The number of deaths and the death-rates per 1,000 for the past fifteen years are shown below:— Table V. (From 1913 to 1927.) Year. Number of Deaths. Westminster Rate. London Rate. 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 1926 1,608 11.6 11.6 1927 1,682 12.3 11.9 The deaths of males were 908, females 774. Table VI. This table shows the total deaths distributed among age periods:— 1927. Under 1 year 1 to 2 years 2 to 5 years 5 to 15 years 15 to 25 years 25 to 45 years 45 to 65 years 65 and up. years Total. M. 51 8 10 17 23 88 324 387 908 F. 45 5 10 7 19 91 209 388 774 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 1926 96 28 20 24 50 185 509 096 1,608 1927 96 13 20 24 42 179 533 775 1.682 The causes of death are set out in Table IV. There was an increase among the males of deaths from the following causes:—Influenza, cancer, valvular disease of heart, respiratory and circulatory diseases, and deaths 14 by accident and negligence. Among the females the causes showing an increase were respiratory and circulatory diseases, influenza, cancer, prematurity, cirrhosis, Bright's disease, accidents of parturition, and deaths by accidents and negligence. There were, however, more deaths from cancer : 111 among males and 125 in females. The corresponding figures in 192G were 96 and 111. Deaths from tuberculosis were decreased by 19. Diseases of the circulatory system still stand at the head of all causes of death, with a total of 352 (186 males and 166 females), an increase on the number shown last year (345, 179 males, 166 females). Under this category are included deaths from apoplectic strokes, and by far the most cases occur in the age period above 65 years. Deaths from valvular disease of the heart have increased this year by more than a-half. Influenza was prevalent in the early part of the year and took a higher toll of elderly people. In 1926 the deaths over 45 years numbered 14. In 1927 they numbered 49. Deaths from cancer also increased from 207 to 236, the increase being most pronounced among those over 65 years of both sexes. Circulatory diseases caused the same number of deaths among females as last year, but showed an increase among males. There was a pronounced increase in the deaths from valvular disease of the heart among the elderly of both sexes. Tuberculosis continues to decrease. The deaths from tuberculosis of the lungs have fallen by approximately 20 per cent. as compared with 1926. 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. 1923. 1924. 1925. 1926. 1927. m. F. Total. m. f. Total. m. f. Total. m. f. Total. m. f. Total. Conduit 11 12 23 11 11 22 11 4 15 5 5 4 4 Grosvenor 48 47 95 50 52 102 80 49 129 60 64 124 58 67 125 Hamlet 29 30 59 30 28 58 23 20 43 11 23 34 25 30 55 K. St. George 45 56 101 43 60 103 58 61 119 58 69 127 74 74 148 Victoria 217 261 478 245 282 527 275 305 580 236 252 488 245 286 531 St. Margaret 43 37 80 50 33 83 37 42 79 51 37 88 42 42 84 St. John 170 166 336 245 196 441 221 189 410 204 162 360 217 138 355 St. Anne 39 21 60 41 26 07 37 29 66 38 32 70 44 33 77 Gt. Marlborough 9 15 24 22 12 34 7 20 27 20 14 34 18 15 33 Pall Mall 12 12 24 33 8 41 19 7 26 22 8 30 21 9 30 Regent 21 30 51 35 22 57 27 21 48 25 18 43 35 20 55 Charing Cross 18 9 27 17 9 26 16 9 25 13 6 19 15 7 22 Covent Garden 34 22 56 20 25 51 31 28 59 39 39 78 29 35 64 Strand 42 8 50 40 7 47 60 3 63 56 6 62 52 5 57 Homeless 18 11 29 23 11 34 23 16 39 22 18 40 29 13 42 15 Infantile Mortality.—The corrected death-rate of infants for Westminster was 68.6 per 1,000 births. The mortality among legitimate infants was 64.5 per 1,000; that of illegitimate 104.1. The infant mortality rate for London was 59. The number of infants dying under 1 year was 96, the same as last year, but, as the total number of births was less, the infantile mortality rate has inevitably risen. The chief contributory causes of death were prematurity and gastro-enteritis. Twenty-seven of the 28 premature deaths occurred before the fourth week of life. It would appear on enquiry that influences classified as follows were at work in causing premature birth:— In 4 instances there were twins, often a predisposing cause of premature birth; the twins in one case were of the rare pathological variety familiar to the public in the Siamese twins, joined together along the spinal column. They were admitted to St. Thomas' Hospital and lived for some days. In 1 case the mother was suffering from consumption. In 1 case the mother was suffering from pneumonia. In 2 cases there was evidence of venereal disease. In 2 cases there were congenital disease and malformation of infant. In 2 cases there was history of shock and accident. In 1 case there was ante-partum haemorrhage. In 1 case there was displacement of womb. In 1 case there was pre-existing kidney disease. In 9 cases no cause could be ascribed for the premature onset of labour. Gastro-enteritis accounted for 17 deaths, all of the infants being over four months old. Only 2 of those occurred during the hot weather, and might be attributed to what is commonly called " summer diarrhoea." Six occurred in November in an institution, 3 of the cases having been admitted for surgical conditions, and it would appear that they were . infected after being admitted. Table VIII shows the deaths as they occurred during the four quarters of the last four years :— Table VIII. Total. Total Total Total. 1927. 1926. 1925. 1924. 1st Quarter 29 30 35 31 2nd „ 16 24 14 27 3rd „ 26 25 24 16 4th 26 17 33 22 96 96 106 96 Of the 25 deaths occurring in the last quarter of the year, 9 were attributable to enteritis, 7 of these children dying in one institution within 21 days. 16 Table IX shows the births and deaths of infants, legitimate and illegitimate, since 1902 onwards, with the corresponding infantile mortality rates for Westminster and for London :— Table IX. Year. Legitimate. Illegitimate. Total Rate, Westminster. Total Rate, London.[/ ###] Births. Deaths. Death-rate per 1,000 Births. Births. Deaths. Death-rate per 1,000 Births. 1902 3,275 410 125 186 32 172 127 140 1903 3,035 345 113 150 25 166 116 130 1904 2,920 320 109 134 40 298 118 146 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 95 166 33 198 103 129 1912 2,194 168 76 155 27 174 83 91 1913 2,057 184 89 176 29 164 95 105 1914 1,995 147 73 162 24 148 79 104 1915 1,798 141 78 181 41 225 92 112 1916 1,632 110 68 178 41 230 83.4 89 1917 1,348 112 83 196 48 239 103.6 104 1918 1,234 112 86.6 225 36 155 100 108 1919 1,383 99 71.5 217 41 188 87.5 85 1920 2,047 123 60 219 44 200 73.6 76 1921 1,729 117 67.7 190 37 194 80.2 80 1922 1,703 84 49.3 199 20 100 54.6 74 1923 1,582 68 42.9 176 15 85.7 47.2 60 1924 1,489 82 55.0 138 14 101.4 59.0 69 1925 1,418 88 62.0 117 18 153.8 69.0 67 1926 1,449 76 52.4 157 20 127.3 59.7 64 1927 1,255 81 64.5 144 15 104.1 68.6 59 Table X shows the causes of death of children who died under one year of age. Figures under the same grouped causes are given from 1921 onwards, showing the proportion per 1,000 births applicable under each heading:— Table X. 1921. 1922. 1923. 1924. 1925. 1926. 1927. Diphtheria 1.4 _ _ 0.65 1.4 Influenza — 3.6 — 0.6 0.65 0.62 0.71 Measles 1.0 — 5.5 2.49 — Whooping Cough 1.5 1.O 11 1.9 4.5 0.62 1.4 Septic diseases 1.4 0.5 1.7 1.2 0.62 0.71 Bronchitis and pneumonia 11 .8 7.3 4.0 10.4 16.2 9.9 6.4 Stomach and bowel complaints 13.4 3.1 1.1 1.9 5.2 8.0 12.1 Syphilis 2.6 2.1 2.8 1.2 1.3 2.8 Congenital malformations 9.3 4.2 5.1 4.9 3.2 4.34 7.8 Prematurity 15.5 16.2 13.1 14.1 16.9 19.3 20.0 Neglect and injury at birth 7.3 5.7 6.8 3.1 0..65 3.72 4.2 Debility from birth and atrophy, rickets, atelectasis 11.0 4.2 6.2 5.3 7.1 3.72 4.2 Tuberculosis 1.4 1.5 1.7 1.8 1.9 1.86 2.1 Other causes 3.6 3.6 2.8 6.7 10.4 4.34 4.2 80.2 54.6 46.6 59.0 69.0 59.7 68.0 17 Table XI shows nett deaths from various causes at several age periods during the first year of life in the City of Westminster:— Table XI.—Infant Mortality, 1927. 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 tinder 6 Months. 6 Months and tinder 9 Months. 9 Months and under 12 months. Total Deaths under 1 Year. Influenza 1 1 Diphtheria 1 — I 2 Measles Whooping Cough 1 1 2 Sepsis — 1 1 1 Tuberculosis 1 — 1 1 3 Meningitis 1 — 1 1 1 Pneumonia (all forms) 1 4 I 2 8 Gastroenteritis 4 9 3 1 17 Injury at birth I i — 1 Neglect at birth 5 — — — 5 — — — — 5 Murder — — — — — — — — — — Atelectasis 3 — — — 3 — — — — 3 Congenital malformations 1 1 2 4 2 3 11 Premature birth 22 3 — 2 27 1 — — 28 Malnutrition, marasmus, debility from birth 1 1 2 3 Accidents Other causes 4 1 — 5 — — — 5 Syphilis 1 1 1 — 3 — — 1 — 4 Totals 37 7 1 3 48 14 17 12 5 1.6 Table XII. Nett Births in the year- Males. Females. Total. Legitimate 638 617 1,255 Illegitimate 74 70 144 712 687 1,399 Nett Deaths in the year of— Males. Females. Total. Legitimate infants 44 37 81 Illegitimate infants 8 7 15 52 44 96 The causes of death of the Illegitimate were:—Neglect at birth 3, prematurity 1, enteritis 5, br.-pneumonia 2, found drowned 1, syphilis 2, and convulsions 1. 18 Table XIII. Infant Mortality, 1927.—Nett Deaths from stated causes at various ages under One Year of Aye in Pimlico Area (Victoria, Knightsbridge 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. Diphtheria — 1 _ 1 Influenza — — — — — — — 1 — 1 Whooping Cough — — — — — — 1 — — 1 Measles — — — — — — — — — Tuberculosis — — — — — — 1 1 Bronchitis — — — — — 1 1 Pneumonia (all forms) — — — — — — 2 1 1 4 Gastro-enteritis — — — — — 2 4 2 1 9 Injury at birth 1 — —' — 1 — — 1 Atelectasis 1 — — — 1 1 Congenital tions — — — 4 2 1 — 7 Premature birth 13 1 — 2 16 — 16 Want of attention at birth 3 — — — 3 — — _ 3 Malnutrition,marasmus and debility from birth 1 — — — 1 1 — — 2 Accidents — — — — — — — — Other causes 2 — — — 2 — — — 2 Meningitis — — — — — — — 1 — 1 Syphilis — 2 — — 2 — — 1 — 3 Sepsis — 1 — — 1 — — — — 1 Totals 21 4 2 27 8 10 8 2 55 Table XIV. Nett Deaths in the year of— Males. Females. Total. Legitimate infants 22 23 45 Illegitimate infants 5 5 10 19 Table XV. Infant Mortality, 1927.—Nett Deaths from stated causes at various ayes under One Year of Age in St. John and St. Margaret Wards. causes of death. Under 1 Week. 1—1 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 Mouths. 9 Months and under 12 Months. Total Deaths under 1 Year. Whooping Cough — — — — — — — — 1 1 Measles — — — — — — — — — — Tuberculosis — — — — — 1 — — — 1 Bronchitis — — — — — — — — — — Pneumonia (all forms) — — — — — 1 — — 1 2 Gastro-enteritis — — — — — — 3 1 — 4 Congenital tions — 1 — 1 2 — — 2 — 4 Premature birth 5 1 — — 6 1 — — — 7 Atrophy, marasmus 1 — — — 1 1 — — — 2 "Want of attention — — — — — — —- — — — Totals 6 2 — 1 9 4 3 3 2 21 Table XVII. Infant Mortality, 1927. Nett Deaths from stated causes at various ages under One Year of Age in the North District (Grosvenor Conduit, St. Anne, Pall Mall, Regnt, Gt. Marlborouyh, Strand, Charing Cross and Covent Garden 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 Mon hs and under 9 Months. 9 Mont lis and under 12 Months. Total Deaths under 1 Year. Diphtheria — — — — — — — 1 — 1 Tuberculosis — — — — — — — — 1 1 Pneumonia (all forms) — — — — — — 2 — — 2 Gastro-enteritis — — — — — 1 3 — — 4 Congenital tions — — — — — — — — — — Premature birth 4 — 1 — 5 — — — — 5 Malnutrition, tion and debility from birth 1 — — — 1 — — — — 1 Other causes 1 1 — — 2 — — — — 2 Want of attention 1 — — — 1 — — — — 1 Totals 7 1 1 — 9 1 5 1 1 17 Table XVI. Xett Deaths in the year of— Males. Females. Total. Legitimate infants 10 10 20 Illegitimate infants 1 —— 1 20 Table XVIII. Nett Deaths in the year— Males. Females. Total. Legitimate infants 12 4 16 Illegitimate infants 1 — 1 Table XIX. Deaths of infants with no known address, or found in streets, parks, &c. :— CAUSES OK DF.ATH. Under 1 Week. I—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 Death under 1 Year. Want of attention 1 — — 1 — — — 1 Syphilis 1 — — 1 ___ — — 1 Other causes 1 - — — 1 — — — — 1 3 — 1 3 - — — - 3 Table XX. Legitimate Males. Females. Total. — Illegitimate i 2 3 Table XXa. The following table shows the allocation of the nett births and infant deaths among the various Wards in the City, together with* the infantile mortality rate for the Ward. Wards. Population, 1921 Census. Total Births, 1927. Legitimate. Illegitimate. Total Infant Deaths, 1927. Legitimate. Illegitimate. 1927—Infant death rate per 1,000 births. Legitimate. Illegitimate. Total. Conduit Grosvenor 3,456 13,880 4 76 3 69 1 7 5 4 1 57.9 142.8 65.7 Pall Mall 3,572 12 8 4 — — — — Regent 6,878 31 27 4 1 1 — 37.0 — 32.2 Gt. Marlborough 3,194 19 18 1 1 1 — 55.5 — 52.6 St. Anne 6,699 65 58 7 5 5 — 86.2 — 76.9 Covent Garden 7,064 71 61 10 5 5 — — 70.4 Charing Cross 4,650 11 8 3 — — — — — — Strand 2,116 6 3 3 — — — — — — Victoria 37,396 524 467 57 44 36 8 77.0 140.3 83.9 K. St. George 12,563 145 136 9 4 3 1 22.0 111 .1 27.5 Hamlet 6,687 34 26 8 7 6 1 230.7 125.0 205.8 St. Margaret 9,261 45 39 6 — — — — — St. John 24,162 353 332 21 21 20 I 60.2 47.6 59.4 Homeless — 3 — 3 3 — 3 — 1000.0 1000 .0 Total 141,578 1,399 1,255 144 96 81 15 64.5 104.1 68..6 21 Common Lodging House Deaths. Reference has been made in former reports to the shifting population which inhabits the five 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; 110 deaths of persons giving addresses in common lodging houses occurred in 1927. They were mostly in institutions:— Table XXI. Deaths. Bruce House (L.C.C.) (licensed for 715 men) 40 33, Great Peter Street 5 10, Great Peter Street (Salvation Army) (licensed for 565 men) 16 1G, Strutton Ground (licensed for 201 men) 38 40, Great Peter Street (Church Army) (licensed for 57 women and 2 children) 11 110 22 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. Hospital for Women, Soho Square, 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. Diseases 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. 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. 4 23 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 1923-1927. Details respecting the notifications of infectious disease received are set out on the adjoining page. Table XXII. 1023 1924. 1925 1926 1927 Small-pox 1 1 __— _ _ Diphtheria 91 237 286 223 185 Erysipelas 34 29 44 44 37 Scarlet fever 129 226 214 132 180 Enteric fever 18 15 17 11 24 Continued fever — — — — — Puerperal fever 3 10 6 6 6 Puerperal pyrexia — — — 7 26 Cerebro-spinal meningitis 1 3 3 1 1 Encephalitis lethargica 2 15 7 5 1 Polio-myelitis 1 1 3 2 1 Ophthalmia neonatorum 32 23 21 16 14 Measles 131 852 117 1,026 71 German measles 42 34 117 14 12 Pneumonia 60 92 58 69 64 Malaria — 1 1 — 1 Dysentery — — 3 — — Anthrax — 1 — — — Chicken-pox 169 89 149 198 206 Mumps 95 147 120 64 153 Whooping-cough 35 97 255 46 128 Small-pox.—No cases of this disease were notified in Westminster during the year. Information was received from the various Port Sanitary Authorities of 44 contacts. The names of all contacts are circulated by the Port Sanitary Authorities to the various districts to which they intend to proceed, but this only applies to persons remaining on the vessel until it reaches a port in this country. The contacts who leave the ship en route and proceed overland are entirely lost sight of and cannot be traced. Vaccination.—The Vaccination Officer informs me that the following number of persons were vaccinated by the Public Vaccinators during the year:— Primary 1,273 Secondary 60 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). 24 Table XXIII. City of Westminster.—Cases of Infectious Disease Notified during the Year 1927. notifiablh dlskases. At all Ages. Cases Notified. Cases removed to Hospital. Treated at Home. At allpages| Deaths. At Ages—Years. At Agra—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 150 3 7 u 12 9 58 17 8 20 — I — 145 5 9 2 1 — — 1 4 — — — — — Erysipelas 30 — — — — — — — — 7 6 15 8 24 12 2 — — — — — — — — — — 1 1 Scarlet fever 144 — 4 11 10 9 64 10 10 11 5 3 1 138 6 1 — — — — — — — — — — — 1 Typhus fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — Enteric fever 21 — — 1 — — 2 2 7 7 1 1 — 18 3 1 — — — — — — — — — 1 — — Relapsing fever (R) — — — — — — — — — — — — — — — — — — — — — — — — — — — — Continued fever (C) — — — — — — — — — — — — — — — — — — — — — — — — — — — — Puerperal fever 6 — — — — — — — — 5 1 — — 5 1 1 — — — — — — — 1 — — —— Cerebro-spinal meningitis 1 — 1 — — — — — — — — — — — —— — — — — — — — — — — — — — Polio-myelitis 1 — — — — — — — — — — — — — — — — — — — — — — 1 Encephalitis lethargica 1 — — — — — — — — — — — — — — — — — — — — — — — — 1 — Ophthalmia neonatorum 13 13 — — — — — — — — — — — 4 — — — — — — — — — — — — — — Pneumonia 64 — — 2 1 — 3 1 4 12 14 17 10 48 10 74 1 — — — — 1 — i 3 11 33 23 Malaria 1 — — — — — — — — — — — — — — — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — — — — — — — — — — — — — — — — Trench fever — — — — — — — — — — — — — — — — — — — — — — — — — — — — Puerperal pyrexia 20 — — — — — — — — 18 8 — — 22 4 — — — — — — — — — — — — — Totals 404 16 12 23 24 18 127 30 30 87 35 37 19 400 58 92 3 2 — 1 1 5 — 1 4 14 30 25 Correction has been made for errors iD notification or revision of diagnosis in 40 cases. Cases not notified :— Scarlet fever, 1, 5, 9, 7, 10, 14, 2, 0, 15, 6, 0, 21. 25, 1, 4, 41, 30, 17, 11, 5, 4, 0, 6, 4, 23, 4, 2, 15.,22, 4, 5, 21, 9, 5, 2, 7. Diphtheria, 10,7,,,1, 1, 1, 1, 1, 2, 2, 3, 3, 3, 4, 4, 4, 5, 6, 6, 7, 7, 7, 7, 7, 11, 12, 14, 15, 17, 17, 22, 27, 36, 42, 40. Typhoid, 18, 42, 50. Erysipelas, 27. Ophthalmia neonatorum, 10 days. 25 Table XXIV. City of Westminster.—Infectious Diseases, Distributed in each Ward. Notifiable Diseases. Conduit. Grosvenor. Knightsbridge St. George. Victoria. St. Margaret. St. John. Hamlet of Knightsbridge. Pali Mall. Regent. Great Marlborough. Charing Cross. Covent Garden. Strand. St. Anne. Homeless. Smallpox — — — — — — —, — — — — — — — — Cholera (c). Plague (r) Diphtheria — 10 15 65 11 62 — 1 4 4 — 3 — 12 8 Erysipelas Scarlet fever — 1 15 1 12 6 47 4 12 13 60 2 1 1 2 4 8 1 2 — 2 8 1 5 1 6 12 Typhus fever — — — — — — — — — — — — — — — Enteric fever — 1 3 3 2 12 — 1 — — — 2 — — — Relapsing fever (r) — — — — — — — — — — — — — — — Continued fever (C) — — — — — — — — — — — — — — Puerperal fever — — — 1 — 2 — — 1 1 — 1 — — — Cerebro-spinal meningitis — — — — — 1 — — — — — — — — — Polio-myelitis — — — — — 1 — — — — — — — — — Encephalitis lethargic — 1 — — — — — — — — —— — — 1 — Ophthalmia neonatorum — 2 — 5 — 6 2 — 1 — — — 2 Pneumonia 1 5 6 16 2 15 2 1 1 0 L L 1* Malaria — — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — — — Trench fever — — — — — — — — — — — — — — — Puerperal pyrexia — 1 4 11 1 4 — —- 1 — 1 — — 3 — Totals 1 36 41 144 32 166 5 7 19 9 2 22 8 25 23 • Not a Westminster ca8c. 26 Scarlet Fever.—180 cases of this disease occurred in 1927—an increase of 48 on the figures of 1926. The wards showing a slight increase are those of St. John and Victoria—the former with 12 and the latter with 16 more cases. The disease was contracted mostly by children between the ages of 3 and 15. There was one death. The case rate of this disease per 1,000 of the population was 1.29, the rate for England and Wales being 2.16. The death-rate for Westminster was 0.07 per 1,000, and for England and Wales 0.. Of the total cases in Westminster 96 per cent.were moved to hospital. Diphtheria.—185 cases of this disease occurred, showing a decrease of 38 on the figures of 1926. Again the wards showing the decrease are St. John and Victoria—the former with 12 fewer cases and the latter with 35. At no time was there any semblance of an outbreak during the year, the closest co-operation having existed between the Council's staff and that of the London County Council in the following up and swabbing of contacts of cases already sent to hospital, or of children who were sent home from school with sore throats. Most of the cases and deaths occurred in children between the ages of 3 and 15. There were 9 deaths (5 males and 4 females), giving a rate of 48.6er 1,000 cases. The case rate of this disease for Westminster was 1.2 per 1,000 living, and that of England and Wales 1.3. The death-rate for Westminster was 0.6, and for England and Wales 0.7. All cases that are reported to have been excluded from school on account of suspicious bacilli having been found in swabbings from their nose and throat are visited by the Sanitary Inspectors, and the parents advised to consult their doctor, but in cases where the family is numerous and the income too slender to enable them to call in a medical practitioner, they are visited by the Assistant Medical Officer of Health at their homes, or advised to call at 1, Pimlico Road for swabbing. Thus unsuspected carriers are discovered, often apparently robust in health, but nevertheless a dangerous source of infection to their fellows. Sixty-three diphtheria contacts in school children were swabbed by Dr. Thomson during the year, of whom 3 proved positive. All of the latter were removed to hospital for isolation and for such treatment as is necessary to clear away the infection. It is important that virulence tests should always be carried out on persistent carriers so that those carrying virulent bacilli may be retained for special treatment, while the nonvirulent carriers may safely be discharged to their homes. The following report by Dr. Thomson indicates the progress of the Schick wor since it was begun in the City in 1926. The number of cases 27 tested is not great when compared with those in other areas, but the policy is rather that the people should regard the Schick work as an established institution than as a " boom " in preventive medicine liable to subside after the danger from an outbreak of diphtheria has passed away. The treatment was primarily intended for children under five years, and is carried out at the four Maternity and Child Welfare Centres in the City. By arrangement with the school medical authorities, older children in the same families have been accepted, and, in fact, form almost 40 per cent. of those treated. In view of the relatively high proportion of susceptibles among children between the ages of one to five years, the preliminary testing of these has in some areas been largely given up, but, as Dr. Thomson says, in Westminster the disparity is not so pronounced as to warrant this, nor are the parents desirous that the preliminary test should be eliminated. He lays stress on the need for a re-test after immunisation, and finds that it is better to postpone the re-test until six months after the immunising course has been completed. It was formerly held that immunity should have developed after three months, and it is important to note the observation that by waiting till the sixth month one obtains evidence of immunity, while, if one had tested at the third month, a positive might have resulted and a second immunising course deemed necessary. In spite of the opinions expressed by some anti-vaccinators, it is noteworthy that the parents of some 30 infants who had objected to vaccination on conscientious grounds, having been told of the Schick work, voluntarily brought their children to be tested and treated. Report on Schick Testing and Diphtheria Immunisation Treatment during 1927. This treatment was started in Westminster towards the end of 1926, the first cases being dealt with at the Maternity and Child Welfare Centre at 15, Bessborough Street. During 1927 weekly clinics were held at each of the Council's three Welfare Centres and at the Westminster Health Society's Centre at 30, Page Street. 252 children were treated during the year. This may be considered a fairly satisfactory number when it is remembered that no adults have been treated and that no extensive propaganda work has been carried out. The scheme in Westminster has so far aimed only at making the treatment available for those who wish to take advantage of it. Most of the patients are obtained through the Health Visitors, who bring the (9616) 2 28 treatment to the notice of the mothers at the centres or while visiting the homes. Leaflets are left by the Inspectors when visiting homes where cases of diphtheria have occurred, and in some cases medical practitioners have sent cases for treatment. Latterly it was found that an increasing number of people made enquiries about the treatment, having heard of it from the parents of children already treated. There seems little reason to doubt that the supply of patients will continue to increase as the treatment becomes better known. Detailed description of the treatment was given in the Annual Report of the Medical Officer of Health for 192G. In brief, it consists of two distinct parts—the Schick test and the immunising treatment. The test is made by injecting a minute dose of diphtheria toxin into the skin. If the patient is susceptible to infection with diphtheria a small reddish mark appears round the point of injection in a few days. 'When a positive result of this nature occurs, the prophylactic treatment is advised. A negative result indicates that the patient is already immune to diphtheria. The treatment consists of three injections of a toxoid-antitoxin mixture into the muscle at intervals of a week. The immunity takes at least three months to reach its height, and a re-test with a negative result is necessary before it can be stated definitely that the desired result has been achieved. In Westminster, about six months is usually allowed to elapse before re-testing. In most cases the re-test is negative, but occasionally a further course of treatment is required to ensure complete immunity. It must be clearly realised that the treatment only aims at protecting the patient from the results of infection, and does not prevent him from harbouring the germs of the disease. During the year 301 tests and re-tests were made, 570 protective injections given, and there were 115 attendances for the reading of results only, making a total of 98G attendances. Patients were treated at the different Centres as follows:— Pimlico Road 7 Bessborough Street 42 Frith Street 65 Page Street 70 Total 252 In the following statement the 22 cases treated in 1926 have been included with the 252 done in 1927, giving a total of 274. In a few cases mentioned the treatment extended into 1928. 29 The ages dealt with were as follows :— Under 5 years 154 „ 10 „ . . 96 „ 15 „ . . 22 Over 15 „ . . 2 Total 274 Over 200 cases were between one and eight years of age. Those over eight were in almost every case done along with younger members of the same family. One baby of seven months gave a definite positive result to the test, but very few children under fifteen months were brought up. When a negative result in a very young child was obtained, a re-test later was advised. Such children can reasonably be treated without testing, but it was rarely found that the mother wished this. Most children under a year are negative, deriving a temporary immunity from the mother. After one year the majority are susceptible until they acquire immunity in resisting small doses of infection. The question whether breast feeding increased the early temporary immunity was considered, but the data is so far insufficient to form any definite conclusion. 201 primary tests gave positive results ; 71 were negative. Two cases were not tested. The number of negatives is proportionally greater as age advances. Positive. Per cent. Negative. Per cent. Under 5 years of age 77.2 22.8 „ 10 71.9 28.1 „ 15 57.2 42.8 Over 15 „ — 100 Total 73.9 26.1 The percentage of negatives is rather higher than would be found in a general testing of the children of the country. This is probably due to the fact that many cases came to the Clinic because there was experience of Diphtheria in the family. Of the 71 negative cases, 7 had had Diphtheria and 17 others had had fairly recent cases of Diphtheria in their families and may have been exposed to infection. A few others, young children, were later positive when re-tested, others have not yet had re-tests. Forty-four cases have already been re-tested after treatment; 39 were negative, 2 still gave a definite positive result, received further treatment, and were later negative ; 3 others showed very slight positive results, 2 of these received further treatment but have not yet been re-tested. 30 No signs of reaction were noted when the patients were seen a week after treatment, but a small proportion reported some slight disturbance a day or two after the injection. Usually, in these cases, the mother stated the child seemed cross or tired, or that the arm was uncomfortable. In 5 cases, none of them young children, rather more definite reactions were reported, but only one of these discontinued treatment, so the parents evidently did not take a serious view of these transient reactions. One child had some swelling of the arm with slight temperature after each injection, while her sister, receiving identical treatment, showed no effects. The fact that only 4 out of the 274 cases abandoned the treatment indicates the interest taken by the parents, for one must realise that, to bring a child up on four successive weeks, entails a good deal of trouble. In a few cases the treatment was interrupted, but completed later. A number of parents who attended regularly during the treatment appear to have difficulty in realising the importance of returning to have the children re-tested, however. In other cases the children left Westminster before the re-test was due. Thirty cases dealt with (about 11 per cent.) had not been vaccinated. It is of some interest that such a considerable proportion had evaded compulsory vaccination and yet were willing to consider this voluntary preventive treatment. This may be partly due to the fact that the dangers of Diphtheria are better known to the present generation in London than those of Smallpox. It also suggests that the method adopted of simply explaining the proposed treatment and leaving the decision with them appeals to a certain type of parent. Ian S. Thomson, Assistant Medical Officer of Health. 2nd May, 1928. AMitoxin, 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 (12 bulbs, each containing 8,000 units), that practitioners prefer to send their patients at once into the fever hospitals, where antitoxin 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 antitoxin supplied by the Council. Bacteriological Diagnosis.— Swabs from suspected cases among those residing in the City can be examined by the Council's bacteriologist 31 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 1923 was :— 1923. 1924. 1925. 1926. 1927. 281 556 674 679 595 Enteric Fever.—There were 24 cases of typhoid and paratyphoid which came to the knowledge of the department during 1927. Of these 18 were notified as paratyphoid and 6 were typhoid. There was a history of fish having been consumed in 2 cases, ice-cream in 3 cases, 1 case came from abroad, and in 18 cases there was no history ascertainable. There was 1 death. The death-rate of this disease for England and Wales was 0.01, and for Westminster .007. The case rate for England and Wales was 0.09 and for Westminster 0.17. Paratyphoid.—One case was of the A variety, a form usually found in Southern Europe, and 17 were of the B. type. Eight of the latter group occurred in the fourth week of October in a residential institution, and the following account of the small outbreak may be of interest:— The first case, R. H., a student aged 20, was notified on 20th October, after a positive Widal reaction, and removed to St. George's Hospital. He had been ill since 12th October, the onset being characteristic of a chill with headache. He had diarrhoea on 13th and 14th and his temperature rose to 103° F. The course of his illness subsequently was moderately severe. A similar history was given by H. H., another student, aged 18, whose onset was also on 12th October. He gave a positive Widal on 21st October, and was likewise removed to St. George's Hospital, where his illness was also somewhat severe. On receipt of these notifications I visited the institution as there seemed the likelihood of further cases arising. Two other students, W. T. (18) and C. A. (20), were in bed believed to be suffering from colds, but not entirely free from suspicion. Both exhibited Bome rose spots and were sufficiently definite cases, in my opinion, to be removed. The clinical diagnosis was subsequently confirmed by Widal in Westminster Hospital, to which they were removed that day. Both were mild cases throughout their illness, and the onset in each was the 12th October, as in the case of R. H. and H. H. On the 26th October, S. S., student, aged 19, who had slight colic and diarrhoea, with temperature of 99° F., was also diagnosed and removed to Westminster Hospital, the Widal again proving positive. C. S. (20), student, became bilious, with headache and temperature 100° F., on 23rd October. He was removed to an M.A.B. hospital on 27th October, where his case was bacteriologically confirmed. Two sisters, E. S. (14) and M. S. (18), maids on the domestic staff, developed symptoms as above described on 27th and 28th October respectively. They were removed to an M.A.B. hospital, and although E. S. was the more pronounced case clinically, only M. S. gave a positive Widal. The eight cases were all young adults between tho ages of 14 and 20 ; all but the first two were subsequently treated in the M.A.B. hospitals and all recovered. Owing to the vague and slight symptoms in all except the first two, it was somewhat difficult to fix tho onset. There is, however, a resident nurse on the staff, to whom anyone feeling even slightly ill reports as a matter of routine, and has temperature taken. Thus, 32 it was possible to fix the onset in the cases : R. H., H. H., W. T., C. A. on 12th October; S. S. on I8th October ; C. S. on 23rd October ; E. S. on 18th October ; and M. S. on 27th October. The incubation period is usually shorter than in enterie and may be taken to be about seven days. The first four cases were infected from a common source during the first week of October, and from the 12th to the 21st October were in an infectious state while being up and about part of that period. It may be safely assumed that the second group of cases were infected from the first four during this period by casual contact. With regard to the source of infection, milk and the water supply were soon eliminated. The milk supplied to the institution was from a dairy which also supplied other houses in the district. There were no cases outside the institution nor in the district from which the milk came. The water cisterns and supply pipes did not appear to be the subject of possible contamination. Inquiry into the dietary failed to reveal any likely source of infection, and this negative result was borne out by the fact that no two patients sat at the same table. Had the infection come, for example, from tinned meat it would have seemed feasible that more than one student among the fourteen would be infected from the portion of food supplied to a particular table. There are 14 tables in the dining hall, each seating 6, and the first four cases sat far apart from each other in the hall. Were they infected from food taken outside ? These four were in different years of study and had only one common ground of association. All four were present at the sports ground on the 1st October and on the 5th October, three of them taking part in a Rugby game. It is understood that they had tea there after the matches, and it seems that this was the only occasion on which they could have been infected from a common source. Dr. Mackenzie, of the Ministry of Health, made inquiries at the sports ground, but no definite results were obtained. Diligent search for a carrier source had meanwhile been made among all those living in the institution and those attending daily, whether they were students or staff. Some eight students were kept isolated on suspicion. Bacteriological examination of blood, faeces and urine were carried out on an extensive scale by Dr. Braxton Hicks, of Westminster Hospital, and his staff, who spared neither time nor trouble in their diligent search for bacteriological evidence of a carrier. In some instances examinations were repeated at every stage. Except for the eight cases which were clinically evident no carrier of paratyphoid could be traced among the persons concerned with the institution. Only in two of the eight patients was the bacillus isolated from the blood. Altogether 70 examinations for the Widal reaction were carried out; specimens of urine and fæces were also examined by culture and sub-culture. Beyond what has been indicated above as the possible circumstances of infection, no further definite evidence came to light. Experience has shown that once paratyphoid infection has broken out in a residential institution it spreads rapidly, partly because so many of the cases are so ill-defined, the condition often being put down to a passing chill or gastric upset. In this instance it would appear that all the eight cases had been infected before the first case had been notified to this department. The freedom of the institution from further infection may justifiably be attributed to the prompt diagnosis and removal of the four secondary cases and the measures of isolation and disinfection which were carried out. The cordial co-operation of the Principal and his staff were of very great assistance. Without it it would have been impossible to make the temporary alterations to the premises whereby a temporary isolation ward was improvised for the close observation of suspects and a special nurse engaged to look after them. The normal life of the institution was resumed on the 8th November 18 days after the first notification, or 11 days after the removal of the eighth case. With regard to the infection of the secondary group of four, it is significant that the bedroom of one was directly opposite that of one of the primaries. They had washing facilities in common. Of the two maids in the former group, one was chambermaid to the room occupied by a primary. These maids were sisters and occupied tho same bedroom. 33 The Ministry of Health were informed of the outbreak, and one would wish to acknowledge with gratitude the assistance which they gave by sending Dr. Mackenzie to help in the investigations in the institution and outlying districts. Measles.—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:— 1923. 1924. 1925. 1926. 1927. 131 852 117 1,026 71 The death-rate for England and Wales per 1,000 population was 0.09 and for London 0.01. 15 cases were removed to hospital. There is now no reason why children suffering from measles, in whose surroundings there are present any elements which would militate against their recovery, should not be removed to hospital, the Metropolitan Asylums Board having agreed to receive cases of measles into their hospitals in greater numbers than before, even to the extent of giving these cases preference over scarlet fever cases. This fact, coupled with the nursing facilities offered by the Council, should go far towards lowering the mortality from this disease. Table XXV. Influenza.—The deaths certified from this cause during the last five years are as follows :— 1923. 1924. 1925. 1926. 1927. Males 9 25 13 10 24 Females 11 31 24 9 37 20 56 37 19 61 The death-rate in 1927 was 0.44 per 1,000, the rate for London being 0.39. Last year the corresponding rates were lower, being 0.13 for Westminster and 0.17 for London. Diarrhcea and Enteritis.—Deaths from this cause were slightly lower than in 1926. The total deaths were 16—10 males and 6 females—all being under 1 year old. The infant death-rate from this cause in Westminster was 11.4, and this was mainly due to the deaths of infants in an institution in November to which reference has already been made. 34 Table XXVI. Deaths from Diarrhcea and Enteritis. Under 1 year. Other ages. Total. 1923 2 — 2 1924 3 3 6 1925 8 5 13 1926 13 7 20 1927 16 — 16 42 15 57 The 16 deaths under 1 year of age were distributed over the quarters of the year :— 1st quarter. 2nd quarter. 3rd quarter. 4th quarter. 5 1 1 9 Whooping Cough.—128 cases were notified during the year with 7 deaths—two being under 1 year and 5 between the ages of two and five. This is an increase on the figures of 1926, when 40 cases, with 2 deaths, were recorded. 27 cases were moved to hospital. The deaths from whooping cough during the last five years are thus set out:— Table XXVII. Under 1 year. At other ages. Total. 1923 2 3 5 1924 3 1 4 1925 7 10 17 1926 1 1 2 1927 2 5 7 15 20 35 35 The following table is inserted by courtesy of the Medical Officer of Health of Poplar, who collected the data. The comparative vital statistics are interesting. Cities and Boroughs. Estimated population to the middle of year. Births. Annual rate per 1,000 persons living. Zymotic Deaths. Annual rate per 1,000 persons living. Deathrate per 1,000 living. Deaths of Infants under one year to 1,000 births. LONDON 4,541,000 16.1 — 11 .9 59 West Districts. Paddington 142,700 15.5 0.5 13.5 79 Kensington 176,700 15.0 0.36 13.8 66 Hammersmith 132,800 15.6 0.3 13.0 61 Fulham 161,900 15.1 0.2 11 .3 66 Chelsea 63,690 13.4 0.4 14.1 76 City of Westminster 136,500 10.0 0.5 12.3 68.6 North Districts. St. Marylebone 103,500 13.2 0.4 11.3 59 Hampstead 86,160 11.9 0.2 12.2 51 St. Pancras 213,200 15.5 0.4 12.3 62 Islington 334,300 18.3 0.38 12.3 53 Stoke Newington 52,130 14.0 0.27 12.2 66 Hackney 224,700 15.7 0.46 11.6 64 Central Districts. Holborn 42,209 11.96 0.14 12.5 38 Finsbury 75,500 19.2 0.5 13.4 50 City of London 13,010 8.7 0.23 11.5 105 East Districts. Shoreditch 105,700 20.6 0.7 12.6 74 Bethnal Green 119,900 19.6 0.6 11.1 57.7 Stepney 251,580 18.1 0.5 11.6 68 Poplar 167,000 19.8 0.6 11.8 66 South Districts. Southwark 184,250 19.0 0.8 13.4 61 Bermondsey 121,000 18.5 0.37 12.9 67 Lambeth 307,700 16.2 0.39 12.4 50.6 Battersea 169,000 16.6 0.3 12.2 53.5 Wandsworth 342,700 13.53 0.25 11 .3 51 Camberwell 271,100 15.6 — 11.4 52 Deptford 113,800 16.8 0.3 11.5 OS Greenwich 101,920 16.2 0.3 10.8 53 Lewisham 1 88, 600 15.1 0.15 11.0 40 Woolwich 140,770 15.9 0.2 10.6 42 * The provisional figures relating to London were supplied by the Registrar-General. Other figures supplied by Medical Officers of Health. 36 Cerebro-spinal Fever.—One case only of this disease occurred, with one death. Polio-myelitis.—1 case occurred, with one death. Encephalitis Lethargica.—1 case was notified, with 2 deaths during the year, both males, aged 39 and and 61. Chicken Pox.—206 cases were notified, 3 being moved to hospital. Mumps.—153 cases were recorded, 6 being moved to hospital. Plague, etc.—Intimation was received of two persons coming into Westminster from places infected with plague. Anthrax.—There were no cases in 1927. Puerperal Fever.—6 cases occurred, with one death—5 cases were removed to hospital. 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. 1923 1,752 3 - 1924 1,624 10 2 1925 1,535 6 1 1926 1,606 5 2 1927 1,399 6 1 Puerperal Pyrexia.—26 cases occurred, 21 of these being notified by hospitals and 5 by private practitioners. To the women concerned in the above 26 cases (19 were married and 7 single), 19 children only were born ; the remaining 7 cases arose from miscarriage. The Public Health (Ophthalmia Neonatorum) Regulations, 1926. These regulations have been in force since October, 1926, and under them midwives are no longer obliged to notify, but they are obliged to call qualified medical assistance to all cases of inflammation of the eyes. If the medical practitioner considers the case one of Ophthalmia Neonatorum, he must notify to the Medical Officer of Health. 37 Ophthalmia Neonatorum.—Fourteen cases occurred in 1927—6 males and 8 females. Five were admitted to 1 hospital and 9 treated either at home or as out-patients of hospitals. In addition to these notified cases, 13 cases of slight inflammation of the eyes came to the knowledge of the Department. 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. It will be noted that this year the cases of genuine Ophthalmia are fewer, but those of inflammation of the eyes are more. The following details in tabular form are required by the Ministry of Health of the cases notified in 1927 :— Cases. Total. Treated. Vision unimpaired. Vision impaired. Total blindness. Deaths. At home. In hospital. 14 9 5 11 — — — Of the three remaining children one child died of prematurity and another of congenital syphilis and one child moved away after notification. No cases were notified by midwives during 1927. 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 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 595 Blood in suspected typhoid 3 Intra uterine swabs 2 Sputa for investigation of T.B. 404 Expenditure on first three was £84 18s. lld., and for the fourth £62 0s. 2d., including cost of outfits, postage and telegrams. 38 The Public Health (Infectious Diseases) Regulations, 1927. These Regulations were issued in 1927 and came into force on 1st January, 1928. They revoke the Regulations of 1919 (Pneumonia, Malaria, Dysentery, &c.). The few variations contained in the new Regulations include the removal of trench fever from the list of notifiable diseases, certain modifications regarding the notification of malaria, exempting those cases which have been induced in an institution for therapeutic purposes, but excepting those liable to relapse after discharge. As required by Article 4, noticc of the duties imposed on medical practitioners under these Regulations has been given to all practising in the City. TUBERCULOSIS. In 1927, 190 new cases of pulmonary tuberculosis were notified and 5 moved into the City who had been notified elsewhere—a total of 195. Non-pulmonary forms of tuberculosis gave 40 cases—5 of these being removals into Westminster. Table I. % Tuberculosis, 1927. Age-Periods. New Cases. Deaths. Pulmonary. Non-pulmonary. Pulmonary. Non-pulmonary. M. F. M. P. M. F. M. F. Under 1 — — — — — — 2 1 1 — 1 4 2 — — 3 1 5 — — 8 3 — — 3 — 10 2 — 1 2 — — — — 16 6 11 1 4 4 5 1 1 20 15 12 1 5 4 2 — — 25 29 20 1 6 6 9 — — 35 -32 15 2 2 11 6 1 — 45 32 6 1 3 22 8 — — 55 7 1 1 1 16 1 — — 65 and upwards 4 2 1 1 4 2 1 — Totals 127 68 21 29 67 33 11 3 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. 39 The primary notifications for 1927 show a decrease of 43 on those of 1926. Out of the total cases notified in 1927, 31 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—6 5—6 6—7 7—8 5 3 5 6 6 1 3 — 1 2 Table II. 1923 1924 1925 1926 1927 New cases notified 324 347 282 288 245 Number included in above who died during the year 44 66 46 45 31 (13.5%) (19.0%) (16.3%) (15.6%) (12.6%) Total Tuberculous Deaths 119 138 129 133 114 Death Kates per 100,000 84.7 96.5 92.4 96.0 83.5 The number of cases who died within the year of notification is appreciably fewer, 31 as compared with 45 last year. This might be explained by the reduction in all deaths from tuberculosis, 133 in 1926, 114 in 1927, but the percentage of those "recently" notified deaths is also less, 15.6 per cent. in 1926 and 12.6 per cent. in 1927. This would appear to indicate a tendency for patients to seek medical advice at an earlier and more curable stage of the disease. An analysis of these 31 deaths shows that 19 were males and 12 females. All except 2 were due to pulmonary tuberculosis, the exceptions being a boy of 2 years affected with generalised tuberculosis and a male of 74 years with tuberculosis of the kidneys. Of the women, 4 were under 25 years and 8 were 40 years old and over, 5 being over 50. Of the 19 males, 4 were 25 years and under, 2 between 25 and 40, and the remainder (13) were all over 45 years. 40 Table III. Tuberculosis.—Notifications received during the period from 2nd January, 1927, to 31si December, 1927. 1927. Age periods. Number of notifications on Form A. Primary notifications. Total notifications, on Form A, including cases previously notified. 0 to 1. 1 to 5. 5 to 10. 10 to 15.f 15 to 20. 20 to 25. 25 to 35. 35 to 45. 45 to 55. 65 to 35. 65 and tip. Total new cases. Males — — — 2 6 14 28 31 31 7 4 123 136 Females — 1 — — 11 12 20 14 6 1 2 67 71 Non-pulmonary— Mules — 4 7 1 1 1 1 2 1 1 1 20 22 Females — 1 3 1 4 5 5 1 3 1 1 25 31 Total — 6 10 4 22 32 54 48 41 10 8 235 260 Number of notifications on Form B. (School medical inspection.) Number on Form C. Admissions to Primary notifications. Under 5. 6 to 10. 10 to 16. Total. Total notifications, including cases previously notified. Poor Law institutions. Sanatoria. Pulmonary— Males — — — — — 18 110 Females — — — — — — 64 Non-pulmonary— Males — — — — — — 15 Females — — — — — — 11 Total — — — — — 18 190 (9016) Table IV. Tuberculosis.—New cases coming to (he knowledge of the Medical Officer of Health otherwise than by Notification under the Regulations. (Forms A and B.) 1927. Age Periods. 0 to 1. 1 to 6. 6 to 10. 10 to 16. 16 to 20. 20 to 25. 26 to 36. 36 to 46. 45 to 55. 65 to 65. 66 aod up. Total. Pulmonary— Males — — — — — 1 1 1 1 — — 4 Females — — — — — — — 1 — — — 1 Non-pulmonary Males — — 1 — — — — — — — — 1 Females — 1 — 1 — — 1 1 — — — 4 Total — 1 1 1 — 1 2 3 1 — — 10 C.L.H. General. Non-pulmonary c.l.h. General Total. Notified pulmonary 25 165 1 44 235 Not notified in Westminster — 5 — 5 10 Total 25 170 50 245 41 42 Table V. Tuberculosis.—Table showing distribution in Wards of notified and unnotified cases, and numbers of such persons who have been treated in Institutions. 1927. All Ages. Conduit. Grosvenor. Knightsbridge St. Georgo. Victoria. St. Margaret. St. John. Hamlet of Knightsbridge. Pall Mall. Regent. Great Marlborough. Charing Cross. Covent Garden. Strand. St. Anne. Homeless. Received Institutional Treatment during 1927. Pulmonary— Males 127 1 7 7 32 2 31 2 3 7 3 3 7 14 5 3 94 Females 68 — 6 3 22 2 19 1 — 3 1 1 2 — 8 — 50 Non-pulmonary— Male 21 — — — 9 1 5 — 1 1 1 — — 1 2 — 18 Females 29 — 4 3 10 3 4 1 1 1 — — 1 — 1 — — 245 1 17 13 73 8 59 4 5 12 5 4 10 15 16 3 189 43 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. 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 1926 117 90 29 4 240 18 30 48 288 1927 103 67 24 1 195 21 29 50 245 (Military cites which were excluded during the war were again mide 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 29 deaths from Tuberculosis (24 males and 5 females) during 1927 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 29 non-notified deaths gave a percentage of 25.4 of the total deaths from Tuberculosis for the year. The total number of cases of Tuberculosis on the Register at the end of 1927 was 1,457, as compared with 1,889 at the end of the year 1926. The Public Health (Tuberculosis) Regulations, 1924. The percentage of unnotified deaths is slightly higher this year, but the actual number is down from 32 to 29; the corresponding rates are 24.9 per cent. (1926) and 25.4 per cent. (1927). Enquiries were made, but in no instance did there appear to be neglect on the part of a medical practitioner to notify a case. In 19 instances the diagnosis was made as a result of post-mortem examination, some being of the casual class who had drifted into the infirmary when no longer fit to be about. Six were cases of tuberculous meningitis in children under five (9616) d 2 44 years of age, where the condition became revealed after death. In 8 cases the deaths occurred in other districts of persons giving Westminster addresses, 4 being those of clubs. Two were deaths of asylum inmates. Public Health (Prevention of Tuberculosis) Regulations, 1925. The object of these regulations is to prevent anyone who is aware that he is suffering from an infectious form of tuberculosis from engaging in certain departments of the milk trade. There was no occasion for exercising the powers conferred by these regulations during 1927. Table VII. Pulmonary. Non-Pulmonary. Males. Females. Males. Females. Number of cases on Register at beginning of year 1927 855 593 197 244 Notified for the first time during year 127 68 21 29 982 661 218 273 Removed from the Register on account of death or removal from Westminster 281* 254* 64* 78* 701 407 154 195 Of the *677 cases removed from the Register during the year, 1927, 121 were on account of death, 552 persons suffering from Tuberculosis moved from the City, and the diagnosis was revised in 4 cases. Of the 121 deaths mentioned above, 6 died from causes other than Tuberculosis. Deaths from Tuberculosis.—The total number of deaths from Tuberculosis for 1927 (all forms) was 114—Males 78, Females 36. This gives a death-rate for this disease of .83 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. 1923 119 .84 1924 138 .98 1925 129 .92 1926 133 .96 1927 114 .83 The average live-yearly rate per 1,000 was .91. The following table shows Deaths per 100,000 of civilian population since 1917. *These figures have resulted from special visits of inquiry to cases which had been ill the register since 1922. A large proportion had moved out of the district during that period. 45 Table VIII. Westminster—Leaths from Tuberculosis per 100,000 civilian population. Years. Pulmonary. Non -pul monary. Total. Deaths. Rates. Deaths. Rates. Deaths. Rates. 1917 annual 194 147 29 22 223 169 1918 186 148 31 24 217 173 1919 134 105 21 16 155 121 1920 139 97 18 12 157 109 1921 120 84.9 15 10/6 135 95.5 1922 144 103.3 21 15 165 118.3 1923 103 73.3 16 11/3 119 84.7 1924 124 86.7 14 9.9 138 96.5 1925 115 82.3 14 10.0 129 92.4 1926 119 85.9 14 10.1 133 96.0 1927 100 73.2 14 10.2 114 83.5 WESTMINSTER TUBERCULOSIS DISPENSARY. Report by the Tuberculosis Officer of the "Work of the Dispensary during 1927. The work of the Tuberculosis Dispensary has been carried out throughout the year without any radical change in the routine. Four hundred and twenty-eight new cases were examined during the year, of whom 185 were considered to be definitely tuberculous. In 1925 and 1926 there were 395 and 446 new cases respectively. There has thus been a decrease of 18 new cases as compared with last year. When it is considered that there has been a decrease of 43 in the total number of notifications in Westminster, and presumably a corresponding decrease in the number of contact cases available for examination, the figure for new cases examined at the Dispensary may be considered fairly satisfactory. The following table shows the sources from which new cases have been obtained in the last three years:— 1925. 1926. 1927. Practitioners 136 142 153 Health Visitors (contacts, etc.) 91 161 158 St. Stephen's Hospital 76 54 52 Ministry of Pensions 12 15 9 School Medical Officer 44 33 27 Hospitals 4 12 9 Friends, Charitable Organisations, etc. 32 29 20 395 446 428 46 Thus there is a slight increase in the cases recommended by practitioners. The proportion recommended by Health Visitors is much the same as last year. There is a tendency to gradual decrease in the number of new cases sent by the Ministry of Pensions. As might be expected, there is also a falling-oS in the number of old pensions cases attending the Dispensary. Many pensioners have died, while others have reached a quiescent or chronic stage, when only occasional attendance at the Dispensary is required. New pensions cases, apart from transfers, will soon cease to occur. It is therefore reasonable to expect that the work for the Ministry of Pensions, which was a few years ago a large item in the Dispensary work, will soon dwindle to a very small proportion. If the present marked fall in the incidence of Tuberculosis continues, a gradual falling-off in the number of new cases seen at the Dispensary may be expected. It will be some considerable time, however, before a decrease is very appreciable in the Dispensary work, as much of the work is in connection with old cases who often attend the Dispensary for many years, and are liable to return to the Dispensary with a recrudescence of the disease long after they have been discharged or have ceased to attend regularly. The Work Centre for the production of firewood started by the London County Council for tuberculous pensioners was closed last Autumn, but has been reopened elsewhere. Several of the Dispensary patients have attended this Centre for long periods. This scheme is only available for pensioners, and much benefit could be derived from a scheme open to both men and women, where paid work was available, for patients returning after Sanatorium treatment. The work would have to be easily learnable, fairly light, and carried out under good conditions. If the number of Tuberculosis cases continues to decrease, and the conditions of the labour market improve, schemes of this nature may become more practicable than at present. As things are, much of the benefit derived from 1922. 1923. 1924. 1925. 1926. 1927. New Patients 421 529 613 395 446 428 Old Patients attending 825 800 652 474 519 513 Contacts examined 183 245 271 150 162 131 Individuals who attended 1,246 1,329 1,255 869 965 941 Total Attendances 3,275 3,133 3,292 2,637 2,697 2,627 Written Medical Reports to London County Council and Medical Practitioners 1,554 1,651 1,884 1,280 1,378 1,270 Consultations with Medical Practitioners 181 209 243 90 92 105 Other visits paid by Medical Officer 315 227 178 87 46 149 Visits by Health Visitors to Dispensary Cases 4,995 4,717 4,907 5,636 4,144 4,875 Sputum Examinations 327 360 232 443 223 172 X-ray Examinations 16 5 2 2 5 12 47 Sanatorium treatment may be lost in the many cases where it is impossible for the patient to re-establish himself on a suitable basis when he is ??? to resume work. The following table shows the number of cases recommended for Hospital and Sanatorium treatment in 1927:— Hospitals. Sanatoriums. Insured males 34 41 Insured females 9 10 Uninsured males 4 3 Uninsured females 14 9 Boys 9 2 Girls 5 — 75 65 In addition, many children have been recommended for convalescent treatment through the Invalid Children's Aid Association, the Guardians, the School authorities, St. Henry's Fund, etc., and a few have been recommended for boarding out under the County Council's Contact Scheme. It is unfortunately less easy to obtain convalescent treatment for adults. It seems probable that spells of convalescent treatment at appropriate times might prevent many quiescent cases from losing ground, and possibly save them from reactivation of their disease, and from the need for further spells of Sanatorium treatment. The association with Westminster Hospital has been continued and a number of cases have been referred there during the year for surgical opinions, for orthopaedic treatment, or for treatment such as the removal of tonsils and adenoids. Twelve patients have had X-ray examinations and 172 specimens of sputum have been examined at Westminster Hospital in connection with the work of the Dispensary. Five cases have had Artificial Pneumothorax treatment at Brompton Hospital and elsewhere. In all, 59 refills have been given at a cost to the Council of 10s. 6d. per refill. The results in all these cases have been thoroughly satisfactory. Three cases have been referred to the Council's Dental Clinic for treatment. The total number of attendances was 14; 40 extractions and 12 fillings were performed. In addition, several pensioners were recommended to the Ministry of Pensions for dental treatment. School children are recommended to the school authorities for dental treatment and also for treatment of conditions of the eye and of the nose and throat. 48 TUBERCULOSIS SCHEME OF THE WESTMINSTER CITY COUNCIL. Return showing! the Work of the Dispensary (or Dispensaries) during the Year 1927. Diagnosis. Pulmonary. Non-pulmonary. Total. Adults. Children. Adults. Children. Adults. Children. M. F. M. F. M. F. M. F. M. F. M. F. A.—New Cases examined during the year (excluding contacts): — (a) Definitely tuberculous 82 58 3 2 11 4 13 3 93 62 16 5 (b) Doubtfully tuberculous — — — — — — — — 2 3 2 1 (c) Non-tuberculous — — — — — — — — 26 35 29 23 B.—Contacts examined during tlio year:— (a) Definitely tuberculous 4 1 — — 2 1 — 1 6 2 — 1 (b) Doubtfully tuberculous — — — — — — — — — 1 — — (c) Non-tuberculous — — — — — — — — 20 44 51 C.—Cases written off the Dispensary Register as— (a) Cured — 2 — — — — — — — 2 — — {b) Diagnosis not confirmed or non-tubcrculous (including cancellation of cases notified in error) — — — — — — — — 49 69 89 96 D.—Number of Persons on Dispensary Register on December 31st:— (a) Diagnosis completed 264 180 29 25 18 12 90 59 282 192 119 84 (6) Diagnosis not completed — — — — — — — — — 2 — — 49 1. Number of persons on Dispensary Register on January 1st 712 10. Number of consultations with medical practitioners— 2. Numlier of patients transferred from other areas and of "lost (a) At homes of Applicants 65 sight of" cases returned 7 (6) Otherwise 244 3. Number of patients transferred to other areas and cases "lost 11. Number of other visits by Tuberculosis Officers to homes 149 sight of " 128 12. Number of visits by Nurses or Health Visitors to homes for Dis- 4. Died during tho year 35 pensary purposes 3,794 5. Number of observation cases under A (6) and B (6) above in 13. Number of— which period of observation exceeded 2 months 3 (a) Specimens of sputum, etc., examined 172 6. Number of attendances at the Dispensary (including Contacts) . 2,627 (6) X-ray examinations made 12 •7. Number of attendances of non-pulmonary cases at Orthopaedio in connection with Dispensary work. Out-stations for treatmont or supervision — 14. Number of Insured Persons on Dispensary Register on the *8. Number of attendances at General Hospitals or other Institu- 31st December 333 tions approved for tho purpose, of patients for— 15. Number of Insured Persons under Domiciliary Treatment on (a) "Light" treatment — tho 31st December 197 (b) Other special forms of treatment 54 (A.P.) 16. Number of reports received during tho year in respect of Insured 9. Number of patients to whom Dental Treatment was given, at Persons:— or in connection with the Dispensary 3 (a) Form G.P. 17 — (6) Form G.P. 36 1 * A number of Orthoptedio and surgical cases reoommended to General Hospitals. Cases for Sunlight treatment referred to Ranelngh Road Clinic. (Signed) Ian S. Thomson, M.D., Tuberculosis Officer. 21th February, 1928. 50 The Tuberculosis Care Committee has approved grants for extra diet to 16 persons for varying periods at a cost to the Council of £99. Cases are recommended by the Tuberculosis Officer purely on medical grounds as an adjuvant to the other treatment provided under the Council's Tuberculosis Scheme. Most of the cases are patients who are awaiting or have recently returned from institutional treatment. Care and After-care.—The work of the Tuberculosis Care Committee has been continued as in previous years, and the Committee is preparing an Annual Report on its work. The Committee deals with various questions concerned with the welfare of patients returning from institutional treat ment and with the care of patients' dependants while the breadwinners are away. Many cases are referred to appropriate organisations for help. Advice and support is given on questions of housing and employment. The Committee makes assessments for patients, and recommendations as to grants from the Council for extra diet, dental treatment, etc. During the year the Committee gave consideration to a scheme promoted by the Secretary for the formation of a Handicrafts Class for Dispensary patients. Later this scheme was taken over by a small voluntary Committee which raised the necessary funds and started the class. The class is fortunate in having a highly-qualified teacher in Miss Willatts, who has been for many years a voluntary worker at the Child Welfare Centre at 1, Pimlico Road. It is hoped that the class, by providing interesting occupation for suitable patients, may relieve them from monotony and introspection and so aid them to maintain their health. Such schemes have definite limitations, being only applicable to a certain number of cases, and doing little to help to re-establish even these as wage-earners. It seems possible, however, that if vocational schemes are established later these occupational schemes will form valuable stepping-stones in the process of re-establishment, and even at present definite benefit may be expected to the members of the class. Ian S. Thomson. HOUSING. At the end of 1927 the new housing schemes of the Council at Esher Street and Willow Street were well in hand, the work on the latter being so well advanced that the tenants hope to be in occupation by the beginning of June, 1928. Details concerning both schemes were set out in the report of last year, and it only remains to add a few details relating to the flats in Willow Street. This building is to be named "Admiral House," in honour of Admiral Sir Henry II. Bruce, K.C.B., M.V.O., Chairman of the Housing Committee. The total cost is approximately £33,000, the ground rent being £250 per annum for a 999 years lease. It is 51 anticipated that 231 persons will be housed in the building, which contains 41 separate dwellings, which vary as to number of rooms and rents as follows:— - 11 dwellings. 2 rooms. 25 dwellings. 3 rooms. 5 dwellings. 4 rooms. s. d. s. d. s. d. Ground, 1st, 2nd, 3rd and 4th floors 9 10 13 5 17 3 Fifth floor — 12 0 — Rates are included in these figures. The following is an extract from the official description issued by the Housing Committee:— " The structure, which is generally five storeys in height, is planned on the quadrangle principle, with buildings on three sides facing a large open courtyard, from which the three entrances to the flats are approached. It is divided into three blocks, and comprises— 11 two-roomed flats, 25 three-roomed flats, and 5 four-roomed flats, a total of 41 flats, containing 117 rooms, capable of housing approximately 234 persons. Each flat is provided with a small entrance hall and kitchen, with gas stove and sink, a larder, a coal store, and cupboards. Care has been taken to ensure sunshine in each living room and most of the bedrooms, while the courtyard in front and the space behind give free access of light and air to every apartment. Each flat is artificially lighted by electricity on the slot system. Adjoining each entrance are groups of bathrooms, with baths supplied with constant hot water from the central boiler-house. On the rear portion of the site is a laundry with drying room, together with 11 perambulator stores, for the use of tenants. The lay-out of the buildings shields, to a great extent, the awkward shape of the site, while the courtyard in front and the paved area behind give ample and safe play space for the children. The buildings comply throughout with the provisions of the London Building Act, and are of fire-resisting construction, and the means of escape have been approved by the London County Council." Pulford Street Site.—On representations from the Westminster Housing Association, this area as a possible housing site was re-considered. The fact that so much of the frontage in Pulford Street concerned in giving open access to the site was offered as a gift to the Council was a factor which merited the fullest and most sympathetic consideration. The whole question was therefore surveyed again in its various aspects. The purchase value of the site, together with the extensive nature of the work 52 which would be necessary to secure sound foundations, and the further obligation to house all the tenants to be displaced in the Pulford Street houses abutting on the site, combined to show that the net increase in housing accommodation did not justify the large financial outlay which the scheme would demand. It was therefore very reluctantly resolved not to proceed with the scheme. WormhoU Estate, Hammersmith.—Early in the year a proposal was made by the London County Council with reference to an estate at AVormholt, on the outskirts of Hammersmith. It was suggested that so many of the houses to be built should be allocated to neighbouring metropolitan boroughs in order to relieve overcrowding and other insanitary conditions. There were certain restrictions attached to the offer which were not at first acceptable, but on re-consideration the City Council entered into an agreement to accept allocation of 50 houses, for which the Council pay to the London County Council £7 per annum per house for a period of 20 years. In return for this payment the City Council has the right to nominate Westminster residents for each of the 50 houses. The London County Council retain the right to refuse a nominee, and, further, to dispose of a "Westminster" house to persons from other districts in the event of the City Council not having sufficient nominees to occupy the quota. It was stated that the boroughs of Kensington and Hammersmith had taken 100 each, and St. Marylebone 200. The advantages of the Wormholt scheme as compared with the other housing estates of the London County Council—e.g., Watling—are, that by having houses reserved for Westminster a greater number of tenants can be placed within a short period, and the fact that the Wormholt estate is more accessible to Westminster than any other of the housing estates. The accommodation of the Wormholt houses is specified as follows, the rents quoted being exclusive of rates and water charges:— Per week. s. d. 3 rooms, scullery and bathroom (intermediate house) 11 0 4 rooms, scullery and bathroom (non-parlour end house) 12 6 4 rooms, scullery and bathroom (parlour house, intermediate) 13 6 5 rooms, scullery and bathroom (end house) 14 9 There is no guarantee that any particular houses will remain dedicated to Westminster people, for the London County Council reserve the right, on a house becoming vacant, to let it to any approved applicant; at the same time the Westminster quota will be maintained by the allocation of a house in another part of the estate. The City Council nominated altogether 70 tenants, but unfortunately 15 of those were refused by the London County Council on various grounds, as, for example, insufficient family income in relation to the rents and travelling expenses connected with Wormholt. A further 15 53 of those nominated subsequently withdrew their applications for reasons which in most cases were not given. The practical result has been that a considerable proportion of accepted tenants were those who had been living in Westminster, but were at work in some district not far removed from Wormholt. Up to the end of the year 40 tenants from the City were housed at Wormholt or had definite prospects of being given houses there. During the year 49 tenants were offered houses on the other estates of the County Council, and 30 accepted. Houghton Street.—London County Council Scheme under the Housing Act, 1925, and London County Council (General Powers) Act, 1925.—In pursuance of a scheme to demolish five working class dwellings in Houghton Street the London County Council submitted proposals to the Minister of Health for his approval. As the scheme was submitted under the 5th schedule to the Housing Act, the Minister requested the City Council to put forward any representations which it considered desirable with reference to the re-housing of the tenants who would be displaced. It was pointed out to the Minister that the re-housing proposals of the London County Council on the Old Oak estate would not meet the needs of at least three of the working class tenants who required to live in the neighbourhood of their places of work. It was suggested that the London County Council should find them accommodation near at hand. Among the problems which render the whole matter of housing so perplexing is the fact that, although the London County Council hope to relieve overcrowding and insanitary conditions by providing dwellings in the suburbs, it not infrequently happens that those applicants whose qualifications in these respects seem most pressing are found to be ineligible because of their social circumstances which do not come up to the standards set by the County Council. The County Council, as owners, quite justly wish to be assured that their tenants are in a position to pay the rents and that they will maintain these new dwellings in a clean and sanitary condition. As is only to be expected, this has resulted in a number of the applicants living in overcrowded and insanitary conditions being rejected. In a number of instances the Council's sanitary inspectors have been able to arrange in an informal manner with certain owners for the removal of overcrowded families to better quarters elsewhere—a sort of interchange satisfactory to all parties has taken place. In other instances the financial difficulty has proved insuperable. "How," says an owner, "can I give the tenant an additional room which has fallen vacant in my house when I have not received rent for the past six weeks for the single room which he has been occupying ?" Questions such as these are at 54 the root of the housing problem. Even in some cases where the most bitter complaints have been made by tenants of their dwellings, they evince a strong prejudice against moving to better accommodation in the neighbourhood because, although able to afford it, the rent may be higher. In such cases, where serious overcrowding or the illegal occupation of underground rooms aggravates the situation, the sanitary authority should exercise its powers to the fullest extent. Housing Conditions.—Throughout the year particular attention was paid to the routine inspection of the housing conditions in the district. The work of house-to-house inspection was pursued with even greater activity than last year, the main object being to stimulate the work of re-conditioning houses which by reason of age and decay were falling into disrepair. Reference to Table II shows that 819 inspections under the Housing Regulations, 1925, were made, as compared with 555 last year. These figures indicate primary inspections, and may therefore be taken to represent the number of dwelling-houses visited. These primary visits entail a considerably greater number of re-visits for the purpose of meeting owners or builders on the premises concerning work to be done, to see if the work is in progress after notice, whether work has been completed as required by a notice, for confirmatory details as to overcrowding, and so on. Thus it is that, in proceeding through the houses of a street, a slowing up of primary inspections takes place while the numbers of reinspections multiply greatly. Last year the total re-inspections referred to all premises; in this report the number 7,067 concerns dwelling-houses only. House-to-house inspections have been made in the following streets: Adam Street, Caledonia Place, Cottage Place, Ebury Bridge Road, Glamorgan Street, Glasgow Terrace, Kensington Place, Kinnerton Place North, Lillington Street, Meard Street, Mercer Chambers, Royalty Mansions, St. George's Square Mews, Vincent Street and Westbourne Street. The houses numbered 340, containing the dwellings of 650 families. In them were found a number of cases of overcrowding, of which five were of a serious nature. Of those five two were remedied by informal action or notice by the end of the year. There were two basement dwellings found to be illegally occupied, and in each case occupation was discontinued. Insanitary conditions, such as insufficient water supply, inadequate w.c. accommodation, defective or dirty or damp conditions, or combinations of all or any of these three were found in 210, and appropriate action was taken in each case either informally or by notice. Under the category defined by Section 3, Housing Act, 1925,953 houses were reported as not in all respects reasonably fit for habitation. The number so found last year was 814. The increase does not imply that housing conditions throughout the City are irretrievably bad and are 55 rapidly becoming worse. It indicates rather that house inspections are becoming more intensive. It should not be necessary to explain that such items as the temporary breakdown of the flushing apparatus of a w.c. renders a house not in all respects fit for habitation. Half an hour's work should relieve the house of such a stigma. Again, a leaky roof, causing extensive dampness, is another defect which, when remedied, removes the cause of the insanitary condition which made the house not in all respects, etc., etc. In all 053 instances the defects in question were made good. This point appears to require emphasis in order to avoid confusion with that other category referred to in Sections 9, 10, 11 and 12 of the same Act, which refers to houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation. Three dwellings were found which, although the inmates were living both happily and well, were thoroughly unsatisfactory in their internal structure and lack of conveniences, and thus came dangerously near to being declared in terms of Section 9. In one case the owners, without formal notice, made structural alterations sufficient to remove the anticipated embargo; in the other two cases the premises were vacated by the tenants, and an undertaking was given that the premises would not again be used for living purposes. In another instance a basement room was so deficient in light, and so generally dilapidated, that it fell within this category. Its use as a habitable room was discontinued, and it was altered to serve as a wash-house. A formal complaint under Section 10 of the Housing Act, 1925, was received in February. It concerned 20 houses in the Victoria Ward. As required by the Act, the properties were visited forthwith by the Medical Officer of Health, and a full report was prepared and considered by the Public Health Committee. A copy of the complaint was forwarded to the London County Council as required under Section 25 of the Housing Act. The complaint alleged that these 20 houses were so dangerous or injurious to health as to be unfit for human habitation. It was further submitted that all the houses were more or less damp, verminous and dirty. Defects requiring the service of intimation notices were found in all instances, and in eight statutory notices were necessary before the defects were made good. In the case of two houses belonging to the same owner, the statutory notices had not been complied with within the stated period, and legal proceedings were taken to enforce compliance with the terms of the notices. Obvious signs of vermin were found only in three, but it must be remembered that the inspections were carried out in winter, when such conditions more or less lie dormant. Although none of the houses was fit in "all" respects (as explained above), yet only in two were the conditions such as to render them "unfit for human 56 habitation," and this remark applied also to one basement room in a house. The Public Health Committee reported accordingly to the Council that appropriate action had been taken to remedy the nuisances found, and that in the case of the two unfit houses and one unfit room the owners had taken such steps as obviated the need for closing orders. In all except two cases the conditions which gave rise to complaint were satisfactorily dealt with within three months of receiving the complaint. The work entailed in consequence of a statutory complaint such as has been described adds greatly to the ordinary duties of the Public Health Department. As regards the administrative side, there is increased correspondence, interviews and special reports to be made, while the visits of sanitary inspectors in this instance numbered no fewer than 208. Further additional work resulted from the allegations contained in an unofficial survey of the Victoria Ward which was published in May. This pamphlet received enormous publicity, partly by reason of the picturesque style adopted by the authors in their descriptions of premises. This Survey Report, in addition to a number of generalisations regarding the housing conditions in the Victoria Ward, made a detailed commentary on houses in certain streets without references to street numbers. A considerable period elapsed before the promoters of the survey considered themselves justified in revealing the identity of the houses which they had severely criticised. In the meantime their publication—which was, after all, an expression of unofficial opinion—gave rise to much unjustified criticism, both written and verbal, of the state of the public health in Westminster. The vital statistics produced by the Registrar-General are in themselves sufficient proof that Westminster will compare well with any urban area of similar size and age throughout the country. In due course the identity of the houses was revealed, and the Public Health and Housing Committees were in a position to report to the Council as to the accuracy of the statements in the Survey Report. Two reports were published, one a joint report by the two committees concerned dealing with the policy of the Council in regard to Public Health and Housing, and the other an official report by the Medical Officer of Health dealing with the sanitary condition of the 22 houses which were specifically commented upon in the Survey Report. In a number of instances he was unable to find confirmatory evidence of the conditions which had lent themselves to such vivid and appealing description in the Survey Report published only a few months before. Investigation by a responsible official of such allegations as serious overcrowding requires time and considerable exactitude, for his opinion must be supported by requirements laid down in statutes and bye-laws. In fully half of the cases there was no overcrowding as defined 57 by public health law, all hough it might appear to exist as seen through the eyes of an amateur. So also with the statements as to disease associated with housing conditions. It was apparent that tenants' complaints were accepted as facts to be soberly recorded and published. None was confirmed from the health records in the department. An indication of the work which the investigation of the statements in the Survey Report entailed may be gauged by the 106 special inspections which were necessary for the purpose of the Medical Officer of Health's report on the matter. Houses Let in Lodgings.—In the Annual Report for 1926 reference was made to the forming of a fresh register of houses let in lodgings rendered necessary by the coming into force of the by-laws made by the London County Council which contain many new provisions. The number of houses on the new register at the end of 1927 was 155. During the year 1,278 visits of inspection were paid to houses of this class and in 104 instances infringements of the byelaws were reported, appropriate action being taken in each case. Four tenants were prosecuted for failing to furnish the Council with a statement of particulars required for the purpose of registration. In one case a fine of 1s. and £1 1s. costs was imposed, two cases were withdrawn on payment of £1 Is. costs, and one was not proceeded with owing to the death of the person concerned. Vnderground Bedrooms.—The use of underground rooms as sleeping rooms contrary to the regulations made by the Council under the Housing, Town Planning, &c., Act, 1909, which have effect as if made under the Housing Act, 1925, was brought to the notice of the sanitary authority in 31 instances. Notices were served upon the owners and occupiers of the premises concerned and in 27 cases the use of the rooms as bedrooms was discontinued. In 19 of those cases compliance with legal requirements was obtained by means of an alteration in domestic arrangements ; rooms which were in use as living rooms or kitchens and which complied with the regulations of the Council being converted to use as bedrooms and vice versa. In the eight remaining cases the basements were considered to be unsuitable for use as separate dwellings, and on the recommendation of the Medical Officer of Health, six of the tenants concerned were rehoused in dwellings of the City Council or of the London County Council. In the other two cases the tenants themselves found alternative accommodation. Restriction of Rent Acts.—Two applications were received for certificates under these Acts, and both were granted. (9616) E 58 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. (a) Total 0 (b) With State assistance under the Housing Acts— (i) By the Local Authority 0 (ii) By other bodies or persons 0 1. Unfit dwelling-houses. Inspection—(1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 3,805 (2) Number of dwelling-houses which were inspected and recorded under the Housing Consolidated Regulations, 1925 819 (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 953 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 53 3. Action under Statutory Powers. A.—Proceedings under Section 3 of the Housing Act, 1925. (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 (6) 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 59 B.—Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 1,040 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 1,007 (b) By Local Authority in default of owners 0 C.—Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925. (1) Number of representations made with a view to the making of Closing Orders 0 (2) Number of dwelling-houses in respect of which Closing Orders were made 0 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwellinghouses having been rendered fit . 0 (4) Number of dwelling-houses in respect of which Demolition Orders were made 0 (5) Number of dwelling-houses demolished in pursuance of Demolition Orders 0 General Sanitary Conditions. The table given below shows in considerable detail matters relating to the general 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; and other specialised duties. It was pointed out last year that the increasing number of new buildings in the City had added greatly to the duties and responsibilities of members of the department. This statement applies with still greater force on this occasion. In certain large buildings a careful examination of the drainage system frequently involves several whole days being devoted to this purpose by a sanitary inspector. (9616) E 2 60 Table II. Inspection of premises :— Sanitary work supervised :— Dtoelli tig-houses— Drains— Primary Inspections- Constructed 1,345 fa) On complaint 984 Repaired and amended 364 (b) Infectious disease 477 Ventilated 942 (e) Housing Regulations, 1925 819 Interceptor traps fixed 235 Sealed off from sewer 83 (rf) Other reasons 1,525 Gully traps fixed 1,693 Re-inspcctions 7,067 Defective traps abolished 244 Other Premises— Manholes built 918 Primary Inspections— „ repaired 276 (a) On complaint 433 „ covers fixed or repaired 584 (6) Other reasons 1,862 Re-inspections 3,713 Fresh air inlets fixed or repaired 376 Sanitary Works— Tested by smoke 171 Total Inspections— „ chemical 400 (a) Under notice 2,475 ,, water 1,722 (6) Voluntary works 9,781 „ air 27 Soil Pipes— Fixed 666 Nuisances and other matters dealt with :— Ventilated 376 Repaired 260 Tested by smoke 230 Public Health Acts— ,, chemical 440 Dirty conditions 1,938 „ air 628 Damp conditions 457 „ water 64 Verminous conditions 405 Water-closets— Defective drainage, waterclosets, &c. 422 Constructed 2,222 Repaired 397 „ roofs 331 Traps ventilated 1,991 „ walls and ceilings 832 Flushing cisterns fixed 2,150 ,, floors, staircases, &c. 370 ,, ,, repaired 272 „ paving of yards, &c. 376 Waste Pipes— Water-close tB— Constructed 1,959 Insufficiently lighted or ventilated 106 Repaired 410 Trapped 2,394 Directly approached from Ventilated 2,182 rooms 54 Disconnected from drain 734 Insufficient 43 Rainwater Pipes— Keeping of animals 22 Fixed or repaired 927 Other nuisances 796 Disconnected from drain 321 Overcrowding (families) 46 Urinals— ,, abated 32 Constructed 266 Underground rooms— Repaired or improved 70 Illegal occupation 3 Water Supply— Occupation discontinued 3 Provided 209 Housing Act, 1925— Taps off main provided 529 Underground bedrooms— Cisterns fixed 274 Contrary to Regulations 31 Pipes repaired 282 Use discontinued 27 Stables— L.C.C. (General Pou-ers) Act, 1907- Drained 4 Absence of water supply to upper floors of tenement houses 22 Paved 9 Petrol interceptors provided 6 By-laws as to Removal of Offensive Refuse.—Three cases were reported of removal in unsuitable vehicles and in inadequate receptacles. Including those there were 8 instances of removal during prohibited hours. A summons was ordered in each case, the proceedings resulting in fines amounting to £9 10s. 61 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 is a daily collective of house refuse, the removal of trade refuse being subject to special arrangements: 100,270 tons of the former were collected during the year and 723 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. During 1927, 83,279 tons were sent away in barges and 10,497 tons were treated at the salvage plant. The remainder was carted away by various private firms. Nuisances.—Intimation notices were served in 1,450 instances and 1,512 letters were sent dealing with those notices or kindred matters. Statutory notices authorised by the sanitary authority numbered 49 and related to 48 premises. Police court proceedings were taken in 5 instances in order to enforce compliance with the requirements of statutory notices. The following are the comparative figures since 1923 :— 1923. 1924. 1925. 1926. 1927. Intimation Notices 1,373 1,098 980 1,074 1,450 Letters 1,141 1,028 1,592 1,802 1,512 Statutory Notices 38 41 27 43 49 Legal Proceedings 2 2 5 10 5 In the 5 instances of legal proceedings the cases were:— (1) Dirty, damp and defective state Fined Is. and £1 Is. costs. of dwelling-house. (2) Dirty and defective state of Fined 1s. and £1 1s. costs. dwelling-house. (3) Overcrowded and illegally occu- Summons adjourned sine die, pied basement room. the room having been vacated. (4) Unventilated state of kitchen, Summons adjourned sine die bathroom and water-closet on payment of £1 1s. costs, apartment. the work having been pleted. (5) Dirty and damp state of dwell- Summons withdrawn on- ing-house. ment of £1 Is. costs, the work having been completed. Unfit Dwellings and Rooms.—The difficulty in obtaining abatement of overcrowding, the illegal occupation of underground rooms and unfit dwellings generally, when housing accommodation is still extremely 62 limited, can readily be appreciated. Even in bad cases which have been taken before the magistrate orders have not been made. When rooms become vacant, however, which had previously been illegally occupied, it is the practice to inform the owner in writing that such rooms must not be relet so as again to constitute illegal occupation. It is clearly pointed out that the sanitary authority after issuing this warning will, if necessary, take legal proceedings to prevent a recurrence of the former conditions. In 31 instances owners were so informed during 1927 and in none of these cases has reoccupation of an illegal nature occurred. Rat Repression.—Twenty-seven complaints of rats were received and in each case an inspector investigated as to the cause of the complaint. In 11 instances it was found that they had entered through faulty or defective drains and sewers. Twenty-eight connections were examined by the City Engineer's staff at the request of the Public Health Department. 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 distributed to householders and to business firms. During that week 15,000 baits were laid in the Council's sewers. Water Supply.—The Metropolitan Water Board sent seven notices of withdrawal of water supply to premises. In six cases the reason for the action of the Board was failure to pay water rate, and in the remaining one defects in the water fittings, causing waste of water. Water Supply in Tenement Houses.—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 1923 is as follows:— 1923. 1924. 1925. 1926. 1927. 36 27 55 44 22 New Sanitary Construction.—Plans relating to work of this description numbered 750, of which 93 represented sanitary provisions in entirely new buildings. The corresponding figures since 1923 are as follows:— 1923. 1924. 1925. 1926. 1927. Plans 651 602 658 724 750 Plans of work in new buildings included in above 73 80 102 110 93 In 35 instances the plans related to houses wholly or partially being converted into flats, and in 15 instances to premises in mews being converted into dwellings of a superior class. 63 Of the total of plans submitted, 3 were not approved, as the work proposed did not comply with the by-laws. In 6, the proposals were withdrawn. Combined drainage orders were made in 25 cases. Infringements of the by-laws were reported to the Public Health Committee in 24 instances in respect of failure to give notice of intention to construct or to deposit plans. Nineteen builders were cautioned and four were summoned in respect of these offences and were convicted, fines and costs amounting to £9 1s. A prosecution was ordered in another case, but could not be proceeded with as the builder concerned could not be found. Smoke Abatement.—A conference organised by the Smoke Abatement Society was held at the Guildhall in November. Delegates from authorities in London and Greater London, together with representatives from industrial undertakings and other bodies representing commerce, attended. The Council's delegates were Councillor Mrs. Home and the Medical Officer of Health. A general committee of representatives from various bodies was set up to consider and report on the following heads of reference:— "(1) The possibility of effecting a standardisation of procedure of the efficient observation of smoke emission. (2) The by-laws that might reasonably be made under the provisions of the Public Health (Smoke Abatement) Act, 1926. (3) The permissible smoke emission periods. (4) The type of case in which legal proceedings ought to be taken. (5) The possibility of joint action being taken by all the Public Health Authorities of London and Greater London, and the form which such joint action, if any, should assume. (6) The consideration of new methods by which the duties of Smoke Inspectors can be facilitated." This committee, to which your Medical Officer was appointed as a representative of the Metropolitan Standing Joint Committee, is to hold its first meeting at the Ministry of Health early in 1928. Special Course for Inspectors dealing with Smoke Nuisances.—In view of the possible requirements to be laid down in by-laws to be made under the Smoke Abatement Act, 1926, the Royal Sanitary Institute drew attention to a special course of instruction for those engaged in inspection of smoke nuisances. Apart, from the exercise of statutory powers much can be done by giving expert advice as to how furnaces should be stoked, the alterations in structure or apparatus used in stoking, suitability of fuel for particular purposes, and in other directions. It was resolved, therefore, to send the two sanitary inspectors engaged in this work to attend this special course, the expenditure having received the approval of the Ministry. 64 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. 1923. 1924. 1925. 1926. 1927. Complaints received 12 40 80 62 79 Observations taken 600 2,309 1,999 2,490 2,057 Notices issued— Preliminary 8 42 23 26 29 Statutory 2 — — — 1 Summons 1 — — — — Nuisance from Pigeons.—The London County Council (General Powers) Act, 1927, gave powers to metropolitan sanitary authorities to adopt measures for dealing with this nuisance. The appropriate section No. 52 (1), is as follows:— " For the purpose of abating or mitigating any nuisance annoyance or damage caused by the congregation at any place in the county of house doves or pigeons having or believed by the local authority to have no owner or of preventing or minimising any such nuisance annoyance or damage which might in the opinion of the local authority be so caused the local authority may notwithstanding anything in the Larceny Act 1861 or in any other Act seize and destroy or sell or otherwise dispose of or cause to be seized and destroyed or sold or otherwise disposed of any such house doves or pigeons in excess of such number as the local authority may consider reasonable and take such other steps as they may deem necessary for any such purpose. Provided that a local authority shall not in the exercise of the powers conferred by this section— (a) enter upon any building or land (other than a public highway) without the consent of the occupier or the authority body or person having the exclusive control and management of such building or land; or (b) cxccute or do any work or thing affecting the structure of such building or the use of such land without the consent of the authority-body or person in whom such building or land is vested ; or (c) knowingly destroy sell or otherwise dispose of or cause to be destroyed sold or otherwise disposed of any house dove or pigeon belonging to any person." A number of complaints have been received from time to time from ratepayers in various parts of the City relating to the damage to property and annoyance to persons from deposits of pigeons' excrement. It has been stated that no less than between 2 and 3 tons were removed from the roof and belfry of St. Martin's-in-the-Fields. Other buildings in the neighbourhood of a popular feeding ground such as Trafalgar Square are similarly affected. It was suggested by your Medical Officer that as pigeons are migratory to a certain extent it would be desirable for the central boroughs to take common action, and the London County Council, which had obtained the Parliamentary powers, were requested to convene 65 a meeting of the medical officers concerned. Those from the City, Westminster, Holborn, Marylebone, Kensington, Chelsea and Battersea attended. It was agreed to suggest the appointment of an expert birdcatcher who would use his own method of trapping. He would act as the agent of the local authority for the purpose of entering premises, consent to enter having been obtained. The birds would be removed alive to a depot and there all ringed birds would be segregated and removed by him to the official collector of the Homing Union. The remaining ownerless birds would then be humanely disposed of in the presence of an official of the local authority and given to the trapper. For his services he would receive payment for the number of ownerless birds caught. It was hoped to put a scheme in force by the end of the year, but difficulties arose in another district owing chiefly to interference by onlookers whose sympathies were on the side of the pigeons and who succeeded in attracting them away from the snare of the trapper. The whole matter is therefore being reconsidered and it is hoped to bring up a fresh proposal in 1928. Fouling of Footways by Doys.—This has been a cause of complaint for many years to the Highways department responsible for the cleansing of streets and footways, and to this department responsible for the abatement of nuisances. It was considered that the adoption of a by-law similar to that in force in Kensington, Fulham, Chelsea, and many other districts outside London might have a deterrent effect on the carelessness of owners who permit their dogs to soil the pavements. Presentments from both committees were brought forward in support of a by-law and were approved by the Council. The by-law reads as follows:— "No person being in charge of a dog in any street or public place and having the dog on a lead shall allow or permit such dog to deposit its excrement upon the public footw ay. Any person offending against this by-law shall be liable to a penalty not exceeding 40s. This by-law shall cease to be in force after the First day of January, 11130, unless a by-law confirming and continuing its provisions has been duly made and come into force before that date." By arrangement with the Home Office complaints of any offences will be brought to the notice of the Council by the police. Public Health Act, 1925.—Consideration was given as to the desirability of incorporating in a London County Council General Powers Bill certain powers which had been conferred on all authorities outside London by the Public Health Act, 1925. The Medical Officer of Health drew attention to certain useful provisions which would be of advantage if applied to the health administration of the City. These briefly were as follows, reference being to sections of the Public Health Act, 1925:— 66 Sec. 13.—The provision of street or orderly bins for the deposit or collection of street refuse, sand, &c. (already in the Hackney Borough Council Act, 1926). Sec. 21.—The prevention of water flowing on footpath from adjoining premises. Owners to take necessary steps within 28 days' notice from local authority. Sec. 39.—Drains not to be covered in without 24 hours' notice to local authority. This would ensure closer supervision of sanitary work. Sec. 48.—Verminous Persons.—Compulsory removal to a cleansing station for the purpose of cleansing and disinfection. Experience has shown this to be very desirable in certain eases. Sec. 57.—Contact with body of person dying from a dangerous infectious disease—reasonably practical steps to prevent persons coming in contact with. Sec. 58.—Power to M.O.H. to enter common lodging-houses to examine inmates for evidence of infectious disease. Although such power is in the Hackney Act, the sanitary administration of these houses is in the hands of the L.C.C. Sec. 62.—Power to remove to hospital infectious persons suffering from pulmonary tuberculosis. It is very desirable that the local authority should be in a position to exercise in certain cases. Experience elsewhere has proved that the moral force bestowed by legal powers is generally sufficient for the purpose in view. Already in force in Hackney under its Act. Sec. 64.—Power of local authorities to subscribe to hospitals, &c. In effect, a wide extension of the powers similar to those conferred by the Maternity and Child Welfare Act for maternity and child welfare purposes. Sec. 73.—Prevention of infection conveyed in toys. Rag and bone dealers not to sell food and toys. These various points were fully reported on and in addition it was recommended that there should be obtained for London powers similar to those contained in Sec. 56 of the Bradford Corporation Act, 1925, dealing with the removal from their abodes of infirm and diseased persons incapable of looking after themselves and living in insanitary conditions. The section is lengthy and deals with the procedure entailing application to a magistrate for an order on proof being submitted by the Mcdical Officer of Health, period of detention in a suitable institution and other technical matters. Finally the section in the Hackney Act dealing with the definition of a combined drain was included in the recommendation. Lighting of Staircases of Tenement Buildings.—Sec. 61 (1) of the London County Council General Powers Act, 1927, is as follows:— "The owner of every tenement building in the county shall— (a) wherever practicable provfde every common staircase in that building with adequate means of lighting by natural light including (in the case of a building constructed or reconstructed after the commencement of this Act) a window or windows or opening or openings on the staircase at each storey opening dirctly into the external air ; and 67 (6) provide adequate means for the artificial lighting of every common staircase in that building and keep such means efficient and lighted daily from one hour after sunset until eleven o'clock in the afternoon : Provided that in the case of a common staircase leading to not more than two separate or self-contained flats or tenements in a two-storey tenement building the owner of such building shall not be required to light or keep lighted such means for artificial lighting as aforesaid." On a reference from the Metropolitan Standing Joint Committee the Association of Metropolitan Town Clerks were invited to draft a method of procedure for the guidance of the metropolitan sanitary authorities, and the following suggestions of the association were adopted:— "(a) That each Metropolitan Borough Council should prepare a schedule of tenement buildings within its area and cause a survey of the same to be made with a view to ascertaining which of the staircases do not already contain the adequate lighting by day and/or by night contemplated by the section. (b) That in any case in which it appears to the Borough Council as the result of this survey that any staircase is not so lit and that it is practicable so to light it either by day or by night or both, a letter be sent in the first place to the owner drawing his attention to the section and asking him what steps he proposes to take in order to make such provision by the 1st August, 1928. (c) That in the event of his proposals being regarded as reasonably sufficient they be acccpted, and that if not, he be invited to amend his proposals in such direction as the Borough Council may think necessary or desirable. (d) That if the owner still dissents he be afforded an opportunity of placing his views personally before the appropriate Committee of the Borough Council. (e) That the Borough Council, by inspection through a Committee or a sub-committee, should satisfy itself that the owner is in default before taking proceedings." A survey of the tenement buildings in the City was made and a schedule prepared. Of the 107 tenements surveyed 6 were found to contain staircases in which there was inadequate means of artificial lighting. In all cases there was satisfactory natural lighting. The six owners were communicated with as to the lack of artificial lighting and requested to provide means for the same before 1st August, 1928, the date on which the section of the Act comes into force. L.C.C. Draft Drainage By-Laws made under See. 39 of the Public Health (London) Act, 1891.—The draft revised by-laws, to which brief reference was made in the Annual Report for 1926, contain provisions relating to water-closets, urinals, earth-closets, privies, cesspools, ashpits and receptacles for dung. The requirements of the existing by-laws as to the situation, lighting and ventilation of water-closets have been amended or modified in order to meet the present-day conditions of site limitations and the greater height and depth below ground of modern buildings. Important new provisions regarding the 68 mode of construction of water-closets and urinal apartments and of lobby approaches thereto are included; the construction of waterclosets without access to natural light and air is permitted under certain conditions; urinal apartments are to be constructed in accordance with the requirements laid down in the case of water-closets; and the provisions as to the lighting and ventilation of water-closets are to apply in the case of entrance lobbies to sanitary conveniences. The responsibilities devolving upon owners, occupiers and lodgers respectively under the by-laws are clearly defined. The Public Health Committee considered the draft by-laws, together with a report by the Medical Officer of Health, and made a presentment to the Council. Suggestions were made that the by-laws should be amended in certain respects, particularly in the case of the proposal to permit the construction of water-closets without access to natural light and air. This provision was regarded with strong disfavour as being in the nature of a retrograde step, and its omission from the bylaws was recommended. A communication was addressed to the London County Council requesting that the by-laws be amended in accordance with the views expressed in the report of the City Council. Local By-laws and Regulations.—The following by-laws and regulations made by the City Council are in force in the City and became operative on the dates mentioned:— By-laws under the Public Health (London) Act, 1891— Paving of yards and open spaces in connection with dwelling-houses.— 24th August, 1908. Cleansing of Cisterns.—24th August, 1908. Water-closets—water supply to.—24th August, 1908. For the prevention of nuisances arising from— (1) Snow, ice, salt, dust, ashes, rubbish, offal, carrion, fish or filth or other matter or thing in any street. (2) Any offensive matter running out of any manufactory, brewery, slaughterhouse, knacker's yard, butcher's or fishmonger's shop or any dunghill, into any uncovered space, whether or not surrounded by a wall or fence. (3) Keeping of animals in such place or manner as to be injurious or dangerous to health.—24th August, 1908. Regulations as to underground sleeping places under Section 17 (7), Housing, Town Planning, etc., Act, 1909.—llth January, 1916. 69 Factories, Workshops and Workplaces. Ventilation in Workshops.—Although the powers of the sanitary authority arc mostly concerned with the number of persons employed in workshops in order to maintain standards which shall not permit of overcrowding, there are other considerations which are not laid down in statutes but to which due regard should be paid. The work of Prof. Leonard Hill has shown clearly that vitiation of the atmosphere and the signs of fatigue to which it gives rise are not primarily due to the C02 of human respiration but to the amount of moisture present together with a rising temperature and stagnation of the air. He holds that so long as the air is kept moving and is not fully saturated with moisture reasonably comfortable conditions can be maintained. In order to estimate what he terms the cooling power of the air, Prof. Hill has devised the Kata thermometer. The principles of the working are similar to those of the wet and dry bulb hygrometer. Both dry and wet thermometers are heated in warm water to over 100° F., surplus moisture is shaken off and then is noted how long (by means of a stopwatch) the level of the spirit takes to fall to a standard mark on the thermometer (95° F.). If it falls quickly a relatively satisfactory condition of the air in the room is indicated. Certain standards have been worked out by Prof. Hill, e.g., 7 dry and 20 wet for schools, 6 dry and 18 wet for workshops in temperatures 60°—65° F. The Kata thermometer has been used with the object of obtaining confirmatory evidence as to the state of ventilation in workshops. During 1927 the lady sanitary inspector made 718 observations, 371 with the djy bulb and 347 wet bulb, in 360 workshops. According to the standard set by Prof. Hill for workshops—namely, figures of 6 and 18 for the dry and wet bulbs respectively—it has been found so far that while most of the workshops were well-ventilated as judged by absence of stuffiness and satisfactory working temperature, very few came within the standards mentioned. In those that did the movement of air was almost too strong. The need for further investigation into the practical application of the principles is suggested. Occupations and Workshops.—In the. following tables are shown in detail the number and variety of work premises on the register at the end of 1927, the number of inspections made, and the results of such inspections:— 70 Table IV. Work Premises. Total Number Tailors, outfitters, shirt makers, hat, cap and helmet maters 1,271 Dressmakers, milliners, embroiderers, lace makers, blouse maker*, costumiers, lingerie makers, children's outfit makers, feather dyeing, corset makers, furriers, etc. 1,101 Leather workers, boot and shoe makers, harness makers, etc. 68 Carpentry, upholstery, carvers, gilders, etc. 54 Surgical and dental instrument makers 10 Tobacco manufacturers 13 Wig makers and hair workers 46 Printing, bookbinding, lithographers, envelope making, stationers, relief stamping, etc. 60 Jewellers, silversmiths and burnishers, diamond cutters and polishers, engravers, etc. 59 Metal workers 17 Miscellaneous—Basket making, fancy work, shoe ornaments, hat pins, stamp sorters, postcard tinters, fan makers, artificial flower makers, etc. 37 Florists 21 Laundries 25 Bakehouses 77 Photographers 38 Jewel case makers 7 Cinema film workplaces 37 Total 2,941 The use of 379 workshops was discontinued, and 171 additions were made to the register during the year. Table V.—Inspection. Premises. Number of Inspection!. ReInspections. Defects Found. Intimation Notices. Statutory Notices. Prosecutions. Factories 140 55 25 5 — — Workshops 1,694 1,275 453 242 7 Workplaces 1,168 1,542 345 163 1 — Total 3,002 2,872 823 410 8 — 71 Table VI.—Defects found. Particulars. Number of Defects. Number of Prosecutions Nuisances under the Public Health Acts:— Lack of cleanliness 301 — Insufficient ventilation 38 — Unventilated gas stoves 21 — Overcrowding 47 — Floors without means of drainage 29 — Sanitary accommodation— — Insufficient 21 — Unsuitable 67 — Defective 101 — Not separate for sexes 39 — Other defects 159 — Total 823 — Offences under the Factory and Workshop Act:— — Illegal occupation of underground bakehouses .. — — Breach of special sanitary requirements for bakehouses (included above) — — Other offences — — Table VII.—Other Matters. Class. Number. Visits to Outworkers' premises other than workshops 200 Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act 166 Absence of means of worming — Matters referred bv H.M. Inspectors 115 Workrooms measured .. 335 Visits of Enquiry re Employment of Womon .. 155 „ „ Outworkers 133 Underground bakehouses in use at the end of the year 50 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 Sections 107, 108, 109 aud 110 is appended. 72 Table VIII. 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 1,108 1,823 8,846 35 32 115 435 6,418 122 — 1 — — — 15 — — Curtains, etc — — — — — — 2 — — — — — — — — — Linens, etc. 4 22 55 — — — 3 61 2 — — — — — — — Cutlery, electroplate, etc. — — — — — — — — — — — — — — — — — —Furriers 11 21 31 1 1 2 11 35 2 — — — — — — — — Umbrellas, toys, artificial flowers, etc. 4 91 113 — — — — 143 — — — — — — — — — Engraving, metal work, etc. — — — — — — 2 — — — — — — — — — — Hairwork — — — — — — 4 — — — — — — — — — — Total 1,127 1,960 9,045 36 33 117 459 6,657 126 — 1 — — — 15 — — 73 Outworkers.—The total number of lists received during the year amounted to 1,163. Notices in respect of failure to send lists were sent to 126 firms. In one case a prosecution was ordered and the firm concerned was ordered to pay £1 1s. costs. The lists contained 11,155 names and addresses of which 6,657 were in other districts, 5,623 being within the Metropolitan area and 697 in the London Suburban Districts. The number of individual outworkers in the City at the close of the year was 1,715, of whom 1,413 were registered as occupying workshops. The number of houses in which outwork was being carried on was 833. Disinfection. Legislation is contemplated in respect of obtaining power for compelling the removal of verminous persons to a cleansing station for the purpose of cleansing and disinfection. There have been instances in the City of vagrants in a filthy and verminous condition frequenting places of public resort; but neither the police nor the sanitary authority, at present, have any powers to enforce cleansing in such cases. 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. Books are treated with formalin. The cleansing of persons and of premises in a verminous state has been carried out by the Disinfecting Staff. Visits were paid to 57 houses, and 5,001 articles of clothing, bedding, etc., were removed for disinfection. Individuals, numbering 331 men and 20 women, and 7 children under school age, were given medicated baths at the Disinfecting Station, which necessitated their making 361 attendances. Notices from the London County Council in regard to school children affected with vermin numbered 640, and the Disinfecting Superintendent and the Sanitary Inspectors paid 720 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 (9616)q F 74 children from the boroughs of Battersea, Chelsea, Holborn, Kensington, Lambeth, Paddington, St. Pancras, St. Marylebone, and the City of London. There were among Westminster children, 498 cases of head lice treated, 6 of body lice and 13 of scabies. In all these cases the clothing was disinfected together with the bedding from their homes, amounting in all to 442 articles. Children from the above-mentioned boroughs treated for similar conditions were as follows : 251 for head lice and 13 for scabies. The number of attendances of these children for baths at the station was 1,204. The following table shows the total number of individuals treated at the station for verminous conditions:— Table IX. 1927. Head lice. Body lice. Scabies. Total. Children 756 8* 26 790 Adults 7 328 16 351 703 336 42 1,141 * Two were under school age. All the lice and scabies cases were dealt with at the station. Table X. 1923. 1924. 1925. 1926. 1927. Rooms 742 984 1,081 932 890 Articles disinfected 21,933 23,382 22,833 21,775 12,201 Articles washed 8,079 4,862 5,142 5,550 4,841 Articles destroyed 173 198 265 372 152 Books disinfected * 215 425 454 166 48 Vehicles ,, 3 3 8 4 7 Offices and business premises — — 21 25 9 * School books, 1; library books, 32; private books, 15. The motor van during 1927 ran 4,172 miles and carried 3,549 cwt. of goods, the highest amount in any one day being 31 cwt. The petrol consumption was 451 gallons, equal to 9.2 miles per gallon. Mortuaries. The number of bodies removed to the Council's mortuaries under older of the Coroner, or to await burial, was 357—in one instance on account of infectious disease. 75 Inquests were help at Horseferry Road, where the Coroner's Court is situated, in 341 cases, and there were 18 adjourned inquests. Postmortem examinations were made in 80 instances. Sixteen bodies were received in the mortuary chapel to await burial. The number of dead bodies taken to the mortuaries for purposes of nquest, and to await burial, during the last 25 years were:— Table XI. Total. For Inquest. To await Burial. Total. For Inquest. To await Burial. 1903 396 341 55 1916 281 252 29 1904 381 322 59 1917 278 265 13 1905 368 307 61 1918 285 242 43 1906 344 283 61 1919 308 269 39 1907 358 281 77 1920 289 269 20 1908 364 298 66 1921 273 238 35 1909 291 258 33 1922 269 247 22 1910 333 281 52 1923 336 318 17 1911 383 334 49 1924 340 328 12 1912 324 284 40 1925 334 317 17 1913 328 286 42 1926 343 323 20 1914 323 295 , 28 1927 357 341 16 1915 376 349 27 There are resting places for the dead at Ebury Bridge, Dufours Place and Drury Lane. MATERNITY AND CHILD WELFARE. The persistently high rate of maternal mortality throughout the country has continued to engage most serious attention. The problem, although existent in London, does not assume the grave dimensions found in some of the Northern industrial towns. The most pressing need seems to be more maternity hospital accommodation and a higher standard of midwifery in the homes of the people. It has been stated that no fewer than 3,000 women lose their lives each year in childbirth and these melancholy figures are as bad as they were twenty years ago. There has been no improvement comparable with the reduction in infantile mortality. The earlier report of Dame Janet Campbell of the Ministry of Health on "Maternal Mortality" and her more recent work " The Protection of Motherhood "deal exhaustively with various aspects of this disturbing question and have been the means of arousing a widespread desire for active measures to combat it. These reports, masterly in their critical survey of the factors which contribute to maternal mortality, suggest the foundations on which the whole fabric of preventive effort should be built. It is apparent that there is need for much greater development of ante-natal supervision of the mother. The clinics could be used to greater practical advantage. In midwifery (9616)q t 2 76 practice a much higher standard must be aimed at. By far the greater proportion of maternal deaths is due to sepsis and this, so far as extraneous sources are concerned, is preventible. It was recommended that a greater supply of highly trained midwives should be available and that the midwifery training of future medical practitioners should be considerably improved. The study of midwifery and its practice should be regarded in the schools as certainly no less important than the courses in medicine and surgery. It is becoming clear that none but the simplest operative procedures in obstetrics should be done in poor homes. For anything requiring considerable manipulation or surgical methods, patients should be placed in suitable institutions where strict antiseptic principles can be enforced. Even then no great advantage will be gained unless difficulties are diagnosed early and the patient admitted to hospital at once. The cases which go wrong in hospital are usually those which have received considerable interference before admission. In these days midwifery is a science to be practised by experts. To allow a handy woman to interfere with a lying-in woman is as much a crime as to permit her to attempt a surgical operation. It is extremely important that there should be in every district an adequate number of maternity beds in an institution where skilled help is available. In the City, towards the end of the year, it was reported that there was a difficulty in obtaining sufficient accommodation for women who desired to have their confinements in hospital. The question as to the provision of maternity beds is a matter which will engage attention during the next year. The Maternity and Child Welfare services of the Council remain as described in the report for last year. During the year visits were paid to the Council's centres and to that of the Westminster Health Society by a medical inspector from the Ministry of Health. The Ministry in referring to the inspector's report expressed appreciation of the maternity and child welfare services of the Council and commended the work of the Council's officers and those of the Society. The question of rheumatism in all its forms has evoked particular study during the year. In some districts special clinics have been set up with the objects of discovering rheumatism in childhood in its earliest stages. It is during childhood and early adolescence that the seeds of the most disabling effects of rheumatism are sown. The large and increasing number of deaths in later life from valvular disease of the heart is due almost entirely to acute rheumatism contracted in childhood. In very young children the disease may be very insidious in onset, appearing in the form of recurring tonsillitis or "growing pains" or slight forms of St. Vitus dance. If such cases could be detected at the 77 child welfare centres in their earliest stages, it might be possible by special care and treatment to prevent permanent damage afterwards to the heart. The Metropolitan Asylums Board have, allocated a certain number of beds for the treatment of such cases. The influence of damp dwellings as the causation of rheumatism is also being investigated, and it might be well if the younger inmates of such houses were medically examined in order to find whether there is definite evidence on this point. Two Acts of Parliament which have a reference to the work of Health Visitors require mention. The Widows and Orphans Contributory Pensions Act, 1925.— The City Council resolved to accept delegation from the County Council of powers to administer under Section 6. The Local Authority may, in cases of desertion of a child or in the case of an orphan, administer the payment on behalf of the child. Xo cases have so far been reported to the Council. Births and Deaths Registration Act, 1926, came into force on 1st July, 1927. Reference has already been made to the requirement that all still births must be registered. 'Where neither a qualified medical practitioner nor a midwife has been present a declaration relating to the circumstances of the birth must be made to the Registrar by the relatives on a prescribed form. It is suggested by the Ministry of Health that in such a case the Registrar may deem it necessary to inform the Local Authority, so that the Medical Officer of Health may authorise inquiries by a Health Visitor and be in a position to inform the Registrar whether he is satisfied that the child was really still born or whether there are suspicious circumstances concerning the case. While there is every desire to assist the Registrar in obtaining accurate information such as may be obtained by a Health Visitor in her routine inquiries, it should be pointed out that it.would be foreign to the whole principle of health visiting for her to pursue inquiries which might resemble methods of criminal investigation. Ante-natal I York.—The supervision of expectant mothers is recognised to be of increasing importance, and for this purpose it is extremely desirable that they should avail themselves of the expert advice obtainable at the centres and at the hospitals. The following table shows the number of cases which were dealt with through the various centres and how they became known to the health visitors. The co-operation of the hospitals with the welfare centres continues to develop, and there is interchange of much useful information between those bodies which should result in greatly improved conditions for confinements. 78 Table I.—Ante-natal Cases. City Council's Centres. A. Westminster Health Society. Totals. Name of Hospital. No. 1, Pimlico Road. No. 15, Bess borough Street. No. 9. Frith Street. No. 30, Page Street. General Lying-in 21 25 4 22 72 St. George's 29 17 3 5 54 Westminster 11 33 — 34 78 St. Thomas' 6 9 2 4 21 Charing Cross — 1 — 4 5 Middlesex 1 6 26 2 35 Woolwich — — 1 1 St. Stephen's — — — 21 21 Queen Charlotte's — — — — — St. Bartholomew's — — — — Clapham Maternity — — — 1 1 Royal Free — — 1 — 1 Elizabeth Garrett Anderson — — 1 — 1 King's College — — — 1 1 Found by Health Visitors 43 97 38 — 178 By Private Doctors and Midwives — — — 35 35 Reported to Centre voluntarily 80 52 17 50 199 Totals 191 240 92 180 703 Ante-natal Visiting.—To the 703 expectant mothers who became known to the Centre, 663 piimary visits were paid by health visitors. Subsequent visits were also paid to these cases to the number of 1,055. The attendances by those mothers at the clinics held by Dr. Vernon are detailed below:— Table II.—Ante-natal Clinics. Centre. Sessions. First Attendance. Subsequent Attendances. Total. No. of Individuals. Pimlico Road 61 68 51 119 92 Bessborough Street 50 120 121 241 169 Ante-natal clinics are also held at Charing Cross, St. George's, Westminster and Middlesex Hospitals for mothers who have made arrangements for their confinements with these hospitals. Mothercraft.—Classes in mothercraft are held at the various centres, and health talks have been given each week throughout the year in connection with those classes. 79 Table III.—Mothercraft Classes. 1927. Pimlico Road. Bessboro' Street. Frith Street. Page Street. Total. Number of classes 47 50 46 88 231 Total attendances 6G8 1,098 659 3,131 5,556 Average attendances 14.02 21.8 14.3 35.5 24.0 Number of expectant mothers 11 82 16 88 197 Number of attendances by expectant mothers 47 278 74 648 1,047 Number of other mothers .... 65 159 96 209 529 Number of attendances by other mothers 621 820 585 2,483 4,509 Attendances of children in nurseries during classes 280 1,200 657 2,278 4,415 Materials are purchased in quantity, and sold to the mothers at cost price. The number of garments made at Pimlico Road were 314; at Bessborough Street, 481; at Frith Street, 639; and at Page Street, 1,832. In addition to those, many renovations were carried out. The class at Frith Street, under the charge of Mrs. Steflens, is held every Tuesday afternoon at 2.30; at Bessborough Street, on Wednesdays at 2.30, and at Pimlico Road on Mondays at 2.30, under the charge of Mrs. Colman. Midwifery Services.—The work performed by the Council's midwife is summarised below, and comparative figures since 1922 are given. Her area, which was formerly contained in Victoria Ward, now takes in that part of St. John's Ward bounded on the east by Vauxhall Bridge Road. Table IV. 1922. 1923. 1924. 1925. 1926. 1927. Number of cases attended— As midwife 95 108 75 73 80 65 As emergency 7 2 — — — — With hospital students 7 5 — — — — With private doctor — 1 — — — — Total 109 116 75 73 80 65 Number of— Pre-natal visits 527 610 570 779 860 678 Lying-in visits 866 1,402 920 939 1,005 812 Subsequent visits 358 172 315 335 351 415 Visits to infants under 1 year, other than lying-in visits 215 172 266 234 262 376 Total number of visits 1,966 2,356 2,071 2,287 2,478 2,281 80 Table V. Attendances by midwife at ante-natal and other clinics:— 1922 1923 1924 1925 1926 1927 1, Pimlico Road 41 72 40 54 43 39 15, Bessborough Street 73 62 83 75 87 82 Total 114 134 123 129 130 121 The Westminster Health Society provide midwifery services in St. Margaret and St. John Wards, the western boundary being Vauxhall Bridge Road. The following table gives figures relating to the work performed in this area during the year:— Table VI. Number of cases attended— St. Margaret and St. John Wards. As midwife 46 With hospital students 10 With private doctors 6 62 Midwifery visits 868 Nursing visits 95 963 As mentioned earlier in the report, there is a greatly increasing tendency for women from other districts to come into Westminster institutions for their confinements. The hospital beds available are as follows:—Charing Cross, 15; St. George's, 11; Westminster, 4; St. Stephen's, 28. Five hundred and thirty-two women from other districts were confined in Westminster and 540 women belonging to the City were delivered in the hospitals mentioned—the number in St. Stephen's alone being 203. The number of children born to Westminster parents in institutions outside the City numbered 576. The following table shows the number of confinements in the hospitals mentioned:— Table VII. Charing Cross Hospital: 196, of which 50 were Westminster cases. St. George's Hospital: 229, of which 41 were Westminster cases. Westminster Hospital: 110, of which 46 were Westminster cases. St. Stephen's Hospital: 203. Sheffield St. Hospital: 36. Infancy and Early Childhood.—At the centres in the City weekly clinics are held for the purpose of giving medical advice. The following figures give an approximate number of the births in the four areas divided for the purposes of maternity and child welfare 81 1, Pimlico Road. 15, Bessborough St. 30, Page St. 9, Frith St. 446 354 303 295 The health 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 VIII. Pimlico Road. Bessborough Street. Frith Street. Page Street. Total. Pre-natal— First visits 191 220 89 177 677 Other visits 367 220 200 296 1,083 Children under 1 year of age— First visits 482 371 272 301 1,426 Other visits 1,609 1,252 1,407 1,357 5,625 Children over 1 and under 5 years- Visits 2,208 2,137 2,932 2,951 10,228 Death enquiries, still-births, &c 56 37 29 19 141 Infectious diseases 143 114 93 48 398 The Council's midwife paid 678 visits before, and 376 after, confinements which are not included in the above Table. 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). 9, Frith Street—2 p.m. Wednesday. Westminster Health Society— 30, Page Street—2 p.m. Tuesday. 2 p.m. Friday. It will be noted from the following table of attendances that the work at the centres is steadily increasing, and that a greater number of new infants arc being brought to the centres. The average attendance per session has increased, as also have the total attendances. The comparative totals since 1922 are also shown:— 82 Table IX. Attendances at Infant Consultations, 1927. Centre. Number of Sessions. First Attendances. Subsequent Attendances. Total. Total. Under 1 year. Over 1 year. Under 1 year. Over 1 year. Under 1 year. Over 1 year. 1. Pimlico Road 102 203 53 1,978 1,550 2,181 1,603 3,784 15, Bessborough Street 101 224 111 2,390 1,789 2,614 1,900 4,514 9, Frith Street 51 100 28 980 381 1,080 409 1,489 30, Page Street 99 209 88 2,129 1,549 2,338 1,637 3,975 1927 353 736 280 7,477 5,269 8,213 5,549 13,762 1926 354 863 272 6,847 4,871 7,710 5,143 12,853 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 The average attendances per session were— 1927. 1926. 1925. 1924. 1923. 1922. Pimlico Road 37.1 42.4 32.2 29.7 26.0 27.7 Bessborough Street 44.7 38.5 33.6 31.0 29.1 29.1 Frith Street 29.2 231 — — — — Page Street 40.1 36.3 — — — . — The number of individual children medically inspected were— 1, Pimlico Road 593 9, Frith Street 249 15, Bessborough Street 573 30, Page Street 596 83 Puerperal Fever, Puerperal Pyrexia and Mortality in Childbirth.— There were eight deaths of women from causes attributable to childbirth, giving a maternal mortality rate of 5.7 per 1,000 births. The causes were as follows(a) Puerperal Fever, 1; (b) and (c) Ruptured ectopic gestation, 2; (d) Rupture of uterus due to malformation of foetus, 1; (e) Haemorrhage during obstructed childbirth, 1; (/) Inflammation of womb, followed by septicaemia, 1; (g) Foetal toxaemia with Caesarean section, 1; (h) Pneumonia following miscarriage, 1. The results of inquiries are given as follows:— (а) Aged 30, third pregnancy, normal labour, sepsis arose from retained decidua which were removed. (In hospital.) (b) Aged 38. History of miscarriage at third month, removed to hospital next day, acute abdominal symptoms, operation, evidence of ruptured tubal pregnancy which had become gangrenous before admission. (In hospital.) (c) Aged 37. Haemorrhage from womb, due to ruptured extra uterine pregnancy. (In hospital.) (d) Aged 40. Admitted in labour after two attempts to deliver at home, child dead, removal by craniotomy—womb found ruptured and removed by abdominal operation. (In hospital.) (e) Aged 28. Shock following hemorrhage during obstructed childbirth. (In hospital.) First confinement instrumental; second and third normal. No evidence of foetal life after 33rd week. Labour began before admission. Prolapsed hand and cord, with offensive discharge. Removal by decapitation and cleidotomy under anaesthetic. Foetus in advanced state of maceration. Severe haemorrhage followed with collapse and death one hour after delivery. (/) Aged 29. Natural labour, but history of septic condition previously which appeared to come from a chronic endometritis. Blood culture showed streptococcus haemolyticus. Symptoms were those of septicaemia. (At home.) (g) Aged 29. Foetal toxaemia with Caesarean section. (In Nursing Home.) (h) Aged 33. Admitted with threatened miscarriage, fibroid of uterus present. Symptoms of lobar pneumonia developed with death on the fourth day. (In hospital.) As previously mentioned in this report, six cases of puerperal fever occurred, with one death, and it may be of interest to make a short analysis of the causes attributed to this disease, so far as it concerns these cases. Aged 29. High temperature and fever, from which patient recovered after a few days. 84 Aged 25. Fever followed removal of stillborn child after four days of labour. Patient had attended ante-natal clinic at a hospital for a few months. Aged 29. Had suffered from endometritis before confinement. Aged 30. After exploration of uterus, decomposed placenta was removed. Curetting performed and septic contents removed. Death ensued, see (a) above. Aged 33. Fever followed one day after abortion. Aged 39. Fever followed abortion. Twenty-six cases of puerperal pyrexia occurred—21 of these being in hospital. Only 19 children were bom to those 26 women, the remaining 7 being cases of miscarriage or abortion, and out of the total of 32 cases of puerperal fever and puerperal pyrexia, 9 (or 28 per cent.) could be attributed to this source. 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, but they do not come within the maternity and child welfare scheme of the Council, nor do the clinics at the Infants' Hospital, Vincent Square. The Council's arrangement with St. George's Hospital for the admission of cases recommended by the Council's officers remains in force. It is in operation over the area served by the centres at Pimlico Road and Bessborough Street. Nursing.—Under the Maternity and Child Welfare Scheme of the Council arrangements are in force with the three District Nursing Associations, the Pimlico, Belgravia and Chelsea; the Westminster; and the Metropolitan Associations, for the nursing of children under five years of age suffering from various ailments. A flat rate of 1s. 6d. is paid for each visit made by the Association concerned. The following table shows the nature of certain conditions for which nursing visits were paid:— Table X. Patients. Visits. Ophthalmia neonatorum and conjunctivitis 8 162 Influenza 2 33 Pneumonia 12 287 Bronchitis 4 47 Measles 83 08 Whooping cough 128 100 Other complaints 111 1,744 Total 348 2,441 85 Ophthalmia neonatorum has been notifiable since 1011. The percentage of mild (non-purulent) and notified (purulent) cases in relation to births from the year 1921 is as follows:— Table XI. Cases (notified). Rate per 100 births for both classcs of cases. 1921 21 1.8 1022 24 2.4 1923 30 3.4 1924 23 2.4 1925 21 2.0 1926 16 1.6 1927 14 1.9 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 with the inclusion of the year 1927. 1901-5 2.8 1916-20 4.95 1906-10 3.2 1921-25 1.7 1911-15 2.4 1926 0.62 1927 2.8 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. Fourteen cases were notified during the year, 5 of those being treated in hospital. There were also 13 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 8 cases, 162 visits being paid. Dental Treatment.—The Council's scheme provides for the treatment of cases both under the Maternity and Child Welfare and Tuberculosis Schemes. Figures relating to the latter will be found in the Tuberculosis Section of the Report. Expectant and nursing mothers, and children under five years of age, are eligible for treatment. 86 Mr. W. H. Turner, the Dental Surgeon, submits the following report:— "I have pleasure in forwarding details of the work of the Dental Clinic during 1927, and note that the high figures for 1926 have been well maintained, whilst with regard to the attendances of patients the total numbers have now exceeded 1,000. "I have only to mention that the few difficulties which have arisen in the smooth-running routine have been caused by the lack of a second attendance during the week. This was foreshadowed in the report for 1926 in which was mentioned the possibility of it becoming necessary to have a bi-weekly session. "We may still be able to postpone this step—for a time, at least— but meanwhile it will help the work of the clinic if the fortnightly afternoon sessions and the fortnightly gas sessions are transferred to another weekday. The regular morning sessions being held on Wednesdays, I consider that the most suitable and useful time for the alternate sessions would be on Fridays. "Amongst the many advantages of this course may be mentioned the possibility of patients being seen in less than a week after extensive 'gas' extractions, and also, in the alternate weeks, the opportunities of patients being attended twice weekly for acute dental conditions or for urgent fillings. "It is satisfactory to note the increase in the number of fillings completed during the year, as from the dental point of view this ' conservation ' work is of great importance." Table XII. 1922. 1923. 1924. 1925. 1926. 1927. Number of Sessions 69 70 79 92 92 90 New patients— First attendance 121 123 179 205 209 204 Subsequent attendances 403 479 522 613 629 802 Teeth extractions 942 1,056 1,349 1,278 1,668 1,198 Teeth filled 73 91 154 167 189 248 Other dental operations 232 433 478 616 699 777 Anesthetics administered— Local 17 20 25 38 31 17 General 200 202 240 255 295 263 Dentures supplied 5 3 4 6 2 6 Patients contributed £21 Is. 6d. in small sums according to their means. Convalescent Homes.—There arc 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 87 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. There are two other homes in the City which exist for a similar purpose. Day Nursery.—There are two nurseries in which mothers who work away from home may place their young children during working hours. 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, 3,206 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 £87 9s. 9d. INSPECTION AND SUPERVISION OF FOOD. The sanitary administration under this heading falls under two main categories: the supervision of food premises, and the inspection of foodstuffs with the examination of samples by analysis. The importance of safeguarding food from contamination is being more and more recognised in the provisions made bv Parliament from time to time and in the Regulations of the Ministry of Health and bye-laws of Local Authorities." Attention has recently been directed towards the conditions under which ice cream is made, and powers are being sought in the London County Council (General Powers) Bill, 1928. to enable the Local Authority to register such premises in terms similar to those in force for Dairies and Milkshops. The legal powers of the Local Authorities as regards the control of food supplies may be summarised thus:— 88 (a) The Sale of Food and Drugs Acts, 1875 to 1927, viz.:— Sale of Food and Drugs Act, 1875. Sale of Food and Drugs Amendment Act, 1879. Margarine Act, 1887. Sale of Food and Drugs Act, 1899. Butter and Margarine Act, 1907. Sale of Food and Drugs Act, 1927. (b) Legislation amending and supplementing the Sale of Food and Drugs Acts, viz.:— Section 10 of the Licensing Act, 1921 (Dilution of Spirits). Milk and Dairies (Consolidation) Act, 1915. Section 4 of the Milk and Dairies (Amendment) Act, 1922. Section 23 of the Finance Act, 1921 (Sending Samples to Government Chemist). (c) Orders and Regulations made under the Sale of Food and Drugs Acts, viz.:— Order as to Registration of Margarine Factories, &c., 1900. Order as to Registration of Butter Factories, &c., 1907. Regulation as to Competency of Analysts, 1900. Sale of Milk Regulations, 1901 and 1912. Sale of Butter Regulations, 1902. Milk and Dairies Order, 1926. Milk (Special Designations) Order, 1923. (d) Regulations made under the Public Health (Regulations as to Food) Act, 1907, viz.:— * Public Health (Milk and Cream) Regulations, 1912 and 1917. Public Health (Condensed Milk) Regulations, 1923. Public Health (Condensed Milk) Amendment Regulations, 1927. Public Health (Dried Milk) Regulations, 1923. Public Health (Dried Milk) Amendment Regulations, 1927. Public Health (Preservatives, &c., in Food) Regulations, 1925. Public Health (Preservatives, &c., in Food) Amendment Regulations, 1926 and 1927. * These will be revoked as from 1st January, 1928. Sale of Food and Drugs Act, 1927.- Gives effect to the recommendation of the Departmental Committee on the use of preservatives and colouring matters in food. It was mentioned in last year's report that a private 89 bill giving effect to the recommendation that any prohibitions or limitations imposed by the Public Health (Preservatives in Food) Regulations, 1925, should be binding on the Courts in proceedings taken under the Sale of Food and Drugs Acts, 1875—1907, had been passed into law. The first section of this short Act, quoted in full below, makes it clear that for the purposes of Section 6 and Section 3 of the Sale of Food and Drugs Act, 1875, articles of food must, when demanded by purchasers, be assumed to comply with the Regulations, otherwise offences under either or both of these sections have been committed. "1.—(1) Where any regulations made under the Public Health (Regulations as to Food) Act, 1907, as amended by any subsequent enactment and the enactments mentioned in that Act, prescribe the composition of any article of food or drink intended for sale or prohibit or restrict the addition of any preservative or other ingredient or material to any such article, a purchaser of such article shall, unless the contrary is proved, be deemed for the purposes of section six of the Sale of Food and Drugs Act, 1875, to have demanded an article complying with the provisions of the regulations, as regards the presence or amount of any constituent, ingredient or material specified in the regulations, and the addition of any such ingredient or material, in contravention of the regulations, shall, for the purposes of the said Act, of 1875, be deemed to render the article injurious to health. (2) "Where any such regulations restrict the addition of any preservative, or other ingredient or material, to an article of food or drink, the addition of any such ingredient or material to an amount not exceeding the limit specified by the regulations shall not, for the purposes of the Sale of Food and Drugs Act, 1875, be deemed to render the article injurious to health." Further list of legal provisions relating to food and food supply:— Public Health (London) Act, 1891. Sale of Horseflesh Regulations, 1889. London County Council (General Powers) Act, 1902 (Ice Cream Manufacture and Sale). London County Council (General Powers) Act, 1907 (Milk Supply (Tuberculosis)). London County Council (General Powers) Act, 190S (Storage of Food in Shops ; Fried Fish Shops, dc.). (9616) G 90 London County Council (General Towers) Act, 1909 (Storage of Food (Tenements). London County Council (General Powers) Act, 1927 (Regulation of Street Trading). Shell Fish Regulations, 1915. Soft Fruit (Sales) Order, 1918. Sale of Food Order, 1921 (Marking Imported Meat). Public Health (Meat) Regulations, 1924. World's Dairy Congress, 1928, for the Consideration of all Problems connected with the Production and Distribution of Milk and Milk Products. Arrangements are being made for the forthcoming World's Dairy Congress to be held in this country next year, from 26th June to 11th July, 1928. The Congress is being organised with the fullest support and encouragement from the Ministries of Health and Agriculture, who are represented on the Committees in charge of the arrangements. It is the eighth Congress of its kind, but the first to be held in this country. It is being arranged in conjunction with the International Dairy Federation and with the concurrence of the International Institute of Agriculture, Rome. His Majesty the King has graciously consented to act as Patron, and the Ministers of Agriculture and Health have agreed to become Presidents. The Chairman of the Organising Committee is the Right Hon. the Lord Kenyon, K.C.V.O. The main object of the Congress is to bring about a meeting between all who are concerned with milk questions, both in this country and in others, with a view to further progress being made in the direction of placing an abundant supply of clean milk and of milk products within the reach of the consuming public. The Medical Officer of Health has been appointed the Council's delegate to this Congress. The Milk and Dairies Order, 1926. Registration of Dairymen, etc.—At the end of the year the register contained the names of 408 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. Eighteen new applications to be registered during the year were received. Of those, seven concerned the transfer of business to another proprietor, while the premises continued to be used for the same 91 purpose. In 99 premises the sale of milk was discontinued. One milk seller was prosecuted for carrying on the trade of dairyman without beiDg registered, and a fine of 10s. was inflicted. The sanitary inspectors paid 825 visits to premises in which milk is sold. In three instances conditions were found requiring the service of notices. These concerned the cleanliness of walls and ceilings. There was also a case where the requirements of the London County Council (General Powers) Act, 1908, in reference to premises used for the storage of food were infringed. In each case conditions were remedied without resort to legal proceedings. Bottling Milk in the Street.—Article 31 of the Order lays it down that where milk is delivered in sealed bottles they shall be filled and sealed only in registered premises. The object of providing sealed bottles is to improve on the method of filling household milk jugs from the milkman's cans which, when performed in the street, offers possibilities of contamination. Although all milk vendors in the City were circularised as to the requirements of the Order when it came into force there was evidence that a number do not appreciate the importance of complying with this section of the Order. Roundsmen have been observed filling dirty empty bottles which had been left outside overnight by householders and sealing them with discs taken from the depths of their trousers' pockets. This proceeding defeats the whole object of providing clean and sterile bottles to be filled and capped under proper conditions in approved dairy premises. Moreover, the public are being deluded as they are led to believe that milk is being delivered t.o them in a much more hygienic manner than the can and milk jug, whereas abuse of the bottling method is infinitely more open to objection than the former. In recent years so much attention has been given to the production of cleaner milk that any practice which appears to betoken dirty methods must be regarded as a serious oSence to be dealt with summarily. Ten dairymen were prosecuted for this improper bottling of milk; in eight of these, the employees (roundsmen) were summoned. Fines amounting to £18 were inflicted, with £2 2s. costs. Milk and Dairies Amendment Act, 1922. Under the Milk (Special Designation) Order, 1923, made under this Act the Council issued licenses for the sale of:— Certified milk 18 Grade A (Tuberculin tested) milk 13 Grade A milk 1 Pasteurized milk12 16 samples were taken for bacteriological analysis. (961C) G2 92 These samples for bacteriological examination are taken by the Council's inspectors by arrangement with tL^ Ministry, and the reports are sent to the Council as well as to the Ministry. Of the sixteen samples, thirteen were found to comply with the bacteriological standards of the Order, while three were found to contain B coli, thus showing evidence of contamination. Further samples from the farms where the contaminated milk was produced were examined by the Ministry, with the result that the licences to produce graded milk were withdrawn. Pasteurization 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 the 44 samples of Preserved Cream there were none which showed an excess of preservative over the amount permitted (28 grs. per lb.); 9 showed no preservative at all, and the remainder of the total contained amounts below the allowed standard. Table I. The Public Health (Milk and Cream) Regulations, 1912 and 1917. Samples analysed during the Year 1927. Article. Number of samples examined for preservative. Number containing preservative and percentage of preservative found in each sample. Milk 944 No preservative found. Separated milk 7 No preservative found. Sterilized Milk 1 No preservative found. Cream 42 Two contained preservative (10 and 14 grains of boric acid per lb. respectively). The vendor of the sample containing 14 grains was prosecuted and fined £3. The other vendor was prosecuted and ordered to pay £2 2s. costs. 93 Preserved Cream. VNumber examined. Without preservative. Preservative under amount stated on label (0.4 per cent.). Preservative over amount stated on label. Milk fat in preserved cream. Above 35 per cent. Below 35 per cent. 44 9 35* Nil. 44 Nil. * Samples contained respectively 24.5, 23.0, 23.0, 22.4, 22.0, 21.0, 21.0, 21.0, 21.0, 21.0, 20.3, 18.9, 18.9, 18.4, 18.2, 18.0, 17.3, 17.9, 17.0, 16.9, 16.8, 16.8, 16.5, 16.5, 16.0, 14.0, 14.0, 13.0, 12.6, 12.0, 11.0, 10.4, 10.0, 9.8, 8.0, grains of boric acid per lb. Aotioh Taken—Nil. Infringements under Article 5 (1)—Nil. Infringements under Article 5 (2)—NiL During the year 76 milk sellers took advantage of the provision contained in 3rd Schedule of the Milk and Dairies Act, 1915, to request the Local Authority to take samples from the consignors at the place of delivery. The form of written request is prescribed in the Schedule, and although 70 of the requests were in proper legal form, almost double that number were quite inadmissible in that they specified neither time nor place where the samples could be taken nor did they express a request for such samples to be taken. It is important to note that there is no obligation on the Local Authority to take the extra samples from the consignor unless the request is submitted in due legal form and lodged with the authority within GO hours of the taking of the original sample. Unless the precise requirements of the schedule are observed a warranty cannot be pleaded. It proved necessary to take samples from consignors only in 4 cases, in response to the requests from 76 vendors, as 72 of the original samples from the vendors proved genuine. The analysis of samples from vendors which were not genuine are summarised below, together with the results of the corresponding samples taken subsequently from the consignors:— 94 Vendor's Sample. Action taken and Resi Consignor's Sample, number taken. Result of Analysis. Action taken and Result. Had 7 per cent. fat abstracted. Had 13 percent. fat abstracted. Contained 3.5 percent. added water. Had 8 per cent. fat abstracted. Prosecution. Warranty proved, summons dismissed. Prosecution. Warranty proved, summons dismissed. Prosecution. Warranty proved, summons dismissed. Prosecution. Notice of warranty given but the Magistrate was not satisfied and ordered defendant to pay £2 2s. costs. 10 4 5 6 All genuine 3 genuine, 1 adulterated (5 per cent. fat abstracted). All genuine. AH genuine. No action. Solicitors advised, no action against consignor. No action. No action. Analysis of Milk Samples.—Percentage of adulterated samples since 1910 is given on page 95. The legal minimum standards for milk fat and non-fatty solids as laid down in the Sale of Milk Regulations, 1901, are 3 per cent, and 8-5 per cent, respectively. Samples which do not show higher percentages than these are regarded by the analysts as of poor quality. Therefore it may be taken that the legal standards do not indicate any degree of excellence but rather milk which has barely escaped the stigma of adulteration. The grades of quality as set up by the analysts are as follows:— Good quality: Over 3.8 per cent. of fat. Fair quality: Between 3.3 per cent. and tinder 3.8 per cent. Poor quality: Between 3 per cent. and 3.3 per cent. Adulterated: Below 3 per cent. fat and 8.5 per cent. non-fatty solids. 95 In the year 1927 the samples taken in each of the two districts of the City are given. Table II. Good Quality. Fair Quality. Poor Quality. Adulterated. District. Total. No. Percent. No. Percent. No. Tcrccnt. No. Percent.###] North 477 215 45.0 215 45.0 37 7.7 10 2.1 South 467 296 63.3 130 28.0 34 7.2 7 1.4 944 511 54.1 345 36 5 71 7.5 17 1.8 1926 910 502 55.1 298 32.7 100 10.9 10 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 33.8 138 13.8 29 2.9 1921 977 449 45.9 362 37.0 131 13.4 35 3.5 1920 987 321 32.5 400 40.5 236 23.9 30 3.0 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 1.12 1917 920 329 35.7 304 33.0 102 17.6 125 1.36 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 35.0 328 346 179 18.9 108 11.40 It vrill be noted with satisfaction that the quality of the milk supplied in the City still maintains a very high standard. More than 90 per cent, of all the 944 milk samples were superior to the legal standards and only 1*8 per cent, below it and were thus classified as adulterated. Legal Proceedings for Adulteration.—Of the 17 cases, 10 were considered sufficiently serious to warrant prosecution. Details of the offences and results of proceedings are set out below. Milk— 15 per cent, added water 13 per cent, fat abstraction 13 per cent, fat abstraction 12 per cent, fat abstraction 8-7 per cent, fat abstraction 8 per cent, fat abstraction 8 per cent, added water 7 per cent, fat abstraction.... Fine. £3. Warranty proved, summons dismissed. 10s. Defendant deceased, summons withdrawn. £2. - - Warranty proved, summons dismissed. Costs. - 12s. 6d. - £2 2s. £3 3s. 96 Milk— 4 per cent, added water 3 5 per cent, added water Fine. £5. Warranty proved, summons dismissed. Costs. - Of the total 944 samples of milk taken during the year, 32 were obtained on Sundays. Of the latter, 2 were adulterated (1 per cent, added water, 8-7 per cent, fat abstracted). The vendor of the sample deficient in fat was prosecuted and fined £2. Samples taken in course of delivery.—Seven samples were taken as the milk was being delivered by consignors to hospitals, etc. On analysis all were found to be genuine and of "good" quality. Public Health (Preservatives in Food) Regulations, 1925, and Public Health (Preservatives in Food) Amendment Regulations, 1926 and 1927. These Regulations were discussed in detail in the reports for 1925 and 1926. They came into force at stated periods in 1927 as affecting particular articles of food, and this enforcement by steps will be continued in 1928, the final prohibition which has effect as from July lst) 1928, refers to butter containing a preservative for the purpose of making certain articles of food. Butter used thus after this date must not contain preservative. The other articles on which prohibitions were gradually imposed and were in effect after 31st December, 1927, are bacon, ham, egg yolk, butter and cream, margarine, whether used themselves as food or used in the preparation of other food. Only the following articles may contain preservative which must be either sulphur dioxide or benzoic acid as specified in the regulations. Sausage and sausage meat, fruit and fruit pulp not dried, dried fruit, unfermented grape juice and non-alcoholic wines, cordials and fruit juices, jam, candied peel, sugar, corn syrup, gelatine, beer, cider, alcoholic wines, sweetened mineral waters, brewed ginger beer, coffee extract, pickles and sauces made from fruit or vegetables. Twenty infringements of these regulations were found as the result of analyses of samples. A detailed list of samples is set out below, with notes as to analysis and action taken. 97 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 1927. Number Article of Food. Number of samples purchased. Genuine. (Inferior In brackets.) Adulterated. Prosecutions. Convictions. Withdrawn or dismissed. Fines. Coats. 1 Milk £ 8. d. £ s. d. 944 881 (46) 17 10 4 6 10 10 0 5 17 6 2 Do. Separated 7 7 - - 3 Do. Sterilized 1 1 - 4 Do. Condensed 21 21 - - - 5 Cream 42 40 2 2 1 1 3 0 0 2 2 0 6 Do. Preserved 44 44 - - 7 Do. Cheese 1 1 - 8 Do. Ice 13 13 - 9 Butter 145 144 1 - - - 10 Margarine 31 31 11 Tea 1 1 . - 12 Chocolate 8 8 _ - 13 Mincemeat 3 3 - 14 Meat pies (various) 23 23 — — — — — 15 Sausages 93 85 8 16 Meat & Fish Paste 75 75 _ 17 Salmon (tinned) 2 2 — 18 Crayfish (tinned) 1 1 — — — — — 19 Olives 2 2 - 20 Olive Oil 10 10 21 Peas (tinned) 13 12 1 - 22 Beans (tinned) 5 5 — 23 Pickles 1 1 24 Mushrooms (tinned) 1 1 - - - - - 25 Spaghetti (tinned) 1 1 — — — — — 26 Tomatoes (tinned) 1 — 1 — 27 Tomato Sauce 3 3 28 Tomato Soup 1 1 29 Vegetables, mixed 3 2 1 — — — — — 30 Apples 2 2 — — — — — — 31 Peaches 1 1 32 Fruit Salad 1 1 33 Jam 7 7 34 Lemon Squash 14 8 6 1 1 2 2 0 35 Do. Cup 1 1 — 36 Do. Curd 1 1 __ 37 Lime Juice 6 5 1 38 Fruit (tinned) 31 29 2 1 1 — 2 0 0 3 3 0 39 Whiskey 117 98 19 3 2 1 10 0 0 6 5 0 40 Brandy 36 35 1 — — — — — 41 Rum 39 38 1 — — 42 Gin 29 27 2 _ _ — 43 Milk of Sulphur 8 8 — — 44 Camphorated Oil 8 8 — — — — — — 45 Klcnazone "— preservative 3 3 — — — — — — Totals 1,800 1,691 (46) 63 17 8 9 10 0 19 9 6 98 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:— Butter.—145 samples were taken and 1 contained 1.7 per cent. excess of water, the vendor of which was cautioned by letter. Sausages.—03 samples of various kinds were taken and 8 only contained the preservative in the form of sulphur dioxide in parts varying from 90 to 500 per million. The vendor of the sample containing the latter amount was cautioned by letter. The amount of sulphur dioxide permitted is 450 parts per million. Peas.—13 samples of tinned peas were taken and only 1 was found to contain crystallised copper sulphate, which form of preservative is now forbidden. This sample contained 0.2 grain per lb., and as it was taken unofficially no action was taken. Tomatoes.—1 sample of tinned tomatoes was taken and found to contain 2.5 grains of tin per lb. The vendor was cautioned by letter. Mixed Vegetables.—3 samples were taken, 1 of which was found to contain -05 grain of crystallised copper sulphate per lb. The quantity was so minute no action was taken other than by the purchase of further samples which proved to be genuine. Lemon Squash.—14 samples were taken, and 6 contained sulphur dioxide in parts varying from 40 to 142 parts per million, the latter sample was found to contain in addition to sulphur dioxide 100 parts of salicylic acid per million of lemon squash. The vendor was prosecuted and ordered to pay £2 2s. costs. Lime Juice.—6 samples were taken, 1 of which contained 150 parts per million of sulphur dioxide. No action was taken as the amount was well within the prescribed limit. Fruit (tinned).—31 samples were taken and 2 were found to contain tin to the extent of 3.86 grains per lb. each. The first was an unofficial sample, followed by the official sample as soon as the Analyst's report was received, the vendor concerned was prosecuted and fined £2 and £3 3a. costs. Regulation of Street Trading. The London County Council (General Powers) Act, 1927, provides for the regulation of street trading by the issue of licences which must he renewed annually. Special observation is kept by the Sanitary Inspectors of all stalls where food is exposed for sale and the premises where the food is stored. 'Where stall-holders have their food stores in other districts the addresses are forwarded for the attention of the sanitary authority concerned. Meat Regulations, 1924. There are no slaughterhouses in the City and the duties imposed are confined to the supervision of meat shops, stalls and stores. In addition to routine and special inspection, visits are paid to all meat premises in Ithe City at certain periods in the year for the purpose of a general inspection of the requirements in the Regulations. A register is kept of all meat vendors and the number at the end of 1927 was 144, to which the inspectors paid 428 visits. 99 Only in one case were conditions found to be unsatisfactory. A stallholder was using premises which did not adequately fulfil the requirements of the Regulations as to storage of meat. Alterations were made to the store which rendered it satisfactory for this purpose. Other Food Premises. The total number of inspections to food premises was 3,887, and these include visits to milk shops and butchers' shops which have already been detailed. Other premises where food is prepared for sale, deposited for sale or sold include bakers' shops, greengrocery and fruit shops, ice-cream shops, fish shops, fried fish shops, eating places, tea shops and restaurants. As a result of these inspections 105 notices requiring sanitary defects to be remedied were issued. Restaurants.—The keeping of restaurants, both great and small, is one of the most important trades in Westminster. A permanent day population almost four times as large as the resident population, together with the enormous daily influx of people who come for shopping, theatres or other social reasons, require to be catered for. Early in the year it was arranged to compile a register of all restaurants and to inspect systematically. The survey had not been completed by the end of the year, but 709 restaurants had already been indexed. During the year 930 visits were paid by the inspectors, particular attention being given to kitchens, pantries, messroom arrangements for staff, systems for washing up, and general sanitary arrangements. Defects requiring notices were found in 80 instances, and in each case the work was satisfactorily carried out. Fish Shops and Fried Fish Shops were periodically examined. Certain defects, such as defective flooring and roofs were reported in two instances but were remedied on the service of notices. There are 27 of these shops in the City to which the Food Inspectors paid 54 visits. Ice-Cream Premises.—The inspectors paid 121 visits for the purpose of supervision to premises where ice-cream is prepared or sold. It is particularly necessary that there should be a high standard of cleanliness in the 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. Legislation is being promoted for the better control and inspection of these premises. 100 Bakehouses.—At the end of 1927 there were 77 bakehouses in the City, of which 52 were underground. Four of the latter, (although originally certified by the Council, fell into disuse for some years; two of these were re-opened in 1927. During the year 238 visits of inspection were made, and in all instances the cleansing which is required to be done twice a year was carried out. 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 for destruction. Table IV. Articles of Food submitted. Tons. cwts. lbs. Tons. ewts Ibe Aubergines — 3 24 Hors-d'oeuvres . — 3 96 Apples — 13 55 Horseradish . — 3 — Artichokes — 12 60 Lettuce — 11 32 Asparagus — 2 106 Melons . — 12 36 Bananas 5 4 — Onions 6 1 86 Beans — 6 24 Oranges 4 9 90 „ (French) — 1 68 Parsley . — — 15 Black Currants — 2 96 Peaches 1 10 55 Cabbage — 1 86 Pears 81 4 22 Carrots — 12 — Peas — 14 32 Chestnuts — 3 41 „ (French) — — 16 Cranberries 2 6 Plums — 1 96 Cucumbers 3 2 Potatoes 1 2 56 Egg Fruit — 7 31 Pine-apples 1 2 110 fig" — 14 95 Spinach — 4 — Gooseberries — 2 — Strawberries (Cape) — — 91 Grapes — 4 32 Tomatoes 1 16 26 Greengages — 3 64 Walnuts 1 13 104 Fish, wet 10 cwt. 56 lbs. Meat 8 cwt. 3 lbs. „ tinned 65 tins Ham 9½lbs. „ smoked .4 cwt. 87 lbs. Chicken 1 Steak-and-Kidney Pies 6 Rabbits 1 cwt. 6 lbs. Certification of Food for Export.—Certificates enabling the export of certain articles of food to Canada were granted in sixteen instances. 101 Table V. Sale of Food and Drugs Act. Spirit Samples, 1927. 221 Samples of whiskey, brandy, rum and gin were taken during the year. In 23 cases it was found that the spirits were diluted below the standard strength of 35 degrees U.P. The following table shows details concerning the samples of spirits which proved to be adulterated, and the results where legal action was taken No. Article. Result of Analysis. Degrees UP. Notice or No Notice. Action taken and Result. 93n Whiskey. 35.9 N. Caution Vendor. 67n 99 35.9 N. Caution Vendor. 57s ,, 36.2 N. Caution Vendor. 180n ,, 36.2 N. Caution. 181n 99 39.2 N. Proceedings. £5 fine. 297n 99 38.6 N. Proceedings. £5 fine, £1 costs. 293n 99 35.9 N. Caution (previous prosecution in respect of Gin). 295n 99 35.4 N. Call attention of Vendor to result. 298n 99 35.5 N. Call attention of Vendor to result. 292n 99 35.6 N. Call attention of Vendor to result. 564n 99 35.4 N. Call attention of Vendor to result. 563n 99 35.4 N. Call attention of Vendor to result. 566n 99 36 0 N. Caution. 567n 99 35.4 N. Call attention of Vendor to result. 568n 99 36.8 N. Caution. 572n 99 36.5 N. Caution. 766s 99 36.4 N. Caution. 768n 99 38.4 N. Proceedings. £5 5s. costs. 773k 99 35.4 N. Call attention of Vendor to result. 27s Gin. 36.7 N. No Action. 293s 99 . 36.1 N. No Action. 420s Brandy. 35.5 N. Caution. (The Vendor's attention had on two previous occasions been called to the fact that samples of Whiskey purchased from him by the Council's Inspector have been below legal limit.) 422s Rum. 36.2 N. Caution. It will be noted that there is a considerable improvement in the number of defective samples, many of the cases being only just below the standard strength. 102 STAFF of the PUBLIC HEALTH DEPARTMENT. Mcdical Officer of Health and Administrative Tuberculosis Officer: †Andrew J. ShinnieM.D., D.P.H., &o. Assistant Medical Officers : JIan S. Thomson M.A., M.D., D.P.H. (Tuberculosis Officer and Asst. Medical Officer of Health.) f*ethel M. VernonM.D., B.S. (Maternity and Child Welfare.) Duncan LeysM.B., B.Ch., M.R.C.P. (Maternity and Child Welfare) Obstetric Consultant: *A. Goodwin O.B.E., M.D., F.R.C.S. Bacteriologist: *J. A. Braxton Hicks M.D., M.R.C.P., D.P.H. Dental Clinic: †*W. H. Turneb L.D.S., R.C.S., Eng. †*T. Graham Scott (Ana:sthetist) M.R.C.S., L.R.C.P. Public Analysts : *Cecil H. Cribb B.Sc., F.I.C. *P. A. Ellis Richards F.I.C. Clerical Staff: A. Wise S. G. Bennett. A. J. Manhood. tMiss M. MacFarlane (Tuberculosis Dis- F. W. Lake. pensary). W. Jenkins. Sanitary Inspectors: †F. A. Abis (retired 30th June, 1927) R.S.I. †m. Canton (Food & Drugs, &c.) S.I.E.B., Meat Cert., R.S.I. (Now District Inspector). †C. J. Dee S.I.E.B., R.S.I., and Meat and Food Cert. †W. L. French S.I.E.B., R.S.I., Meat and Food Cert. †F. J. Haioh S.I.E.B. †H. R. HardyR.S.I., M.I. San. Eng. †T. H. Jackson S.I.E.B. †E. J. Martinson (retired 2nd June, R.S.L 1927). tC. RatcliffS.I.E.B., Meat and Food Cert. †J.Sanderson (Senior Sanitary In- R.S.I., San. Sc. Cert., Gold Medallist 6 pec tor) Carpenters' Company. †F. E. Siddle (Food & Drugs, &c.) S.I.E.B., Meat Cert., R.S.I. (Now District Inspector) †W. G. T. Sutton (Food & Drugs, &c.) S.I.E.B., Meat and Food Cert. (Appointed 1st July, 1927) †H. E. White (Food & Drugs, &c.) S.I.E.B., Meat Cert., Dept. for Hygiene, (Appointed 1st June, 1927.) R.S.I. †Miss C. HuohesdonS.I.E.B., R.S.I., H.V., Certified Midwife, Dipl. Nat. Health Soc. * Part time Officers. †The Council receives Exchequer grant towards the salaries of these officers. 103 Health Visitors: †Miss A. Sanders H.V. †Miss J. G. Alexander H.V., Certified Midwife, Hosp. Nursing. †Miss D. H. M. Waldino 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. †Miss M. M. Scott S.I.E.B., H.V., Certified Midwife, Dipl. Board of Education. †Miss H. Blick H.V., Certified Midwife, Dipl. Board of Education. †Miss F. Rigo H.V., Certified Midwife, Dipl. Boafd of Education. †*mrs. Coleman (Mothercraft Classes) Red Cross Cert. 1st el., and gold medal. †*mrs. Steffens Midwife: †Miss A. J. Irving Certified Midwife, Hosp. Nursing. Other Staff: A. E. Bmcn, Keeper of Mortuary and Coroner's Court. (Deceased 3rd January, 1927). R. Watlino, Keeper of Mortuary and Coroner's Court. (Appointed 4th January, 1927.) A. W. Nicholls, Mortuary Assistant. (Temporary appointment, 5th January; Permanent appointment, 24th May, 1927.) A. Wheal, Superintendent of Disinfection. W. Slattery, Engineer. J. Atkins, Disinfector. E. C. Powell, Disinfector. (Deceased 1st December, 1927.) S. C. West, Disinfector. P. W. Attwater, Disinfector. A. B. Holland, Disinfector. J. R. Doyle, Motor Driver. (Appointed 14th November, 1927.) A. T. Steward, Assistant to Inspectors. W. H. Smith, Messenger. Mrs. Wheal, Attendant, Verminous Children. †MRS. W. Jenkins, Caretaker, 15, Bessborough Street. †MRS. Hawthorn, Miss Mates and Miss Barry,t 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: *N. Olivier Richards M.D., M.R.C.P., Maternity and Child Welfare. Health Visitors: Miss Callaghan (Supt., Centre) ... H.V., San. Insp. Cert. Domestic Economy, &c. Miss PinchenH.V. Miss Reid H.V. and Midwife. Miss Cross Midwife. (With assistants, paid and voluntary, holding H.V. certificates, and nursing experience.) Mrs. Steffens (Mothercraft Classes). * Part time Officers. †The Council receives Exchequer grant towards the salaries of these officers.